FINAL PAPER PRACTICE
QUESTIONS ANSWERS ACCURATE
A+
◉ A nurse is caring for a group of clients. Which of the following
findings should the nurse report?
A client who is taking clozapine and has a WBC count of 7,500/mm3
A client who is taking lamotrigine and has developed a rash
A client who is taking valproate and has a platelet count of
150,000/mm3
A client who is taking lithium and has a lithium level of 1.2 mEq/L.
Answer: 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 effect of the medication and report this finding
immediately.
◉ A nurse on a mental health unit is admitting a client who is anxious
and tells the nurse, "I hear voices telling me what to do." Which of the
following actions should the nurse take?
Tell the client that the voices do not really exist.
Touch the client to help reduce feelings of anxiety.
,Instruct the client to go to a quiet room when the voices start talking.
Ask the client what the voices are saying..
Answer: Ask the client what the voices are saying.
It is important for the nurse to ask the client directly about the
hallucinations to determine if the client or others are at risk for injury.
◉ A nurse is communicating with a client in an inpatient mental health
facility. Which of the following actions by the nurse demonstrates the
use of active listening?
Offering self
Use of silence
Attention to body language
Reflection of feelings.
Answer: Attention to body language
Use of active listening involves identifying verbal and nonverbal
communication by the client, which includes attention to body language.
◉ A client who has paranoid schizophrenia is attending a treatment
planning conference with a family member. During the discussion of the
medication adherence portion of the plan, a nurse notices that the family
member seems distracted. Which of the following actions should the
nurse take?
,Call the family member to the side to inquire if they have questions or
concerns about the treatment plan.
Advise the family member that this treatment plan has been developed
specifically for the client to follow.
Ask the family member if they have any thoughts or questions about the
treatment plan.
Document that the family member does not support the medication
treatment plan..
Answer: Ask the family member if they have any thoughts or questions
about the treatment plan.
This action involves the family member and allows them a venue to
communicate about the client's medication treatment plan.
◉ A nurse is caring for a client who has schizophrenia and is
experiencing psychosis. The nurse should identify that which of the
following findings indicates a potential psychiatric emergency?
The client is exhibiting echolalia.
The client reports command hallucinations.
The client reports loss of motivation.
The client is exhibiting blunted affect..
Answer: The client reports command hallucinations.
, The nurse should identify that command hallucinations can indicate a
potential psychiatric emergency for a client who has schizophrenia.
Command hallucinations can direct the client to harm themselves or
others.
◉ A nurse is caring for a client who is experiencing alcohol withdrawal.
Which of the following medications should the nurse administer first?
Exhibit 1: HR 110/min; BP 170/96; Temp 38.9 (102)
Exhibit 2: Client states drank alcohol 12 hr prior; Client has 2 pack/day
smoking history
Exhibit 3: Tremors of hands and fingers; emesis of 30 mL bile; Client is
restless and unable to sit still; client is diaphoretic and has flushed skin
Diazepam 5 mg IV bolus
Clonidine 0.1 mg transdermal patch
Naltrexone 380 mg IM
Bupropion 150 mg PO.
Answer: Diazepam 5 mg IV bolus
The greatest risk to the client who is experiencing alcohol withdrawal is
seizures, an elevated heart rate, and elevated blood pressure. IV
diazepam acts rapidly to prevent seizures, stabilize vital signs, and
decrease the intensity of withdrawal manifestations.