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ATI Med Surg B, RN Adult Med Surg A,
ATI MED SURG, ATI A, ATI B, ATI C/2023/2024
Part II
A nurse is contributing to the plan of care for a client who has labyrinthitis. Which of the
following interventions should the nurse include in the plan?
a) Limit fluid intake.
b) Monitor client's cardinal fields of vision.
c) Encourage ambulation.
d) Ensure the room is brightly lit
Answer: b)
Rationale:
Labyrinthitis can affect balance and spatial orientation. Monitoring the client's cardinal fields of
vision can help assess for nystagmus, which is a common symptom of labyrinthitis.
A nurse is contributing to the plan of care for a client who is admitted with a deep vein
thrombosis (DVT) of the left leg. Which of the following interventions should the nurse include
in the plan?
a) Apply ice to the extremity
b) Monitor platelet levels
c) Restrict oral fluids
d) Administer vasodilating medications
Answer: b)
Rationale:
Monitoring platelet levels can help assess for the risk of thrombus formation and evaluate the
effectiveness of anticoagulant therapy in treating the DVT.
A nurse is caring for a client who comes to the clinic to be tested for tuberculosis (TB) after a
close family contact tests positive. Which of the following measures should the nurse anticipate
preparing for this client?
a) Tuberculin skin test

b) Sputum culture for acid-fast bacillus (AFB)
c) Bacille Calmette-Guérin (BCG) vaccine
d) Chest x-ray
Answer: d)
Rationale:
A chest x-ray is typically performed to assess for the presence of active TB infection in the lungs,
especially when there is a known exposure to TB.
A nurse is reviewing data for a client who has a head injury. Which of the following findings
should indicate to the nurse that the client might have diabetes insipidus?
a) Serum sodium 145 mEq/L
b) Urine specific gravity 1.028
c) Urine output 650 mL/hr
d) Blood glucose 198 mg/dL
Answer: c)
Rationale:
Diabetes insipidus is characterized by excessive urine output (polyuria) and low urine specific
gravity, which is a measure of urine concentration.
A nurse is caring for a client who has recurrent kidney stones and a history of diabetes mellitus.
The client is scheduled for an intravenous pyelogram (IVP). The nurse should collect additional
data about which of the following statements made by the client?
a) "I took a laxative yesterday."
b) "I took my metformin before breakfast."
c) "I haven't had anything to eat or drink since last night."
d) "The last time I voided it was painful."
Answer: b)
Rationale:
Metformin, a medication commonly used to treat diabetes mellitus, can increase the risk of lactic
acidosis when used with contrast media for procedures like an IVP. Therefore, the nurse should
assess if the client took metformin before the procedure.

A nurse is collecting data from a client who is having an acute asthma exacerbation. When
auscultating the client's chest, the nurse should expect to hear which of the following sounds?
a) Expiratory wheeze
b) Pleural friction rub
c) Fine rales
d) Rhonchi
Answer: a)
Rationale:
Expiratory wheezing is a common finding in clients with asthma and is caused by airway
narrowing and obstruction.
A nurse is planning to change an abdominal dressing for a client who has an incision with a
drain. Which of the following actions should the nurse plan to take?
a) Remove the entire dressing at once.
b) Loosen the dressing by pulling the tape away from the wound.
c) Don clean gloves to remove the dressing.
d) Open sterile supplies before removing the dressing.
Answer: c)
Rationale:
It is important to maintain aseptic technique when changing a dressing to prevent infection.
Donning clean gloves helps protect the wound from contamination during the dressing change.
A nurse is caring for a client who is scheduled to undergo thoracentesis. In which of the
following positions should the nurse place the client for the procedure?
a) Prone with arms raised over the head.
b) Sitting, leaning forward over the bedside table.
c) High Fowler's position
d) Side-lying with knees drawn up to the chest.
Answer: b)
Rationale:

The client should be in an upright sitting position, leaning forward over the bedside table or on a
pillow. This position allows for better access to the thoracic cavity and helps prevent inadvertent
puncture of the diaphragm during the procedure.
A nurse is caring for a client newly diagnosed with ovarian cancer. Which of the following
reactions from the client should the nurse initially expect?
a) Denial
b) Bargaining
c) Acceptance
d) Anger
Answer: a)
Rationale:
Denial is a common initial reaction to a cancer diagnosis as the client tries to process the
information and cope with the emotional impact of the diagnosis.
A nurse is contributing to the plan of care for a client who is postoperative following peritoneal
lavage for peritonitis. The client has a nasogastric tube to low-intermittent suction and closedsuction drains in place. Which of the following interventions should the nurse include in the
plan?
a) Irrigate the nasogastric tube with tap water.
b) Mark abdominal girth once daily.
c) Ambulate the client twice daily.
d) Place the client in a high Fowler's position.
Answer: d)
Rationale:
Placing the client in a high Fowler's position helps reduce intra-abdominal pressure and promotes
drainage from the peritoneal cavity, which is beneficial for the client post-peritoneal lavage.
A nurse is caring for a client who is receiving hemodialysis. Which of the following client
measurements should the nurse compare before and after dialysis treatment to determine fluid
losses?

a) Neck vein distention
b) Blood pressure
c) Body weight
d) Abdominal girth
Answer: c)
Rationale:
Comparing the client's body weight before and after hemodialysis treatment can help determine
fluid losses during the procedure. Hemodialysis removes excess fluid from the body, so a
decrease in body weight indicates successful fluid removal.
A nurse is caring for a client who is receiving a unit of packed RBCs. About 15 min following
the start of the transfusion, the nurse notes that the client is flushed and febrile, and reports chills.
To help confirm that the client is having an acute hemolytic transfusion reaction, the nurse
should observe for which of the following manifestations?
a) Urticaria
b) Muscle pain
c) Hypotension
d) Distended neck veins
Answer: c)
Rationale:
Acute hemolytic transfusion reactions are severe and potentially life-threatening. Symptoms
include fever, chills, flushing, hypotension, and hemoglobinuria. Urticaria, muscle pain, and
distended neck veins are not typically associated with acute hemolytic transfusion reactions.
A nurse is caring for a client who has a seizure disorder and reports experiencing an aura. The
nurse should recognize the client is experiencing which of the following conditions?
a) A continuous seizure state in which seizures occur in rapid succession
b) A sensory warning that a seizure is imminent
c) A period of sleepiness following the seizure during which arousal is difficult
d) A brief loss of consciousness accompanied by staring
Answer: b)

Rationale:
An aura is a sensory warning that a seizure is about to occur. It can manifest as visual, auditory,
or other sensory experiences. It is not a seizure itself but rather a precursor to a seizure.
A nurse is caring for a client who just had cataract surgery. Which of the following comments
from the client should the nurse report to the provider?
a) "The bright light in this room is really bothering me."
b) "My eye really itches, but I'm trying not to rub it."
c) "It's really hard to see with a patch on one eye."
d) "I need something for the horrible pain in my eye."
Answer: d)
Rationale:
Severe pain after cataract surgery can indicate complications such as increased intraocular
pressure or infection and should be reported to the provider immediately. The other statements
are common postoperative experiences and do not require immediate attention.
A nurse is caring for a client who is scheduled for a colonoscopy. The client asks the nurse if
there will be a lot of pain during the procedure. Which of the following responses should the
nurse make?
a) "You shouldn't feel any pain since the local area is anesthetized."
b) "Most clients report more discomfort from the preparation than from the procedure itself."
c) "You may feel some cramping during the procedure."
d) "Don't worry; you won't remember anything about the procedure due to the effects of the
medication."
Answer: c)
Rationale:
Cramping is a common sensation during a colonoscopy due to the air and movement of the
scope. While sedation is typically provided, it may not completely eliminate discomfort. Options
a, b, and d provide inaccurate information or false reassurance.

A nurse caring for a client at risk for increased intracranial pressure is monitoring the client for
manifestations that indicate that the pressure is increasing. To do this, the nurse should check the
function of the third cranial nerve by performing which of the following data-collection
activities?
a) Observing for facial asymmetry
b) Checking pupillary responses to light
c) Eliciting the gag reflex
d) Testing visual acuity
Answer: b)
Rationale:
The function of the third cranial nerve (oculomotor nerve) can be assessed by checking pupillary
responses to light. An increase in intracranial pressure can cause compression of the nerve,
leading to changes in pupil size and reactivity. Options a, c, and d are not specific to assessing
the function of the third cranial nerve.
A nurse is caring for a client during the immediate postoperative period following thoracic
surgery. When administering an opioid analgesic for pain, the nurse should explain that the
medication should have which of the following effects?
a) Reducing anxiety
b) Increasing blood pressure
c) Increasing coughing
d) Increasing the client's respiratory rate
Answer: a)
Rationale:
Opioid analgesics primarily act to reduce pain and can have a secondary effect of reducing
anxiety. They do not typically increase blood pressure, coughing, or respiratory rate.
A nurse is collecting data on a client who has hyperthyroidism. Which of the following
manifestations should the nurse expect the client to report?
a) Frequent mood changes
b) Constipation

c) Sensitivity to cold
d) Weight gain
Answer: a)
Rationale:
Hyperthyroidism is characterized by an overactive thyroid gland, which can lead to symptoms
such as frequent mood changes, weight loss, sensitivity to heat, and diarrhea. Constipation,
sensitivity to cold, and weight gain are more commonly associated with hypothyroidism.
A nurse is collecting data from a client who has skeletal traction. Which of the following findings
should the nurse identify as an indication of infection at the pin sites?
a) Serosanguineous drainage
b) Mild erythema
c) Warmth
d) Fever
Answer: d)
Rationale:
Fever is a systemic sign of infection, indicating that the body is mounting an immune response.
Serosanguineous drainage, mild erythema, and warmth may be present at the pin sites but are not
specific indicators of infection.
A nurse is reinforcing teaching with a client who has type 2 diabetes mellitus. The nurse
determines that teaching has been effective when the client identifies which of the following
manifestations of hypoglycemia? (Select all that apply.)
a) Polyuria
b) Blurry vision
c) Tachycardia
d) Polydipsia
e) Sweating
Answer: b)
c) Tachycardia,
e) Sweating

Rationale:
Hypoglycemia is characterized by low blood sugar levels. Symptoms include blurry vision,
tachycardia, sweating, tremors, hunger, and confusion. Polyuria and polydipsia are more
commonly associated with hyperglycemia (high blood sugar levels).
A nurse is collecting data from a client who has an exacerbation of gout. Which of the following
findings should the nurse expect? (Select all that apply.)
a) Edema
b) Erythema
c) Tophi
d) Tight skin
e) Symmetrical joint pain
Answer: a)
b) Erythema,
c) Tophi,
d) Tight skin
Rationale:
Gout is a type of arthritis caused by the buildup of uric acid crystals in the joints. Symptoms of a
gout exacerbation include edema (swelling), erythema (redness), tophi (deposits of uric acid
crystals), and tight skin over the affected joint. Gout typically affects one joint at a time, so
symmetrical joint pain is not a common finding.
A nurse is caring for a client who has myasthenia gravis (MG). Which of the following is a
complication of MG for which the nurse should monitor?
a) Respiratory difficulty
b) Confusion
c) Increased intracranial pressure
d) Joint pain
Answer: a)
Rationale:

Myasthenia gravis can lead to muscle weakness, including respiratory muscles, which can result
in respiratory difficulty. This is a significant complication of MG that requires monitoring,
especially during exacerbations.
A nurse is caring for a client who is experiencing an acute exacerbation of ulcerative colitis. The
nurse should recognize that which of the following actions is the priority?
a) Review stress factors that can cause disease exacerbation.
b) Evaluate fluid and electrolyte levels.
c) Provide emotional support.
d) Promote physical mobility.
Answer: b)
Rationale:
During an acute exacerbation of ulcerative colitis, there is a risk of dehydration and electrolyte
imbalances due to diarrhea and fluid loss. Evaluating fluid and electrolyte levels is a priority to
ensure the client's stability and prevent complications such as hypovolemic shock.
A nurse is reinforcing teaching about rifampin with a female client who has active tuberculosis.
Which of the following statements should the nurse include in the teaching?
a) "You should wear glasses instead of contacts while taking this medication."
b) "The medication causes amenorrhea if taken along with an oral contraceptive."
c) "A yellow tint to the skin is an expected reaction to the medication."
d) "Lifelong treatment with this medication is necessary."
Answer: a)
Rationale:
Rifampin can cause a harmless, but noticeable, red-orange discoloration of body fluids, including
tears. This can stain contact lenses, so wearing glasses is recommended during treatment. The
other statements are incorrect or not directly related to rifampin.
A nurse is reinforcing teaching about cyclosporine for a client who is postoperative following a
renal transplant. Which of the following statements by the client indicates an understanding of
the teaching?

a) "I will take this medication until my BUN returns to normal."
b) "This medication will help my new kidney make adequate urine."
c) "I will need to take this medication for the rest of my life."
d) "This medication will boost my immune system."
Answer: c)
Rationale:
Cyclosporine is an immunosuppressant medication used to prevent organ rejection after
transplantation. It is typically taken for the rest of the recipient's life to prevent rejection. Options
a, b, and d are incorrect statements about cyclosporine.
A nurse is caring for a client who has Parkinson's disease and is taking selegiline 5 mg by mouth
twice daily. Which of the following therapeutic outcomes should the nurse monitor for with a
client who is taking this medication?
a) Improved speech patterns
b) Increased bladder function
c) Decreased tremors
d) Diminished drooling
Answer: c)
Rationale:
Selegiline is a medication used to treat Parkinson's disease by helping to increase dopamine
levels in the brain. One of the expected therapeutic outcomes of selegiline is a reduction in
tremors, which are a common symptom of Parkinson's disease.
A nurse is assisting in the care of a client who is receiving a transfusion of packed red blood
cells. The client develops itching and hives. Which of the following actions should the nurse take
first?
a) Obtain vital signs
b) Stop the transfusion
c) Notify the registered nurse
d) Administer diphenhydramine
Answer: b)

Rationale:
Itching and hives are signs of an allergic reaction to the transfusion. The first action the nurse
should take is to stop the transfusion to prevent further administration of the allergen. Vital signs
should be obtained next, and the registered nurse should be notified. Diphenhydramine may be
administered to relieve itching, but stopping the transfusion is the priority.
A nurse is reinforcing teaching with a client about how to prevent the onset of manifestations of
Raynaud's phenomenon. Which of the following statements should the nurse identify as an
indication that the client needs further teaching?
a) "I will keep my house at a cool temperature."
b) "I will try to anticipate and avoid stressful situations."
c) "I will complete the smoking cessation program I started."
d) "I will wear gloves when removing food from the freezer."
Answer: a)
Rationale:
Raynaud's phenomenon is characterized by vasospasm in response to cold or stress, leading to
reduced blood flow to the extremities. Keeping the house at a warm temperature would be more
beneficial for someone with Raynaud's phenomenon. The other statements are appropriate for
managing the condition.
A nurse is reinforcing teaching with a client who has iron deficiency anemia and is to start taking
ferrous sulfate twice a day. Which of the following statements by the client indicate an
understanding of the teaching?
a) "I will take the medication with orange juice."
b) "I should expect to have loose stools while taking this medication."
c) "I will have clay-colored stools while taking this medication."
d) "I should take the medication with milk."
Answer: a)
Rationale:
Taking iron supplements with vitamin C (such as orange juice) can help improve iron absorption.
Loose stools are a common side effect of iron supplements, but clay-colored stools are not

expected. Milk can decrease iron absorption and should be avoided when taking iron
supplements.
A nurse is reinforcing teaching about pernicious anemia with a client following a total
gastrectomy. Which of the following dietary supplements should the nurse include in the
teaching as the treatment for pernicious anemia?
a) Vitamin B12
b) Vitamin C
c) Iron
d) Folate
Answer: a)
Rationale:
Pernicious anemia is caused by a lack of intrinsic factor, which is needed for the absorption of
vitamin B12. Treatment typically involves vitamin B12 supplementation, either through
injections or high-dose oral supplements. Vitamin C, iron, and folate supplements are not
specific treatments for pernicious anemia.
A nurse is caring for a client who is scheduled for surgical repair of a femur fracture and has a
prescription for lorazepam preoperatively. Which of the following statements by the client should
indicate to the nurse that the medication has been effective?
a) "My mouth is very dry."
b) "I feel very sleepy."
c) "I am not hungry any longer."
d) "My leg feels numb."
Answer: b)
Rationale:
Lorazepam is a benzodiazepine used to reduce anxiety and induce sedation. Feeling very sleepy
indicates that the medication has been effective in producing a calming and sedative effect,
which is desirable preoperatively to reduce anxiety.

