1. A client on the psychiatric unit is in an uncontrolled rage and is threatening other clients and staff. What is the most appropriate action for the nurse to take?

  • Call security for assistance and prepare to sedate the client.
  • Tell the client to calm down and ask him if he would like to play cards.
  • Tell the client that if he continues his behavior he will be punished.
  • Leave the client alone until he calms down.

2. After two weeks of receiving lithium therapy, a patient in the psychiatric unit becomes depressed. Which of the following evaluations of the patient’s behavior by the nurse would be MOST accurate?

  • The treatment plan is not effective; the patient requires a larger dose of lithium.
  • This is a normal response to lithium therapy; the patient should continue with the current treatment plan.
  • This is a normal response to lithium therapy; the patient should be monitored for suicidal behavior.
  • The treatment plan is not effective; the patient requires an antidepressant

3. The client with dementia is experiencing confusion late in the afternoon and before bedtime. The nurse is aware that the client is experiencing what is known as:

  • Chronic fatigue syndrome
  • Normal aging
  • Sundowning
  • Delusions

4. A client is brought to the emergency room by the police. He is combative and yells, “I have to get out of here. They are trying to kill me.” Which assessment is most likely correct in relation to this statement?

  • The client is experiencing an auditory hallucination.
  • The client is having a delusion of grandeur.
  • The client is experiencing paranoid delusions.
  • The client is intoxicated.

5. To provide effective feedback to a client, the nurse will focus on:

  • The present and not the past.
  • Making inferences of the behaviors observed.
  • Providing solutions to the client.
  • The client.

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  1. A patient with a Bipolar Disorder makes a sexually inappropriate comment to the nurse. One should take which of the following actions?

  • Ignore the comment because the client has a mental health disorder and cannot help it.
  • Report the comment to the nurse manager.
  • Ignore the comment, but tell the incoming nurse to be aware of the client’s propensity to make inappropriate comments.
  • Tell the client that is it inappropriate for clients to speak to any nurse that way.

2. A client with pancreatic cancer has an infusion of TPN (Total Parenteral Nutrition). The doctor has ordered for sliding-scale insulin. The most likely explanation for this order is:

  • Total Parenteral Nutrition leads to negative nitrogen balance and elevated glucose levels.
  • Total Parenteral Nutrition cannot be managed with oral hypoglycemics.
  • Total Parenteral Nutrition is a high-glucose solution that often elevates the blood glucose levels.
  • Total Parenteral Nutrition leads to further pancreatic disease.

3. A carer has reported that she has seen a resident fall off his bed. What initial assessment should be done?

  • Check the patient’s Early Warning Score along with the Glasgow Coma Scale immediately.
  • Ask the patient if he is in pain; if so, administer painkillers immediately.
  • Dial 999 and request for an ambulance to take your patient to the hospital.
  • Contact the out-of-hours GP and request for a home visit.

4. You were on the phone with a family member, and one of the carers has reported that one of your residents has stopped breathing and turned blue. What should you do first?

  • End your conversation with the family member, attend to your patient and do the CPR.
  • End your conversation with the family member, go to your patient’s bedroom and assess for airway, breathing and circulation.
  • End your conversation with the family member, and dial 999 to request for an ambulance.
  • Dial 111, and request for an urgent visit from the General Practitioner.

5. Karen, one of the residents in the nursing home, has not yet had her mental capacity assessment done. She has been making decisions that you personally think are not beneficial for her. Which of the following should not be implemented?

  • Force her to change her mind every time she makes a decision
  • Explain the benefits of making the right decision
  • Allow her to make her own decision, as she still has mental capacity
  • All of the above

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 1. A two-year-old is admitted for repair of a fractured femur and is placed in Bryant’s traction. Which finding by the nurse indicates that the traction is working properly?

  • The infant no longer complains of pain.
  • The buttocks are 15° off the bed.
  • The legs are suspended in the traction.
  • The pins are secured within the pulley.

