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346 HESI
OBGYN/Psychiatric Nursing HESI
| Question | Answer |
|---|---|
| Which finding indicates to the nurse that a 4-day-old infant is receiving adequate breast milk? | Saturates 6 to 8 diapers per day. |
| Using an anticonvulsant for epilepsy. | Anticonvulsants may yield false-positive pregnancy test results |
| Which finding in the medical history of a post-partum client should the nurse withhold the administration of a routine standing order for methylergonovine maleate (Methergine)? | Pregnancy induced hypertension. |
| A client who is stable has family members present when the nurse enters the birthing suite to assess the mother and newborn. What action should the nurse implement at this time? | Observe interactions of family members with the newborn and each other. **An opportunity to assess the emotional adjustment of individual family members to birth and lifestyle changes is presented. |
| While inspecting a newborn’s head, the nurse identifies a swelling of the scalp that does not cross the suture line. Which finding should the nurse document? | Cephalohematoma. **collection of blood beneath the periosteum of the cranial bone causing scalp swelling that does not cross the suture line |
| Molding | overlapping of cranial bones that occurs as the fetal head accommodates for the descent through the vaginal vault. |
| Caput Succedaneum | differentiated from a cephalohematoma by generalized edematous swelling of the presenting part of the head. |
| Bulging Fontanel | Fontanel tension should feel slightly concave and well defined against the edges of the cranial bones, whereas a bulging anterior fontanel is tense and distends from an increased intracranial pressure, such as seen in congenital hydrocephalus. |
| congenital hydrocephalus | baby born with excessive accumulation of cerebrospinal fluid (CSF) in the brain |
| The nurse is teaching a primigravida at 10-weeks gestation about the need to increase her intake of folic acid. Which explanation should the nurse provide that supports preventative perinatal care? | adequate folic acid during embryogenesis reduces the incidence of neural tube defects. **Folic acid can significantly reduce neural tube defects |
| A preterm infant with an apnea monitor experiences an apneic episode. Which action should the nurse implement first? | Gently rub the infant's feet or back. **Gentle stimulation of the infant's feet and back can cause an infant to resume spontaneous respirations. |
| The nurse is assessing a full-term newborn’s breathing pattern. Which findings should the nurse assess further? (Select all that apply.) | chest breathing & nasal flaring, grunting heard with stethoscope. ** Breathing with nasal flaring, diaphragmatic breathing with chest retraction, and grunting are signs of respiratory distress in the infant |
| Which cardiovascular findings should the nurse assess further in a client who is at 20-weeks gestation? | Decreased pulse rate. ** Between 14 and 20 weeks gestation, the pulse increases about 10 to 15 beats/minute, which persists to term- decrease is concerning |
| A client with asthma who is 8 hours post-delivery is experiencing postpartum hemorrhage. Which prescription should the nurse administer? | oxytocin (Pitocin). **will not exacerbate symptoms of asthma |
| A woman, whose pregnancy is confirmed, asks the nurse what the function of the placenta is in early pregnancy. What information supports the explanation that the nurse should provide? | Secretes both estrogen and progesterone. **early functions of the placenta as an endocrine gland is the production of four hormones, hCG, hPL, estrogen, and progesterone (C), necessary to maintain the pregnancy and support the embryo and fetus |
| Which gastrointestinal findings should the nurse be concerned about in a client at 28-weeks gestation? | Pica. ** the consumption of low- or non-nutrient substances, may cause more nutritious foods to be displaced from the diet, and depending on the substance ingested, may be toxic or interfere with the absorption of nutrients and minerals (cardboard) |
| During a preconception counseling session for women trying to get pregnant in 3 to 6 months, what information should the nurse provide? | Make sure to include adequate folic acid in the diet. |
| The nurse is assessing a 12-hour-old infant with a maternal history of frequent alcohol consumption during pregnancy. Which finding should the nurse report that is most suggestive of fetal alcohol syndrome (FAS)? | Flat nasal bridge. **manifested by craniofacial anomalies, including short eyelid opening, flat midface or flat nasal bridge flat upper lip groove, thin upper lip, and microcephaly |