A nurse is collecting data from a client who has AIDS. When checking the client's mouth, the
nurse notes a white, creamy covering on the tongue and buccal membranes. The nurse should
recognize this is a manifestation of which of the following conditions?
a) Xerostomia
b) Gingivitis
c) Candidiasis
d) Halitosis
Answer: c)
Rationale:
Candidiasis, or oral thrush, is a fungal infection caused by Candida species. It presents as a
white, creamy covering on the tongue and buccal membranes. It is common in clients with AIDS
due to their weakened immune systems.
A nurse is caring for a client who is postoperative open reduction and internal fixation with
placement of a wound drain to repair a hip fracture. Which of the following actions should the
nurse take?
a) Empty the suction device every 4 hr.
b) Monitor circulation on the affected extremity every 2 hr for the first 12 hr.
c) Position the client's hip so that it is internally rotated.
d) Encourage foot exercises every 4 hr.
Answer: a)
Rationale:
After open reduction and internal fixation of a hip fracture with a wound drain, the nurse should
empty the suction device regularly to maintain proper drainage and prevent complications such
as blockage or excessive suction pressure. Monitoring circulation, positioning the hip, and
encouraging foot exercises are also important but are not the immediate priority.
A nurse is assisting with teaching a client who has a history of smoking about recognizing early
manifestations of laryngeal cancer. The nurse should instruct the client to monitor and report
which of the following manifestations of laryngeal cancer?
a) Aphagia

b) Hoarseness
c) Tinnitus
d) Epistaxis
Answer: b)
Rationale:
Hoarseness is a common early symptom of laryngeal cancer. It is important to monitor and report
any changes in voice quality, especially in individuals with a history of smoking, as early
detection can improve treatment outcomes. Aphagia (difficulty swallowing), tinnitus (ringing in
the ears), and epistaxis (nosebleeds) are not typically associated with laryngeal cancer.
A nurse is collecting data from a client who has systemic lupus erythematosus (SLE). Which of
the following laboratory values should the nurse review to determine the client's renal function?
a) Antinuclear antibody
b) C-reactive protein
c) Erythrocyte sedimentation rate
d) Serum creatinine
Answer: d)
Rationale:
Serum creatinine levels are commonly used to assess renal function. In clients with SLE, renal
involvement is common, and monitoring serum creatinine levels can help assess kidney function
and detect early signs of renal impairment. Antinuclear antibody, C-reactive protein, and
erythrocyte sedimentation rate are used to diagnose and monitor SLE activity but are not specific
indicators of renal function.
A nurse is collecting data from a client who has Cushing's syndrome. Which of the following
manifestations should the nurse expect?
a) Bruising
b) Weight loss
c) Hyperpigmentation
d) Double vision
Answer: a)

Rationale:
Cushing's syndrome is characterized by an excess of cortisol in the body, which can lead to
thinning of the skin and easy bruising. Weight gain, not weight loss, is a common symptom of
Cushing's syndrome. Hyperpigmentation, or darkening of the skin, can also occur due to
increased melanocyte-stimulating hormone. Double vision is not typically associated with
Cushing's syndrome.
A nurse is caring for a client who is postoperative and requesting something to drink. The nurse
reads the client's postoperative prescriptions, which include, "Clear liquids, advance diet as
tolerated." Which of the following actions should the nurse take first?
a) Offer the client apple juice.
b) Elevate the client's head of bed.
c) Auscultate the client's abdomen.
d) Order a lunch tray for the client.
Answer: c)
Rationale:
Before offering the client anything to drink, the nurse should assess the client's bowel sounds to
ensure that the gastrointestinal tract is functioning properly and that there is no risk of aspiration.
Elevating the head of the bed can help prevent aspiration but is not the first priority. Offering
apple juice or ordering a lunch tray can wait until after assessing bowel sounds.
A nurse is collecting data on a client who has a surgical wound healing by secondary intention.
Which of the following findings should the nurse report to the charge nurse?
a) The wound is tender to touch.
b) The wound has pink, shiny tissue with a granular appearance.
c) The wound has serosanguineous drainage.
d) The wound has a halo of erythema on the surrounding skin.
Answer: d)
Rationale:

A halo of erythema (redness) on the surrounding skin can indicate infection, especially if it is
warm to the touch. This finding should be reported to the charge nurse for further evaluation. The
other findings are typical in a wound healing by secondary intention.
A nurse is assisting with the care of a client who has multiple injuries following a motor vehicle
crash. The nurse should monitor for which of the following manifestations of a pneumothorax?
a) Inspiratory stridor
b) Expiratory wheeze
c) Absence of breath sounds
d) Coarse crackles
Answer: c)
Rationale:
A pneumothorax is a condition in which air collects in the pleural space, causing partial or
complete collapse of the lung. One of the key signs of a pneumothorax is the absence of breath
sounds on the affected side due to decreased or absent air movement in the lung. Inspiratory
stridor and expiratory wheeze are associated with airway obstruction, while coarse crackles can
indicate conditions such as pneumonia or pulmonary edema.
A nurse is collecting data from a client who has right-sided heart failure. Which of the following
findings should the nurse expect?
a) Frothy sputum
b) Dyspnea
c) Orthopnea
d) Peripheral edema
Answer: d)
Rationale:
Right-sided heart failure is characterized by the inability of the right side of the heart to pump
blood effectively, leading to fluid buildup in the body, particularly in the lower extremities.
Peripheral edema, or swelling in the legs and ankles, is a common manifestation of right-sided
heart failure. Frothy sputum can indicate pulmonary edema, which is more common in left-sided
heart failure. Dyspnea and orthopnea are also more common in left-sided heart failure.

A nurse is caring for a client who is receiving chemotherapy for treatment of ovarian cancer and
experiencing nausea. Which of the following actions should the nurse take?
a) Advise the client to lie down after meals.
b) Instruct the client to restrict food intake prior to treatment.
c) Provide the client with an antiemetic 2 hr prior to the chemotherapy.
d) Encourage the client to drink a carbonated beverage 1 hr before meals.
Answer: d)
Rationale:
Carbonated beverages can help alleviate nausea by reducing stomach distension and stimulating
the release of gas. This can help reduce feelings of fullness and nausea. Lying down after meals
may worsen nausea, restricting food intake prior to treatment is not recommended, and
antiemetics are typically given before chemotherapy, not before meals.
A nurse is assisting with the care of a client following a transurethral resection of the prostate
(TURP) and has an indwelling urinary catheter. Which of the following actions should the nurse
take?
a) Weigh the client weekly.
b) Irrigate the catheter as prescribed.
c) Instruct the client to report an urge to urinate.
d) Instruct the client to bear down as if to have a bowel movement every hour.
Answer: b)
Rationale:
Following a TURP, the client may have blood clots or mucus obstructing the catheter, so catheter
irrigation may be necessary as prescribed by the healthcare provider to ensure proper drainage.
Weighing the client weekly may be done for other conditions but is not specific to TURP.
Instructing the client to report an urge to urinate is not necessary with an indwelling catheter, and
bearing down as if to have a bowel movement is not indicated and could increase intraabdominal pressure, potentially causing harm.

A nurse is evaluating discharge instructions for a client following a right cataract extraction.
Which of the following client statements indicates the teaching is effective?
a) "I will take a stool softener until my eye is healed."
b) "I will expect to have moderately severe pain for 1-2 days."
c) "I will refrain from cooking for 1 week."
d) "I will bend at the waist to tie my shoes."
Answer: a)
Rationale:
Taking a stool softener can prevent constipation, which is important because straining during
bowel movements can increase intraocular pressure and strain on the surgical site. Expecting
moderately severe pain, refraining from cooking, and bending at the waist to tie shoes are not
indications of effective teaching for cataract extraction.
A nurse is collecting data from a client who is 6 days post craniotomy for removal of an
intracerebral aneurysm. The nurse should monitor the client for which of the following
manifestations of increased intracranial pressure?
a) Decreased pedal pulses
b) Hypertension
c) Peripheral edema
d) Diarrhea
Answer: b)
Rationale:
Hypertension can be a sign of increased intracranial pressure due to the body's compensatory
response to maintain cerebral perfusion pressure. Decreased pedal pulses, peripheral edema, and
diarrhea are not typically associated with increased intracranial pressure.
A nurse is caring for a client who has COPD. Which of the following actions should the nurse
take?
a) Encourage the client to drink 8 glasses of water a day.
b) Instruct the client to cough every 4 hr.
c) Provide the client with a low protein diet.

d) Advise the client to lie down after eating.
Answer: a)
Rationale:
Encouraging adequate hydration can help thin mucus secretions, making them easier to clear
from the airways, which can be beneficial for clients with COPD. Coughing every 4 hours,
providing a low protein diet, and advising the client to lie down after eating are not specific
interventions for managing COPD.
A nurse is caring for a client who was admitted with major burns to the head, neck, and chest.
Which of the following complications should the nurse identify as the greatest risk to the client?
a) Hypothermia
b) Hyponatremia
c) Fluid imbalance
d) Airway obstruction
Answer: d)
Rationale:
Burns to the head, neck, and chest can lead to airway edema and compromise the airway. Airway
obstruction is a life-threatening complication that requires immediate intervention to maintain a
patent airway. While hypothermia, hyponatremia, and fluid imbalance are potential
complications of burns, airway obstruction poses the greatest immediate risk to the client's life.
A nurse is collecting data from a client who was bitten by a tick one week ago. Which of the
following client manifestations should the nurse identify as an indication of the development of
Lyme disease?
a) An expanding circular rash
b) Swollen, painful joints
c) Decreased level of consciousness
d) Necrosis at the site of the bite
Answer: a)
Rationale:

An expanding circular rash, known as erythema migrans, is a hallmark sign of Lyme disease. The
rash typically appears at the site of the tick bite and gradually expands over time. Swollen,
painful joints, decreased level of consciousness, and necrosis at the bite site are not characteristic
manifestations of Lyme disease.
A nurse is contributing to the plan of care for a client who is 12 hr postoperative following a
right radical mastectomy with closed suction drains present. The nurse should expect that the
client will be unable to perform which of the following activities with her right arm?
a) Combing her hair
b) Eating her breakfast
c) Buttoning her blouse
d) Tying her shoes
Answer: a)
Rationale:
Following a right radical mastectomy, the client will have limited range of motion and mobility
in the right arm due to surgical incisions and drain placement. Combing her hair involves raising
the right arm above shoulder level, which may be restricted postoperatively. Eating, buttoning a
blouse, and tying shoes typically do not require the same range of motion and may be possible
for the client to do with some adaptation.
A nurse in a provider's office is collecting data for a 45-year-old client who is having
manifestations associated with perimenopause. Which of the following findings should the nurse
expect?
a) Report of urinary retention
b) Elevated blood pressure above 140/90
c) Report of dryness with vaginal intercourse
d) Elevated body temperature above 37.8° C (100° F)
Answer: c)
Rationale:

Dryness with vaginal intercourse is a common symptom of perimenopause due to hormonal
changes that affect vaginal lubrication. Urinary retention, elevated blood pressure, and elevated
body temperature are not typically associated with perimenopause.
A nurse is reinforcing teaching about breast self-examination (BSE) with a client who has a
regular menstrual cycle. The nurse should instruct the client to perform BSE at which of the
following times?
a) On the same day every month
b) Prior to the beginning of menses
c) Three to seven days after menses stops
d) On the second day of menstruation
Answer: c)
Rationale:
Performing BSE three to seven days after menstruation stops allows the breasts to be less tender
and lumpy, which can make it easier to detect any unusual changes. Performing BSE on the same
day every month, prior to the beginning of menses, or on the second day of menstruation may
not be ideal due to changes in breast tissue associated with the menstrual cycle.
A nurse is caring for a client who has second- and third-degree burns and a prescription for a
high-calorie, high-protein diet. Which of the following menu choices should the nurse
recommend?
a) ½ cup whole-grain pasta with tomato sauce and pears
b) Turkey and cheese sandwich with scalloped potatoes
c) ½ cup black beans with a brownie
d) Roast beef with romaine lettuce salad
Answer: b)
Rationale:
A turkey and cheese sandwich with scalloped potatoes provides a high-calorie, high-protein
meal, which is suitable for a client with burns who requires increased nutritional intake for
wound healing. Whole-grain pasta with tomato sauce and pears, black beans with a brownie, and
roast beef with romaine lettuce salad may not provide the same level of calories and protein.

A nurse is reinforcing teaching to a client who is scheduled for an intravenous pyelogram. Which
of the following should the nurse include in the teaching?
a) Omit your daily dose of aspirin.
b) Take a laxative the evening before the procedure.
c) Expect to be drowsy for 24 hr following the procedure.
d) You will feel cold chills after the dye has been injected
Answer: b)
Rationale:
Taking a laxative the evening before the procedure helps to cleanse the bowel and prepare for the
intravenous pyelogram. Omitting the daily dose of aspirin is not typically necessary. Drowsiness
for 24 hours following the procedure is not expected. Feeling cold chills after the dye has been
injected is not a common reaction to an intravenous pyelogram.
A nurse is collecting data from a client in the health clinic who is reporting epigastric pain.
Which of the following statements made by the client should the nurse identify as being
consistent with peptic ulcer disease?
a) "The pain is worse after I eat a meal high in fat."
b) "My pain is relieved by having a bowel movement."
c) "I feel so much better after eating."
d) "The pain radiates down to my lower back."
Answer: c)
Rationale:
Relief of pain after eating is a common symptom of peptic ulcer disease, as food can temporarily
neutralize stomach acid. Pain worsening after eating a high-fat meal, pain relief with a bowel
movement, and pain radiating to the lower back are not typical symptoms of peptic ulcer disease.
A nurse is contributing to the plan of care for a client who has a terminal illness. Which of the
following interventions should the nurse identify as the priority?
a) Promote the client's expression of feelings about loss of self-care ability.
b) Encourage the client to recall positive life events.

c) Schedule pain medication on a routine basis.
d) Suggest ways the client can continue interacting with social contacts.
Answer: c)
Rationale:
For a client with a terminal illness, managing pain and maintaining comfort is a priority.
Scheduling pain medication on a routine basis helps to ensure that the client's pain is adequately
managed. While promoting the client's expression of feelings, encouraging recall of positive life
events, and suggesting ways to interact with social contacts are important, pain management
takes precedence for comfort and quality of life.
A nurse is reinforcing teaching with a client who has been newly diagnosed with chronic openangle glaucoma. Which of the following statements by the client indicates an understanding of
the teaching?
a) "When my vision improves, I will be able to stop taking the eye drops."
b) "If I forget to take my eye drops, I should wait until the next time they are due."
c) "I should call the clinic before taking any over-the-counter medications."
d) "Every two years I will need to have my vision checked by an eye doctor."
Answer: c)
Rationale:
It is important for a client with chronic open-angle glaucoma to avoid certain medications that
can increase intraocular pressure. Calling the clinic before taking any over-the-counter
medications helps to ensure that the client is using eye drops safely. The other statements are
incorrect.
A nurse is teaching a client who has schizophrenia about her new prescription for risperidone.
Which of the following statements should the nurse include in the teaching?
a) "You should continue this medication if you develop muscle rigidity".
b) "You will experience weight loss while taking this medication."
c) "You will notice your symptoms improve within 24 hours of taking this medication."
d) "You should increase your consumption of complex carbohydrates."
Answer: a)

Rationale:
Muscle rigidity can be a side effect of risperidone, and it's important for the client to continue
taking the medication even if this side effect occurs. Stopping the medication abruptly can be
dangerous and should be avoided without consulting a healthcare provider.
A nurse is admitting a client who has generalized anxiety disorder. Which of the following
actions should the nurse plan to take first?
a) Provide the client with a quiet environment
b) Determine how the client handles stress.
c) Teach the client to use guided imagery.
d) Ask the client to identify her strengths
Answer: a)
Rationale:
Providing a quiet environment can help reduce anxiety for the client with generalized anxiety
disorder. It creates a calming atmosphere, which can be beneficial during the initial stages of
assessment and care.
A nurse is conducting an admission interview with a client who is experiencing mania. Which of
the following should the nurse report to the provider?
a) States that he hasn't bathed in 2 days
b) Reports eating twice in the past two weeks.
c) Makes inappropriate sexual comments.
d) Speaks in rhyming sentences.
Answer: b)
Rationale:
Reporting that the client has eaten only twice in the past two weeks is crucial because it indicates
a severe lack of nutrition, which can be dangerous. This behavior requires immediate attention
and intervention by the healthcare team.
A nurse is planning care for a client who has obsessive-compulsive disorder. Which of the
following recommendation should the nurse include in the client's plan of care?

a) Validation therapy
b) Thought stopping
c) Operant conditioning
d) Reality orientation therapy
Answer: b)
Rationale:
Thought stopping is a technique commonly used in cognitive-behavioral therapy for clients with
obsessive-compulsive disorder. It involves interrupting obsessive thoughts to reduce anxiety and
compulsive behaviors.
A nurse is caring for a client who has bipolar disorder and is experiencing a manic episode.
Which of the following actions should the nurse take?
a) Encourage the client to join group activities
b) Dim the lights in the client's room
c) Provide detailed explanations to the client
d) Administer methylphenidate
Answer: b)
Rationale:
Dimming the lights can help create a calming environment for a client experiencing a manic
episode. Bright lights can sometimes exacerbate manic symptoms, so reducing the lighting can
be beneficial.
A nurse is leading a crisis intervention group for adolescents who witnessed the suicide of a
classmate. Which of the following actions should the nurse take first?
a) Initiate referrals
b) Review community resources
c) Identify prior coping skills
d) Discuss the importance of confidentiality
Answer: c)
Rationale:

Identifying prior coping skills is the first step in crisis intervention. It allows the nurse to build on
existing strengths and resilience in the group members, which can help them cope with the
current crisis more effectively.
A nurse overhears a client saying, "I am a spy, a spy for the FBI. I am an I, an eye for an eye in
the sky. Sky is up high." The nurse should document the client's statement as which of the
following speech alterations?
a) Echolalia
b) Word salad
c) Neologism
d) Clang association
Answer: d)
Rationale:
Clang association is a speech pattern characterized by the association of words based on sound
rather than meaning. In this statement, the client's words are linked by sound (e.g., spy, I, sky)
rather than logical meaning.
An older adult client is brought to the mental health clinic by her daughter. The daughter reports
that her mother is not eating and seems uninterested in routine activities. The daughter states,
"I'm so worried that my mother is depressed." Which of the following responses should the nurse
make?
a) Everyone gets depressed from time to time.
b) You shouldn't worry about this because depressive disorder is easily treated.
c) Older adults are usually diagnosed with depressive disorder as they age.
d) Tell me the reasons you think your mother is depressed.
Answer: d)
Rationale:
Asking the daughter to elaborate on her concerns about her mother's depression allows the nurse
to gather more information and assess the situation more effectively. It also demonstrates
empathy and encourages open communication.

