Exam Review
- Cartton is 70 years old and has recently lost his wife and his best male friend within the past 3 months. His daughter brings him to the clinic because he has become forgetful, is not eating, has been sleeping poorly, and is frequently complaining of many aches and pains. Which assessment instrument would be most helpful at this time, considering his symptom presentation?A)Delirium Rating ScaleB)Confusion Assessment Instrument (CAM)C)Mini Mental Status Exam (MMSE)D)Geriatric Depression Scale
- A nurse provides care for an adolescent patient diagnosed with an eating disorder. Which behaviour by this nurse indicates that additional clinical supervision is needed?A)The nurse interacts with the patient in a protective fashionB)The nurse refers the patient to a self-help group for individuals with eating disordersC)The nurse teaches the patient to recognize signs of increasing anxiety and ways to interveneD)The nurse's comments to the patient are compassionate and nonjudgmental
- A patient diagnosed with depression tells the nurse, "I want to try supplementing my selective serotonin reuptake inhibitor with St John's wort." Which action should the nurse take first?A)Advise the patient of the danger of serotonin syndromeB)Suggest the patient decrease the antidepressant doseC)Assess the patient for depression and risk for suicideD)Suggest that aromatherapy may produce better results
- A 14-year-old belongs to a gang that bullies and punishes other teens, engages sexually promiscuous behaviour, attends school infrequently and argues with her parents, claiming they are just old-fashioned and don't understand her. What does the assessment data support about the patient?A)That she cannot accurately appraise realityB)That she is exhibiting problems related to conduct and behaviourC)That she is seriously and persistently mentally illD)That she should be considered for group home placement
Exam Review
- An older adult patient was diagnosed with schizophrenia at age 18. A nurse at the outpatient medication clinic interviews this patient. Which communication strategy will be most helpful?A)Use silence often and let the patient take the leadB)Ask clear, simple questions using concrete languageC)Use open-ended, indirect questionsD)Ask questions that can be answered with "yes" or "no"
- When determining whether an elderly patients confusion is related to delirium or another problem, what information would be of particular value?A)The patient's level of motor activityB)Evidence of spasticity or flaccidityC)Was this an acute onset of symptomsD)The patient's level of preoccupation with somatic symptoms
- Which nursing intervention demonstrates false imprisonment?A)An involuntary hospitalized patient with suicidal ideation runs out of the psychiatric unit. The nurse rushes after the patient and convinces the patient to return to the unitB)An involuntarily hospitalized patient with homicidal ideation attempts to leave the facility. A nurse calls the security team and uses established protocols to prevent the patient from leaving.C)A confused and combative patient says, "I'm getting out of here, and no one can stop me." The nurse restrains this patient without a health care providers order until the next morning at which time he obtains an orderD)A patient has been irritating and attention-seeking much of the day. A nurse escorts the patient down the hall saying, "Stay in your room, or you be put in seclusion"
- The RPN is unsure if Henry Picard, age 87, is manifesting symptoms of delirium or dementia. Which question might he ask the Picard family?A)"Do you know if Henry has Alzheimer's disease?"B)"How long has Henry shown confused thinking?"C)"Has Henry ever been violent?"D)"Do you have any family members with a history"
Exam Review
- A patient with Schizophrenia has been prescribed an antipsychotic medication. They return to the clinic complaining they are experiencing leaking from their breasts. What drug would the nurse assume is responsible for this side effect?A)LoxapineB)RisperidoneC)ZyprexaD)Haldol
- Which documentation for patient diagnosed with major depression indicates the treatment plan was effectiveA)Slept 5 hours with brief interruptions. Personal hygiene adequate with assistance. Weight loss of 1 pound.B)Slept 10 hours uninterrupted. Attended craft group; stated "project was a failure, just like me"C)Slept 7 hours uninterrupted. Preoccupied with perceived inadequaciesD)Slept 6 hours uninterrupted. Sang with activity group. Anticipates seeing grandchild
- Individuals with affective instability personality disorder display a pattern of intense and chaotic relationships withA)Borderline Personality disorderB)Avoidant personality disorderC)Histrionic personality disorderD)Antisocial personality disorder
- Mr Olsen, age 75 years, lives in a nursing home and diagnosed with mild dementia. Occasionally he attempts to get out of bed during the night and is a risk tor falls. What nursing intervention should the practical nurse use to ensure his safety?A)Restrict fluid intake after 1800HB)Place the bed in the lowest position at bedtimeC)Ensure that all side rails are up at bedtimeD)Apply a PRN restraint at HS
Exam Review
- Patient reveals that she induces vomiting as often as a dozen times a day. Which at the following would the nurse expect assessment findings to reveal?A)HypolipidemiaB)HypercalcemiaC)TachycardiaD)Hypokalemia
- Which intervention is appropriate an individual diagnosed with antisocial personality disorder who frequently manipulates others?A)Ignore, rather than confront, inappropriate behaviourB)Ensure limits are adhered to by all staffC)Provide negative reinforcement for acting-out behaviourD)Encourage the patient to discuss feelings of fear and inferiority
- During a psychiatric assessment, the nurse observes a patients facial expression is without emotion. The patient says, "Life feels so hopeless to me I've been feeling sad for several months." How will the nurse document the patient's affect and mood?A)Affect depressed; mood flatB)Affect and mood incongruentC)Affect labile: mood euphoricD)Affect flat; mood depressed
- A 79-year-old male tells a nurse, "I have felt very sad lately. I do not have much to live for. My family and friends are all dead, and my own health is failing." The nurse should analyze this comment as which of the following?A)Normal pessimism of the elderlyB)Normal grievingC)A call for sympathyD)Evidence of risks for suicide
Exam Review
- While conducting the initial interview with a patient in crisis, the nurse should do which of the following?A)Convey a sense of urgency to the patientB)Let the patient know the nurse controls the interviewC)Be forthright about time limits of the interviewD)Listen carefully and summarize often
- A nurse documents, "Patient is mute despite repeated efforts to elicit speech. Makes no eye contact. Inattentive to staff. Gazes off to the side or looks upward rather than at speaker." Which nursing diagnosis should be considered?A)Decisional conflictB)Maladaptive defensive copingC)Impaired verbal communicationD)Risk for other directed violence
- Which indication warrants the use of seclusion?A)To decrease environmental stimulationB)To protect from self-harmC)To encourage self-reflectionD)To increase self-isolation
- A patient admitted for injuries sustained while intoxicated has been hospitalized for 48 hours. The patient is now shaky, irritable, anxious and diaphoretic and reports nightmares. The pulse rate is 130 beats/min. The patient shouts, "Bugs are crawling on my bed. I've got to get out of here." Select the most accurate assessment of this situation.A)The patient has symptoms of alcohol-withdrawal deliriumB)The patient may have sustained a head injury before admissionC)The patient is attempting to obtain attention by manipulating staffD)The patient is having an acute psychosis.