| microcephaly | small, underdeveloped head of baby. **cephalic- of, in , or relation to head |
| A client at 29-weeks gestation with possible placental insufficiency is being prepared for prenatal testing. Information about which diagnostic study should the nurse provide information to the client? | Ultrasonography. **Gestational age, fetal growth, and the status and position of the placenta are monitored by ultrasound. |
| A primigravida at 37-weeks gestation tells the nurse that her "bag-of-water" has broken. While inspecting the client's perineum, the nurse notes the umbilical cord protruding from the vagina. What action should the nurse implement first? | Place the client in the knee-chest position. **to relieve compression of the presenting part on the umbilical cord, which can compromise fetal oxygenation |
| A primigravida at 12-weeks gestation tells the nurse that she does not like diary products. Which food should the nurse recommend to increase the client's calcium intake? | Canned sardines. **A 3 ounce can of sardines (with bones) provides about the same amount of calcium as 1 cup of milk |
| A 36-week gestation client with pregnancy-induced hypertension (PIH) is receiving an IV infusion of magnesium sulfate. Which assessment finding should the nurse report to the healthcare provider? | Respiratory rate of 11 breaths/minute. **A sign of magnesium toxicity is respiratory depression |
| The nurse assesses a male newborn and determines that he has the following vital signs: axillary temperature 95.1 F, heart rate 136 beats/minute and a respiratory rate 48 breaths/minute. Based on these findings, which action should the nurse take first? | Assess the infant's blood glucose level. **infant is displaying signs of hypothermia (normal newborn axillary temperature is 96 to 98 F) and hypoglycemia may occur as glucose is metabolized in an effort to meet cellular energy demands |
| An infant born at 37-weeks gestation, weighing 4.1 kg (9.02 pounds) is 2 hours old and appears large for gestational age, flushed, and tremulous. What procedure should the nurse follow to implement a glucose screening? | 1. wrap infant heel with warmer for 5 min 2. collect spring-loaded autonomic puncture device 3. restrain infant heel 4. cleanse puncture site on lateral aspect of heel |
| A client at 28-weeks gestation experiences blunt abdominal trauma. Which parameter should the nurse assess first for signs of internal hemorrhage? | Changes in fetal heart rate patterns. **Hypoperfusion of the fetus may be present / external fetal monitor tracings should be assessed first to determine signs of fetal hypoxia due to internal bleeding in the mother |
| What assessment finding should the nurse report to the healthcare provider that is consistent with concealed hemorrhage in an abruptio placenta? | Hard, board-like abdomen. **Abruptio placenta causes concealed intrauterine hemorrhage when the placenta separates and its edges do not. |
| A newborn infant who is 24-hours-old is on a 4-hour feeding schedule of formula. To meet daily caloric needs, how many ounces are recommended at each feeding? | 3.5 ounces. **19 to 21 ounces of formula each day (six feedings per 24-hour period x 3.5 = 21) |
| The nurse is planning for the care of a 30-year-old primigravida with pre-gestational diabetes. What is the most important factor affecting this client's pregnancy outcome? | Degree of glycemic control during pregnancy. **Clients with tight glucose control and no blood vessel disease should have positive pregnancy outcomes |
| What action should the nurse implement with the family when an infant is born with anencephaly? | Prepare the family to explore ways to cope with the imminent death of the infant. **Anencephaly, a neural tube congenital malformation, is the incomplete embryological formation of both cerebral hemispheres, which often results in death. |
| The nurse notes an irregular bluish hue on the sacral area of a 1-day old Hispanic infant. How should the nurse document this finding? | Mongolian spots. **common skin variation in newborns of African, Asian, Native American, and Hispanic descent |
| A multigravida client at 40+ weeks gestation is induced using oxytocin (Pitocin). An (IUPC) is in place when the client's membranes rupture after 5 hours of active labor. Which finding should require the nurse to implement further action? | Intensity of contractions is 130 mm Hg. **IUPC reading of 40 to 90 mm Hg for contractions when giving oxytocin (too high at 130). |
| A primigravida at 12-weeks gestation who just moved to the United States indicates she has not received any immunizations. Which immunization(s) should the nurse administer at this time? | Diphtheria & Hep B. **killed viruses may be administered during pregnancy, live viruses which would be contraindicated during pregnancy |