A nurse is planning care for an adolescent who has autism spectrum disorder. Which of the
following outcomes should the nurse include in the plan of care?
a) Meets own needs without manipulating others.
b) Initiates social interactions with caregivers.
c) Changes behavior as a result of peer pressure.
d) Acknowledges his delusions are not real.
Answer: b)
Rationale:
Initiating social interactions with caregivers is a realistic and achievable outcome for an
adolescent with autism spectrum disorder. It promotes social skills development and enhances
the quality of interactions with others.
A nurse is providing behavior therapy for a client who has obsessive-compulsive disorder. The
client repeatedly checks that the doors are locked at night. Which of the following instructions
should the nurse give the client when using the thought stopping technique?
a) Snap a rubber band on your wrist when you think about checking the locks.
b) Ask a family member to check the locks for you at night.
c) Focus on abdominal breathing whenever you go to check the locks.
d) Keep a journal of how often you check the locks each night.
Answer: a)
Rationale:
The thought stopping technique involves interrupting obsessive thoughts with a competing
response, such as snapping a rubber band on the wrist. This technique can help the client break
the cycle of obsessive thoughts and compulsive behaviors.
A nurse is caring for a client who is starting treatment for substance use disorder. Which of the
following actions indicate the nurse is practicing the ethical principle of nonmaleficence?
a) Provide the client with quality care regardless of their ability to pay for treatment.
b) Educating the client about legal rights concerning treatment.
c) Withholding the prescribed medication that is causing adverse effects for the client.
d) Being truthful with the client about the manifestations of withdrawal.

Answer: c)
Rationale:
The principle of nonmaleficence means to do no harm. Withholding medication that is causing
adverse effects for the client aligns with this principle as it prevents harm to the client.
A nurse in a group home facility is caring for a client who is developmentally disabled. The
client has been stealing belongings from other clients. Which of the following techniques should
the nurse use?
a) Crisis intervention to decrease anxiety.
b) Aversion therapy to provide distraction.
c) Positive reinforcement to increase desired behavior.
d) Systematic desensitization to extinguish the behavior.
Answer: c)
Rationale:
Positive reinforcement involves rewarding desired behaviors to increase the likelihood of their
recurrence. In this case, using positive reinforcement can help decrease the client's stealing
behavior.
A nurse is caring for a client who is experiencing a panic attack. Which of the following actions
should the nurse take?
a) Ask the client to discuss precipitating events.
b) Speaks to the client in a high-pitched voice.
c) Place the client in seclusion.
d) Have the client breathe into a paper bag.
Answer: d)
Rationale:
Breathing into a paper bag can help reduce hyperventilation and decrease symptoms of a panic
attack by increasing carbon dioxide levels in the blood. This can help alleviate symptoms such as
dizziness and tingling.

The nurse is caring for a client following a physical assault. The client states "I don't remember
what happened to me." The nurse should recognize that the client is using which of the following
defense mechanisms?
a) Repression.
b) Displacement.
c) Rationalization.
d) Denial.
Answer: a)
Rationale:
Repression is a defense mechanism that involves blocking out memories or thoughts that are
distressing. In this case, the client's inability to remember the assault indicates the use of
repression.
A nurse is caring for a client who has anorexia nervosa. Which of the following findings require
immediate intervention by the nurse?
a) +2 edema of the lower extremities.
b) BUN 21 mg/dL.
c) Lanugo covering the body.
d) Blood pH 7.60.
Answer: d)
Rationale:
A blood pH of 7.60 indicates alkalosis, which can be life-threatening. Immediate intervention is
required to correct the pH imbalance and prevent further complications.
A nurse is caring for a client in a mental health facility. The client is agitated and threatens to
harm herself and others. Which of the following is the priority intervention?
a) Place the client in restraints
b) Administer an anti-anxiety medication to the client
c) Put the client in seclusion
d) Set limits on the client's behavior
Answer: d)

Rationale:
Setting limits on the client's behavior is the priority intervention in this situation. It is important
to establish boundaries to ensure the safety of the client and others while also maintaining a
therapeutic environment.
Dosage Calculation Question.
Answer: dosage calc
Rationale:
Calculations are important in nursing:
1. Patient Safety: Accurate dosage calculations are essential to ensure that patients receive the
correct amount of medication, which is crucial for their safety and well-being.
2. Medication Effectiveness: Proper dosing is necessary for medications to be effective in
treating the patient's condition. Incorrect dosages can lead to treatment failure.
3. Prevention of Adverse Effects: Overdosing or underdosing can result in adverse effects or
complications. Accurate calculations help prevent these risks.
4. Legal and Ethical Considerations: Nurses have a legal and ethical responsibility to administer
medications safely and accurately. Proper dosage calculations are part of fulfilling this
responsibility.
5. Professional Competency: Competence in dosage calculations is a fundamental skill for
nurses, demonstrating their ability to provide safe and effective patient care.
Overall, dosage calculations are critical for ensuring the safe and effective administration of
medications in nursing practice.
A nurse is caring for a client who was involuntarily committed and is scheduled to receive
electroconvulsive therapy (ECT). The client refuses the treatment and will not discuss why with
the health care team. Which of the following actions should the nurse take?
a) Ask the client's family to encourage the client to receive ECT
b) Inform the client that ECT does not require consent.
c) Document the client's refusal of the treatment in the medical record.
d) Tell the client he cannot refuse the treatment because he was involuntarily committed.
Answer: c)

Rationale:
It is important to respect the client's right to refuse treatment, even if they are involuntarily
committed. The nurse should document the client's refusal in the medical record to ensure that
this decision is acknowledged and communicated to the healthcare team.
A nurse in the emergency department is caring for a client who reports feeling sad, worthless,
and hopeless 9 months after the death of her son. Which of the following actions should the
nurse take first?
a) Request a mental health consult for the client.
b) Ask the client if she has thought about harming herself.
c) Encourage the client to attend a grief support group.
d) Discuss the client's coping skills.
Answer: d)
Rationale:
The first step in caring for a client experiencing grief and depression is to assess their coping
skills. This information will help the nurse determine the most appropriate interventions and
support for the client.
A nurse is caring for a client who has borderline personality disorder and has been engaging in
self-mutilation. The nurse should encourage the client to participate in which of the following
groups?
a) Dual diagnosis treatment group
b) Dialectical treatment group
c) Desensitization therapy
d) Co-dependents support group.
Answer: b)
Rationale:
Dialectical behavior therapy (DBT) is a type of therapy that is highly effective in treating
borderline personality disorder. It focuses on teaching skills to manage emotions, improve
relationships, and reduce self-destructive behaviors like self-mutilation.

The nurse is reviewing the medication administration record of a client who has schizophrenia.
The nurse should plan to initiate the Abnormal Involuntary Movement Scale to monitor for
adverse effects of which of the following medications?
a) Amantadine
b) Diphenhydramine
c) Benztropine
d) Haloperidol
Answer: d)
Rationale:
Haloperidol is an antipsychotic medication commonly used to treat schizophrenia. It can cause
extrapyramidal symptoms, including tardive dyskinesia. The Abnormal Involuntary Movement
Scale (AIMS) is used to monitor for these adverse effects.
A nurse is counseling a client following the death of a client's partner 8 months ago. Which of the
following client statements indicates maladaptive grieving?
a) "I am so sorry for the times I was angry with my partner."
b) "I find myself thinking about my partner often."
c) "I still don't feel up to returning to work."
d) "I like looking at his personal items in the closet."
Answer: c)
Rationale:
Maladaptive grieving involves prolonged and intense symptoms of grief that interfere with daily
functioning. Not feeling up to returning to work after 8 months may indicate maladaptive
grieving.
A nurse is caring for a client who has borderline personality disorder. Which of the following
outcomes should the nurse include in the treatment plan?
a) The client will report a decrease in hallucinations.
b) The client will communicate needs.
c) The client will verbalize improved mood.
d) The client will attend to personal hygiene.

Answer: c)
Rationale:
Borderline personality disorder is characterized by unstable mood, behavior, and relationships.
Improving mood stability is an important treatment goal.
A nurse is caring for a client who is prescribed massage therapy to treat panic disorder. The client
states "I can't stand to be touched by another person." Which of the following responses should
the nurse make?
a) "Why don't you like to be touched by others?"
b) "Don't worry about it. Your anxiety will lessen once the massage begins."
c) "I will tell your provider you would like a treatment other than a massage."
d) "I will request that the massage therapist wear gloves during your treatment."
Answer: c)
Rationale:
It is important to respect the client's preferences and comfort level. Offering alternative
treatments that do not involve touch is appropriate in this situation.
A nurse is creating a plan of care for a client who has major depressive disorder. Which of the
following interventions should the nurse include in the plan?
a) Encourage physical activity for the client during the day
b) Discourage the client from expressing feelings of anger
c) Keep a bright light on in the client's room at night.
d) Identify and schedule alternative group activities for the client.
Answer: a)
Rationale:
Physical activity has been shown to be beneficial in managing depression by improving mood
and reducing symptoms. Encouraging the client to engage in physical activity can be an effective
intervention.

A nurse is providing counseling for a family that consists of two parents and their two adolescent
children. Which of the following family members should the nurse identify as acting in the role
as the monopolizer?
a) The mother who expresses hostility toward her spouse.
b) The adolescent son who refuses to share personal feelings.
c) The father who intervenes whenever the siblings argue.
d) The adolescent daughter who attempts to dominate the conversation.
Answer: d)
Rationale:
In family dynamics, a monopolizer is someone who attempts to dominate conversations or
interactions, often by speaking excessively or interrupting others. The adolescent daughter fits
this description by attempting to dominate the conversation.
A nurse is developing a teaching plan for the family of an older adult client who is to receive
transcranial magnetic stimulation. Which of the following information should the nurse include
in the teaching plan?
a) The client might have a headache after treatment.
b) The client will experience seizure during treatment.
c) The client will require intubation after treatment.
d) The client is at risk for aspiration during treatment.
Answer: a)
Rationale:
Transcranial magnetic stimulation (TMS) is a non-invasive procedure used to treat depression.
Headache is a common side effect of TMS and should be included in the teaching plan.
A nurse is providing teaching about disulfiram to a client who has a history of alcohol use.
Which of the following instructions should the nurse include in the teaching? (Select all that
apply)
a) "You will need to take the medication once daily"
b) "You will receive treatment in an inpatient setting"
c) "You should avoid using mouthwash that contains alcohol"

d) "You should avoid drinking carbonated beverages while taking the medication"
e) "You can expect to develop a physical dependence on the medication"
Answer: a), c)
Rationale:
Disulfiram is a medication used to treat alcohol use disorder by creating an unpleasant reaction
when alcohol is consumed. It is usually taken once daily, and individuals taking disulfiram
should avoid alcohol-containing products, including mouthwash.
A nurse is caring for a client who is in the manic phase of bipolar disorder. Which of the
following actions should the nurse take?
a) Avoid power struggles by remaining neutral
b) Allow the client to set limits for his behavior
c) Provide in-depth explanation of nursing expectations
d) Encourage the client to participate in group activities
Answer: a)
Rationale:
During the manic phase of bipolar disorder, clients may exhibit high energy levels and be prone
to impulsivity. It is important for the nurse to remain neutral to avoid escalating behaviors and to
maintain a therapeutic relationship.
A nurse is assessing a young adult female client for schizophrenia. Which of the following
findings should the nurse identify as a risk factor for this condition?
a) Environmental stress
b) Gender
c) Depression
d) Birth order
Answer: d)
Rationale:
Birth order has been identified as a potential risk factor for schizophrenia, with some studies
suggesting that individuals who are first-born or born later in the birth order may have a higher
risk.

A nurse is providing discharge teaching about manifestations of relapse to the family of a client
who has schizophrenia. Which of the following information should the nurse include in the
teaching?
a) The client exhibits an inflated sense of self
b) The client develops an inability to concentrate
c) The client increases participation in social activities
d) The client begins sleeping more than usual
Answer: b)
Rationale:
An inability to concentrate can be a manifestation of relapse in schizophrenia. Other signs of
relapse may include changes in sleep patterns, social withdrawal, and worsening of psychotic
symptoms.
A nurse is assessing a client who is restless and constantly mutters to himself. Which of the
following findings should lead the nurse to suspect delirium?
a) The client is unable to recognize objects.
b) The client manifestations developed suddenly
c) The client has a flat affect
d) The client's speech is slow and repetitious
Answer: b)
Rationale:
Delirium is characterized by a rapid onset of confusion and changes in cognition. The sudden
development of symptoms is a key indicator of delirium, distinguishing it from other mental
health conditions.
A nurse is caring for a client in an inpatient mental health facility. The client tells the nurse that
the government is reading her mail. Which of the following responses should the nurse make?
a) "You know that's not true, because it is against the law for others to read your mail"
b) "All of your letters come sealed, so that seems unlikely"
c) "It must be frightening to think that someone is reading your mail"

d) "Why do you think the government wants to read your mail?"
Answer: c)
Rationale:
This response acknowledges the client's feelings without confirming or denying the delusional
belief. It demonstrates empathy and helps build rapport with the client.
A nurse is assessing a client who has neuroleptic malignant syndrome. Which of the following
clinical findings should the nurse expect?
a) Heart rate 48 min
b) Temperature 40 C (104 F)
c) WBC 3,000 mm3
d) Hypotonicity
Answer: b)
Rationale:
Neuroleptic malignant syndrome (NMS) is a rare but serious side effect of antipsychotic
medications. It is characterized by a high fever, typically above 38°C (100.4°F), along with
muscle rigidity, altered mental status, and autonomic dysfunction.
A nurse is reviewing the medical record of a client who is taking clozapine. For which of the
following findings should the nurse withhold the medication and notify the provider? (Click on
the "Exhibit" button for additional information about the client. There are three tabs that contain
separate categories of data.)
a) WBC count
b) Blood glucose level
c) Report of photosensitivity
d) Heart Rate
Answer: a)
Rationale:
Clozapine is an antipsychotic medication known to cause agranulocytosis, a serious condition
characterized by a severe decrease in white blood cell (WBC) count. Therefore, the nurse should

withhold clozapine and notify the provider if the client's WBC count is low to prevent the risk of
infection.
A nurse is caring for a client who has personality disorder and is using transference to cope.
Which of the following behaviors should the nurse expect?
a) Talking negatively about other staff members
b) Expressing frustration regarding unit rules
c) Reacting to the nurse as though she were his mother
d) Refusing to participate in group activities
Answer: c)
Rationale:
Transference occurs when a client unconsciously transfers feelings and attitudes from a person or
situation in the past onto the nurse or another individual in the present. Reacting to the nurse as
though she were his mother is an example of transference.
A nurse in a mental health facility is caring for a newly admitted client. Which of the following
resources should the nurse recommend to help the client adapt to the health care setting?
a) A community meeting
b) A medication group
c) A self-help meeting
d) A symptom-management group
Answer: a)
Rationale:
A community meeting can provide the client with an opportunity to interact with other clients
and staff in a social setting, which can help them adapt to the health care setting.
A nurse is assisting with obtaining informed consent for a client who has been declared legally
incompetent. Which of the following actions should the nurse take?
a) Request that the client's guardian sign the consent
b) Ask the charge nurse to obtain informed consent
c) Contact the facility social worker to obtain the consent

d) Explain implied consent to the client's family
Answer: a)
Rationale:
In cases where a client has been declared legally incompetent, the client's guardian is usually
responsible for providing informed consent on behalf of the client.
A nurse is caring for a client who has cocaine use disorder. Which of the following
manifestations should the nurse expect the client to have during withdrawal?
a) Hand tremors
b) Rapid speech
c) Fatigue
d) Seizures
Answer: c)
Rationale:
During withdrawal from cocaine, clients often experience fatigue, depression, increased appetite,
and vivid dreams.
A nurse is providing teaching about disorder management for a client who has posttraumatic
stress disorder (PTSD). Which of the following statements should the nurse include in the
teaching?
a) "Avoiding stimuli that trigger memories of the trauma can help you overcome your PTSD"
b) "Talking about the traumatic experience is recommended"
c) "Response prevention is an effective treatment for PTSD"
d) "You should try to limit the number of hours that you sleep each day"
Answer: b)
Rationale:
Talking about the traumatic experience, also known as trauma-focused therapy, is a
recommended treatment for PTSD as it can help the client process and cope with the trauma.
A nurse is assessing a client who has bipolar disorder and is taking lamotrigine. Which of the
following findings is the nurse's priority?

