1. Flumazenil (Romazicon) has been ordered for a male client who has overdosed on oxazepam (Serax). Before administering the medication, nurse Gina should be prepared for which common adverse effect?
d. Chest pain
2. Nurse Tim is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is to:
a. avoid shopping for large amounts of food
b. control eating impulses
c. identify anxiety-causing situations
d. eat only three meals per day
3. A female client who’s at high risk for suicide needs close supervision. To best ensure the client’s safety, nurse Gio should:
a. check the client frequently at irregular intervals throughout the night
b. assure the client that the nurse will hold in confidence anything the client says
c. repeatedly discuss previous suicide attempts with the client
d. disregard decreased communication by the client because this is common in suicidal clients
4. Which of the following drugs should nurse Marlyn prepare to administer to a client with a toxic acetaminophen (Tylenol) level?
a. deferoxamine mesylate (Desferal)
b. succimer (Chemet)
c. flumazenil (Romazicon)
d. acetylcysteine (Mucomyst)
5. A male client is admitted to the substance abuse unit for alcohol detoxification. Which of the following medications is nurse Apple most likely to administer to reduce the symptoms of alcohol withdrawal?
a. naloxone (Narcan)
b. haloperidol (Haldol)
c. magnesium sulfate
d. chlordiazepoxide (Librium)
6. During postprandial monitoring, a female client with bulimia nervosa tells the nurse, “You can sit with me, but you’re just wasting your time. After you sat with me yesterday, I was still able to purge. Today, my goal is to do it twice.” What is the nurse’s best response?
a. “I trust you not to purge.”
b. “How are you purging and when do you do it?”
c. “Don’t worry. I won’t allow you to purge today.”
d. “I know it’s important for you to feel in control, but I’ll monitor you for 90 minutes after you eat.”
7. A male client admitted to the psychiatric unit for treatment of substance abuse says to the nurse, “It felt so wonderful to get high.” Which of the following is the most appropriate response?
a. “If you continue to talk like that, I’m going to stop speaking to you.”
b. “You told me you got fired from your last job for missing too many days after taking drugs all night.”
c. “Tell me more about how it felt to get high.”
d. “Don’t you know it’s illegal to use drugs?”
8. For a female client with anorexia nervosa, nurse Jay is aware that which goal takes the highest priority?
a. The client will establish adequate daily nutritional intake
b. The client will make a contract with the nurse that sets a target weight
c. The client will identify self-perceptions about body size as unrealistic
d. The client will verbalize the possible physiological consequences of self-starvation
9. When interviewing the parents of an injured child, which of the following is the strongest indicator that child abuse may be a problem?
a. The injury isn’t consistent with the history or the child’s age
b. The mother and father tell different stories regarding what happened
c. The family is poor
d. The parents are argumentative and demanding with emergency department personnel
10. For a female client with anorexia nervosa, nurse Rose plans to include the parents in therapy sessions along with the client. What fact should the nurse remember to be typical of parents of clients with anorexia nervosa?
a. They tend to overprotect their children
b. They usually have a history of substance abuse
c. They maintain emotional distance from their children
d. They alternate between loving and rejecting their children
11. In the emergency department, a client with facial lacerations states that her husband beat her with a shoe. After the health care team repairs her lacerations, she waits to be seen by the crisis intake nurse, who will evaluate the continued threat of violence. Suddenly the client’s husband arrives, shouting that he wants to “finish the job.” What is the first priority of the health care worker who witnesses this scene?
a. Remaining with the client and staying calm
b. Calling a security guard and another staff member for assistance
c. Telling the client’s husband that he must leave at once
d. Determining why the husband feels so angry
12. . Nurse Venus is caring for a client with bulimia. Strict management of dietary intake is necessary. Which intervention is also important?
a. Fill out the client’s menu and make sure she eats at least half of what is on her tray.
b. Let the client eat her meals in private. Then engage her in social activities for at least 2 hours after each meal
c. Let the client choose her own food. If she eats everything she orders, then stay with her for 1 hour after each meal
d. Let the client eat food brought in by the family if she chooses, but she should keep a strict calorie count.
