Extract:

Question 1 of 5

A client diagnosed with Undifferentiated Schizophrenia gained 50 lb in 6 months while taking olanzapine (Zyprexa). After seeing her psychiatrist who changed the medication to ziprasidone (Geodon), the client tells the nurse, 'I don't want to take this Geodon either. I can't gain any more weight.' Which response by the nurse is most appropriate for this client?

Correct Answer: A

Rationale: Addressing the client's concern about weight gain by noting that ziprasidone is associated with less weight gain than olanzapine provides reassurance and encourages adherence.

Question 2 of 5

A client admitted for violent behavior toward a family member expresses remorse and asks how to prevent future incidents. Which of the following should the nurse include in the teaching plan?

A. Avoid all family interactions until emotions are stable. B. Attend anger management classes to learn coping strategies. C. Take prescribed sedatives before family visits. D. Write a letter of apology to the family member.

Correct Answer: B

Rationale: Attending anger management classes provides the client with tools to manage emotions and prevent violence, addressing the root cause. Avoiding family is impractical, sedatives are a temporary measure, and an apology letter does not teach coping skills.

Question 3 of 5

The client is laughing and telling jokes to a group of clients. Suddenly, the client is crying and talking about a death in the family. A moment later, the client is laughing and joking again. The nurse should:

A. Call the psychiatrist for an order for Ativan as needed. B. Place the client in seclusion and call the psychiatrist for an order for the seclusion. C. Ignore the client's behavior in order not to give the client too much attention. D. Ask the client to come to a quiet area to talk to the nurse individually.

Correct Answer: D

Rationale: Redirecting to a quiet area allows assessment of labile mood and de-escalation.

Question 4 of 5

A soldier is stationed in Iraq on his second tour of duty. His division was notified of the date they will be deployed to Afghanistan. As this date approaches, he is showing signs of excess anxiety and irritability and inability to sleep at night because of nightmares of IED (improvised explosive devices) tragedies, all leading to poor work performance. He is admitted to the base hospital for an evaluation. The admitting nurse should take the following actions in order of priority from first to last?

Order the Items

Source Container

Remind him that any feelings and problems he is having are typical in his current situation.

Ask him to talk about his upsetting experiences in Iraq.

Remove any weapons and dangerous items he has in his possession.

Acknowledge any injustices/unfairness related to his experiences and offer empathy and support.

Correct Answer: C, A, D, B

Rationale: The order is: 1) Remove weapons for safety (
C). 2) Remind him feelings are typical to normalize symptoms (
A). 3) Acknowledge injustices and offer empathy to build rapport (
D). 4) Ask about experiences to explore trauma (
B). Safety is the priority, followed by support and exploration.

Question 5 of 5

A nurse notices a client with a history of self-harm hiding sharp objects. Which is the priority nursing action?

A. Place the client in seclusion. B. Search the client's belongings for sharp objects. C. Initiate one-on-one observation. D. Administer a PRN sedative.

Correct Answer: C

Rationale: Initiating one-on-one observation ensures immediate safety by monitoring the client closely, preventing self-harm. Seclusion, searching belongings, or sedation are more invasive or less immediate without ongoing supervision.