a) Thyroid-stimulating hormone (TSH) 4.0 microunits per mL
b) Alanine transaminase (ALT) 20 IU per L
c) Skin rash
d) Epistaxis
Answer: c)
Rationale:
A skin rash is a common side effect of lamotrigine and can be indicative of a serious allergic
reaction known as Stevens-Johnson syndrome. It is important for the nurse to prioritize
assessment and intervention for the skin rash to prevent potential complications.
A nurse is caring for a client who has schizophrenia and displays severe negative symptoms of
the disorder. Which of the following actions should the nurse take?
a) Manage the client's loud, rambling, and incoherent communication patterns
b) Direct the client to perform her own daily hygiene and grooming tasks
c) Assist the client to identify somatic and thought-broadcasting delusions
d) Use medication to decrease the frequency of auditory and visual hallucinations
Answer: b)
Rationale:
Negative symptoms of schizophrenia include deficits in functioning, such as decreased
motivation, social withdrawal, and self-care deficits. Directing the client to perform her own
daily hygiene and grooming tasks promotes independence and self-care.
A nurse is beginning a therapeutic relationship with a client. The nurse should plan to accomplish
which of the following tasks during the working phase?
a) Inform the client about confidentiality rights
b) Establish boundaries between the nurse and the client
c) Set short and long-term objectives for the future
d) Evaluate progress toward predetermined goals
Answer: d)
Rationale:

During the working phase of a therapeutic relationship, the nurse and client work together to
achieve mutually agreed-upon goals. Evaluating progress toward predetermined goals helps to
assess the effectiveness of the interventions and the therapeutic relationship.
A nurse in a mental health facility is making plans for a client's discharge. Which of the
following interdisciplinary team members should the nurse contact to assist the client with
housing placement?
a) Clinical nurse specialist
b) Recreational therapist
c) Occupational therapist
d) Social worker
Answer: d)
Rationale:
Social workers are trained to assist clients with various psychosocial needs, including housing
placement. They can help the client access resources and services in the community to support
their housing needs.
A nurse is caring for a client who reports that he is angry with his partner because she thinks he
is just trying to gain attention. When the nurse attempts to talk to the client, he becomes angry
and tells her to leave. Which of the following defense mechanisms is the client demonstrating?
a) Denial
b) Displacement
c) Compensation
d) Rationalization
Answer: b)
Rationale:
Displacement is a defense mechanism in which a person transfers their feelings from the original
source to a less threatening recipient or object. In this case, the client is displacing his anger from
his partner onto the nurse.

A charge nurse is discussing the care of a client who has a substance use disorder with a staff
nurse. Which of the following statements by the staff nurse should the charge nurse identify as
countertransference?
a) "The client is just like my brother who finally overcame his habit"
b) "The client needs to accept responsibility for his substance use"
c) "The client generally shares his feelings during group therapy sessions"
d) "The client asked me to go on a date with him, but I refuse"
Answer: a)
Rationale:
Countertransference occurs when a healthcare provider projects their own feelings or experiences
onto a client. In this statement, the staff nurse is relating the client to their brother, which may
affect their ability to provide unbiased care.
A nurse is caring for a client who is admitted to a mental health facility after attempting suicide.
Which of the following actions should the nurse take first?
a) Establish a rapport to foster trust
b) Implement continuous one-to-one observation
c) Ask the client to sign a no-suicide contract
d) Encourage the client to participate in group therapy
Answer: b)
Rationale:
The first priority when caring for a client who has attempted suicide is to ensure their safety.
Implementing continuous one-to-one observation can help prevent further attempts and provide
immediate support.
A nurse is providing teaching for a newly licensed nurse about the constructive use of defense
mechanisms. Which of the following examples should the nurse include in the teaching?
a) A student who is upset with her teacher writes a story about an excellent student
b) A school-age child whose mother died 2 years ago talks about her in the present tense
c) A woman who has health concerns postpones a medical appointment until after a vacation
d) An adult who was sexually abused as a child is unable to remember the incident

Answer: a)
Rationale:
Using a defense mechanism in a constructive manner involves finding healthy ways to cope with
stress or conflict. Writing a story about an excellent student allows the student to express their
feelings in a creative and non-harmful way.
A nurse in an inpatient mental health facility is assessing a client who has schizophrenia and is
taking haloperidol. Which of the following clinical findings is the nurse's priority?
a) High fever
b) Urinary hesitancy
c) Insomnia
d) Headache
Answer: a)
Rationale:
A high fever in a client taking haloperidol could indicate a serious side effect known as
neuroleptic malignant syndrome (NMS), which is a medical emergency requiring immediate
intervention.
A nurse is planning care for a client who has a recent diagnosis of antisocial personality disorder.
Which of the following outcomes should the nurse include in the care plan?
a) The client recognizes the importance of others
b) The client conforms to social norms regarding clothing choices
c) The client reduces self-dramatization
d) The client treats others with respect
Answer: a)
Rationale:
Antisocial personality disorder is characterized by a disregard for the rights of others. One of the
goals of treatment is to help the client recognize and respect the importance of others in order to
improve interpersonal relationships.

A nurse is planning care for a newly admitted client who has anorexia nervosa. Which of the
following interventions should the nurse include in the plan?
a) Negotiate with the client how much weight she should gain each week.
b) Decrease the client's daily intake of fiber
c) Weight the client weekly for the first month
d) Notify the client about designated time for meals
Answer: d)
Rationale:
Establishing a regular schedule for meals and snacks can help regulate the client's eating patterns
and promote a sense of structure and control.
A client is fearful of driving and enters a behavioral therapy program to help him overcome his
anxiety. Using systematic desensitization, he is able to drive down a familiar street without
experiencing a panic attack. The nurse should recognize that to continue positive results, the
client should participate in which of the following?
a) Therapist modeling
b) Positive reinforcement
c) Frequent practice
d) Biofeedback
Answer: c)
Rationale:
Systematic desensitization involves gradually exposing the client to the feared object or
situation, allowing them to practice coping strategies and reduce anxiety over time.
A nurse in the emergency department is counseling a client who reports experiencing intimate
partner violence. Which of the following actions should the nurse take?
a) Request permission from the client to take photographs of the injuries
b) Offer to help the client escape from the partner the next time violence occurs
c) Determine what the client did to trigger the violent incident
d) Tell the client that staying with the partner shows a lack of judgment
Answer: a)

Rationale:
Documenting the injuries with photographs can provide objective evidence of the violence,
which may be useful for legal purposes or if the client decides to press charges.
A nurse is caring for a client who has a prescription for phenelzine. The nurse should instruct the
client to avoid which of the following over-the-counter medications?
a) Ranitidine
b) Pseudoephedrine
c) Ibuprofen
d) Docusate sodium
Answer: b)
Rationale:
Pseudoephedrine is a decongestant that can interact with phenelzine, a monoamine oxidase
inhibitor (MAOI), and may lead to a hypertensive crisis. Clients taking MAOIs should avoid
medications that can increase blood pressure.
A nurse is caring for a client who is experiencing active auditory hallucinations. Which of the
following actions should the nurse take?
a) Avoid asking direct questions about the client's experience
b) Convey sympathy for the client's experience
c) Tell her client her experience is not real
d) Focus the client on reality-based activities
Answer: d)
Rationale:
Redirecting the client's focus to reality-based activities can help decrease the intensity of the
hallucinations and provide a sense of grounding.
A nurse is caring for a client who has just returned to the unit after receiving an electroconvulsive
therapy treatment. Which of the following assessments is the nurse's priority?
a) First voiding
b) Short-term memory

c) Presence of gag reflex
d) Return of bowel sounds
Answer: b)
Rationale:
Assessing the client's short-term memory is a priority after electroconvulsive therapy (ECT) as it
can be temporarily impaired following the treatment. Monitoring short-term memory helps
determine the effectiveness of the treatment and the client's recovery from the procedure.
A nurse is talking to a client following a group therapy session. The client tells the nurse that one
of the other clients in the group made an inappropriate comment. Which of the following
responses should the nurse make?
a) "I think you should ignore the comment"
b) "You sound upset about today's session"
c) "Why do you think that he said that to you?"
d) "I agree that the comment was inappropriate"
Answer: b)
Rationale:
Reflecting the client's feelings validates their emotions and can help them process their
experience in group therapy.
A nurse is assessing a client who is experiencing acute alcohol withdrawal. Which of the
following findings should the nurse expect?
a) Hypotension
b) Insomnia
c) Bradycardia
d) Diminished reflexes
Answer: b)
Rationale:
Insomnia is a common symptom of acute alcohol withdrawal, along with anxiety, tremors, and
irritability.

A nurse is teaching a client who has bipolar disorder and a new prescription for lithium
carbonate. Which of the following statements by the client indicates an understanding of the
teaching?
a) "I should drink at least 6 liters of water per day"
b) "I should be on a low-sodium diet"
c) "I will call my doctor if I have diarrhea"
d) "I will see my doctor to check my lithium levels annually"
Answer: c)
Rationale:
Monitoring for and reporting diarrhea is important when taking lithium carbonate, as it can lead
to dehydration and lithium toxicity.
A nurse in an acute care mental health facility is planning discharge care for a client who
sustained a traumatic brain injury. For which of the following needs should the nurse collaborate
with a clinical psychologist?
a) The client needs a prescription for medication to promote nighttime sleep while in the facility
b) The client needs to find a place to live after discharge
c) The client needs to begin a group therapy program prior to discharge
d) The client needs to relearn how to perform skills that require fine motor coordination
Answer: c)
Rationale:
Collaborating with a clinical psychologist is important for planning a group therapy program to
address the client's emotional and psychological needs following a traumatic brain injury.
A nurse is reviewing the laboratory report of a client who is taking carbamazepine for bipolar
disorder. Which of the following laboratory results should the nurse report to the provider?
a) Urine specific gravity 1.029
b) Platelets 90,000 per mm3
c) Urine pH 5.6
d) RBC 4.7 per mm3
Answer: b)

Rationale:
A platelet count of 90,000 per mm3 is below the normal range (150,000 to 450,000 per mm3) and
may indicate thrombocytopenia, which can be a side effect of carbamazepine. The nurse should
report this finding to the provider for further evaluation.
A nurse is teaching the caregiver of a client who has advanced Alzheimer's disease about home
safety. Which of the following statements by the caregiver indicates an understanding of the
teaching?
a) I will ensure the bedroom is dark while he is sleeping at night
b) I will place a sliding bolt lock just above the doorknob
c) I will notify law enforcement within 2 hours if he cannot be found
d) I will give his most recent photo to the police
Answer: c)
Rationale:
Notifying law enforcement within 2 hours if the client cannot be found is important for ensuring
the client's safety and prompt assistance in case of wandering, which is common in individuals
with Alzheimer's disease.
A nurse is teaching a client who has a new prescription for phenelzine to treat depression. The
nurse instructs the client to avoid foods with tyramine to prevent which of the following?
a) Hypertensive crisis
b) Cardiac toxicity
c) Serotonin Syndrome
d) Urinary retention
Answer: a)
Rationale:
Phenelzine is a monoamine oxidase inhibitor (MAOI), and consuming foods high in tyramine
while taking an MAOI can lead to a hypertensive crisis due to the interaction between the
medication and the tyramine-containing foods.

A nurse in an outpatient clinic is assessing a client who has anorexia nervosa. Which of the
following findings indicates the need for hospitalization?
a) Potassium 3.8 mEq per L
b) Heart Rate 56 per min
c) Temperature 35.6C (96.1F)
d) Weight 10% below ideal weight
Answer: c)
Rationale:
A temperature of 35.6C (96.1F) is below the normal range and may indicate hypothermia, which
can be a sign of severe malnutrition in a client with anorexia nervosa and may require
hospitalization for closer monitoring and treatment.
A nurse is obtaining a medical history from a client who is requesting a prescription for
bupropion for smoking cessation. Which of the following assessment findings in the client's
history should the nurse report to the provider?
a) Hepatitis B Infection
b) Hypothyroidism
c) Knee arthroplasty 1 month ago
d) Recent head injury
Answer: d)
Rationale:
A recent head injury may be a contraindication for bupropion use due to the risk of increased
seizures, as bupropion is associated with a higher risk of seizures in individuals with certain
conditions, including recent head trauma. The nurse should report this finding to the provider for
further evaluation.
A nurse is providing crisis intervention for a client who was involved in a violent mass casualty
situation in the community. Which of the following actions should the nurse take during the
initial session with the client?
a) help the client focus on a wide variety of topics regarding the crisis
b) identify the client's usual coping style

c) tell the client that his life will soon return to normal
d) encourage the client to display anger toward the cause of the crisis
Answer: b)
Rationale:
Identifying the client's usual coping style can help the nurse tailor the crisis intervention to meet
the client's specific needs and preferences, facilitating a more effective therapeutic relationship.
A nurse in the community health facility is interviewing a client who recently lost his job. The
client states "I was fired because my boss doesn't like me." Which of the following defense
mechanisms is the client displaying?
a) Rationalization
b) Displacement
c) Dissociation
d) Repression
Answer: a)
Rationale:
Rationalization involves creating logical explanations to justify or explain away unacceptable
behaviors, thoughts, or feelings. In this case, the client is rationalizing the loss of his job by
attributing it to his boss's dislike rather than considering other factors.
A nurse is providing teaching to a client who has depressive disorder and a new prescription for
doxepin. Which of the following instructions should the nurse include in the teaching?
a) sit on the side of the bed for a few minutes before standing
b) decrease the prescribed dose by half when mood improves
c) avoid over the counter magnesium when taking this medication
d) eat a snack before going to bed
Answer: c)
Rationale:
Doxepin is a tricyclic antidepressant that can interact with over-the-counter magnesiumcontaining products, potentially leading to increased side effects or decreased effectiveness of the
medication. Therefore, it is important for the client to avoid such products while taking doxepin.

