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CORRECT ANSWERS 2026/2027 n n 7
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A nurse is planning care for a client following a suicide attempt. Which of the f
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ollowing n
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interventions should the nurse include in the plan? ( Correct answers ) Pro
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vide the n
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client with plastic eating utensils.
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The client can use glass dishes and metal silverware to cause self harm, ther
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efore, the n n
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nurse should arrange for the client to have only plastic products on their me
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al tray.n
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A nurse is performing an admission assessment for a client who appears with
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drawn and n n
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fearful. Which of the following actions should the nurse take first? ( Correct
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answers ) n
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Inform the client that this admission is confidential.
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-According to evidence- n n
based practice, the nurse should first inform the client about confidentiality du
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ring the orientation phase of the nurse client relationship. This action establis
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hes trust between the client and the nurse, which in turn decreases the client'
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s anxiety level.
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A nurse is caring for an adolescent client who has anorexia nervosa. The clie
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nt states, "Have I done any permanent damage to my body?" Which of the foll
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owing responses should the nurse make? ( Correct answers ) You're afraid y
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ou have caused physical injury to yourself?
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Repeating the main idea of what the client has said, which will allow for clarifi
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cation of n n
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any misunderstanding on the part of the client or the nurse.
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A nurse is caring for a client following a fire that destroyed her home and kille
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d one of her children. The client is crying and does not make eye contact with
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,the nurse. Which of the following questions should the nurse ask first? ( Corre
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ct answers ) Have you thought of harming yourself?
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The greatest risk to this client is self harm due to the loss of her child and hom
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e, therefore, the first question the nurse should ask a client who is having a pe
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rsonal crisis is to determine if the client has suicidal ideation. If so, the nurse s
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hould take action to protect the client from self harm.
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A nurse is checking laboratory values for a hospitalized young adult client
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who has n
bipolar disorder and is taking lithium. Which of the following values is the prior
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ity for the n n n
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nurse to report to the provider? ( Correct answers ) Serum creatinine 2.
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1 mg/dL
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-Reference range of 0.5-1.2 mg/dL. n n n n n
The greatest risk to this client is decreased kidney function, which can cause
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an increase in the client's lithium level; therefore, this value is the priority for t
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he nurse to report to the provider. The clients lithium dosage might need to be
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nmodified based on this lab value. The cause of increased serum creatinine in
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clude dehydration as well as renal disorders. Lithium is contraindicated for cli
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ents who have severe renal disease, cardiac disease, or severe dehydration.
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A nurse is providing information to a client who is seeking voluntary admissio
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n to a mental health facility. Which of the following information should the nurs
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e include? ( Correct answers ) You will still need to give informed consent for t
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reatment after admission. n n n
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A client who seeks voluntary admission to a mental health facility has the sa
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me rights as clients receiving any other kind of health care. The client will sti
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ll need to give informed consent for treatment and therapies, such as electr
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oconvulsive therapy. n n
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A nurse is developing a plan of care for an adolescent client who has conduct
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disorder. n
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Which of the following interventions should the nurse include in the plan? (
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Correct
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answers ) Initiate a behavioral contract with the client.
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A client who has conduct disorder can demonstrate patterns of behavior that
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are aggressive, disrespectful of others rights, and can lead to injury of others.
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A behavioral contract helps to develop trust between the client and the nurse
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and emphasizes the client's responsibility to commit to work on changes in be
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havior. n
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A hospice nurse is talking with the family of a client who recently died from
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cancer
following a series of chemotherapy treatment. One of the adult children is ang
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ry with the n n n
provider and blames the provider for their father's death. Which of the followin
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g defense
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mechanisms is the family member using? ( Correct answers ) Displac n n n n n n n n n nn
ement
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When this family member uses displacement, they are transferring their feeli
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ngs of anger to the provider so they do not have to cope with their own feeling
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s of sadness and loss.
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A nurse in an acute care facility is providing teaching for the adult child of an o
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lder adult n n
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client who is admitted with a urinary tract infection and delirium. The client h
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as been n
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living independently at home. Which of the following statements by the ad
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ult child n
demonstrates the teaching has been effective? ( Correct answers ) I expec n n n n n n n n n nn n
t that my
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father will no longer be confused when he is discharged.
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A nurse is caring for a client who is experiencing a manic episode. Which of th
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e following actions should the nurse take first? ( Correct answers ) Encourag
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e the client to rest each hour.
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The greatest risk to this client is injury from exhaustion due to the manic phas
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e, therefore, the priority action the nurse should take is to encourage the clien
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t to rest for 3-5mins every hour.
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