1. A nurse is reviewing assessment items for child abuse. Which of the following includes risk
factors for abuse toward a child? Select All That Apply (SATA):
A. The child has a history of mental illness.
B. The child is under 4 years of age.
C. The child has a strong sense of self identity.
D. The child is physically disabled.
E. The child is a result of an unwanted pregnancy.
2. Neurocognitive Disorders: Identifying Risk Factors for Alzheimer's Disease. The nurse will
identify the following risk factors for Neurocognitive Disorder of Alzheimer’s Disease (AD)
– (SATA):
A. Respiratory disease
B. Cardiovascular disease
C. Prior head trauma
D. Family history of AD
E. History of multiple infections
3. The nurse will include the following interventions for behavioral management of Autism
Spectrum Disorder (SATA):
A. Change routine schedules often to avoid boredom.
B. Determine emotional and situational triggers.
C. Role-play situations that involve conflict and conflict resolution strategies.
D. Avoid eliciting verbal communication as this is often a source of stress.
E. Limit self-stimulating and ritualistic behaviors by providing alternative play activities.
F. Limit use of a reward system.
G. Refer to speech and occupational/activity therapy.
4. Home safety to include for a client with Neurocognitive Alzheimer’s Disease includes:
A. Elevate mattress so the client does not have to bend down too low.
B. Lock water heater thermostat and monitor water temperature.
C. Mark steps with colored tape and provide lighting.
D. Secure electrical cords to scattered rugs.
E. Install door locks that is not easily opened.
F. Keep cleaning supplies within reach so that the client does not struggle and get frustrated.
5. A nurse identifies a client’s delusions. Examples of delusions include (SATA):
A. Ideas of reference
B. Reversal of thought
C. Grandeur
D. Persecution
E. Mixed messages
F. Thought broadcasting
, 6. The nurse is monitoring for heroin withdrawal. The client exhibits which of the
following symptoms of withdrawal?
A. Seizures, tremors, dry heaves
B. Dry mouth, dizziness, mania
C. Muscle rigidity, irritability, pruritis
D. Piloerection, rhinorrhea, pain in muscles and bones
7. Nursing care of a client with opioid disorder includes which of the following? (SATA)
A. Teach responsibility for their behaviors after withdrawal manifestations have subsided.
B. Use physical management and mechanical restraints as a first resort to promote safety.
C. Provide substitution therapy and cognitive behavioral therapy.
D. Monitor for nutrition, hydration, and give medications for withdrawal manifestations.
E. Begin to develop motivation and commitment for abstinence and recovery.
F. Give information to nearby support groups.
8. Therapeutic effects of Naltrexone include which of the following?
A. Suppresses cravings, pleasure effects of alcohol and for opioid withdrawals.
B. Decreases autonomic activity such as nausea, vomiting, diarrhea.
C. Decreases anxiety and restlessness.
D. Suppresses mania, decreases amygdala activation, and promotes limbic system
regulation.
9. The nurse observes manifestations of alcohol withdrawal as which of the following? (SATA):
A. Can begin within 4-12 hours of the last intake and can continue up to 5-7 days.
B. Vomiting, diarrhea, excessive sleep.
C. Vomiting, tremors, insomnia, restlessness.
D. Diaphoresis, illusions, tonic-clonic seizures.
E. Delirium can occur immediately after cessation of alcohol intake.
F. Irritability, increased heart rate, blood pressure, respiratory rate, and temperature.
10. The nurse includes which of the following in planning care for a client experiencing acute
alcohol withdrawal? (SATA)
A. Administer Lorazepam prn per orders, based on CIWA score.
B. Initiate elopement precautions.
C. Initiate seizure precautions.
D. Monitor vital signs and neurologic status.
E. Give propranolol or clonidine per orders if heart rate is less than 60/min.
F. Give carbamazepine per orders to prevent seizures.
11. Which would be the initial medication ordered to administer for acute alcohol withdrawal?
(SATA)
A. Lorazepam or Diazepam
B. Acamprosate or Naltrexone
C. Clonidine or Propranolol
D. Disulfiram or Methadone
12. Priority interventions for alcohol use disorder includes the following:
A. Teach the client to recognize indications of relapse and factors that contribute to
relapse. B. Give 12-step program information and encourage attendance for recovery.
C. Family Therapy to recognize codependency traits.
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