A nurse is planning care for a client who has dementia. Which of the following interventions
should the nurse include in the plan?
a) give detailed instructions for completion of self-care activities
b) confront the client when he exhibits inappropriate behavior
c) provide finger foods to enhance caloric intake
d) remove clocks from the client's room
Answer: c)
Rationale:
Providing finger foods can enhance caloric intake for clients with dementia who may have
difficulty eating with utensils or sitting through regular meals. Finger foods are easier to manage
and can promote independent eating.
A nurse is planning overall strategies to address problems for a client who has borderline
personality disorder. Which of the following strategies is the priority for the nurse to incorporate
into the plan of care?
a) discuss the appropriate use of assertive behavior with the client
b) encourage the client to attend weekly support group meetings
c) assist the client to maintain awareness of her thoughts and feelings
d) implement measures to prevent intentional self-inflicted injury
Answer: d)
Rationale:
For a client with borderline personality disorder who is at risk for self-harm, implementing
measures to prevent intentional self-inflicted injury is the priority. This may include close
monitoring, removing potentially harmful objects, and developing a safety plan.
A nurse is caring for a school-aged child who has conduct disorder and is being physically
aggressive toward other children in the unit. Which of the following actions should the nurse
take first?
a) Place the child in seclusion
b) Use therapeutic hold technique

c) Apply wrist restraints
d) Administer risperidone
Answer: a)
Rationale:
Placing the child in seclusion is the first action to ensure the safety of both the child and others in
the unit. It allows for immediate containment of the aggressive behavior while also providing a
safe environment for assessment and intervention.
A nurse is caring for a client who has a new diagnosis of bulimia nervosa. Which of the
following diagnosis procedures should the nurse anticipate the provider should describe during
the medical evaluation?
a) Chest x-ray
b) ECG
c) Coagulation studies
d) Liver function test
Answer: b)
Rationale:
An ECG (electrocardiogram) is often included in the medical evaluation of a client with bulimia
nervosa to assess for potential cardiac complications, such as electrolyte imbalances or
arrhythmias, which can result from purging behaviors associated with bulimia nervosa.
A nurse is caring for a client who exhibits excessive compliance, passivity, and self-denial. The
nurse should recognize that these findings are associated with which of the following personality
disorders?
a) Dependent
b) Paranoid
c) Borderline
d) Histrionic
Answer: a)
Rationale:

Excessive compliance, passivity, and self-denial are characteristic features of dependent
personality disorder, which is characterized by a pervasive and excessive need to be taken care of
that leads to submissive and clinging behavior and fears of separation.
A nurse is caring for a client who is involuntarily admitted for major depressive disorder and
refuses to take prescribed antianxiety medication. Which of the following actions should the
nurse take?
a) Inform the client that he does not have the right to refuse medication
b) Administer the medication to the client via IM injection
c) Offer the client the medication at the next scheduled dose time
d) Implement consequences until the client take the medication
Answer: c)
Rationale:
In the case of an involuntarily admitted client refusing medication, the nurse should offer the
medication at the next scheduled dose time and continue to provide education and support to
encourage the client to take the medication voluntarily. Using force or coercion is not
appropriate.
A nurse is caring for a client in the emergency department who states she was beaten and
sexually assault by her partner. After a rapid assessment, which of the following actions should
the nurse plan to take next?
a) Conduct a pregnancy test
b) Requests mental health consultation for the client
c) Provide a trained advocate to stay with the client
d) Offer prophylactic medication to prevent STI's
Answer: d)
Rationale:
After a rapid assessment of a client who has experienced sexual assault, offering prophylactic
medication to prevent sexually transmitted infections (STIs) is an important intervention to
reduce the risk of infection. Other interventions, such as providing emotional support and
advocacy, should also be initiated as appropriate.

A nurse is caring for a client who has major depressive disorder. After discussing the treatment
with his partner, the client verbally agrees to electroconvulsive therapy (ECT) but will not sign
the consent form. Which of the following actions should the nurse take?
a) Request that the client's partner sign the consent form
b) Cancel the scheduled ECT procedure
c) Proceed with the preparation for ECT based on implied consent
d) Inform the client about the risks of refusing the ECT
Answer: b)
Rationale:
Without the client's signature on the consent form, the nurse should cancel the scheduled ECT
procedure to ensure that the client's rights are respected and that the treatment is performed with
proper authorization.
A nurse is caring for a client who reports that he is angry with his partner because she thinks he
is just trying to gain attention. When the nurse attempts to talk to the client, he becomes angry
and tells her to leave. Which of the following defense mechanisms is the client demonstrating?
a) Rationalization
b) Denial
c) Compensation
d) Displacement
Answer: d)
Rationale:
Displacement involves redirecting an emotion from its original source to a substitute target. In
this scenario, the client is displacing his anger from his partner to the nurse.
A nurse is advising an assistive personnel (AP) on the care of a client who has major depressive
disorder. The AP states that he is irritated by the client's depression. Which of the following
statements by the nurse is appropriate?
a) Please don't take what the client said seriously when she is depressed
b) It's important that the client feel safe verbalizing how she is feeling

c) Everybody feels that way about this client so don't worry about it
d) I'll change your assignment to someone who doesn't have depressive disorder
Answer: b)
Rationale:
It's important for the AP to understand the significance of the client's expression of feelings and
to create a supportive environment for the client to feel safe in discussing their emotions.
A nurse is assessing a child in the emergency department. Which of the following findings places
the child at the greatest risk for physical abuse?
a) The child is 10 years old
b) The child is homeschooled
c) The has no siblings
d) The child has cystic fibrosis
Answer: d)
Rationale:
Children with chronic illnesses, such as cystic fibrosis, are at increased risk for physical abuse
due to the stress and challenges associated with caring for a child with a chronic condition.
A nurse is providing behavioral therapy for a client who has obsessive-compulsive disorder. The
client repeatedly checks that the doors are locked at night. Which of the following instructions
should the nurse give the client when using thought stopping technique?
a) Keep a journal of how often you check the locks each night
b) Snap a rubber band on your wrist when you think about checking the locks
c) Ask a family member to check the lock for you at night
d) Focus on abdominal breathing whenever you go to check the locks
Answer: b)
Rationale:
Thought stopping involves interrupting or redirecting unwanted thoughts or behaviors. Using a
rubber band to snap on the wrist serves as a physical interruption to the thought pattern
associated with checking the locks.

A nurse is assessing a client who is experiencing alcohol withdrawal. For which of the following
findings should the nurse anticipate administration of lorazepam?
a) Bradycardia
b) Stupor
c) Afebrile
d) Hypertension
Answer: a)
Rationale:
Lorazepam is commonly used in the treatment of alcohol withdrawal to help manage symptoms
such as agitation, tremors, and autonomic hyperactivity. Bradycardia may indicate a more severe
withdrawal state, and lorazepam can help stabilize vital signs.
A nurse is creating a plan of care for a client who has anorexia nervosa. Which of the following
interventions should the nurse include in the plan?
a) Weigh the client twice per day
b) Prepare the client for electroconvulsive therapy
c) Set a weight gain goal of 2.2 kg (5 lbs) per week
d) Encourage the client to participate in family therapy
Answer: d)
Rationale:
Involving the client in family therapy can address underlying family dynamics that may
contribute to the client's eating disorder. It can also provide support and education for family
members on how to best support the client's recovery.
A nurse is planning care for a 3-year-old child who has autism spectrum disorder. Which of the
following findings should the nurse expect?
a) Readily initiates conversation
b) Enjoys imaginative play
c) Strong relationship with sibling and peers
d) Attachment to objects that spin
Answer: d)

Rationale:
Children with autism spectrum disorder often exhibit repetitive behaviors and a strong
attachment to specific objects or interests. Attachment to objects that spin is a common behavior
seen in children with autism.
A nurse is planning care for a client who has bipolar disorder. The client reports not sleeping for
3 days and is exhibiting a euphoric mood. The nurse should identify which of the following as
the priority intervention?
a) Secure the client's valuable possessions
b) Limit loud noises in the client's environment
c) Encourage the client to participate in structured solitary activities
d) Provide high-calorie snacks to the client
Answer: b)
Rationale:
In this scenario, the client's lack of sleep and euphoric mood may indicate a manic episode, and
managing the environment to limit stimuli and promote rest is a priority. Loud noises can
exacerbate agitation and sleep disturbances in clients experiencing mania.
A nurse is evaluating the medication response of a client who takes naltrexone for the treatment
of alcohol use disorder. The nurse should identify that which of the following is a therapeutic
effect of this medication?
a) Blocks aldehyde dehydrogenase
b) Prevents the anxiety of abstinence
c) Reduces substance craving
d) Decreases the likelihood of seizures
Answer: c)
Rationale:
Naltrexone is an opioid antagonist that helps reduce alcohol craving and relapse in individuals
with alcohol use disorder. It does not prevent the anxiety of abstinence or decrease the likelihood
of seizures associated with alcohol withdrawal.

A nurse in an alcohol treatment facility is caring for a client who states "my job is so stressful
that the only way I can come it is to drink." The nurse should recognize that the client is
displaying which of the following defense mechanisms?
a) Repression
b) Rationalization
c) Introjection
d) Intellectualization
Answer: b)
Rationale:
Rationalization is a defense mechanism where an individual justifies or excuses their behavior or
feelings by providing logical or socially acceptable reasons, even if those reasons are not valid.
In this case, the client is rationalizing their drinking as a way to cope with stress from work.
A nurse is caring for a client who has depression following a recent job loss. Which of the
following questions should the nurse ask to assess the client's personal coping skills?
a) How does this situation affect your life?
b) Do you see your current situation affecting your future?
c) Can you describe how you are currently feeling?
d) How have you dealt with similar situations in the past?
Answer: c)
Rationale:
Asking the client to describe how they are currently feeling can provide insight into their
emotional state and coping mechanisms. Understanding the client's current emotions can help the
nurse assess their coping skills and provide appropriate support.
A school nurse is caring for an adolescent client whose teacher reports changes in school
performance and withdrawal from interaction with classmates. Which of the following
interventions is the nurse's priority at this time?
a) Contact the adolescent's parents
b) Suggest the adolescent join support groups
c) Ask the adolescent if he is considering hurting himself

d) Determine when the adolescent's change in behavior began
Answer: d)
Rationale:
Determining when the adolescent's change in behavior began can help identify potential triggers
or underlying issues. This information is important for developing an appropriate plan of care
and addressing the adolescent's needs.
A nurse is assessing a client who is withdrawing from heroin. Which of the following
manifestations should the nurse expect?
a) Slurred speech
b) Hypotension
c) Bradycardia
d) Hyperthermia
Answer: a)
Rationale:
Heroin withdrawal can cause symptoms such as slurred speech, muscle aches, sweating, and
agitation. Slurred speech is a common symptom associated with central nervous system
depression, which occurs during heroin withdrawal.
A nurse is assessing a client who has histrionic personality disorder. Which of the following
findings should the nurse expect?
a) Lack of remorse
b) Attention seeking
c) Splitting of staff
d) Identity disturbance
Answer: b)
Rationale:
Histrionic personality disorder is characterized by attention-seeking behavior, exaggerated
emotions, and a need for reassurance or approval. Individuals with this disorder often seek to be
the center of attention and may engage in dramatic or seductive behavior to achieve this.

A nurse is providing teaching to the daughter of an older client who has obsessive-compulsive
disorder. Which of the following statements by the daughter indicates an understanding of the
disorder?
a) I will limit my mother's clothing choices when she is getting dressed
b) I will provide my mother with detailed instructions about how to perform self-care
c) I will wake my mother up a couple of times in the night to check on her
d) I will discourage my mother from talking about physical complaints
Answer: a)
Rationale:
Limiting the client's clothing choices can help reduce stress and anxiety related to decisionmaking, which is a common symptom of obsessive-compulsive disorder (OCD).
A nurse in a mental health facility is caring for a client who has borderline personality disorder.
Which of the following should the nurse expect?
a) Self-mutilation
b) Pacing back and forth
c) Preoccupation with details
d) Disorganized speech
Answer: a)
Rationale:
Self-mutilation is a common behavior associated with borderline personality disorder. Clients
may engage in self-harming behaviors as a way to cope with emotional pain or distress.
A nurse is reviewing the laboratory results on an adolescent who has anorexia nervosa. Which of
the following findings should the nurse expect?
a) Blood glucose 100 mg/dL
b) T4 11 mcg/dL
c) Potassium 3.7 mEq/L
d) Hgb 10 g/dL
Answer: d)
Rationale:

Anemia (low hemoglobin) is a common finding in clients with anorexia nervosa due to
inadequate nutrient intake. It can lead to symptoms such as fatigue, weakness, and shortness of
breath.
A nurse is teaching about benztropine to a client who has schizophrenia. Which of the following
statements should the nurse include in the teaching?
a) This medication is given to help with extrapyramidal side effects
b) This medication is given to help with your depression
c) Benztropine helps alleviate your hallucinations
d) Benztropine is used to counteract your tachycardia
Answer: a)
Rationale:
Benztropine is an anticholinergic medication commonly used to treat extrapyramidal side effects
(EPS) caused by antipsychotic medications, such as dystonia, akathisia, and parkinsonism.
A nurse is planning care for a client with acute delirium. Which of the following instructions
should the nurse include in the plan?
a) Reinforce the client's orientation with the calendar
b) Refute the client's perception of visual hallucinations
c) Teach the client assertive techniques
d) Assign the client to a different caregiver each shift
Answer: a)
Rationale:
Reinforcing the client's orientation with the calendar can help maintain their sense of time, place,
and reality, which can be impaired in delirium.
A nurse is creating a plan of care for a client who has major depressive disorder. Which of the
following interventions should the nurse include in the plan?
a) Discouraged client from expressing feelings of anger
b) Identify and schedule alternative group activities for the client
c) Encourage physical activity for the client during the day

d) Keep a bright light on in the client's room at night
Answer: c)
Rationale:
Encouraging physical activity during the day can help improve mood and alleviate symptoms of
depression. Exercise has been shown to release endorphins, which are known as "feel-good"
hormones.
A nurse is caring for a client who has posttraumatic stress disorder related to military service.
Which of the following actions should the nurse take?
a) Encourage the client to suppress feelings of trauma
b) Assign the same staff to care for the client each day
c) Address the client in an authoritative manner
d) Limit the amount of time spent with the client
Answer: b)
Rationale:
Assigning the same staff to care for the client each day can help establish a sense of trust and
continuity, which is important in the care of clients with posttraumatic stress disorder (PTSD).
A nurse is providing teaching for a school-age child and his parents regarding a new prescription
for risperidone. Which of the following statements by the parent indicates an understanding of
the teaching?
a) "I will provide a low sodium diet for my son"
b) "I will make sure my son takes the last dose of the day by 4 PM"
c) "I should expect my son to develop hand tremors"
d) "I should contact my doctor if my son urinates excessively"
Answer: c)
Rationale:
Hand tremors are a potential side effect of risperidone. It is important for parents to be aware of
potential side effects and to report them to the healthcare provider if they occur.

A nurse is caring for a client who has a lithium level of 0.8 mEq/L. Which of the following
actions should the nurse take?
a) Withhold the next dose of lithium
b) Repeat the lithium level test
c) Administer the next dose of lithium
d) Recommend a low sodium diet
Answer: c)
Rationale:
A lithium level of 0.8 mEq/L is within the therapeutic range for treating bipolar disorder. The
nurse should administer the next dose of lithium as prescribed.
A nurse in a community mental health clinic is caring for a group of clients. The nurse should
encourage participation in cognitive-behavioral family therapy in response to which of the
following client statements?
a) "I want to learn how to change the way I react to problems within my family"
b) "I want to understand why my past experiences are affecting my family relationships"
c) "I want to improve my family's understanding of each other's boundaries"
d) "I want each of my family members to be more aware of each other's feelings"
Answer: d)
Rationale:
Cognitive-behavioral family therapy focuses on improving communication and understanding
among family members. Encouraging each family member to be more aware of each other's
feelings can help improve family dynamics and relationships.
A nurse is providing teaching to the caregiver of an older adult client who has Alzheimer's
disease and is being cared for at home. The client wanders at night and has a history of previous
falls. Which of the following instructions should the nurse include in the teaching? (Select all)
a) Position the mattress on the floor
b) Install sensor devices on outside doors
c) Encourage physical activity prior to bedtime
d) Put locks at the top of doors

e) Place the client in a reclining chair
Answer: a), b), d)
Rationale:
• Positioning the mattress on the floor can reduce the risk of injury if the client falls out of bed.
• Installing sensor devices on outside doors can alert the caregiver if the client attempts to
wander outside.
• Putting locks at the top of doors can prevent the client from wandering outside during the night.
A nurse is reviewing laboratory values for a client who has bipolar disorder and a prescription for
lithium. The nurse should identify that which of the following laboratory results places the client
at risk for lithium toxicity?
a) Calcium 9.0 mg/dL
b) Sodium 130 mEq/L
c) Chloride 98 mEq/L
d) Potassium 5.0 mEq/L
Answer: b)
Rationale:
A low sodium level (hyponatremia) can increase the risk of lithium toxicity because lithium
competes with sodium for renal reabsorption, so lower sodium levels can lead to increased
lithium reabsorption.
A nurse is assisting with obtaining informed consent from a client who has been declared legally
incompetent. Which of the following actions should the nurse take?
a) Contact the facility social worker to obtain the consent
b) Explain implied consent to the client's family
c) Request that the client's guardian sign the consent
d) Ask the charge nurse to obtain an informed consent
Answer: c)
Rationale:
When a client has been declared legally incompetent, the consent must be obtained from the
client's legal guardian.

