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NU401 Exam 3 Latest Update @ 2024
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NU401 Exam 3 Latest Update @ 2024A nurse discovers a clients suicide note that details the time, place, and means to
commit
suicide. What should be the priority nursing action, and why?
1. Administer lorazepam (Ativan) prn, because the client is angry about plan exposure.
2. Establish room restrictions, because the clients threat is an attempt to manipulate the
staff.
3. Place client on one-to-one suicide precautions, because specific plans likely lead to
attempts.
4. Call an emergency treatment team meeting, because the clients threat must be
addressed - Answer 3
In planning care for a suicidal client, which correctly written outcome should be a
nurses first
priority?
1. The client will not physically harm self.
2. The client will express hope for the future by day three.
3. The client will establish a trusting relationship with the nurse.
4. The client will remain safe during hospital stay. - Answer 4
A nurse administers 100% oxygen to a client during and after electroconvulsive therapy
treatment (ECT). What is the rationale for this procedure?
1. To prevent increased intracranial pressure resulting from anoxia.
2. To prevent decreased blood pressure, pulse, and respiration owing to electrical
stimulation.
3. To prevent anoxia resulting from medication-induced paralysis of respiratory
muscles.
4. To prevent blocked airway, resulting from seizure activity. - Answer 3
Immediately after electroconvulsive therapy (ECT), in which position should a nurse
place the
client?
1. On his or her side, to prevent aspiration
,2. In high Fowlers position, to prevent increased intracranial pressure
3. In Trendelenburgs position, to promote blood flow to vital organs
4. In prone position, to prevent airway blockage - Answer 1
A client is diagnosed with major depressive episode. Which nursing diagnosis should a
nurse
assign to this client, to address a behavioral symptom of this disorder?
1. Altered communication R/T feelings of worthlessness AEB anhedonia
2. Social isolation R/T poor self-esteem AEB secluding self in room
3. Altered thought processes R/T hopelessness AEB persecutory delusions
4. Altered nutrition: less than body requirements R/T high anxiety AEB anorexia -
Answer 2
A client diagnosed with major depressive episode hears voices commanding self-harm.
Which
should be the nurses priority intervention at this time?
1. Obtaining an order for locked seclusion until client is no longer suicidal.
2. Conducting 15-minute checks to ensure safety.
3. Placing the client on one-to-one observation while continuing to monitor suicidal
ideations.
4. Encouraging client to express feelings related to suicide. - Answer 3
A nurse assesses a client suspected of having the diagnosis of major depressive
episode.
Which client symptom would rule out this diagnosis?
1. The client is disheveled and malodorous.
2. The client refuses to interact with others and isolates self in room.
3. The client is unable to feel any pleasure.
4. The client has maxed-out charge cards and exhibits promiscuous behaviors. - Answer
4
A client with a history of suicide attempts has been taking fluoxetine (Prozac) for one
month.
The client suddenly presents with a bright affect, rates mood at 9 out of 10, and is much
,more
communicative. Which action should be the nurses priority at this time?
1. Give the client off-unit privileges as positive reinforcement.
2. Encourage the client to share mood improvement in group.
3. Increase the level of this clients suicide precautions.
4. Request that the psychiatrist reevaluate the current medication protocol. - Answer 3
A nurse reviews the laboratory data of a client suspected of having the diagnosis of
major
depressive episode. Which lab value would potentially rule out this diagnosis?
1. Thyroid-stimulating hormone (TSH) level of 25 U/mL
2. Potassium (K+) level of 4.2 mEq/L
3. Sodium (Na+) level of 140 mEq/L
4. Calcium (Ca2+) level of 9.5 mg/dL - Answer 1
A depressed client reports to a nurse a history of divorce, job loss, family estrangement,
and
cocaine abuse. Which theoretical principle best explains the etiology of this clients
depressive
symptoms?
1. According to psychoanalytic theory, depression is a result of negative perceptions.
2. According to object-loss theory, depression is a result of overprotection.
3. According to learning theory, depression is a result of repeated failures.
4. According to cognitive theory, depression is a result of anger turned inward. - Answer
3
What is the rationale for a nurse to perform a full physical health assessment on a client
admitted with a diagnosis of major depressive episode?
1. The attention during the assessment is beneficial in decreasing social isolation.
2. Depression can generate somatic symptoms that can mask actual physical disorders.
3. Physical health complications are likely to arise from antidepressant therapy.
4. Depressed clients avoid addressing physical health and ignore medical problems. -
, Answer 2
A nurse is planning care for a 13 -year-old who is experiencing depression. Which
medication is approved by the Food and Drug Administration (FDA) for the treatment of
depression in adolescents?
1. Paroxetine (Paxil)
2. Sertraline (Zoloft)
3. Citalopram (Celexa)
4. Escitalopram (Lexipro) - Answer 4
A nurse admits an older client with memory loss, confused thinking, and apathy. A
psychiatrist suspects a depressive disorder. What is the rationale for performing a
mini-mental
status exam?
1. To rule out bipolar disorder
2. To rule out schizophrenia
3. To rule out neurocognitive disorder
4. To rule out personality disorder - Answer 3
A nurse recently admitted a client to an inpatient unit after a suicide attempt. A
health-care
provider orders amitriptyline (Elavil) for the client. Which intervention, related to this
medication, should be initiated to maintain this clients safety upon discharge?
1. Provide a 6-month supply of Elavil to ensure long-term compliance.
2. Provide a 1-week supply of Elavil, with refills contingent on follow-up appointments.
3. Provide pill dispenser as a memory aid.
4. Provide education regarding the avoidance of foods containing tyramine. - Answer 2
An older client has recently been prescribed sertraline (Zoloft). The clients spouse is
taking
paroxetine (Paxil). A nurse assesses that the client is experiencing restlessness,
tachycardia,
diaphoresis, and tremors. Which complication should a nurse suspect, and why?
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