| A client who is at 24-weeks gestation presents to the emergency department holding her arm and complaining of pain. The client reports she fell down the stairs. Which observation should alert the nurse to a possible battering situation? | Other parts of her body have injuries that are in different stages of healing. **A battered woman often has multiple injuries in various stages of healing |
| The nurse is caring for a client whose labor is being augmented with oxytocin (Pitocin). Which finding indicates that the nurse should discontinue the oxytocin infusion? | The fetal heart rate is 180 bpm without variability. **A fetal heart rate (FHR) without variability (D) is a non-reassuring finding that indicates the oxytocin should be discontinued, and the healthcare provider should be notified |
| Which nonpharmacologic interventions should the nurse implement to provide the most effective response in decreasing procedural pain in a neonate? | Oral sucrose and nonnutritive sucking. **oral sucrose and nonnutritive sucking (D), such as the provision of a pacifier, are effective in reducing objective indicators of pain after an invasive procedure. |
| A woman who is bottle-feeding her newborn infant calls the clinic 72 hours after delivery and tells the nurse that both of her breasts are swollen, warm, and tender. What instructions should the nurse give? | Apply ice to the breasts. **Ice applications to the breast cause vasoconstriction which reduces engorgement and provides topical pain relief. |
| A client at 25-weeks gestation tells the nurse that she dropped a cooking utensil last week and her baby jumped in response to the noise. What information should the nurse provide? | The fetus can respond to sound by 24-weeks gestation. ** ability to hear loud environment sounds can illicit a startle response |
| rapid labor, boggy fundus, heavy lochia, fundus difficult to locate, rubra lochia remains heavy, what action should the nurse implement next? | notify HCP. **Treatment of excessive bleeding requires the collaboration of the healthcare provider. |
| An infant in respiratory distress is placed on pulse oximetry. The oxygen saturation indicates 85%. What is the priority nursing intervention? | Begin humidified oxygen via hood. |
| A multiparous client is experiencing bleeding 2 hours after a vaginal delivery. What action should the nurse implement next? | Determine the firmness of the fundus. |
| pale, straw-colored fluid with small white particles. After reviewing the fetal monitor strip for fetal distress, what action should the nurse implement? | Perform a nitrazine test. **flecks of vernix with an alkaline pH, so should be done to confirm the pH of the fluid. |
| equipment needed for amniotomy | sterile glove, amniotic hook, doppler |
| Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's blood pressure drops from 120/80 to 90/60. What action will the nurse take? | Place the woman in a lateral position. **lateral position, increase fluids, admin O2 (10-12 L/min), if BP remains low, contact MD |
| The nurse is caring for a woman with a previously diagnosed heart disease who is in the second stage of labor. Which assessment findings are of greatest concern? | edema, basilar tones, irregular pulse- cardiac decompensation |
| terbutaline (Brethine). Which assessment is the highest priority for the nurse to monitor during the administration of this drug? | maternal and fetal heart rates- can cause tachycardia while relaxing uterus |
| A 42-week gestational client is receiving an intravenous infusion of oxytocin (Pitocin) to augment early labor. Which pattern of contractions should alert the nurse to discontinue the oxytocin infusion? | Transition labor with contractions every 2 minutes, lasting 90 seconds each.-- inadequate resting time between contractions |
| A client who gave birth to a healthy 8 pound infant 3 hours ago is admitted to the postpartum unit. Which nursing plan is best in assisting this mother to bond with her newborn infant? | meet moms needs and demonstrate warmth towards infant-- "taking in phase" care for mom so she can care for babe |
| late decelerations | REPO. INC IV FLUIDS. O2 FACE MASK. CALL HCP. (rio) |
| A woman with Type 2 diabetes mellitus becomes pregnant, and her oral hypoglycemic agents are discontinued. Which intervention is most important for the nurse to implement? | Describe diet changes that can improve the management of her diabetes. |