A nurse is giving a presentation about intimate partner abuse for a community group. Which of
the following statements by a group member indicates an understanding of the teaching?
a) Survivors of abuse often feel guilty
b) Abusers often have high self-esteem
c) The honeymoon stage of violence usually gets longer over time
d) As abuse continues, victims become more determined to be independent
Answer: a)
Rationale:
Survivors of abuse often experience feelings of guilt, which can be a result of manipulation and
control tactics used by the abuser.
A nurse is planning care for a client who has experienced intimate partner abuse. The nurse
should identify which of the following outcomes as the priority?
a) The client joins a support group
b) The client identifies techniques to reduce her stress
c) The client develops a safety plan
d) The client identifies support systems
Answer: c)
Rationale:
Developing a safety plan is the priority for a client who has experienced intimate partner abuse to
ensure her safety in future situations.
A nurse is developing a behavioral contract with a client who has antisocial personality disorder.
Which of the following client goals should the nurse include in the contract?
a) Use projection during group therapy
b) Increase self-esteem
c) Use bargaining skills for behavioral consequences
d) Decrease the number of verbal outbursts
Answer: d)
Rationale:

Clients with antisocial personality disorder often have difficulty controlling their impulses and
may exhibit verbal outbursts. Decreasing the number of verbal outbursts is a specific and
measurable goal that can be included in a behavioral contract.
A nurse is caring for a client who has schizophrenia and takes clozapine. Which of the following
findings is a priority for the nurse to report to the provider?
a) Nausea
b) Random blood glucose 130 mg/dL
c) Heart rate 104 per minute
d) Sore throat
Answer: d)
Rationale:
Clozapine can cause agranulocytosis, which is a potentially life-threatening condition
characterized by a severe reduction in white blood cell count. A sore throat can be an early sign
of agranulocytosis and should be reported immediately to the provider.
A nurse is counseling an adult client whose parent just died. The client states, "My son is 4, and I
don't know how he'll react when he finds out that grandpa died." The nurse should inform the
client that the preschool-age child commonly has which of the following concepts of death?
a) Death is not permanent and the loved one may come back to life
b) Death is contagious and can cause other people he loves to die
c) Death creates an interest in the physical aspects of dying
d) Death is a part of life that eventually happens to everyone
Answer: a)
Rationale:
Preschool-age children often do not have a full understanding of death and may believe that it is
not permanent, leading to the idea that the loved one may come back to life.
A nurse is reviewing the medical records for clients. Which of the following findings should the
nurse identify as a risk factor for violent behavior?
a) Schizoid personality disorder

b) Alcohol intoxication
c) Dysthymic disorder
d) Long-term isolation
Answer: b)
Rationale:
Alcohol intoxication is a known risk factor for violent behavior as it can impair judgment and
increase impulsivity.
A nurse in a provider's office is assessing a school-age child who has a spiral fracture. The parent
of the child provides different accounts for the cause of the injury. Which of the following
actions should the nurse take first?
a) Request that the parent leaves the room while you interview the child
b) Report suspected abuse to child protective services
c) Ask the child how the injury occurred
d) Determine the immediate safety needs of the child
Answer: d)
Rationale:
The priority is to ensure the immediate safety of the child. Determining the immediate safety
needs of the child, such as ensuring the child is not in a dangerous environment, should be the
first action.
An older adult client is brought to the mental clinic by her daughter. The daughter reports that
her mother is not eating and seems uninterested in routine activities. The daughter states, "I'm so
worried that my mother is depressed." Which of the following responses should the nurse make?
a) Older adults are usually diagnosed with depressive disorder as they age
b) Everyone gets depressed from time to time
c) You shouldn't worry about this because depressive disorder is easily treated
d) Tell me the reasons you think your mother is depressed
Answer: d)
Rationale:

Asking the daughter to elaborate on her concerns can help the nurse gather more information
about the situation, which is essential for assessment and planning appropriate care.
A nurse in a mental health facility is caring for a client. Which of the following actions should
the nurse take during the working phase of the nurse-client relationship?
a) Summarize goals and objectives
b) Address confidentiality
c) Promote problem-solving skills
d) Establish a participation contract
Answer: c)
Rationale:
Promoting problem-solving skills is a key aspect of the working phase, where the nurse and
client work together to explore issues and develop coping strategies.
A nurse is caring for a client who suddenly directs profanities at her, then abruptly hangs his head
and says, "please forgive me, I'm not sure what came over me I don't know why said those
things." The nurse interprets this behavior as which of the following?
a) Emotional lability
b) Confabulation
c) Flight of ideas
d) Neologism
Answer: a)
Rationale:
Emotional lability refers to rapid and unpredictable changes in emotions, which can manifest as
sudden outbursts followed by remorse or confusion.
A nurse is providing teaching for the family of a client who has dementia. Which of the
following should the nurse include in the teaching as a contributing factor for this disorder?
a) Hypotension
b) Alcohol use disorder
c) Dehydration

d) Change in environment
Answer: b)
Rationale:
Alcohol use disorder is a known contributing factor to the development of dementia, particularly
in older adults.
A nurse is caring for a client who has been taking valproic acid. Which of the following is an
expected outcome of the medication?
a) The client reports improved short-term memory
b) The client has a decreased euphoric mood
c) The client reports absence of auditory hallucinations
d) The client has decreased anxiety
Answer: d)
Rationale:
Valproic acid is often used to treat anxiety disorders, so a decrease in anxiety would be an
expected outcome of the medication.
A nurse is teaching a client who has major depressive disorder about electroconvulsive therapy.
Which of the following information should the nurse include?
a) This therapy works as a cure for major depressive disorders
b) You will be awake and alert during the procedure
c) You might experience confusion for a few hours after treatment
d) This therapy will stimulate the vagus nerve to improve your mood
Answer: c)
Rationale:
Option c is correct because confusion is a common side effect of electroconvulsive therapy
(ECT) that typically resolves within a few hours after treatment. Options a, b, and d are incorrect.
ECT is not a cure for major depressive disorder but rather a treatment option. Patients are usually
under general anesthesia during the procedure, so they are not awake and alert. ECT does not
stimulate the vagus nerve; instead, it induces a controlled seizure to treat severe depression.

A nurse in the emergency department is assessing a client who has major depressive disorder.
Which of the following actions should the nurse take?
a) Ask the client if she has eaten foods containing tyramine
b) Give regular insulin subcutaneously to the client
c) Prepare the client for electroconvulsive therapy
d) Administer dantrolene IV bolus to the client
Answer: a)
Rationale:
Option a is correct because foods containing tyramine, such as aged cheese and certain meats,
can interact with monoamine oxidase inhibitors (MAOIs), a common class of medications used
to treat depression, potentially leading to a hypertensive crisis. Options b, c, and d are incorrect
because they are not appropriate actions for assessing or managing major depressive disorder.
A nurse is reviewing the laboratory report of a client who is taking carbamazepine for bipolar
disorder. Which of the following laboratory results should the nurse report to the provider?
a) Urine specific gravity 1.029
b) Platelets 90,000/mm3
c) Urine pH 5.6
d) RBC 4.7/mm3
Answer: b)
Rationale:
Option b is correct because a platelet count of 90,000/mm3 is below the normal range (150,000 to
400,000/mm3) and may indicate thrombocytopenia, a potential side effect of carbamazepine.
Options a, c, and d are within normal ranges and do not require reporting.
A nurse is caring for a client who has schizophrenia and started taking clozapine two months ago.
Which of the following laboratory results should the nurse report to the provider?
a) WBC 3,000/mm3
b) Potassium 4.2 mEq/L
c) Hgb 16 g/dL
d) Platelets 300,000/mm3

Answer: a)
Rationale:
Option a is correct because a white blood cell (WBC) count of 3,000/mm 3 is below the normal
range (4,500 to 11,000/mm3) and may indicate agranulocytosis, a potentially life-threatening side
effect of clozapine. Options b, c, and d are within normal ranges and do not require reporting.
A nurse is assessing the boundaries of a client's family. One of the family members says to the
client, "I know exactly what you're thinking right now." The nurse should recognize that the
following family boundaries?
a) Rigid
b) Inconsistent
c) Enmeshed
d) Clear
Answer: d)
Rationale:
Option d is correct because clear boundaries are characterized by distinct roles and expectations
within the family, and members have a clear sense of individuality and privacy. In this scenario,
the family member's statement indicates a normal level of understanding within the family.
Options a, b, and c are incorrect because they describe dysfunctional family boundary patterns.
A nurse is assessing a client who requires bupropion for smoking cessation. Which of the
following findings in the client's history should the nurse recognize as a contraindication for
taking this medication?
a) Seizures
b) Anemia
c) Migraines
d) Asthma
Answer: a)
Rationale:

Option a is correct because bupropion is contraindicated in clients with a history of seizures due
to the increased risk of seizure activity associated with this medication. Options b, c, and d are
not contraindications for taking bupropion.
A nurse is caring for a client with Alzheimer's disease. Which of the following actions should the
nurse take?
a) Seat the client at a dining table with six or more residents
b) Provide the client with several choices for meal selection
c) Give complete directions before starting client care
d) Use symbols to assist the client in locating rooms
Answer: d)
Rationale:
Option d is correct because clients with Alzheimer's disease often have difficulty with spatial
orientation and may benefit from visual cues, such as symbols, to help them navigate their
environment. Options a, b, and c are not specific actions for managing clients with Alzheimer's
disease.
A nurse is assessing a newly admitted client who has schizophrenia and takes thioridazine.
Which of the following findings should the nurse document as an adverse effect of this
medication?
a) Anhedonia
b) Waxy flexibility
c) Contractions of the jaw
d) Incongruent affect
Answer: b)
Rationale:
Option b is correct because waxy flexibility is a side effect of thioridazine, a typical
antipsychotic medication used to treat schizophrenia. Options a, c, and d are not typically
associated with thioridazine.

A nurse in an inpatient mental health facility is assessing a client who has schizophrenia and is
taking haloperidol. Which of the following clinical findings is the nurse's priority?
a) High fever
b) Insomnia
c) Urinary hesitancy
d) Headache
Answer: a)
Rationale:
Option a is correct because a high fever can be a sign of neuroleptic malignant syndrome (NMS),
a potentially life-threatening side effect of antipsychotic medications such as haloperidol.
Options b, c, and d are not indicative of NMS.
A nurse is speaking with a client. Which of the following responses by the nurse demonstrates
the communication technique of reflection?
a) "I would like to sit with you for a while"
b) "You feel upset when this happens?"
c) "Let's work together to try to solve your problem"
d) "Can you tell me what is happening now?"
Answer: b)
Rationale:
Option b is correct because reflection involves restating the client's feelings or thoughts to show
empathy and understanding. Options a, c, and d do not demonstrate reflection but are still
examples of therapeutic communication techniques.
A nurse is leading a grief support group for bereaved clients. Which of the following client
statements should the nurse report to the provider as an indication of clinical depression?
a) "I don't know how I could cope if I didn't have my family's support"
b) "It'll be a long time before I'm happy again"
c) "I don't feel anything but numbness anymore"
d) "I feel like I'm angry at the whole world right now"
Answer: c)

Rationale:
Feeling numbness can be a sign of clinical depression, as it may indicate emotional detachment
or a lack of ability to feel pleasure or other emotions.
A nurse is preparing to administer chlorpromazine hydrochloride 25 mg PO to an older adult
client. Available is chlorpromazine hydrochloride syrup 10 mg 5 mL. How many mL should the
nurse administer? (Round to nearest tenth)
Answer: 12.5 mL
Rationale:
To determine the amount of syrup to administer, use the formula: desired dose / stock dose =
volume to administer. In this case, 25 mg / 10 mg = 2.5 mL. Round to the nearest tenth, which is
2.5 mL.
A nurse is teaching the parent of a school-age child who has ADHD and a prescription for
atomoxetine 40 mg daily. Which of the following information should the nurse include in the
teaching?
a) Expect the child to gain weight while taking this medication
b) Crush the medication and mix it with 120 mL (4 oz) of juice
c) Therapeutic effects will occur within 24 hr of starting treatment
d) Administer the medication before the child goes to school in the morning
Answer: d)
Rationale:
Atomoxetine is usually administered once daily in the morning to minimize interference with
sleep. Administering the medication before school helps provide symptom control during school
hours.
A nurse is caring for a client who has bipolar disorder and is experiencing a manic episode.
Which of the following actions should the nurse take?
a) Place the client in a group therapy session
b) Rotate staff members who work with the client
c) Encourage the client to participate in physical activities

d) Distract the client with increased environmental stimuli
Answer: c)
Rationale:
Encouraging the client to participate in physical activities can help manage the excess energy and
agitation often seen in manic episodes of bipolar disorder.
A nurse in a mental facility is assessing a client for suicide risk factors using the SAD PERSONS
scale. Which of the following findings indicates a risk for suicide?
a) The client is married
b) The client is female
c) The client is 50 years of age
d) The client has diabetes mellitus
Answer: d)
Rationale:
The SAD PERSONS scale assesses various risk factors for suicide. Having a chronic illness such
as diabetes mellitus is considered a risk factor, as it can contribute to feelings of hopelessness or
despair.
A nurse is performing a mental status examination for a client who has schizophrenia. The nurse
should recognize that which of the following actions requires the client to think abstractly?
a) Explain what to do if he misses the bus
b) Determine the meaning of a proverb
c) Name the last three presidents of the United States of America
d) Count by adding sevens consecutively
Answer: b)
Rationale:
Determining the meaning of a proverb requires abstract thinking, as the client needs to
understand the metaphorical or symbolic meaning behind the words.
A nurse is developing a plan of care for a school-age child who has ADHD. Which of the
following interventions should the nurse include in the plan?

a) Administer olanzapine
b) Institute consequences for deliberate behaviors
c) Provide a stimulating environment
d) Encourage thought-stopping techniques
Answer: c)
Rationale:
Providing a stimulating environment can help manage ADHD symptoms by reducing boredom
and increasing engagement, which can help improve focus and attention.
A nurse in a mental health facility is making plans for a client's discharge. Which of the
following interdisciplinary team members should the nurse contact to assist the client with
housing placement?
a) Clinical nurse specialist
b) Recreational therapist
c) Social worker
d) Occupational therapist
Answer: c)
Rationale:
A social worker is best suited to assist with housing placement, as they have expertise in
navigating community resources and providing support for clients' social and environmental
needs.
A nurse is providing crisis intervention for a client who was involved in a violent mass casualty
situation in the community. Which of the following actions should the nurse take during the
initial session with the client?
a) Encourage the client to display anger toward the cause of the crisis
b) Tell the client that his life will soon return to normal
c) Identify the client's usual coping style
d) Help the client focus on a wide variety of topics regarding the crisis
Answer: c)
Rationale:

Identifying the client's usual coping style can help the nurse tailor the crisis intervention to best
support the client's needs and preferences.
A nurse is planning to conduct a support group for adolescents who have cancer. Which of the
following actions should the nurse include during the orientation phase?
a) Manage conflict within the group
b) Establish rapport with group members
c) Encourage the use of problem-solving skills
d) Maintain the group's focus on identified issues
Answer: b)
Rationale:
Establishing rapport with group members during the orientation phase is important to build trust
and create a supportive environment for the group discussions that will follow.
A nurse is assessing a client who recently started antidepressant therapy for the treatment of
major depressive disorder. Which of the following findings indicates the client is at an increased
risk for suicide?
a) Increased energy
b) Hypersomnia
c) Unkempt appearance
d) Psychomotor retardation
Answer: a)
Rationale:
Increased energy can sometimes be a warning sign of suicidal ideation, as the client may have
the energy to act on suicidal thoughts. Similarly, an unkempt appearance may indicate a lack of
interest in personal hygiene, which can be a sign of worsening depression and potential suicidal
risk.
A nurse in a rehabilitation unit is caring for a client who has a traumatic brain injury. To which of
the following members of the client's interprofessional team should the nurse refer the client in
order to help him relearn how to use eating utensils?

a) Neuropsychiatrist
b) Occupational therapist
c) Physical therapist
d) Social worker
Answer: b)
Rationale:
Occupational therapists specialize in helping individuals relearn activities of daily living,
including how to use eating utensils, after injuries such as traumatic brain injury.
A nurse is caring for a group of clients on a mental health unit. For which of the following clients
is the nurse mandated to report to the appropriate agency?
a) A client who reports that she took $20 from the cash register where she works
b) A client who reports that her partner ties their child to a bed as punishment
c) A client who reports that he enjoys smoking marijuana on weekends
d) A client who reports lying to his provider about having suicidal ideation
Answer: b)
Rationale:
Tying a child to a bed as punishment is a form of abuse and must be reported to the appropriate
authorities.
A nurse is obtaining a medical history from a client who is requesting a prescription for
bupropion for smoking cessation. Which of the following assessment findings in the client's
history should the nurse report to the provider?
a) Recent head injury
b) Hepatitis B infection
c) Hypothyroidism
d) Knee arthroplasty 1 month ago
Answer: a)
Rationale:
Bupropion can lower the seizure threshold, so a recent head injury is a significant risk factor that
should be reported to the provider.

