Extract:

Question 1 of 5

A 90-year-old client diagnosed with major depression is suddenly experiencing sleep disturbances, inability to focus, poor recent memory, altered perceptions, and disorientation to time and place. Lab results indicate the client has a urinary tract infection and dehydration. After explaining the situation and giving the background and assessment data, the nurse should make which of the following recommendations to the physician?

Correct Answer: C

Rationale: The symptoms suggest delirium caused by a urinary tract infection and dehydration, which require medical treatment in a medical unit to address the underlying causes.

Question 2 of 5

A client with dementia repeatedly asks, 'Where's my wife?' What is the nurse's best response?

A. Your wife passed away last year.' B. Let's look for her together.' C. She's not here right now, but you're safe.' D. Why do you want to see her?'

Correct Answer: C

Rationale: Reassuring the client of their safety while gently redirecting avoids distress caused by confronting the reality of the wife's death.

Question 3 of 5

The nurse is reviewing the medication administration record (MAR) of a client with bipolar disorder who is receiving lithium carbonate. Which of the following laboratory results should the nurse report to the physician immediately?

A. Serum lithium level of 0.8 mEq/L. B. Serum sodium level of 140 mEq/L. C. Serum potassium level of 4.0 mEq/L. D. Serum lithium level of 2.0 mEq/L.

Correct Answer: D

Rationale: A lithium level of 2.0 mEq/L is toxic (therapeutic range: 0.6–1.2 mEq/L), requiring immediate reporting to prevent harm.

Question 4 of 5

A client reports having blurred vision after 4 days of taking haloperidol (Haldol) 1 mg BID, and benztropine (Cogentin) 2 mg BID. The nurse contacts the physician to explain the situation, background, and the patient's disease, which information reported to the physician is the assessment of the situation?

A. Mr. Roberts is taking 1 mg of Haldol BID and Cogentin 2 mg BID.' B. I think Mr. Roberts might need a lower dose of Cogentin.' C. Mr. Roberts reports having blurred vision since this morning.' D. The higher dose of Cogentin could be causing Mr. Roberts' blurred vision.'

Correct Answer: C

Rationale: Reporting the client's symptom (blurred vision since this morning) provides the physician with the specific assessment data needed to evaluate the situation.

Question 5 of 5

A 21-year-old female was arrested on charges of solicitation. Jail staff asked for a mental health evaluation when the woman used a fork to stab herself. She also had an episode of rage after waking up from a nightmare and screamed repeatedly to 'let her out of the locked room.' After she was admitted to the psychiatric unit, she admitted to being kidnapped and held from ages 8 to 16 by a convicted child pornographer. She said she never contacted her family after her release from captivity. The nurse should do the following in what order of priority from first to last?

Order the Items

Source Container

Initiate suicide precautions and a no harm contract.

Ask the client if she wishes to contact her family while hospitalized.

Offer empathy and support and be non-judgmental and honest with her.

Encourage safe verbalizations of her emotions, especially anger.

Correct Answer: A,C,B,D

Rationale: The nurse should prioritize: 1) Suicide precautions and no harm contract (
A) due to self-harm; 2) Offer empathy and support (
C) to build trust; 3) Ask about contacting family (
B) to explore reconnection; 4) Encourage verbalizing emotions (
D) to process trauma.