2. The nurse has a preop order to administer Valium (diazepam) 10mg and Phenergan (promethazine) 25mg. The correct method of administering these medications is to:

  • Administer the medications together in one syringe
  • Administer the medication separately
  • Administer the Valium, wait five minutes, and then inject the Phenergan
  • Question the order because they cannot be given at the same time

3. The nurse is checking the client’s central venous pressure. The nurse should place the zero of the manometer at the:

  • Phlebostatic axis
  • PMI
  • Erb’s point
  • Tail of Spence

4. The home health nurse is visiting an 18-year-old with osteogenesis imperfecta. Which information obtained on the visit would cause the most concern? The client:

  • Likes to play football
  • Drinks carbonated drinks
  • Has two sisters
  • Is taking acetaminophen for pain

5. The physician orders lisinopril (Zestril) and furosemide (Lasix) to be administered concomitantly to the client with hypertension. The nurse should:

  • Question the order.
  • Administer the medications.
  • Administer separately.
  • Contact the pharmacy.

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 1. Which of the following approaches creates a barrier to communication?

  • Using to many different skills during a single interaction
  • Giving advise rather than encouraging the patient to problem solve
  • Allowing the patient to become too anxious before changing the subject
  • Focusing on what the patient is saying rather than on the skill used

2. Which therapeutic communication technique is being used in this nurse­ client interaction? Client: "When I get angry, I get into a fistfight with my wife or I take it out on the kids." Nurse: "I notice that you are smiling as you talk about this physical violence."

  • Formulating a plan of action
  • Making observations
  • Exploring
  • Encouraging comparison

3. The wife of a client with PTSD (post traumatic stress disorder) communicates to the nurse that she is having trouble dealing with her husband’s condition at home. Which of the following suggestions made by the nurse is CORRECT?

  • “Discourage your husband from exercising, as this will worsen his condition.”
  • “Encourage your husband to avoid regular contact with outside family members.”
  • “Do not touch or speak to your husband during an active flashback. Wait until it is finished to give him support.”
  • “Keep your cupboards free of high-sugar and high-fat foods.”

4. Compassion in Practice - the culture of compassionate care encompasses:

  • Care, Compassion, Competence, Communication, Courage, Commitment - DoH -“Compassion in Practice”
  • Care, Compassion, Competence
  • Competence, Communication, Courage
  • Care, Courage, Commitment

5. Which nursing statement is a good example of the therapeutic communication technique of giving recognition?

  • You did not attend group today. Can we talk about that?”
  • I’ll sit with you until it is time for your family session.
  • “I notice you are wearing a new dress and you have washed your hair.”
  • “I’m happy that you are now taking your medications. They will really help.”

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1. A client being treated with sodium warfarin (Coumadin) has a Protime of 120 seconds. Which intervention would be most important to include in the nursing care plan?

  • Assess for signs of abnormal bleeding.
  • Anticipate an increase in the Coumadin dosage.
  • Instruct the client regarding the drug therapy.
  • Increase the frequency of neurological assessments.

2. The primary reason for rapid continuous rewarming of the area affected by frostbite is to:

  • Lessen the amount of cellular damage
  • Prevent the formation of blisters
  • Promote movement
  • Prevent pain and discomfort

3. You were on your rounds with one of the carers. You were turning a patient from his left to his right side. What would you do?

  • Both of you can stay on one side of the bed as you turn your patient
  • You go on the opposite side of the bed and use the bed sheet to turn your patient
  • You keep the bed as low as possible because the patient might fall
  • You go on the opposite side and grab the slide sheet to use

4. A client hospitalized with MRSA is placed on contact precautions. Which statement is true regarding precautions for infections spread by contact?

  • The client should be placed in a room with negative pressure.
  • Infection Requires close contact; therefore, the door may remain open.
  • Transmission is highly likely, so the client should wear a mask at all times.
  • Infection Requires skin-to-skin contact and is prevented by hand washing, gloves, and a gown.

5. Which of the following would be an appropriate strategy in reorienting a confused patient to where her room is?

  • Place picture of her family on the bedside stand
  • Put her name in a large letter on her forehead
  • Remind the patient where her room is
  • Let the other residents know where the patient's room is

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