A charge nurse is orienting a newly licensed nurse and observes the newly licensed nurse
imitating her behaviors. The nurse should recognize this behavior as which of the following
defense mechanisms?
a) Suppression
b) Reaction formation
c) Identification
d) Compensation
Answer: c)
Rationale:
Identification is a defense mechanism in which an individual adopts the behaviors or
characteristics of another person, often as a way to cope with anxiety or uncertainty in a new
role.
A nurse is reviewing the medication administration record of a client who has major depressive
disorder and a new prescription for selegiline. The nurse should recognize that which of the
following client medications is contraindicated when taken with selegiline?
a) Warfarin
b) Fluoxetine
c) Calcium carbonate
d) Acetaminophen
Answer: b)
Rationale:
Fluoxetine is contraindicated with selegiline due to the risk of serotonin syndrome, a potentially
life-threatening condition characterized by symptoms such as confusion, hallucinations, rapid
heart rate, and high blood pressure.
A nurse in a long-term care facility is assessing a client who has dementia. Which of the
following findings should the nurse identify as a risk for this client?
a) Outside doors have locks
b) The bed is in the low position
c) Hallways are long distances

d) The room has an area rug
Answer: d)
Rationale:
An area rug can be a tripping hazard for a client with dementia, increasing the risk of falls.
A nurse is providing behavioral therapy for a client who has obsessive-compulsive disorder. The
client repeatedly checks that the doors are locked at night. Which of the following instructions
should the nurse give the client when using thought stopping technique?
a) "Ask a family member to check the locks for you at night"
b) "Keep a journal of how often you check the locks each night"
c) "Snap a rubber band on your wrist when you think about checking the locks"
d) "Focus on abdominal breathing whenever you go to check the locks"
Answer: c)
Rationale:
Thought stopping techniques, such as snapping a rubber band on the wrist, can help interrupt
obsessive thoughts and behaviors associated with obsessive-compulsive disorder.
A nurse in an inpatient mental health facility is assessing a client who has schizophrenia and is
taking haloperidol. Which of the following clinical findings is the nurse's priority?
a) Insomnia
b) Urinary hesitancy
c) Headache
d) High fever
Answer: d)
Rationale:
A high fever can indicate a potentially serious side effect of haloperidol known as neuroleptic
malignant syndrome, which requires immediate medical attention.
A nurse is caring for a client who has Alzheimer's disease. Which of the following findings
should the nurse expect?
a) Failure to recognize familiar objects

b) Altered level of consciousness
c) Excessive motor activity
d) Rapid mood swings
Answer: a)
Rationale:
Alzheimer's disease often causes difficulty in recognizing familiar objects and people, known as
agnosia, which is a hallmark symptom of the disease.
A nurse in a mental health facility is interviewing a new client. Which of the following outcomes
must occur if the nurse is to establish a therapeutic nurse-client relationship?
a) The nurse is seen as an authority figure
b) A written contract is established to clarify the steps of the treatment plan
c) The nurse maintains confidentiality unless the client's safety is compromised
d) The nurse is seen as a friend
Answer: c)
Rationale:
Maintaining confidentiality is essential in building trust and establishing a therapeutic nurseclient relationship. It helps ensure that the client feels safe to share personal information and
concerns.
A nurse is teaching a client who has a new prescription for disulfiram. Which of the following
statements by the client indicates an understanding of the teaching?
a) "If I cut myself, I can clean the wound with isopropyl alcohol"
b) "I can wear my cologne on special occasions"
c) "When I take my favorite cookies, I can use pure vanilla extract for flavoring"
d) "I can continue to eat aged cheese and chocolate"
Answer: d)
Rationale:
Disulfiram (Antabuse) is a medication used to treat alcoholism by causing unpleasant effects if
alcohol is consumed. Aged cheese and chocolate contain tyramine, which can interact with
disulfiram and cause a hypertensive crisis.

A nurse is planning care for a client who has narcissistic personality disorder. Which of the
following actions is appropriate for the nurse to include in the plan of care?
a) Ask the client to sign a no-suicide contract
b) Remain neutral when communicating with the client
c) Request an antipsychotic medication from the provider
d) Provide the client with high-calorie finger foods
Answer: b)
Rationale:
Remaining neutral when communicating with a client who has narcissistic personality disorder
can help prevent power struggles and maintain a therapeutic relationship. It can also help prevent
the reinforcement of attention-seeking behavior.
A nurse is reviewing the laboratory report of a client who is taking carbamazepine for bipolar
disorder Which of the following laboratory results should the nurse report to the provider?
a. Urine specific gravity 1.029
b) Platelets 90,000/mm
C. Urine pH 5.6
d. RBC 4.7/mm
Answer: b)
Rationale:
Carbamazepine can cause bone marrow suppression, leading to a decrease in platelet count. A
platelet count of 90,000/mm is below the normal range and should be reported to the provider.
A nurse is providing teaching about relapse prevention to a client who has schizophrenia. Which
of the following statements by the client indicates an understanding of the teaching?
a) "I should avoid being around others if I think I'm having a relapse"
b) "I should let my counselor know if I am having trouble sleeping"
с) "I shouldn't worry about the voices because they are a part of my illness"
d) "I should increase my carbohydrate intake to maintain my energy level"
Answer: b)

Rationale:
Reporting trouble sleeping to the counselor is important because changes in sleep patterns can be
an early sign of relapse in schizophrenia. Early intervention can help prevent a full relapse
episode.
A nurse is assessing a client for negative manifestations of schizophrenia. Which of the following
findings should the nurse expect?
a) Echopraxia
b) Delusions
c) Anergia
d) Tangentiality
Answer: c)
Rationale:
Anergia refers to the lack of energy or physical activity often seen in negative symptoms of
schizophrenia. It can include symptoms such as fatigue, lethargy, and a lack of motivation or
interest in activities.
A nurse is preparing for an interprofessional team meeting regarding a newly admitted client who
has major depressive disorder. Which of the following findings obtained during the initial
assessment is the priority to report to other disciplines?
a) Poor problem-solving skills
b) Markedly neglected hygiene
с) Significant weight loss
d) Psychomotor retardation
Answer: d)
Rationale:
Psychomotor retardation, which is characterized by slowed physical movements and speech, can
be a sign of severe depression and may indicate a risk for self-harm or suicide. It is important to
report this finding promptly to ensure appropriate monitoring and interventions are implemented.

A nurse is preparing to administer methylphenidate 25 mg PO to a school-age child who has
ADHD. Available is methylphenidate 10mg/5ml liquid. How many ml should the nurse
administer? (Round to nearest tenth)
Answer: 12.5
Rationale:
To calculate the dose of medication to administer, use the formula:
Dose desired (25 mg) ÷ Dose available (10 mg) × Quantity available (5 mL) = X mL
25 mg ÷ 10 mg × 5 mL = X mL
X = 12.5 mL
A nurse is caring for a school-age child who has a fractured arm. The child has other injuries that
cause the nurse to suspect abuse. Which of the following actions is appropriate for the nurse to
take when assessing the child's situation?
a) Ask the parents directly if the child's fracture is due to physical abuse
b) Direct the parents to the waiting room before interviewing the child
c) Interview the child with the provider and social worker present
d) Ask clarifying questions as the child explains how the injuries occurred
Answer: d)
Rationale:
Asking clarifying questions while the child explains how the injuries occurred can help the nurse
gather more information about the situation without directly accusing the parents of abuse. It is
important to maintain a non-judgmental and supportive approach when interviewing the child.
A nurse is assisting with obtaining consent for a client who has been declared legally
incompetent. Which of the following actions should the nurse take?
a) Ask the charge nurse to obtain informed consent
b) Contact the facility social worker to obtain consent
c) Request that the client's guardian sign the consent
d) Explain implied consent to the client's family
Answer: c)
Rationale:

When a client has been declared legally incompetent, consent for medical treatment must be
obtained from their legal guardian. The nurse should request that the client's guardian sign the
consent form after ensuring they understand the nature of the treatment.
A nurse in a mental health facility is reviewing a client's medical record. Which of the following
actions should the nurse take first?
a) Teach the client about nutritional needs
b) Initiate 0.9% sodium chloride with 40 mEq potassium chloride
c) Administer acetaminophen 500 mg PO
d) Encourage the client to attend group therapy sessions
Answer: a)
Rationale:
Teaching the client about nutritional needs is a priority to ensure the client's basic needs are met.
This can help improve the client's overall health and well-being, which is essential for effective
treatment in a mental health facility.
A nurse is assessing a client who has delirium. Which of the following findings require
immediate intervention by the nurse?
a) Rapid mood swings
b) Command hallucinations
c) Impaired memory
d) Inappropriate speech patterns
Answer: a)
Rationale:
Rapid mood swings can indicate a worsening of delirium and may be a sign of agitation or
distress. Immediate intervention is needed to address the underlying cause and ensure the client's
safety.
A nurse is developing a teach plan for family have an older adult client who's receive transcranial
magnetic stimulation. Which of the following information to the nurse include in the teaching
plan?

a) The client is at risk for aspiration during treatment
b) The client will experience a seizure during treatment
c) The client require intubation after treatment
d) The client might have a headache after treatment
Answer: d)
Rationale:
Headache is a common side effect of transcranial magnetic stimulation (TMS) and should be
included in the teaching plan. It is important for the family to be aware of this potential side
effect and how to manage it.
A nurse is obtaining a medical history from a client who is requesting a prescription for
bupropion for smoking cessation. Which of the following assessment findings in the client's
history should the nurse report to the provider?
a) recent head injury
b) hypothyroidism
c) knee arthroplasty 1 month ago
d) hepatitis B infection
Answer: a)
Rationale:
Bupropion is contraindicated in clients with a recent history of head injury, as it may increase the
risk of seizures. The nurse should report this finding to the provider for further evaluation.
A nurse is developing a plan of care for a client who has paranoid personality disorder. Which of
the following actions should the nurse include in the plan?
a) Provide written information about the clients treatment plan
b) Monitor the client for splitting behaviors
c) Encourage counter transferance when developing the nurse client relationship
d) Isolate the client from social or group interactions
Answer: d)
Rationale:

Isolating the client from social or group interactions can exacerbate feelings of paranoia and
mistrust. It is important to encourage the client to engage in social interactions while maintaining
appropriate boundaries to ensure their safety and well-being.
A nurse is caring for a client who receives lamotrigine daily for bipolar disorder and reports a
rash on his arm. Which of the following actions should the nurse take?
a) ask the client about a recent change in laundry detergent
b) Explain that the medication causes a temporary rash
c) Apply hydrocortisone cream on the clients rash
d) Withhold the next dose of the medication
Answer: d)
Rationale:
Lamotrigine can cause a serious rash known as Stevens-Johnson syndrome. Any rash in a client
taking lamotrigine should be assessed promptly, and the medication should be withheld until
further evaluation by a healthcare provider.
A nurse is caring for a client who begins yelling and pacing around the room. Which of the
following actions should the nurse take? (Select all that apply)
a) Stand directly in front of the client
b) Identify the client's stressors
c) Request that security guards restrain the client
d) Use a reward system for appropriate behavior
Answer: b), d)
Rationale:
a) Standing directly in front of the client might be perceived as confrontational and escalate the
situation. It's important to maintain some distance and approach the client calmly.
b) Identifying the client's stressors can help address the underlying cause of the behavior and
provide appropriate support.
c) Requesting that security guards restrain the client should be a last resort and only considered if
the client poses a danger to themselves or others.

d) Using a reward system for appropriate behavior can help reinforce positive behaviors and
promote a calmer environment.
A nurse is developing a plan of care for a school-age child who has autism spectrum disorder.
Which of the following interventions should the nurse include in the plan?
a) Allow flexibility in the child's daily schedule
b) Assign the child to a room with another child of the same age
c) Discourage the child from making eye contact with caregivers
d) Use a reward system for appropriate behavior
Answer: d)
Rationale:
a) Allowing flexibility in the child's daily schedule can help accommodate their needs and reduce
stress.
b) Assigning the child to a room with another child of the same age might not be appropriate, as
it depends on the individual needs and preferences of the child.
c) Discouraging the child from making eye contact with caregivers is not recommended, as eye
contact can be an important form of communication for children with autism.
d) Using a reward system for appropriate behavior can help reinforce positive behaviors and
encourage the child to engage in desired activities.
The nurse is caring for a client who has posttraumatic stress disorder (PTSD). Which of the
following clinical findings are associated with this disorder?
a) Depersonalization
b) Pressured speech
c) Hypervigilance
d) Compulsive behavior
Answer: a)
Rationale:
a) Depersonalization, or feeling detached from oneself or one's surroundings, is a common
symptom of PTSD.

b) Pressured speech is more commonly associated with conditions like mania in bipolar disorder,
rather than PTSD.
c) Hypervigilance, or being overly alert and sensitive to potential threats, is a symptom of PTSD.
d) Compulsive behavior is not a typical symptom of PTSD; it is more commonly associated with
obsessive-compulsive disorder (OCD).
A nurse is teaching a client about the use of cognitive reframing for stress management. Which
of the following statements by the client indicates an understanding of the teaching?
a) "I will focus on a mental image while concentrating on my breathing"
b) "I will practice replacing negative thoughts with positive self-statements"
c) "I will progressively relax each of my muscle groups when feeling stressed"
d) "I will learn how to voluntarily control my blood pressure and heart rate"
Answer: b)
Rationale:
a) This statement describes a relaxation technique, not cognitive reframing.
b) Correct. Cognitive reframing involves replacing negative thoughts with more positive or
realistic ones.
c) This statement describes progressive muscle relaxation, another stress management technique.
d) This statement describes a form of biofeedback, not cognitive reframing.
A nurse is caring for a client who has schizophrenia and has been taking chlorpromazine for five
years. Which of the following assessments should the nurse use to determine if the client is
experiencing adverse effects of the medication?
a) Addictions severity index (ASI)
b) Mood disorder questionnaire (MDQ)
c) Abnormal involuntary movement scale (AIMS)
d) Hamilton depression scale
Answer: c)
Rationale:
a) The Addictions Severity Index (ASI) is used to assess the severity of substance use disorders,
not adverse effects of antipsychotic medication.

b) The Mood Disorder Questionnaire (MDQ) is used to screen for bipolar disorder, not adverse
effects of antipsychotic medication.
c) Correct. The Abnormal Involuntary Movement Scale (AIMS) is used to assess for
extrapyramidal symptoms, which can be side effects of antipsychotic medication like
chlorpromazine.
d) The Hamilton Depression Scale is used to assess the severity of depression, not adverse effects
of antipsychotic medication.
A nurse in a mental health facility is assessing a client for suicide risk factors using the SAD
PERSONS scale. Which of the following indicates a risk of suicide?
a) The client is married
b) The client has diabetes mellitus
c) The client is 50 years of age
d) The client is female
Answer: b)
Rationale:
The SAD PERSONS scale assesses various risk factors for suicide, including depression,
previous suicide attempts, substance abuse, and physical illness. Having a physical illness, such
as diabetes mellitus, can increase the risk of suicide.
A nurse is providing crisis intervention for a client who is involved in a violent mass casualty
situation in the community. Which of the following actions should the nurse take during the
initial session with a client?
a) Identify the client's usual coping style
b) Help the client focus on a wide variety of topics regarding the crisis
c) Tell the client that his life will soon return to normal
d) Encourage the client to display anger towards the cause of the crisis
Answer: a)
Rationale:

During the initial session, it is important for the nurse to identify the client's usual coping style to
better understand how they may respond to the crisis. This information can help guide the nurse
in providing appropriate support and interventions.
A nurse is caring for a client with schizophrenia experiencing auditory hallucinations. Which of
the following actions should the nurse take first?
a) Encourage the client to listen to music
b) Monitor the client for indications of anxiety
c) Ask the client what she is missing
d) Focus the client on reality-based topics
Answer: d)
Rationale:
The priority intervention for a client experiencing auditory hallucinations is to focus the client on
reality-based topics. This can help ground the client and reduce the intensity of the
hallucinations.
A nurse is planning to lead a support group for clients with alcohol use disorder. One of the
group members speaks a different language than the nurse. The nurse should ask which of the
following individuals to assist with communication?
a) A family member of the client
b) Another client who speaks the same language as the client
c) A translator of the same gender as the client
d) A unit secretary who speaks the same language as the client
Answer: c)
Rationale:
When a language barrier exists, it is important to use a qualified interpreter to ensure effective
communication. Using a translator of the same gender as the client can help the client feel more
comfortable and enhance communication.
A nurse in an emergency department is assessing a client who reports recently using cocaine.
Which of the following clinical manifestations should the nurse expect?

a) Lethargy
b) Hypothermia
c) Hypertension
d) Bradycardia
Answer: c)
Rationale:
Cocaine use can cause hypertension due to its stimulant effects on the body.
A nurse is caring for a client with severe depression scheduled to receive electroconvulsive
therapy. The nurse should recognize that the client will receive succinylcholine to prevent which
of the following adverse effects?
a) Muscle distress
b) Aspiration
c) Elevated blood pressure
d) Decreased heart rate
Answer: a)
Rationale:
Succinylcholine is given before electroconvulsive therapy to prevent muscle distress and reduce
the risk of injury during the procedure.
A nurse in an outpatient clinic is assessing a client with anorexia nervosa. Which of the following
indicates a need for hospitalization?
a) Temperature 35.6°C (96.1°F)
b) Heart rate 56/min
c) Weight 10% below ideal weight
d) Potassium 3.8 mEq/L
Answer: a)
Rationale:
An abnormally low body temperature (hypothermia) can indicate severe malnutrition and
electrolyte imbalances, which may require hospitalization for monitoring and treatment.

