1. A nurse is admitting a client who has schizophrenia. During the initial interview, the client takes off his belt and screams, “A snake!” Which of the following responses is appropriate? a. “You know that is you belt and not a snake, don’t you?” b. “Your belt doesn’t look like a snake.” c. “This is your belt. I understand how this is scary for you.” d. “Why do you think your belt is a snake?” 2. nurse working in the emergency department is A
assessing a client who has generalized anxiety disorder. Which of the following actions should the nurse take first? a. Move the client to a quiet area b. Allow the client time to express his feelings c. Instruct the client to use guided imagery d. Assist the client to identify his coping skills A nurse is caring for a client who has dementia. Which 3.
of the following is an appropriate nursing intervention ? a. Encourage the client to make choices regarding care. b. Advise family to visit frequently as a group c. Maintain a low-stimulation environment d. Assign several tasks at the same time. 4. 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 his 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 contagious and can cause other people he loves to die b. Death creates an interest in the physical aspects of dying c. Death is not permanent and the loved one may come back to life. d. Death is a part of life that eventually happens to everyone. 5.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? (p. 156) a. Chlordiazepoxide b. Disulfram c. Acamprosate d. Naltrexone 6.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. “I’ll change your assignment to someone who doesn’t have depressive disorder.” c. “It’s important that the client feel safe verbalizing how she is feeling.” d. “Everybody feels that way about this client, so don’t worry about it.” 7.A nurse is caring for a client who reports he is angry with his partner because she thinks he is trying to seek attention. When the nurse questions the client, he becomes angry and tells her to leave. Which of the following defense mechanisms is the client demonstrating? (p. 30) a. Compensation b. Displacement c. Denial d. Rationalization 8.A nurse working in a mental health facility has just put a client in provider -prescribed seclusion. Which of the following is the nurse required to document? (Select all that apply) a. The client’s feelings about being secluded b. The client’s behaviors that resulted in the need for seclusion c. c. Previous interventions used to prevent the need for seclusion d. d. The client’s vital signs e. The time the client entered seclusion
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