1. A school nurse is assessing a school aged child who
experienced the trau- matic loss of a parent 8 months ago.
Which of the following findings should the nurse identify as an
indication that the child is experiencing post traumatic stress
disorder (PTSD)
1. Clinging behaviors directed toward a teacher
2. Increased time spent sleeping
3. Intense focus on school work
4. Lack of interest in an upcoming holiday: Correct = 4. Lack of interest in an
upcoming holiday
The child who has PTSD will have negative moods and diflculty remembering aspects of the
traumatic event. The child can also have a loss of interest or lack of participation in significant
activities and events (e.g., Holidays)
*PTSD manifestations seen in children include detachment or estrangement from others, diflculty
sleeping/distressing dreams, diflculty concentrating on tasks
2. A nurse is caring for a group of clients. Which of the following
finding should the nurse report?
1. A client who is taking clozapine and has a WBC count of 7,500
2. A client who is taking lamotrigine and has developed a rash
3. A client who is taking valproate and has a platelet count of
150,000
4. A client who is taking lithium and has a lithium level of 1.2:
Correct = 2. A client who is taking lamotrigine and has developed a rash
Lamotrigine is an anticonvulsant medication that is used as a mood stabilizer. The nurse should
identify that a rash is a potentially life threatening adverse ettect of the medication and report the
finding immediately
3. A nurse is reviewing laboratory results for a client who has
schizophrenia and is taking clozapine. Which of the following values
,should the nurse identify as contraindication for receiving
clozapine?
1. WBC count 2,500
2. Hgb 11.5
3. Platelets 150,000
, 4. RBC count 3.5: Correct - 1. WBC count 2,500
Clozapine can cause agranulocytosis, which can be fatal due to overwhelming infection. The nurse
should identify a WBC count of less than 3,000 as a possible manifestation of agranulocytosis and
should withhold the medication and notify the provider
4. A nurse is planning care for a client who has depression
and has made frequent suicide attempts. Which of the
following statements indicates the client has a decreased risk
for suicide?
1. "I'm relieved now that my financial affairs are in order."
2. "It is easier to talk about my feelings now."
3. "Suddenly I have enough energy to do anything I want."
4. "Thank you for always taking such good care of me.": Correct - 2. "It is
easier to talk about my feelings now."
When clients express their feelings, this indicates a positive treatment outcome
*When clients who have depression verbalize getting their attairs in order, or suddenly have more
energy are at an increased risk of suicide. Clients who have depression often show an
appreciation for loved ones when they are contemplating suicide
5. During a client's initial interview in a mental health inpatient
setting, a nurse identifies that the client is maintaining eye
contact and leaning forward. Which of the following assumptions
should the nurse make based on the client's nonverbal
behaviors?
1. The client is interested in what the nurse is saying
2. The client is attempting to manipulate the nurse
3. The client is physically attracted to the nurse
4. The client is seeking acceptance by the nurse: Correct - 1. The client is
interested in what the nurse is saying
, The client's posture and eye contact demonstrate an interest in the interview and what the nurse is
saying
experienced the trau- matic loss of a parent 8 months ago.
Which of the following findings should the nurse identify as an
indication that the child is experiencing post traumatic stress
disorder (PTSD)
1. Clinging behaviors directed toward a teacher
2. Increased time spent sleeping
3. Intense focus on school work
4. Lack of interest in an upcoming holiday: Correct = 4. Lack of interest in an
upcoming holiday
The child who has PTSD will have negative moods and diflculty remembering aspects of the
traumatic event. The child can also have a loss of interest or lack of participation in significant
activities and events (e.g., Holidays)
*PTSD manifestations seen in children include detachment or estrangement from others, diflculty
sleeping/distressing dreams, diflculty concentrating on tasks
2. A nurse is caring for a group of clients. Which of the following
finding should the nurse report?
1. A client who is taking clozapine and has a WBC count of 7,500
2. A client who is taking lamotrigine and has developed a rash
3. A client who is taking valproate and has a platelet count of
150,000
4. A client who is taking lithium and has a lithium level of 1.2:
Correct = 2. A client who is taking lamotrigine and has developed a rash
Lamotrigine is an anticonvulsant medication that is used as a mood stabilizer. The nurse should
identify that a rash is a potentially life threatening adverse ettect of the medication and report the
finding immediately
3. A nurse is reviewing laboratory results for a client who has
schizophrenia and is taking clozapine. Which of the following values
,should the nurse identify as contraindication for receiving
clozapine?
1. WBC count 2,500
2. Hgb 11.5
3. Platelets 150,000
, 4. RBC count 3.5: Correct - 1. WBC count 2,500
Clozapine can cause agranulocytosis, which can be fatal due to overwhelming infection. The nurse
should identify a WBC count of less than 3,000 as a possible manifestation of agranulocytosis and
should withhold the medication and notify the provider
4. A nurse is planning care for a client who has depression
and has made frequent suicide attempts. Which of the
following statements indicates the client has a decreased risk
for suicide?
1. "I'm relieved now that my financial affairs are in order."
2. "It is easier to talk about my feelings now."
3. "Suddenly I have enough energy to do anything I want."
4. "Thank you for always taking such good care of me.": Correct - 2. "It is
easier to talk about my feelings now."
When clients express their feelings, this indicates a positive treatment outcome
*When clients who have depression verbalize getting their attairs in order, or suddenly have more
energy are at an increased risk of suicide. Clients who have depression often show an
appreciation for loved ones when they are contemplating suicide
5. During a client's initial interview in a mental health inpatient
setting, a nurse identifies that the client is maintaining eye
contact and leaning forward. Which of the following assumptions
should the nurse make based on the client's nonverbal
behaviors?
1. The client is interested in what the nurse is saying
2. The client is attempting to manipulate the nurse
3. The client is physically attracted to the nurse
4. The client is seeking acceptance by the nurse: Correct - 1. The client is
interested in what the nurse is saying
, The client's posture and eye contact demonstrate an interest in the interview and what the nurse is
saying
