NUR2811 Midterm Latest Exam
NUR2811 Midterm Latest Exam 1 Review
ICHS Nursing Capstone (NUR2811) Exam
QUESTIONS AND ANSWERS WITH
DETAILED RATIONALES GRADED A+
GUARANTEED PASS
A male client with schizophrenia who is taking fluphenazine decanoate (Prolixin decanoate) is
being discharged in the morning. A repeat dose of medication is scheduled for 20 days after
discharge. The client tells the nurse that he is going on vacation in the Bahamas and will
return in 18 days. Which statement by the client indicates a need for health teaching?
A) When I return from my tropical island vacation, I will go to the clinic to get my Prolixin
injection.
B) While I am on vacation and when I return, I will not eat or drink anything that contains
alcohol.
A+ TEST BANK 1
, NUR2811 Midterm Latest Exam
C) I will notify the healthcare provider if I have a sore throat or flu-like symptoms.
D) I will continue to take my benztropine mesylate (Cogentin) every day.
Photosensitivity is a side effect of Prolixin and a vacation in the Bahamas (with its tropical
island climate) increases the client's chance of experiencing this side effect. He should be
instructed to avoid direct sun (A) and wear sunscreen. (B, C, and D) indicate accurate
knowledge. Alcohol acts synergistically with Prolixin (B). (C) lists signs of agranulocytosis,
which is also a side effect of Prolixin. In order to avoid extrapyramidal symptoms (EPS),
anticholinergic drugs, such as Cogentin, are often prescribed prophylactically with Prolixin.
Correct Answer(s): A
2.
A male client is admitted to the mental health unit because he was feeling depressed about
the loss of his wife and job. The client has a history of alcohol dependency and admits that he
was drinking alcohol 12 hours ago. Vital signs are: temperature, 100° F, pulse 100, and BP
142/100. The nurse plans to give the client lorazepam (Ativan) based on which priority nursing
diagnosis?
A) Risk for injury related to suicidal ideation.
B) Risk for injury related to alcohol detoxification.
C) Knowledge deficit related to ineffective coping.
D) Health seeking behaviors related to personal crisis.
The most important nursing diagnosis is related to alcohol detoxification (B) because the
client has elevated vital signs, a sign of alcohol detoxification. Maintaining client safety related
to (A) should be addressed after giving the client Ativan for elevated vital signs secondary to
alcohol withdrawal. (C and D) can be addressed when immediate needs for safety are met.
Correct Answer(s): B
A+ TEST BANK 2
, NUR2811 Midterm Latest Exam
3.
The charge nurse is collaborating with the nursing staff about the plan of care for a client who
is very depressed. What is the most important intervention to implement during the first 48
hours after the client's admission to the unit?
A) Monitor appetite and observe intake at meals.
B) Maintain safety in the client's milieu.
C) Provide ongoing, supportive contact.
D) Encourage participation in activities.
The most important reason for closely observing a depressed client immediately after
admission is to maintain safety (B), since suicide is a risk with depression. (A, C, and D) are all
important interventions, but safety is the priority.
Correct Answer(s): B
4.
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 most appropriate for the nurse to make?
A) I'll leave your tray here. I am available if you need anything else.
B) You're not being poisoned. Why do you think someone is trying to poison you?
C) No one on this unit has ever died from poisoning. You're safe here.
D) I will talk to your healthcare provider about the possibility of changing your diet.
(A) is the best choice cited. The nurse does not argue with the client nor demand that she
eat, but offers support by agreeing to "be there if needed", e.g., to warm the food. (B and C)
are arguing with the client's delusions, and (B) asks "why" which is usually not a good
question for a psychotic client. (D) has nothing to do with the actual problem; i.e., the
problem is not the diet (she thinks any food given to her is poisoned.)
Correct Answer(s): A
A+ TEST BANK 3
, NUR2811 Midterm Latest Exam
5.
A client who is being treated with lithium carbonate for bipolar disorder develops diarrhea,
vomiting, and drowsiness. What action should the nurse take?
A) Notify the healthcare provider immediately and prepare for administration of an antidote.
B) Notify the healthcare provider of the symptoms prior to the next administration of the
drug.
C) Record the symptoms as normal side effects and continue administration of the prescribed
dosage.
D) Hold the medication and refuse to administer additional amounts of the drug.
Early side effects of lithium carbonate (occurring with serum lithium levels below 2.0 mEq per
liter) generally follow a progressive pattern beginning with diarrhea, vomiting, drowsiness,
and muscular weakness. At higher levels, ataxia, tinnitus, blurred vision, and large dilute urine
output may occur. (B) is the best choice. Although these are expected symptoms, the
healthcare provider should be notified prior to the next administration of the drug. (A, C, and
D) would not reflect good nursing judgment.
Correct Answer(s): B
6.
The parents of a 14-year-old boy bring their son to the hospital. He is lethargic, but responsive.
The mother states, "I think he took some of my pain pills." During initial assessment of the
teenager, what information is most important for the nurse to obtain from the parents?
A) If he has seemed depressed recently.
B) If a drug overdose has ever occurred before.
C) If he might have taken any other drugs.
D) If he has a desire to quit taking drugs.
Knowledge of all substances taken (C) will guide further treatment, such as administration of
antagonists, so obtaining this information has the highest priority. (A and B) are also valuable
in planning treatment. (D) is not appropriate during the acute management of a drug
overdose.