| The nurse identifies the presence of meconium fluid on the perineum and determines the fetal heart rate is between 140 to 150 beats/minute. What action should the nurse implement next? | Complete a sterile vaginal exam.-- determine presence of prolapsed cord |
| A pregnant woman comes to the prenatal clinic for an initial visit. In reviewing her childbearing history, the client indicates that she has delivered premature twins, one full-term baby, and has had no abortions. GTPAL | 3-1-1-0-3 (twins are ONE pregnancy) |
| abruptio placentae | dark/red vaginal bleeding, increased uterine irritability, rigid abdomen |
| rheumatic fever (mitral valve prolapse due to increase blood volume during pregnancy) | pedal edema, dyspnea, fatigue, and moist cough. |
| void q2h during labor | avoid over-distended bladder trauma during birth // full bladder can impair contractions and descent of fetus |
| first day of period was Jan. 8, what dates will be fertile? | Jan 30-31-- ovulation is 2 weeks before the next period |
| The infant has spontaneous respirations and the nurse assesses an apical heart rate of 80 beats/minute and respirations of 20 breaths/minute. What action should the nurse perform next? | initiate positive pressure ventilation |
| The nurse performs a vaginal examination that reveals the cervix is 3 centimeters dilated and 75% effaced. What additional information is most important for the nurse to obtain? | date of last menstrual period-- need to find out how far along she is |
| preeclampsia // which finding is most indicative of impending convulsion? | epigastric pain-- edematous liver or pancreas early signs of impending convulsion in eclampsia |
| The nurse is preparing to give an enema to a laboring client. Which client would require the most caution when carrying out this procedure? | A 40-week primigravida who is at 6 cm cervical dilatation and the presenting part is not engaged. |
| When assessing a client who is at 12-weeks gestation, the nurse recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes? | At 30-weeks gestation. |
| A client in active labor is admitted with preeclampsia. Which assessment finding is most significant in planning this client's care? | A 4+ reflex in a client with pregnancy-induced hypertension indicates hyperreflexia, which is an indication of an impending seizure. |
| A client receiving epidural anesthesia begins to experience nausea and becomes pale and clammy. What intervention should the nurse implement first? | Raise the foot of the bed. **suggestive of hypotension which is a side effect of epidural anesthesia. Raising the foot of the bed will increase venous return and provide blood to the vital areas. |
| Which assessment finding should the nursery nurse report to the pediatric healthcare provider? | Central cyanosis when crying. **manifesting poor adaptation to extrauterine life |
| After determining the serum magnesium level to be 15 mEq/L, the nurse should expect which of the following manifestations in the client? | Respiratory distress. |
| A 4-week-old premature infant has been receiving epoetin alfa (Epogen) for the last three weeks. Which assessment finding indicates to the nurse that the drug is effective? | Changes in apical heart rate from the 180s to the 140s. Since the body has not had to compensate for anemia with an increased heart rate, changes in heart rate from high to normal is one indicator that Epogen is effective. |
| A primigravida client who is 5 cm dilated, 90% effaced, and at 0 station is requesting an epidural for pain relief. Which assessment finding is most important for the nurse to report to the healthcare provider? | A platelet count of 67,000/mm3. Thrombocytopenia (low platelet count) should be reported to the healthcare provider because it places the client at risk for bleeding when an epidural is administered. |
| A vaginally delivered infant of an HIV positive mother is admitted to the newborn nursery. What intervention should the nurse perform first? | Bathe the infant with an antimicrobial soap. To reduce direct contact with the human immuno-virus in blood and body fluids |
| A 24-hour-old newborn has a pink papular rash with vesicles superimposed on the thorax, back, and abdomen. What action should the nurse implement? | Document the finding in the infant's record. Erythema toxicum (or erythema neonatorum) is a newborn rash that is commonly referred to as "flea bites," but is a normal finding |
| A primigravida at 40-weeks gestation is receiving oxytocin (Pitocin) to augment labor. Which adverse effect should the nurse monitor for during the infusion of Pitocin? | Hyperstimulation. |
| The nurse determines that the client is not having contractions, the fetal heart rate (FHR) baseline is 144 bpm, and no FHR accelerations are occurring. What action should the nurse take? | Ask the client if she has felt any fetal movement. |
