1. Which interventions should the nurse include

1. Which interventions should the nurse include in the plan of care for an adolescent who is depressed? (Select all that apply.) A. Limit time allowed to play video games. B. Restrict visitors to family members only. C. Encourage the client to discuss thoughts and feelings about wanting to die. D. Reinforce statements regarding a will to live and realistic plans for the future. E. Discuss the client’s suicide plan. 2. A female client with obsessive-compulsive personality disorder is admitted to the hospital for a cardiac catheterization. The afternoon before the procedure, the client begins to keep detailed notes of the nursing care she is receiving, and reports her findings to the nurse at bedtime. What action should the nurse implement? A)Explain to the client that her behavior invades the rights of the nursing staff. B)Ask the client to explain why she is keeping a detailed record of her nursing care. C)Encourage the client to express her feelings regarding the upcoming procedure. D)Teach the client strategies to control her obsessive-compulsive behavior. 3. A client who is an alcoholic receives a prescription for disulfiram 500 mg PO daily. Which instruction should the nurse provide to this client? A. Begin taking the medication immediately and take it daily, regardless of whether or not you drink alcohol. B. Take the medication with at least 8 ounces of water and limit alcohol consumption while taking this medication. C. Take the medication each morning beginning 48 hours after your last drink of alcohol. D. Take the medication at bedtime and avoid consuming any more than one ounce of alcohol daily. 4. A client with a mood disorder receives a new prescription for lithium carbonate. Which information provided by the client requires additional instruction by the nurse? A) Therapeutic effects may take 3 weeks. B) Blood will be drawn routinely. C) Insomnia is a common side effect. D) Gastric upset may be experienced. 5 of 55 A client who was in a motor vehicle collision related to alcohol intoxication recovering in the hospital following surgery. Which statement by the client’s spouse indicates codependency? A. The spouse informs the client of plans to move out of their home if the drinking doesn’t stop. B. The spouse tells the nurse the accident was precipitated by high stress that led to drinking. C. The spouse tells the nurse that the client was irresponsible and reckless for driving while drunk. D. The spouse tells the client they were attending a wedding of friends the following day. 6. A male client with known auditory hallucinations begins talking loudly and gesturing wildly while in the unit’s day room. Which action should the nurse implement first? A. Escort the client to his room. B. Administer a PRN sedative. C. Sit in the chair next to the client. D. Listen to what the client is saying. 7. A client diagnosed with schizophrenia has been receiving haloperidol for the past year, and the treatment plan includes moving the client to a lower maintenance dosage. Which intervention should the nurse include in this client’s plan of care? A. Enforcing a fluid restriction during dosage adjustment. B. Shielding the client from direct sunlight when outdoors. C. Increasing the dosage if the white blood cell count drops. D. Gradually withdrawing the medication over several days. 8. When assessing a client who takes psychotropic medications, the nurse notes that the client has uncontrollable hand movements and is excessively protruding the tongue. Which assessment in the client’s record should the nurse review? A. Abnormal Involuntary Movement Scale (AIMS). B. Recent urine drug testing (UDT) results. C. Baseline nursing admission assessment. D. The healthcare provider’s history and physical. 9. A male client, assessed in the emergency department (ED), has a strong odor of alcohol on his breath. The client denies thoughts of harm to self or others, and the healthcare provider discharges the client. As the client begins to leave, the nurse overhears the client mumble, “Now I’m going to shoot myself.” Which intervention should the nurse implement? A. Inquire about the client’s support system. B. Record the statement in the client’s chart. C. Stop the client from leaving the ED. D. Ask the client to repeat his comment. 10. The nurse is caring for a client who has a history of experiencing delusions. The client describes singing in a concert in the afternoon for thousands of people. Which action should the nurse take? A. Immediately inform the provider that the client is experiencing a delusional episode. B. Attempt to comfort the client by agreeing with the delusions and ask open ended questions. C. Present a personal perception of reality in a non-confrontational manner. D. Disagree with the statement and set clear limits on talking about it SCIENCE HEALTH SCIENCE NURSING NURS NURS-3410

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