A nurse is caring for a client who is under observation for suicidal ideations and has verbalized a
suicide plan. The client demands privacy and to be left alone. Which of the following statements
should the nurse make?
a) "Since you were trying to follow the treatment plan, we can submit your request to the
provider."
b) "We are concerned about you. I need to keep you safe."
c) "Until your medication has reached therapeutic levels, you will need constant observation."
d) "If you complete a contract that states you will not harm yourself, you can be alone."
Answer: b)
Rationale:
It is essential for the nurse to prioritize the client's safety. Verbalizing a suicide plan is a serious
concern, and the nurse should not leave the client alone in this situation.
A nurse on a mental health unit is leading a therapy session for a group of clients. One client
challenges the nurse and shows no empathy for others in the group. Which of the following
actions should the nurse take?
a) Request that the client leave the therapy session immediately.
b) Place the client in seclusion.
c) Reassign the client to another group.
d) Ask the client privately what is causing the anger.
Answer: d)
Rationale:
It is important for the nurse to address the client's behavior privately to understand the
underlying cause and to help the client develop empathy for others.
A nurse in a mental health clinic is assessing a client who has borderline personality disorder.
Which of the following findings should the nurse expect?
a) Inability to maintain employment
b) Intense efforts to avoid abandonment
c) Avoidance of interpersonal relationships
d) Reluctance to discard worthless objects

Answer: b)
Rationale:
Clients with borderline personality disorder often exhibit intense efforts to avoid abandonment,
which can manifest in behaviors such as clinginess or extreme reactions to perceived rejection.
A nurse in a long-term care facility is assessing an older adult for depression. Which of the
following findings should the nurse expect?
a) Rapid mood swings
b) Sundowning
c) Insomnia
d) Rambling speech
Answer: c)
Rationale:
Insomnia is a common symptom of depression in older adults and is often associated with
changes in sleep patterns and difficulty falling or staying asleep.
A nurse is assessing a client who has been taking thioridazine for 2 weeks. The client reports an
inability to be still. Which of the following adverse effects should the nurse suspect?
a) Tardive dyskinesia
b) Pseudoparkinsonism
c) Akathisia
d) Acute dystonia
Answer: c)
Rationale:
Akathisia is a common extrapyramidal side effect of antipsychotic medications like thioridazine
and is characterized by an inability to sit still and a constant need to move.
A nurse in a mental health facility is making plans for a client's discharge. Which of the
following interdisciplinary team members should the nurse contact to assist the client with
housing placement?
a) Clinical nurse specialist

b) Social worker
c) Occupational therapist
d) Recreational therapist
Answer: b)
Rationale:
A social worker is typically responsible for assisting clients with housing placement and other
social services.
A nurse is interviewing a client who was recently sexually assaulted. The client cannot recall the
attack. The nurse should identify that the client is using which of the following defense
mechanisms?
a) Sublimation
b) Reaction formation
c) Suppression
d) Repression
Answer: d)
Rationale:
Repression involves blocking out painful or traumatic memories from consciousness.
A nurse is assessing a client who has antisocial personality disorder. Which of the following
client behaviors should the nurse expect?
a) Attention seeking
b) Anxious
c) Projects blame
d) Manipulative
Answer: d)
Rationale:
Individuals with antisocial personality disorder often exhibit manipulative behavior and a lack of
regard for the rights of others.

A nurse is caring for a client who has physical restraints applied. The nurse determines that the
restraints should be removed when which of the following occurs?
a) The client states that he will harm himself unless the restraints are removed
b) The client refuses to take his medication unless he is released
c) The client demonstrates that he is oriented to place, person, and time
d) The client is able to follow commands
Answer: d)
Rationale:
Restraints should be removed when the client is able to follow commands and is no longer a
danger to themselves or others.
A nurse is caring for a client who states, "Things will never work out." Which of the following
responses should the nurse make?
a) "Why do you feel like things will never work?"
b) "Have you been thinking about harming yourself?"
c) "You should try to focus on yourself for a change."
d) "Maybe an antidepressant will make you feel better."
Answer: b)
Rationale:
This response addresses the possibility of suicidal ideation, which is important to assess in
clients expressing hopelessness.
A nurse in an emergency department is caring for a client who reports recent sexual assault by
her partner. Which of the following statements is the priority for the nurse to make?
a) "I want you to know that you are in a safe place here."
b) "I can contact a support person for you."
c) "A trained sexual assault nurse will be assigned to your care."
d) "I can provide information about an advocacy group in the area."
Answer: a)
Rationale:
Ensuring the client feels safe and supported is the priority in this situation.

After assessing a client in a crisis situation, a nurse determines the client is safe. Which of the
following actions should the nurse take first?
a) Help the client identify social support.
b) Involve the client in planning interventions.
c) Assist the client to lower his anxiety level.
d) Teach the client specific coping skills to handle stressful situations.
Answer: c)
Rationale:
Lowering the client's anxiety level is the first step to stabilize the client in a crisis situation.
A nurse is assessing a client who has bulimia nervosa. Which of the following findings should
the nurse expect?
a) Acrocyanosis
b) Amenorrhea
c) Lanugo
d) Hyponatremia
Answer: a)
Rationale:
Acrocyanosis, a bluish discoloration of the extremities, can occur due to poor circulation in
clients with bulimia nervosa.
A nurse is caring for a client who reports smoking marijuana several times per day. The client
tells the nurse, "I don't know what the big deal is, marijuana is a harmless herb." The nurse
should identify that the client is displaying which of the following defense mechanisms?
a) Rationalization
b) Reaction formation
c) Compensation
d) Suppression
Answer: a)
Rationale:

Rationalization is a defense mechanism where the individual justifies their behavior with logical
reasoning, such as minimizing the perceived harm of marijuana use.
A nurse is creating a plan of care for a client who has major depressive disorder. Which of the
following interventions should the nurse include in the plan?
a) Identify and schedule alternative group activities for the client.
b) Encourage physical activity for the client during the day.
c) Discourage the client from expressing feelings of anger.
d) Keep a bright light on in the client's room at night.
Answer: b)
Rationale:
Encouraging physical activity can help improve mood and reduce symptoms of depression.
A nurse is teaching the family of a client who has Alzheimer's disease about the safety
interventions for nighttime wandering. Which of the following interventions should the nurse
include?
a) Place rubber-backed throw rugs on tile floors
b) Encourage the client to take naps during the day
c) Install locks for the bottom of exits
d) Place the client's mattress on the floor
Answer: d)
Rationale:
Placing the client's mattress on the floor can reduce the risk of injury if the client wanders out of
bed during the night.
A nurse in a mental health facility is reviewing the lab results of a client who is taking lithium
carbonate. Which of the following findings places the client at risk for lithium toxicity?
a) Calcium 10.0
b) WBC 6,000
c) Sodium 132 mEq/L
d) Aspartate aminotransferase 40 units/L

Answer: c)
Rationale:
Low sodium levels (hyponatremia) can increase the risk of lithium toxicity, as sodium depletion
can lead to increased lithium reabsorption by the kidneys.
A nurse in an acute care facility is planning care for a client who has a history of alcohol use
disorder and is admitted while intoxicated. Which of the following interventions should the nurse
plan for the client?
a) Monitor for orthostatic hypotension
b) Administer methadone hydrochloride
c) Implement seizure precautions
d) Acidify the client's urine
Answer: c)
Rationale:
Clients with a history of alcohol use disorder are at risk for alcohol withdrawal seizures when
admitted while intoxicated. Implementing seizure precautions, such as padding the bed rails and
ensuring a safe environment, is essential.
A nurse is developing a safety plan for a client who has experienced intimate partner abuse.
Which of the following items should the nurse include in the plan to provide immediate safety
for the client and her children?
a) The phone numbers for law enforcement agencies
b) A code phrase to use when it is time to leave the house
c) The phone number of the local shelter
d) A referral to a support group
Answer: c)
Rationale:
Providing the phone number of the local shelter can provide immediate safety for the client and
her children in case of further abuse.

A nurse is caring for a client who reports that he is angry with his partner because she thinks he
is just trying to gain attention. When the nurse attempts to talk to the client, he becomes angry
and tells her to leave. Which of the following defense mechanisms is the client demonstrating?
a) Denial
b) Rationalization
c) Displacement
d) Compensation
Answer: c)
Rationale:
Displacement involves transferring emotions, such as anger, from the original source to a less
threatening target.
A nurse is observing a newly licensed nurse administer an IM medication to a client who is
manic and refused the medication. Which of the following actions should the nurse take first?
a) Stop the newly licensed nurse from administering the medication
b) Call the provider for an alternate medication order
c) Report the occurrence to the nurse manager
d) Talk to the newly licensed nurse about the incident
Answer: a)
Rationale:
When a client refuses medication, it is important to respect their autonomy and not administer
the medication. The nurse should stop the newly licensed nurse from administering the
medication to prevent a medication error.
A nurse is planning care for a client who demonstrates prolonged depression related to the loss of
her partner six months ago. Which of the following actions should the nurse take?
a) Explain that it can take a year or more to learn to live with loss
b) Discourage the client from reliving the events surrounding her loss
c) Suggest that the client avoid social interactions that remind her of her partner
d) Direct the client to maintain an unstructured daily routine
Answer: a)

Rationale:
Grieving is a process that can take a year or more, and it is important for the nurse to provide
realistic expectations and support for the client.
A nurse is caring for a client who has bipolar disorder. The client is walking in and out of rooms,
speaking appropriately, and giggling. Which of the following actions should the nurse take?
a) Tell the client there will be negative consequences for her behavior
b) Take the client to the day room to watch a movie with other clients
c) Have the client return to her room to read a book
d) Lead the client outside for a walk
Answer: d)
Rationale:
Engaging the client in physical activity, such as a walk, can help redirect their excess energy and
provide a calming effect.
A nurse is admitting a client who has a new diagnosis of schizophrenia and a history of
aggression. Which of the following actions should the nurse include in the client's initial plan of
care?
a) Agree with the client when he's upset until he can calm down
b) Provide physical exercise activity for the client
c) Avoid eye contact with the client for the first few days
d) Ignore the client's hallucinations
Answer: b)
Rationale:
Providing physical exercise can help reduce agitation and provide a healthy outlet for aggression.
A nurse is caring for a client who has bipolar disorder and is exhibiting mania. Which of the
following findings should the nurse expect?
a) Disorganized speech
b) Heightened concentration
c) Hypersomnia

d) Agoraphobia
Answer: a)
Rationale:
Disorganized speech is a common symptom of mania, characterized by rapid and incoherent
speech patterns.
A nurse is caring for a client who has schizophrenia. The client's employer calls to discuss the
client's condition. Which of the following is the appropriate nursing action?
a) Consult the client
b) Consult the client's family
c) Consult the provider
d) Contact the facility legal department
Answer: a)
Rationale:
The appropriate action is to consult with the client to determine their preferences regarding
disclosure of their condition to their employer.
A nurse is providing teaching to a client who is prescribed methylphenidate for ADHD. Which of
the following statements by the client indicates accurate understanding of this medication's
effects?
a) "I know that I will be able to think more clearly now"
b) "This medication will help me relax and feel less anxious"
c) "I'll take my medicine at bedtime because it will make me drowsy"
d) "I need to tell my doctor if I start gaining weight"
Answer: a)
Rationale:
Methylphenidate is a stimulant medication that is used to improve focus and attention in
individuals with ADHD. The client's statement indicates an understanding of this effect.
An older adult client is brought to the mental health clinic by her daughter. The daughter reports
that her mother is not eating and seems very uninterested in routine activities. The daughter

states, "I'm so worried that my mother is depressed." Which of the following responses should
the nurse take?
a) "You shouldn't worry about this because depressive disorder is easily treated."
b) Older adults are usually diagnosed with depressive disorder as they age.
c) Tell me the reason you think your mother is depressed.
d) Everyone gets depressed from time to time.
Answer: c)
Rationale:
This response is therapeutic because it encourages the daughter to express her concerns and
provides an opportunity for the nurse to gather more information about the situation.
A nurse is providing teaching to a client who has a new prescription for tranylcypromine. Which
of the following over-the-counter medications should the nurse instruct the client to avoid taking
due to adverse interactions?
a) Ranitidine
b) Pseudoephedrine
c) Ibuprofen
d) Magnesium hydroxide
Answer: b)
Rationale:
Tranylcypromine is a monoamine oxidase inhibitor (MAOI), and taking it with pseudoephedrine,
which is a sympathomimetic agent, can lead to a hypertensive crisis due to the interaction
between the two medications.
A nurse in the emergency department is admitting a client who has a history of alcohol use
disorder. The client has a blood alcohol level of 0.26 g/dl. The nurse should anticipate a
prescription for which of the following medications?
a) Disulfiram
b) Chlordiazepoxide
c) Naltrexone
d) Acamprosate

Answer: b)
Rationale:
Chlordiazepoxide is a benzodiazepine used to manage alcohol withdrawal symptoms in clients
with alcohol use disorder. A client with a history of alcohol use disorder and a high blood alcohol
level is at risk for withdrawal symptoms and would likely be prescribed chlordiazepoxide to
manage these symptoms.
A nurse is building a therapeutic relationship with a client who has an eating disorder. Which of
the following activities should the nurse initiate during the relationship's orientation phase?
a) Mutually deciding and agreeing on the goals of the relationship
b) Using memories to validate the relationship experience
c) Discussing the incorporation of new strategies into daily life
d) Teaching and encouraging the use of problem-solving skills
Answer: a)
Rationale:
During the orientation phase of the therapeutic relationship, the nurse and client establish rapport
and trust. This includes discussing and agreeing upon the goals of the relationship, which helps
to set the direction for the rest of the therapeutic work.
A nurse is assessing a client who has schizophrenia. The client tells the nurse, "my heart
exploded and my blood is draining out." The nurse should interpret the statement as which of the
following manifestations?
a) Concrete thinking
b) A visual hallucination
c) A somatic delusion
d) Paranoia
Answer: c)
Rationale:
Somatic delusions are false beliefs about one's body, such as believing that one's organs are not
functioning correctly or that parts of the body are missing or altered. The client's statement about
their heart exploding and blood draining out indicates a somatic delusion.

A nurse is interviewing a client who has schizophrenia. The client states, "aliens are going to
abduct me at midnight tonight." Which of the following responses should the nurse make?
a) Why are the aliens going to abduct you?
b) You were safe from aliens here
c) Believing that aliens will abduct you must be scary
d) Have you ever been abducted by aliens before?
Answer: c)
Rationale:
This response acknowledges the client's feelings and demonstrates empathy without challenging
or reinforcing the delusion.
A nurse is caring for a client who has generalized anxiety disorder and a history of substance
abuse disorder. Which of the following medications should the nurse expect the provider to
prescribe?
a) Chlordiazepoxide
b) Clonazepam
c) Buspirone
d) Alprazolam
Answer: c)
Rationale:
Buspirone is a non-benzodiazepine anxiolytic medication that is often preferred for clients with
anxiety disorders and a history of substance abuse due to its lower risk of abuse and dependence
compared to benzodiazepines like chlordiazepoxide, clonazepam, and alprazolam.
A nurse in an emergency department is creating a plan of care for a client who reports
experiencing intimate partner violence. Which of the following interventions should the nurse
include as a priority?
a) Teach the client stress reduction techniques
b) Help the client devise a safety plan
c) Refer the client to a support group

d) Follow the facility's protocol for reporting the abuse
Answer: d)
Rationale:
Reporting the abuse is a priority to ensure the client's safety and to comply with legal and ethical
obligations to protect the client from further harm.
A nurse in a mental health facility is caring for a client who is being aggressive towards other
clients. Which of the following actions is the priority for the nurse to take?
a) Assist the client to explore techniques to reduce stress
b) Ask the client if he intends to harm others
c) Role model healthy ways to express anger
d) Suggest the client make a list of things to make him angry
Answer: b)
Rationale:
The priority is to assess the client's intent to harm others to ensure the safety of other clients and
staff.
A nurse in the emergency department is caring for a client who has serotonin syndrome. The
nurse should assess the client for which of the following manifestations?
a) Hyperpyrexia
b) Priapism
c) Paresthesia
d) Bradycardia
Answer: a)
Rationale:
Serotonin syndrome is characterized by a triad of symptoms, including cognitive and
neuromuscular hyperactivity, autonomic hyperactivity, and hyperthermia (hyperpyrexia).
Hyperpyrexia is a hallmark symptom of serotonin syndrome.

Document Details

  • Subject: Nursing
  • Exam Authority: ATI
  • Semester/Year: 2023

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