| The nurse instructs a laboring client to use accelerated-blow breathing. The client begins to complain of tingling fingers and dizziness. What action should the nurse take? | Have the client breathe into her cupped hands. |
| The nurse is assessing the umbilical cord of a newborn. Which finding constitutes a normal finding? | Three vessels: two arteries and one vein. |
| When assisting a client to relieve postpaturm uterine contractions, which nursing intervention would be most helpful for the nurse to take?" | Lying client prone with a pillow on the abdomen. |
| A Which complaint would indicate to the nurse that the woman's fallopian tubes are patent? | Shoulder pain. **If the tubes are patent (open), pain is referred to the shoulder from a subdiaphragmatic collection of peritoneal dye/gas. |
| placental abruption, dark red vaginal bleeding, uterus slightly tense, bp 110/68, FHR 110, cervix 1 cm, uneffaced | monitor bleeding from IV sites -- disseminated intravascular coagulation occurs with placental abruptio |
| A client who is in the second trimester of pregnancy tells the nurse that she wants to use herbal therapy. Which response is best for the nurse to provide? | "It is important that you want to take part in your care." |
| A some difficulties in utero. Which diagnostic test should the nurse prepare the client for additional information about fetal status? | Biophysical profile (BPP). 5 areas: fetal breathing movements, fetal movements, amniotic fluid volume, and fetal tone and heart rate. |
| attachment/bonding theory | tracing infants profile while holding in arms |
| ECN UNG into newborn eyes | prevent ophthalmica neonatorum or gonorrhea caused by chlamydia |
| Which drugs would the nurse anticipate administering for tocolysis during preterm labor? | Nifedipine, Indomethacin |
| Preterm premature rupture of membranes (PPROM) | PPROM is PROM that occurs before 36 weeks of gestation. Contractions may or may not be present. PPROM is often associated with PTL, with the greatest risks from preterm birth occurring before completing 34 weeks of gestation. |
| When administering nifedipine for tocolysis, it is important for the nurse to monitor for which serious side effect? | reflex tachycardia-- Reflex tachycardia (maternal pulse greater than 120) can occur with large doses of nifedipine. |
| When evaluating a patient with suspected preterm premature rupture of membranes and preterm labor, the nurse recognizes which cues as signs of preterm labor? | pain/discomfort in upper thighs, back pain, sensation that fetus is "balling up", diarrhea |
| Which order during labor augmentation would cause the nurse to question the health care provider? | Administer oxytocin in dextrose 10% per protocol. **Using hypertonic solutions such as dextrose 10% increases the risk for water intoxication because it increases the antidiuretic effects of oxytocin. |
| Nulliparous | women who has never given birth before |
| Polyhydramnios | excessive amount of amniotic fluid; increased risk for umbilical cord prolapse during labor |
| umbilical cord prolapse | maybe "hidden" during cervix/vagina exam, small fetus, ruptured membranes, variable decelerations, and bradycardia |
| Wernicke’s encephalopathy | Thiamine deficiency can lead to Wernicke’s encephalopathy. All alcoholic patients should be given thiamine supplements |
| CIWA | CIWA is an alcohol withdrawal scale that assesses for alcohol withdrawal symptoms. Clinical Institute Withdrawal Assess. |
| COWS | COWS is an opioid withdrawal scale that helps the nurse assess for opioid withdrawal symptoms such as joint pain, runny nose, and piloerection. Clinical Opiate Withdrawal Scale. |
| CAGE | CAGE identifies alcohol abuse problems. Cut Annoyed Guilty Eye |
| AUDIT | AUDIT identifies alcohol dependencies. Alcohol Use Disorders ID Test |
| A nurse working in the emergency room of a children's hospital admits a child whose injuries could have resulted from abuse. Which statement most accurately describes the nurse's responsibility in cases of suspected child abuse? | The nurse should report any case of suspected child abuse to the nurse in charge. **charge nurse starts the legal reporting process |
| A female client with depression attends group and states that she sometimes misses her medication appointments because she feels very anxious about riding the bus. Which statement is the nurse's best response? | What are some ways that you can cope with your anxiety? **open-ended questions assists to problem solving |