A+ TEST BANK 4
NUR2811 Midterm Latest Exam 1 Review
ICHS Nursing Capstone (NUR2811) Exam
QUESTIONS AND ANSWERS WITH
DETAILED RATIONALES GRADED A+
GUARANTEED PASS
A male client with schizophrenia who is taking fluphenazine decanoate (Prolixin decanoate) is
being discharged in the morning. A repeat dose of medication is scheduled for 20 days after
discharge. The client tells the nurse that he is going on vacation in the Bahamas and will
return in 18 days. Which statement by the client indicates a need for health teaching?
A) When I return from my tropical island vacation, I will go to the clinic to get my Prolixin
injection.
B) While I am on vacation and when I return, I will not eat or drink anything that contains
alcohol.
A+ TEST BANK 1
, NUR2811 Midterm Latest Exam
C) I will notify the healthcare provider if I have a sore throat or flu-like symptoms.
D) I will continue to take my benztropine mesylate (Cogentin) every day.
Photosensitivity is a side effect of Prolixin and a vacation in the Bahamas (with its tropical
island climate) increases the client's chance of experiencing this side effect. He should be
instructed to avoid direct sun (A) and wear sunscreen. (B, C, and D) indicate accurate
knowledge. Alcohol acts synergistically with Prolixin (B). (C) lists signs of agranulocytosis,
which is also a side effect of Prolixin. In order to avoid extrapyramidal symptoms (EPS),
anticholinergic drugs, such as Cogentin, are often prescribed prophylactically with Prolixin.
Correct Answer(s): A
2.
A male client is admitted to the mental health unit because he was feeling depressed about
the loss of his wife and job. The client has a history of alcohol dependency and admits that he
was drinking alcohol 12 hours ago. Vital signs are: temperature, 100° F, pulse 100, and BP
142/100. The nurse plans to give the client lorazepam (Ativan) based on which priority nursing
diagnosis?
A) Risk for injury related to suicidal ideation.
B) Risk for injury related to alcohol detoxification.
C) Knowledge deficit related to ineffective coping.
D) Health seeking behaviors related to personal crisis.
The most important nursing diagnosis is related to alcohol detoxification (B) because the
client has elevated vital signs, a sign of alcohol detoxification. Maintaining client safety related
to (A) should be addressed after giving the client Ativan for elevated vital signs secondary to
alcohol withdrawal. (C and D) can be addressed when immediate needs for safety are met.
Correct Answer(s): B
A+ TEST BANK 2
, NUR2811 Midterm Latest Exam
3.
The charge nurse is collaborating with the nursing staff about the plan of care for a client who
is very depressed. What is the most important intervention to implement during the first 48
hours after the client's admission to the unit?
A) Monitor appetite and observe intake at meals.
B) Maintain safety in the client's milieu.
C) Provide ongoing, supportive contact.
D) Encourage participation in activities.
The most important reason for closely observing a depressed client immediately after
admission is to maintain safety (B), since suicide is a risk with depression. (A, C, and D) are all
important interventions, but safety is the priority.
Correct Answer(s): B
4.
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 most appropriate for the nurse to make?
A) I'll leave your tray here. I am available if you need anything else.
B) You're not being poisoned. Why do you think someone is trying to poison you?
C) No one on this unit has ever died from poisoning. You're safe here.
D) I will talk to your healthcare provider about the possibility of changing your diet.
(A) is the best choice cited. The nurse does not argue with the client nor demand that she
eat, but offers support by agreeing to "be there if needed", e.g., to warm the food. (B and C)
are arguing with the client's delusions, and (B) asks "why" which is usually not a good
question for a psychotic client. (D) has nothing to do with the actual problem; i.e., the
problem is not the diet (she thinks any food given to her is poisoned.)
Correct Answer(s): A
A+ TEST BANK 3
, NUR2811 Midterm Latest Exam
5.
A client who is being treated with lithium carbonate for bipolar disorder develops diarrhea,
vomiting, and drowsiness. What action should the nurse take?
A) Notify the healthcare provider immediately and prepare for administration of an antidote.
B) Notify the healthcare provider of the symptoms prior to the next administration of the
drug.
C) Record the symptoms as normal side effects and continue administration of the prescribed
dosage.
D) Hold the medication and refuse to administer additional amounts of the drug.
Early side effects of lithium carbonate (occurring with serum lithium levels below 2.0 mEq per
liter) generally follow a progressive pattern beginning with diarrhea, vomiting, drowsiness,
and muscular weakness. At higher levels, ataxia, tinnitus, blurred vision, and large dilute urine
output may occur. (B) is the best choice. Although these are expected symptoms, the
healthcare provider should be notified prior to the next administration of the drug. (A, C, and
D) would not reflect good nursing judgment.
Correct Answer(s): B
6.
The parents of a 14-year-old boy bring their son to the hospital. He is lethargic, but responsive.
The mother states, "I think he took some of my pain pills." During initial assessment of the
teenager, what information is most important for the nurse to obtain from the parents?
A) If he has seemed depressed recently.
B) If a drug overdose has ever occurred before.
C) If he might have taken any other drugs.
D) If he has a desire to quit taking drugs.
Knowledge of all substances taken (C) will guide further treatment, such as administration of
antagonists, so obtaining this information has the highest priority. (A and B) are also valuable
in planning treatment. (D) is not appropriate during the acute management of a drug
overdose.
A+ TEST BANK 4
