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After returning to work after a weekend off the nurse gets report that a depressed client has been in bed all weekend. What should the nurse to first?
Assist the client out of bed and involve in activity.
A client with dementia uses the defense mechanism of confabulation. What is the reasoning?
To decrease anxiety.
A husband states to the nurse that his wife is not sleeping, buying impulsively, taking last minute trips, and has lost 22 pounds one month. What is an appropriate nursing dx?
Disturbed thought process.
A nurse is explaining a fire drill routine to a group of clients. A client becomes disruptive and continually interrupts the group. What is the nurse's best response?
When you interrupt, I cannot explain what to do to the group.
When performing a MSE on a client which assessment intervention would best assist the nurse?
Ask the client to interpret the proverb a stitch in time saves nine.
A client comes in after being in a car accident and is experiencing alcohol withdrawal, magnesium level of 1.1, cardiac dysthrythmias. What would you give first?
A woman is just told of her husband's dx of terminal cancer. What would the nurse offer for the spouse (wife)?
How would you like to be involved with your husband's care?
A nurse is to remove staples from an abdominal incision, the client is very anxious. What is the most important intervention?
Attempt to distract the client with general conversation.
A man who was stranded on the roof of his house for two days after a natural disaster, months later ...
Implement anxiety control strategies.
A man dx with bipolar disorder states, "I don't understand, I believe in God and have not done anything to deserve this". What is the nurse's best response?
You didn't do anything wrong. You have a chemical imbalance in your brain.
A client becomes upset when the nurse he requests is not assigned to him, what is the nurse's best response?
Advise the client that nursing assignments are not based on client requests.
A client needs to wash her hands for two hours before able to go on with her morning. She doesn't want to sit on the chairs in the dayroom for fear of getting dirty. What is this mechanism?
A client in group is talking about her prostitution, the nurse asks her if she was abused by her parents. She states "my mother ran my father out when I was young". What defense mechanism was used?
A woman calls the crisis hotline and says she has a loaded gun and is going to kill herself. To maintain patient confidentiality what would the nurse do?
Contact the person the client chooses to go to the home and remove the weapon.
A client with anger management issues uses belt making and bangs the leather heavily. What defense mechanisms is being used?
A bipolar client comes into the clinic and tells the nurse that the next time she sees her sister I'm going to kill her. What should the nurse do?
Inform the sister.
What would be the nurse's highest priority for a newly admitted depressed client upon admission?
The nurse should go through the client's belongings.
A client in the dayroom had tipped over a table and is escalating and has picked up a chair which he is threatening to throw at another client. What should the nurse do first?
Go and get more staff assistance.
A woman who is psychotic is carrying all of her belongings around with her because she is afraid that someone will steal it. What is the best way to establish trust?
Make brief contact with the client throughout the day.
In adolescent group discussing a handout on anger management, a client is becoming increasingly interruptive and talking about his home and pets. What is the nurse's most appropriate response?
Redirect the the handout.
A client who is refusing to take his medication is wandering on the unit and going in and out of resident's rooms. What is the priority?
Wandering in and out of other client's rooms.
A nurse observes a client in the dayroom talking to himself. What should the nurse do first?
Ask the client if they are currently hearing voices?
A client comes to the nurses' station and told the nurse that her roommate had cut her wrists in the bathroom. After assessing and dressing the wounds, what should the nurse do next?
Move the client to a private room by the nurse's station.
A man comes into the ER after being in a car accident with an alcohol level greater than 2, what should the nurse prepare to administer?
Give Ativan (I DONT THINK THIS ONE IS CORRECT)
What would be proper teaching for a client who is to start taking Antabuse?
Has not had anything alcoholic to drink for the last 48 hours.
Alzheimer's patient-nurse goes to do dressing change and the client refuses. What should the nurse do?
Leave and come back 30 minutes later.
A client is confused in an acute care hospital setting. What would support the dx of delirium instead of dementia?
Delerium: Started in hospital.
An elderly woman is brought to the ER with multiple stages of healing bruises. What should the nurse do?
Take the woman aside and ask her about abuse.
A business man is stressed about his finances, has anxiety and sleeplessness.
Limit intake of sugar and caffeine.
A mother comes into the clinic with her son who is being accused of a crime. She is worried her son will go to jail. What should the nurse say to the mother?
Consequences of enabling behaviors.
A client on LSD comes into the ER. How do you approach the client?
Talk calmly and soothing to the client.
An alcoholic father tells his wife and children to stay away from him. What is the most important nursing dx?
Risk for injury.
The parents of a teenager who has overdosed what is the first question to ask?
What drug did the client ingest?
A client becomes agitated when the nurse is talking to his wife. He has not eaten in 3 days. What should the nurse do?
Take to quiet room and give PB crackers.
A client with a hx of depression and abusing alcohol with their depression getting worse. What is the most important nursing dx?
A woman is being abused by her husband, the abuse is escalating. What would the nurse ask first?
Do you have a plan in place when you are not safe? (SAFETY!!!)
A nurse visits a community half way house with one bathroom. The nurse notices urine all over the walls of the bathroom. The toilet is clogged with feces and paper towels.
A client with Alzheimer's keeps asking for his mother. What is the nurses appropriate response?
Your mothers not here but you are safe.
A client is told to come in by friends, clients complaints include losing his job, just got a divorce, single dad with two kids, what would be the best question for nurse to ask?
What is troubling you the most?
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