| An adult female client is admitted to the psychiatric hospital with a diagnosis of bipolar disorder, manic phase. She is demanding and active. Which intervention should the nurse include in this client's plan of care? | Provide a structured environment with little stimuli. **Clients in the manic phase of a bipolar disorder require decreased stimuli and a structured environment |
| The mother states, "I think he took some of my pain pills." During initial assessment of the adolescent, what information is most important for the nurse to obtain from the parents? | If he might have taken any other drugs. **Knowledge of all substances taken guide further treatment, such as administration of antagonists. |
| The nurse suspects child abuse when assessing a 3-year-old boy with several small, round burns on his legs and trunk that appear to be the result of cigarette burns. Which parental behavior provides the greatest validation for such interpretation? | The parents tell the nurse that the child was burned in a house fire which is incompatible with the nurse's observation of the type of burn. |
| A male client is admitted to a mental health unit on Friday afternoon and is very upset on Sunday because he has not had the opportunity to talk with the healthcare provider. Which response is best for the nurse to provide this client? | Let me call and leave a message for your healthcare provider. |
| An anxious client expressing a fear of people and open places is admitted to the psychiatric unit. What is the most effective way for the nurse to assist this client? | Accompany the client outside for an increasing amount of time each day. **The process of gradual desensitization by controlled exposure to the situation which is feared, is the treatment of choice in phobic reactions |
| An older female client reports to the nurse that recently she has been hearing voices. Which question should the nurse ask this client first? | Are you ever alone when you hear the voices? **assist in differentiating between hallucinations and hearing loss, which is common in the aging population. |
| An older female client with Alzheimer's disease is wandering the busy halls of the extended care facility and asks the nurse, "Where should I stand for the parade?" Which response should the nurse provide? | Let's go back to the activity room and see what is going on in there. **Redirecting the client, using an accepting non-judgmental dialogue, to a safer place and familiar activities is most helpful |
| Within several days of hospitalization, a client is repeatedly washing the top of the same table. Which initial intervention is best for the nurse to implement to help the client cope with anxiety related to this behavior? | Allow time for the ritualistic behavior, then redirect the client to other activities. |
| The nurse should withhold the next scheduled dose of a client's haloperidol (Haldol) based on which assessment finding? | Fever of 102 F. **A fever may indicate neuroleptic malignant syndrome (NMS), a potentially fatal complication of antipsychotics. |
| A client who has been admitted to the psychiatric unit tells the nurse, "My problems are so bad that no one can help me." Which response is best for the nurse to make? | How can I help? |
| A 38-year-old female client is admitted with a diagnosis of paranoid schizophrenia. When her tray is brought to her, she refuses to eat and tells the nurse, "I know you are trying to poison me with that food." Which response is best for the nurse to make? | I'll leave your tray here. I am available if you need anything else. **do not argue with a client who is paranoid nor demand that the client eat, but should be supportive and convey the nurse's availability if needed. |
| The nurse is assessing a client's intelligence. Which factor should the nurse remember during this part of the mental status exam? | Intelligence is influenced by social and cultural beliefs. |
| A client who is diagnosed with schizophrenia is admitted to the hospital. The nurse assesses the client's mental status. Which assessment finding is characteristic of a client with schizophrenia? | flat affect- disinterest, diminished or lack of expressions |
| A young adult female client with a diagnosis of anorexia nervosa wants to help serve dinner trays to other clients on a psychiatric unit. What action should the nurse take? | Suggest another way for this client to participate in the unit's activities. **anorexia should not be allowed to plan/prep food |
| A homeless person who is in the manic phase of bipolar disorder is admitted to the mental health unit. Which laboratory finding obtained on admission is most important for the nurse to report to the healthcare provider? | decreased thyroid stimulating hormone levels **hyperthyroidism can effect mood and behaviors |
