11. The nurse assesses a client who

11. The nurse assesses a client who recently began experiencing violent nightmares. Which factor in the client’s history should the nurse further explore? A. Alcohol use. B. Witness to an accident. C. Family history of dementia. D. Inadequate diversional activity. 12. A client with opioid dependence makes a statement to the nurse about desiring to lead a healthier lifestyle by making changes in the next 2weeks. How should the nurse respond? A. Advise the client to reschedule until committing to recovery. B. Provide teaching on the symptoms of substance use dependence. C. Explain the specific skills needed to prevent a relapse. D. Support the client to list small behavioral changes needed. 13. A client who refuses antipsychotic medications disrupts group activities, talks with nonsensical words, and wanders into client’s rooms. The nurse decides that the client needs constant observation based on which of these assessment findings? A Wanders into client’s rooms. B Refuses antipsychotic medications. C Disrupts group activities. D. Talks with nonsensical words. 14. An adolescent who is a heroin addict is admitted to the unit for detoxification. What intervention is most important for the nurse to initiate during the first 24 hours after admission? A. Assess intake and output. B. Limit visitors to family members only. C. Monitor for wheezing and apnea. D. Assign the client to a teen support group 15. A female client with obsessive compulsive disorder complains that she feels “driven to check the locks on her front door at least six times every night. Which response is best for the nurse to provide? A. What are your thoughts when you are checking the locks? B. Feelings of being driven to do something are related to anxiety. C. Repeating the same behavior helps you to diminish your anxiety. D. Have you had a bad experience related to unlocked doors? 16. A client who experiences memory loss is diagnosed with Wernicke encephalopathy caused by alcohol addiction. Which intervention is most important for the nurse to implement? A. Nutrition referral. B. Individual addiction counseling. C. Thiamine administration. D. Initiate disulfiram teaching. 17. The mental health nurse observes that a female client with delusional disorder cames some of her belongings with her because she believes that others are trying to steal them. Which nursing action will promote trust? A. Explain that these beliefs are related to her illness. B. Explain that distrust is related to feeling anxious. C. Initiate short, frequent contacts with the client. D. Offer to keep the belongings at the nurse’s desk. 18. An adolescent who is exhibiting a depressed affect receives a prescription for an antidepressant drug. While the client is taking the antidepressant, which comparison of the client’s behavior before and after taking the drug is most important for the nurse to obtain? A. Appetite. B. The emotional quality of attitude. C. The interactions with others. D. Level of activity. 19. When the nurse addresses questions to an adult female client who is depressed, the client’s responses are delayed. Which intervention should the nurse include in this client’s plan of care? A. Observe for signs of possible psychosis. B. Involve client in daily exercise program. C. Ask the client to describe her depression. D. Spend time sitting in silence with client. 20. While visiting the community mental health center, a client with a diagnosis of major depressive disorder asks the nurse if what is shared with the staff will be shared with family members. How should the nurse respond to this client? A. Tell the client that confidentiality will be maintained, except when one’s safety is threatened. B. Provide the client with a written hospital policy regarding privacy of information laws. C. Nod in the affirmative, but make no verbal commitment to the client. D. Assure the client that information provided will be shared with the staff only. SCIENCE HEALTH SCIENCE NURSING NURS NURS-3410

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