1. The health care provider has just informed a client who has diabetes and chronic kidney

• The health care provider has just informed a client who has diabetes and chronic kidney

disease of the need to start dialysis. The client tearfully says to the nurse, “I don’t know whwat I’m going to do; everything was so overwhelming before, and now there is this.” How should the nurse respond?

• “You can cry and get it all out; I will stay with you.”
• “You have dealt with diabetes; you can conquer dialysis.”
• “You sound very discouraged and frightened.”
• “You still have a lot to live for; think about your family”
• A new nurse is caring for an adolescent transgender client. What question would be

appropriate when assessing the client’s gender identity?

• “Do you prefer being referred to as ‘he’ or ‘she’?”
• “How would you describe your gender?”
• “What gender were you originally?”
• “What is your preferred name?”
• A client with moderate Alzheimer disease becomes agitated during mealtime and throws a

plate of food on the floor. Which of the following responses by the nurse are appropriate?Select all that apply.

a) Administer a dose of prescribed PRN haloperidol before the client’s behavior escalates

further

b) Distract and redirect the client bu asking for help folding napkins for the following day’s

meals

c) Inform the client that the health care provider will be notified about the inappropriate

behavior

d) Promptly obtain another plate of food and insist that unlicensed assistive personnel feed

the client

e) Use direct eye contact and say to the client, “I can see that you are upset; this is a safe

place.”

• The mental health clinic nurse is evaluating the treatment plan for a client with obsessive-

compulsive disorder who counts backwards from 5-1 many times a day. Which of the following client statements indicates progress toward effective coping? Select all that apply.

• “Counting helps me cope with my anxiety. It doesn’t hurt anyone, and it’s better than

drinking alcohol.”

• “Having a heavier workload increase my anxiety and the urge to count, but I calm myself

with deep-breathing exercises.”

• “I used to start counting as soon as I boarded the bus, but now I can ride the for 30

minutes without counting.”

• “My neighbor goes grocery shopping for me because I get overwhelmed by all the choices

and start counting.”

• “When I being feeling anxious, I take a short, brisk walk so I can decompress and refocus.”
• The nurse assesses a pediatric client and finds bruises in various stages of healing on back and

legs. When questioned about the bruises the child begins to cry and states, “Somebody did things to me.” Which of the following communications by the nurse is appropriate? Select all that apply.

• “How long have your parents been doing things to you?”
• “Tell me about what happened, I promise not to tell anyone.”
• “This is terrible. Whoever did this to you will be sorry.”

• “What happened is not your fault. You are not to blame.”
• “You did the right thing by telling me. You are not in trouble.”
• A client with schizophrenia says to the nurse, “The world turns as the world turns on a ball at

the beach. But all the world’s a stagecoach and I took the bus home.” The nurse recognizes this statement as an example of which of the following?

a) Concrete thinking

b) Loose associations

c) Tangentiality

d) Word Salad

• The nurse develops a teaching care plan for the client with a prescription to change

antidepressant medications from imipramine to phenelzine. Which instruction is appropriate to include in the teaching?

a) Continue avoiding foods high in tyramine until the imipramine withdrawal period is over

b) Skip the nighttime dose of imipramine and start the phenelzine the next morning

c) Taper down the imipramine, then discontinue for 2 weeks before starting phenelzine

d) Taper down imipramine while gradually increasing phenelzine

• A 10-year-old client with autism spectrum disorder is hospitalized for a diagnostic workup.

Which is the most appropriate nursing action?

a) Encouraging visits by friends to decrease social isolation

b) Giving the client a schedule of daily activities

c) Placing the client in restraints during invasive procedures

d) Providing the client with variety of toys

• The nurse cares for a client newly diagnosed with acute stress disorder following a traumatic

event. Which of the following communications by the nurse are appropriate? Select all that apply.

• “How has this situation affected your relationships with family and friends?”
• “It is important to focus on coping strategies and not dwell on the event.”
• “It is normal to experience difficult symptoms after a traumatic event.”
• “Please tell me about your current use of alcohol and any drugs.”
• “Share with me any thoughts or plans of self-harm that you have had.”
• An elderly client with dementia frequently exhibits sundowning behavior while living in a

community-based residential facility. When the nurse finds the client wandering at night, which of the following statements is most appropriate?

• “Don’t you know it’s not morning yet?”
• “It’s time to get back to bed now.”
• “You might fall if you wander in the dark.”
• “You should not leave your room without assistance.”
• The clinic nurse reinforces education about intimate partner violence for a group of graduate

nurses. Which of the following are appropriate for the nurse to include? Select all that apply.