| A young adult male client, diagnosed with paranoid schizophrenia, believes that world is trying to poison him. What intervention should the nurse include in this client's plan of care? | Ask one nurse to spend time with the client daily. **developing a trusting relationships, the plan of care should include providing one nurse to spend time with the client daily |
| "Please let me go! I must leave because the secret police are after me." Which response is best for the nurse to make? | Come with me to your room and I will sit with you. **best response offers support without judgment or demands during hallucination or delusions |
| neuroleptic malignant syndrome (NMS) from antipsychotics | fever, rigidity, autonomic instability, and encephalopathy |
| Erikson's "Generativity vs. Stagnation" stage (age 24 to 45) | maintaining intimate relationships and moving toward developing a family |
| obsessive-compulsive disorder (OCD) | compulsions relieve anxiety, anxiety is the key reason for OCD, obsessive thoughts are linked to levels of neurochemicals, and SSRI increase serotonin levels |
| An adult client who has been hospitalized for two weeks for chronic paranoia continues to state that someone is trying to steal the client's clothing. Which action should the nurse to take? | Encourage the client to actively participate in assigned activities on the unit. |
| A client is receiving substitution therapy during withdrawal from benzodiazepines. Which expected therapeutic response has the highest priority during pharmacological management for withdrawal? | Excessive CNS stimulation will be reduced. |
| When he is told that his privileges do not include walking on the grounds, the client becomes verbally abusive. Which approach should the nurse take? | Calmly address the client's inappropriate behavior. |
| A 45-year-old male client tells the nurse that he used to believe that he was Jesus Christ, but now he knows he is not. Which response is best for the nurse to make? | Others have had similar thoughts when under stress. |
| An older female client with advanced dementia is admitted to the hospital with a fractured hip. The client repeatedly tells the staff, "Take me home. I want my Mommy." Which response is best for the nurse to provide? | Tell the client that the nurse is there and will help her. **dementia- offer self and talk to the feelings- provide comfort and security (i.e. like a mother would) |
| Which diet selection by a client who is depressed and taking the MAO inhibitor tranylcypromine sulfate (Parnate) indicates to the nurse that the client understands the dietary restrictions imposed by this medication regimen? | Roast beef, baked potato with butter, and iced tea. **DO NOT contain tyramine |
| HIV infection who has a history of chronic depression. Recently, the client's viral load has begun to increase rather than decrease despite his adherence to the HIV drug regimen. | Ask the client if he takes St. John's Wort routinely. |
| When preparing a teaching plan for a client who is to be discharged with a prescription for lithium carbonate (Lithonate), which instruction is most important for the nurse to include? | Keep your dietary salt intake consistent. **salt intakes influences lithium effectiveness |
| A male client with schizophrenia tells the nurse that the voices he hears are saying, "You must kill yourself." To assist the client in coping with these thoughts, which response is best for the nurse to provide? | Tell yourself that the voices are unreasonable. **use self-talk to disprove the voices since auditory hallucinations are often relentless and difficult to ignore. // schizophrenia uses concrete thinking |
| Moderate levels of anxiety. | nervousness interfering with sleep, appetite, and inability to solve problems |
| Which statement about contemporary mental health nursing practice is accurate? | The psychiatric nursing client may be an individual, family, group, organization, or community. |
| The nurse is preparing to administer phenelzine sulfate (Nardil) to a client on the psychiatric unit. Which side effect reported by the client is related to administration of this drug? | My mouth feels like cotton. **A dry mouth is an anticholinergic response that is an expected side effect of MAO inhibitors |
| An adult male client who was admitted to the mental health unit yesterday tells the nurse that microchips were planted in his head for military surveillance of his every move. Which response is best for the nurse to provide? | Go to occupational therapy and start a project. **delusions generate fear and isolation, encourage participation and activities with others. |
Created by:
jemerson