Psychiatric Nursing | NCLEX Quiz 180 | Attempts: 3596

2.

When planning care for a client who has ingested phencyclidine (PCP). nurse Wayne is aware that the following is the highest priority?

Client’s physical needs
Client’s safety needs
Client’s psychosocial needs
Client’s medical needs

Correct Answer

A. Client’s safety needs

Explanation

The highest priority for a client who has ingested PCP is meeting safety needs of the client as well as the staff. Drug effects are unpredictable and prolonged. and the client may lose control easily.Options A. C. and D: After safety needs have been met. the client’s physical. psychosocial. and medical needs can be met.

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3.

Nurse Mary is caring for a client with bulimia. Strict management of dietary intake is necessary. Which intervention is also important?

Fill out the client’s menu and make sure she eats at least half of what is on her tray.
Let the client eat her meals in private. Then engage her in social activities for at least 2 hours after each meal
Let the client choose her own food. If she eats everything she orders. then stay with her for 1 hour after each meal
Let the client eat food brought in by the family if she chooses. but she should keep a strict calorie count.

Correct Answer

A. Let the client choose her own food. If she eats everything she orders. then stay with her for 1 hour after each meal

Explanation

Allowing the client to select her own food from the menu will help her feel some sense of control.Option A: She must then eat 100% of what she selected.Option B: Remaining with the client for at least 1 hour after eating will prevent purging.Option D: Bulimic clients should only be allowed to eat food provided by the dietary department.

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4.

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?

Remaining with the client and staying calm
Calling a security guard and another staff member for assistance
Telling the client’s husband that he must leave at once
Determining why the husband feels so angry

Correct Answer

A. Calling a security guard and another staff member for assistance

Explanation

The health care worker who witnesses this scene must take precautions to ensure personal as well as client safety but shouldn’t attempt to manage a physically aggressive person alone. Therefore. the first priority is to call a security guard and another staff member.Option A: After doing this. the health care worker should inform the husband what is expected. speaking in concise statements and maintaining a firm but calm demeanor. This approach makes it clear that the health care worker is in control and may diffuse the situation until the security guard arrives.Option C: Telling the husband to leave would probably be ineffective because of his agitated and irrational state.Option D: Exploring his anger doesn’t take precedence over safeguarding the client and staff.

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5.

Nurse Harry is developing a plan of care for a client with anorexia nervosa. Which action should the nurse include in the plan?

Restrict visits with the family until the client begins to eat
Provide privacy during meals
Set up a strict eating plan for the client
Encourage the client to exercise. which will reduce her anxiety

Correct Answer

A. Set up a strict eating plan for the client

Explanation

Establishing a consistent eating plan and monitoring the client’s weight are important for this disorder.Option A: The family should be included in the client’s care.Option B: The client should be monitored during meals — not given privacy.Option D: Exercise must be limited and supervised.

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6.

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 Gian realizes that these symptoms probably result from:

Acetate accumulation
Thiamine deficiency
Triglyceride buildup.
A below-normal serum potassium level

Correct Answer

A. Thiamine deficiency

Explanation

Numbness and tingling in the hands and feet are symptoms of peripheral polyneuritis. which results from inadequate intake of vitamin B1 (thiamine) secondary to prolonged and excessive alcohol intake. Treatment includes reducing alcohol intake. correcting nutritional deficiencies through diet and vitamin supplements. and preventing such residual disabilities as foot and wrist drop.Options A. C. and D: Acetate accumulation. triglyceride buildup. and a below-normal serum potassium level are unrelated to the client’s symptoms.

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7.

Nurse Alice 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?

Carbonated beverages
Aftershave lotion
Toothpaste
Cheese

Correct Answer

A. Aftershave lotion

Explanation

Disulfiram may be given to clients with chronic alcohol abuse who wish to curb impulse drinking. Disulfiram works by blocking the oxidation of alcohol. inhibiting the conversion of acetaldehyde to acetate. As acetaldehyde builds up in the blood. the client experiences noxious and uncomfortable symptoms. Even alcohol rubbed onto the skin can produce a reaction. The client receiving disulfiram must be taught to read ingredient labels carefully to avoid products containing alcohol such as aftershave lotions.Options A. C. and D: Carbonated beverages. toothpaste. and cheese don’t contain alcohol and don’t need to be avoided by the client.

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8.

Nurse Mary is assigned to care for a suicidal client. Initially. which is the nurse’s highest care priority?

Assessing the client’s home environment and relationships outside the hospital
Exploring the nurse’s own feelings about suicide
Discussing the future with the client
Referring the client to a clergyperson to discuss the moral implications of suicide

Correct Answer

A. Exploring the nurse’s own feelings about suicide

Explanation

The nurse’s values. beliefs. and attitudes toward self-destructive behavior influence responses to a suicidal client; such responses set the overall mood for the nurse-client relationship. Therefore. the nurse initially must explore personal feelings about suicide to avoid conveying negative feelings to the client.Option A: Assessment of the client’s home environment and relationships may reveal the need for family therapy; however. conducting such an assessment isn’t a nursing priority.Option C: Discussing the future and providing anticipatory guidance can help the client prepare for future stress. but this isn’t a priority.Option D: Referring the client to a clergyperson may increase the client’s trust or alleviate guilt; however. it isn’t the highest priority.

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9.

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?

The child cries uncontrollably throughout the examination
The child pulls away from contact with the physician.
The child doesn’t cry when the shoulder is examined
The child doesn’t make eye contact with the nurse.

Correct Answer

A. The child doesn’t cry when the shoulder is examined

Explanation

A characteristic behavior of abused children is the lack of crying when they undergo a painful procedure or are examined by a health care professional. Therefore. the nurse should suspect child abuse.Options A. B. and D: Crying throughout the examination. pulling away from the physician. and not making eye contact with the nurse are normal behaviors for preschoolers.

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3

10.

Nurse Taylor is aware that the victims of domestic violence should be assessed for what important information?

Reasons they stay in the abusive relationship (for example. lack of financial autonomy and isolation)
Readiness to leave the perpetrator and knowledge of resources
Use of drugs or alcohol
History of previous victimization

Correct Answer

A. Readiness to leave the perpetrator and knowledge of resources

Explanation

Victims of domestic violence must be assessed for their readiness to leave the perpetrator and their knowledge of the resources available to them. Nurses can then provide the victims with information and options to enable them to leave when they are ready.Option A: The reasons they stay in the relationship are complex and can be explored at a later time.Option C: The use of drugs or alcohol is irrelevant.Option D: There is no evidence to suggest that previous victimization results in a person’s seeking or causing abusive relationships.

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1

Psychiatric Nursing | NCLEX Quiz 180

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?

Quiz Preview

When planning care for a client who has ingested phencyclidine (PCP). nurse Wayne is aware that the following is the highest priority?

Nurse Mary is caring for a client with bulimia. Strict management of dietary intake is necessary. Which intervention is also important?

Nurse Harry is developing a plan of care for a client with anorexia nervosa. Which action should the nurse include in the plan?

Nurse Alice 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?

Nurse Mary is assigned to care for a suicidal client. Initially. which is the nurse’s highest care priority?

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?

Nurse Taylor is aware that the victims of domestic violence should be assessed for what important information?