• “Intimate partner violence is most common in low-income families.”
• “Intimate partner violence is rare in same-sex partnerships.”
• “The abusive partner often demonstrates jealousy and possessiveness.”
• “Victims may not leave due to financial concerns or fear of harm by the abuser.”
• “Violence against a female often intensifies during pregnancy.”
• The nurse is caring for a client with paranoid personality disorder. When the nurse directs the

client to go to the dining room for dinner, the client says, “And eat that poisonous food? You

better not make me go anywhere near that room.” Which statement best explains the client’s behavior?

a) The client has a problem with authority figures

b) The client has an intense need to control the environment

c) The client is hearing voices

d) The client is trying to control anger

• A client presents to the emergency department with alcohol intoxication. Assessment shows

nystagmus, ataxia and confusion. The client’s breath smells of alcohol. Which prescription from the health care provider should the nurse implement first?

a) Blood draw for liver function tests

b) D5 1/2 normal saline

c) Folic acid, IV

d) Thiamine, IV

• The nurse on the mental health unit received report on 4 clients. Which client should the nurse

see first?

a) Client diagnosed with major depressive disorder who has consumed no food from the past

• meal trays.

b) Client diagnosed with post-traumatic stress disorder who reports an anxiety level of 8/10

and is pacing in the room

c) Client newly admitted with bipolar mania who reports sleeping only 4 hours last night

d) Client newly admitted with obsessive-compulsive disorder who has spend the last hour

counting socks

• The nurse provides teaching for a client newly prescribed disulfiram for alcohol abstinence.

Which information is the priority for the nurse to include?

a) Disulfiram is not a cure for alcoholism

b) Importance of continuing to see a therapist

c) List of everyday items containing hidden alcohol

d) Medical alert bracelet should identify disulfiram therapy

• The nurse reviewing teaching about newly prescribed clonazepam with a client who is

receiving palliative care for cancer. Which client statement shows a correct understanding of the nurse’s teaching?

• “I am glad that I can continue to take my kava supplement each morning.”
• “If I can’t sleep, I will take some melatonin with my evening dose of a clonazepam.”
• “If I feel restless, I can put some drops of lavender essential oil in a diffuser to calm myself.”
• “When my anxiety is getting really intense, I will drink some valerian tea to help me relax.”
• A 21-year-old client is being evaluated in the outpatient psychiatric clinic after starting to

isocarboxazid 2 weeks ago. Which of the client’s statements needs to be addressed first?

• “I am not sleeping well at night and would like a sleeping aid.”
• “I do not know how well I will do on this restricted diet.”
• “I have been having quite a bit of nausea and constipation.”
• “The medicine is not working, I am so tired of being depressed.”
• The nurse has completed teaching a client who is being discharged on lithium for a bipolar

disorder. Which statement by the client indicates a need for further teaching?

• “I need to drink 1-2 liters of fluid daily.”
• “I need to have my blood levels checked periodically.”
• “I should not limit my sodium intake.”

• “I should use ibuprofen for pain relief.”
• An elderly client at the end of life is visited by family members. One begins to cry and asks the

nurse, “Will you please stay for a few minutes?” The nurse has other clients to care for as well.Which statement by the nurse is the most helpful?

• “I am busy right now but can stay for a few minutes.”
• “I can call the clergy to come sit with you.”
• “I can stay and sit with you if you would like.”
• “I don’t think I should interrupt your family time.”
• The mental health nurse is planning care for a client newly admitted with dissociative identity

disorder. Which interventions will the nurse include? Select all that apply.

a) Develop a trusting relationship with each of the alternate identities

b) Encourage the client to journal about feelings and dissociation triggers

c) Explain to the client in detail the events of missing memories and lost time

d) Listen for expressions of self-harm from the alternate identities

e) Teach grounding techniques such as deep breathing to hinder dissociation

• The nurse is caring for a client who entered the psychiatric emergency department in a state of

acute psychosis after ingesting illicit substances. The parents ask the nurse if the client will develop schizophrenia. What is the most appropriate response by the nurse?

• “I know it must be terrible to see your son like this, but he will be fine.”
• “Most people have permanent side effects after an episode like this.”
• “You son will have to remain here for observation until we know more.”
• “You son would be fine right now if he had not taken these drugs.”
• The nurse is conducting a seminar for parents adolescents about health issues common to this

age group. Which parent’s statement indicates that the adolescent may have bulimia nervosa?

• “I found several empty boxes of laxatives in my child’s wastebasket.”
• “I have noticed my child has started wearing bulky, oversized clothing.”
• “My child has lost 20 lb (9.1 kg) in the past 2 months.”
• “My child has stopped going to the gym.”
• A client is newly admitted to the mental health unit with a diagnosis of schizophrenia with

persecutory delusions. Which nursing interventions should the nurse include in the client’s plan of care with regard to the delusional thinking? Select all that apply.

a) Explore the meaning behind the client’s delusions

b) Focus on reality and verbally reinforce it

c) Focus on the client’s feelings secondary to the delusions

d) Gently confront the client about the false beliefs

e) Present logical explanations to discredit the delusions

• The client is brought to the emergency department in handcuffs by the police. Witnesses said

that the client became violent and confused after consuming large amounts of alcohol at a party. The client is placed in 4-point restraints, and ziprasidone hydrochloride is administered.The client is sleeping 30 minutes later. What is a priority action for the nurse at this time.

a) Check for a history of bipolar disease

b) Determine if restraints can now be removed

c) Monitor for widened QT intervals and hypotension

d) Obtain blood for the current blood alcohol level