15. A nurse in a substance treatment

15. A nurse in a substance treatment facility is contributing to the plan of care for a newly admitted client. Which of the following interventions should the nurse recommend? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.) 57-year-old male client who has a 10 year history of alcohol use disorder reports consuming 30 beers per day Reports last alcohol intake was 6 hr prior to admission Graphic Record BP 198/90 mm Hg Heart rate 110 / min Respiratory rate 24 / min Complete a CAGE questionnaire every 4 hr. Assist with a client referral to Al-Anon Administer disulfiram Implement seizure precautions 16. A nurse is contributing to the plan of care for a client who has a new prescription for lithiumWhich of the following interventions should the nurse recommend? Administer the medication with meals Decrease the client’s dietary potassium Monitor the client’s for hypoglycemia Increase the clients daily caloric intake 17. is caring for a client who is taking clozapine. Which of the following laboratory test results should the nurse identify as a contraindication for administering clozapine? WBC 2,900/ mm Potassium 5.0 mEq/dL Fasting blood glucose 82 mg Hgb 13.1 g/dL 18.nurse is caring for a client who has major depressive disorder. The client who had a flat affect and was quiet yesterday comes to group therapy appearing happy and content. The client tells the groupEverything will be okay soon.Which of the following actions should the nurse take first Ask the client to sign a 24hr no harm contract Record the client’s mood every 15 min Provide positive feedback to the client for group involvement Ask the client if he plans to himself 19.nurse is caring for a client who has a phobia of elevators. Which of the following behavioral strategies should the nurse plan to use to decrease anxiety? Flooding Systematic desensitization Thought stopping Response prevention 20. A nurse is collecting data from a client who has bipolar disorderWhich of the following findings is the nurse’s priority? The client refuses to eat. The client dresses in vivid , bright colors The client talks excessively. The client sleeps 6 hr at night . 21. A nurse is caring for a client who has major depressive disorder and reports insomnia. The nurse should anticipate a PRN prescription from the provider for which of the following medications? Trazodone Valproic acid Lithium carbonate Methylphenidate 22. A nurse is assisting with a community health education and support service for individuals who have lost loved ones to suicide. Which of the following actions should the nurse take when caring for these individuals? the individual talks about their deceased loved one before mentioning their name Ask open ended questions when talking to the individual about their grief Recommend that the individual wait at least 3 months before joining a support group Refer to the deceased person as the client not the individual 23. is reinforcing discharge teaching with a who has bipolar disorderWhich of the following statements should the nurse identify as an that understands the instructions? It is okay to have a glass of wine with dinner a few nights a week Weekly sessions of electroconvulsive therapy will minimize my symptoms Attending group therapy will decrease my need for medication An early sign of relapse is having trouble sleeping 24.A nurse is caring for a group of clients in a pediatric clinicWhich of the following clients is at highest risk for physical abuse? A preschooler who is reluctant to share An adolescent who is preparing to leave home for college A school-age child who wants to go away to summer camp A toddler who has cystic fibrosis 25. A nurse is reinforcing teaching with a newly licensed nurse about the therapeutic nurse client relationship. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? client explores his feelings about others during the orientation phase of the relationship The responsibilities of the nurse and are discussed during the working phase of the relationship Termination of the therapeutic relationship can lead to feelings of loss for the nurse and client “It is acceptable during the orientation phase of the relationship for the nurse to assure the client that she will keep a secret. 26.A nurse is caring for a client who has major depressive disorder and tells the nurse that although they are feeling better, their future still looks bleakWhich of the following interventions is the nurse’s priority? Use open ended questions to encourage the client to express their feelings Spend scheduled periods with the client during the day Assist the client to evaluate positive and negative life experiences Determine the has any plans to harm themselves 27. A nurse in a pediatric clinic is caring for a school-age child who has a perforated eardrum. The nurse suspects abuse. Which of the following actions should the nurse take? Avoid asking the child what caused the injury Inform the parents that the findings must be reported to authorities Interview the child about the suspected abuse with a parent present Complete an incident report for risk management 28. A nurse at a community mental health center is caring for a client who has bipolar disorder. The nurse should recognize that which of the following statements is an indication that the client is in the manic phase? I’ve been crying in the past 3 days because my cat died I was able to pay my bills last month but this month i fell behind My family says i’m thinking clearly now that taking my medication I haven’t been able to stop talking for the past couple of days . 29. nurse in a long-term care facility is collecting data from an older adult client who has a respiratory infectionWhich of the following findings indicates that the client is developing delirium? Decreased blood pressure Disorganized thinking Pale dry skin Pinpoint pupils 30.A home health nurse is caring for a client who has Alzheimer’s disease and lives with her adult child. The child is concerned for the client’s safety because the client wandered away from home several nights agoWhich of the following recommendations should the nurse make? Provide complex activities to exercise Muscles Encourage the to take naps in the late afternoon Provide a high-Stimulation Environment Establish a place for the client to walk inside the house SCIENCE HEALTH SCIENCE NURSING NURS 210

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