13. Nurse Mary is assigned to care for a suicidal client. Initially, which is the nurse’s highest care priority?
a. Assessing the client’s home environment and relationships outside the hospital
b. Exploring the nurse’s own feelings about suicide
c. Discussing the future with the client
d. Referring the client to a clergyperson to discuss the moral implications of suicide
14. A 24-year old client with anorexia nervosa tells the nurse, “When I look in the mirror, I hate what I see. I look so fat and ugly.” Which strategy should the nurse use to deal with the client’s distorted perceptions and feelings?
a. Avoid discussing the client’s perceptions and feelings
b. Focus discussions on food and weight
c. Avoid discussing unrealistic cultural standards regarding weight
d. Provide objective data and feedback regarding the client’s weight and attractiveness
15. Nurse Desmond is caring for a client being treated for alcoholism. Before initiating therapy with disulfiram (Antabuse), the nurse teaches the client that he must read labels carefully on which of the following products?
a. Carbonated beverages
b. Aftershave lotion
16. Nurse Faith is developing a plan of care for a client with anorexia nervosa. Which action should the nurse include in the plan?
a. Restrict visits with the family until the client begins to eat
b. Provide privacy during meals
c. Set up a strict eating plan for the client
d. Encourage the client to exercise, which will reduce her anxiety
17. Nurse Tina is aware that the victims of domestic violence should be assessed for what important information?
a. Reasons they stay in the abusive relationship (for example, lack of financial autonomy and isolation)
b. Readiness to leave the perpetrator and knowledge of resources
c. Use of drugs or alcohol
d. History of previous victimization
18. A male client is hospitalized with fractures of the right femur and right humerus sustained in a motorcycle accident. Police suspect the client was intoxicated at the time of the accident. Laboratory tests reveal a blood alcohol level of 0.2% (200 mg/dl). The client later admits to drinking heavily for years. During hospitalization, the client periodically complains of tingling and numbness in the hands and feet. Nurse Gio realizes that these symptoms probably result from:
a. acetate accumulation
b. thiamine deficiency
c. triglyceride buildup.
d. a below-normal serum potassium level
19. A parent brings a preschooler to the emergency department for treatment of a dislocated shoulder, which allegedly happened when the child fell down the stairs. Which action should make the nurse suspect that the child was abused?
a. The child cries uncontrollably throughout the examination
b. The child pulls away from contact with the physician.
c. The child doesn’t cry when the shoulder is examined
d. The child doesn’t make eye contact with the nurse.
20. When planning care for a client who has ingested phencyclidine (PCP), nurse Wayne is aware that the following is the highest priority?
a. Client’s physical needs
b. Client’s safety needs
c. Client’s psychosocial needs
d. Client’s medical needs
21. The nurse is aware that the outcome criteria would be appropriate for a child diagnosed with oppositional defiant disorder?
a. Accept responsibility for own behaviors
b. Be able to verbalize own needs and assert rights.
c. Set firm and consistent limits with the client
d. Allow the child to establish his own limits and boundaries
22. A male client is found sitting on the floor of the bathroom in the day treatment clinic with moderate lacerations on both wrists. Surrounded by broken glass, she sits staring blankly at her bleeding wrists while staff members call for an ambulance. How should nurse Grace approach her initially?
a. Enter the room quietly and move beside her to assess her injuries
b. Call for staff back-up before entering the room and restraining her
c. Move as much glass away from her as possible and sit next to her quietly
d. Approach her slowly while speaking in a calm voice, calling her name, and telling her that the nurse is here to help her
23. A female client with anorexia nervosa describes herself as “a whale.” However, the nurse’s assessment reveals that the client is 5′ 8″ (1.7 m) tall and weighs only 90 lb (40.8 kg). Considering the client’s unrealistic body image, which intervention should nurse Angel be included in the plan of care?
a. Asking the client to compare her figure with magazine photographs of women her age
b. Assigning the client to group therapy in which participants provide realistic feedback about her weight
c. Confronting the client about her actual appearance during one-on-one sessions, scheduled during each shift
d. Telling the client of the nurse’s concern for her health and desire to help her make decisions to keep her healthy
24. Eighteen hours after undergoing an emergency appendectomy, a client with a reported history of social drinking displays these vital signs: temperature, 101.6° F (38.7° C); heart rate, 126 beats/minute; respiratory rate, 24 breaths/minute; and blood pressure, 140/96 mm Hg. The client exhibits gross hand tremors and is screaming for someone to kill the bugs in the bed. Nurse Melinda should suspect:
a. a postoperative infection
b. alcohol withdrawal
c. acute sepsis.
25. Clonidine (Catapres) can be used to treat conditions other than hypertension. Nurse Sally is aware that the following conditions might the drug be administered?
a. Phencyclidine (PCP) intoxication
b. Alcohol withdrawal
c. Opiate withdrawal
d. Cocaine withdrawal