A client who has been hospitalized with disorganized type schizophrenia for 8 years can't complete activities of daily

living (ADLs) without staff direction and assistance. The nurse formulates a nursing diagnosis of Self-care deficient:
Dressing/grooming related to inability to function without assistance. What is the least likely appropriate goal for this
client? Select All that Apply? *
"Client will be able to complete ADLs with complete assistance within 1 month."
"Client will be able to complete ADLs with only verbal encouragement within 1 month."
"Client will be able to complete ADLs independently within 1 month."
"Client will be able to complete ADLs with

John, who is receiving Haloperidol (Haldol), complains of a stiff jaw and difficulty swallowing. The actions which nurse
Mark would least likely take would be: Select All that Apply. *
administer as needed dose of benztropine (Cogentin) by mouth as ordered.
reassure the client and administer as needed lorazepam (Ativan) I.M.
administer as needed dose of haloperidol (Haldol) by mouth.
administer as needed dose of benztropine (Cogentin) I.M. as ordered.

Mr. Parker begins banging his head against the wall. It becomes necessary to place Mr. Parker in mechanical restraints
in order that he not hurt himself. Nursing care should include the following: *
Checking on Mr. Parker at least once an hour
Removing all restraints if Mr. Parker becomes less agitated within 10 minutes
Gradually removing restraints until Mr. Parker has only one restraint remaining
Performing range-of-motion exercises every 2 hours and assessing circulation to the extremities

Which of the following is the most important step to restore oxygenation and ventilation for the unresponsive, breathless
submersion (near drowning) victim? *
attempt to drain water from breathing passages by performing the Heimlich maneuver
begin chest compressions
provide cervical spine stabilization because a diving accident may have occurred
open the airway and begin rescue breathing as soon as possible even in the water

Emergency and ambulatory care nurses are among the first health care workers to encounter victims of a bioterrorist
attack. Actions that should be taken by emergency department staff in the event of a biochemical incident. Select All
that Apply. *
Report to public health department or Centers for Disease Control and Prevention per protocol.
Decontaminate the affected individuals in a separate area.
Protect the environment for the safety of personnel and nonaffected clients.
Don personal protective equipment.
Perform triage according to protocol.

A client is admitted to the psychiatric unit of a local hospital with chronic undifferentiated schizophrenia. During the next
several days, the client is seen laughing, yelling, and talking to herself. These behaviors are least likely the
characteristic of: Select All that Apply. *
delusion.
hallucination.
illusion.
looseness of association.

The off-duty nurse hears on the television of a bioterrorism act in the community. Which action should the nurse take
first? *
Immediately report to the hospital emergency room.
Call the Red Cross to find out where to go.
Pack a bag and prepare to stay at the hospital.
Follow the nurse’s hospital policy for responding.

A client presents to the emergency room after being involved in a vehicular accident. The client has obvious facial
fractures and a head injury. The nurseshould refrain from: *
placing a nasogastric tube.
inserting a urinary catheter.
cleaning the blood from the face.
bagging the client with a bag valve mask and high flow oxygen.

The elderly female client with vertebral fractures who has been self-medicating withibuprofen, a nonsteroidal anti-
inflammatory drug (NSAID), presents to the emergencydepartment complaining of abdominal pain; is pale, clammy, and
has a P 110 and a BPof 92/60. Which type of shock would the nurse suspect? *
Cardiogenic shock.
Hypovolemic shock.
Neurogenic shock.
Septic shock.

A psychotic client reports to the evening nurse, that the day nurse, put something suspicious in his water with his
medication. The nurse replies, "You're worried about your medication?" The nurse's communication is least likely
about : Select All that Apply *
reinforcing the client's delusions
an example of presenting reality
focusing on emotional content
a nontherapeutic technique called mind reading.

The most current Family Theory states: *

An individual with schizophrenia is most likely to be product of a cold, aloof mother and absent, distant father.
There is no proof that schizophrenia is caused by family interaction patterns.
Research has indicated schizophrenia is a direct result of dysfunctional family interaction.
The individual with schizophrenia withdraws and hallucinates as a defense against a hostile family environment.

Effective interventions to decrease absorption or increase eliminationof an ingested poison include which of the
following (select allthat apply)? *
Hemodialysis
Milk dilution
Eye irrigation
Gastric lavage
Activated charcoal

Mr. Jones reports that he is hearing voices telling him to cut his wrists and he is highly agitated with complaints of fear
and anxiety. The most appropriate intervention would be to: *
Administer medication, as per protocol, remove dangerous objects from patient’s environment, and place him on constant observation
Administer medication, as per protocol, and encourage Mr. Jones to contract for safety and to notify nursing staff should voices
increase
Administer medication, as per protocol, and encourage Mr. Jones to spend time in his room, after checking for sharp objects and
ensuring the environment is safe
Administer medication, as per protocol, and place him in closed door seclusion with safety checks every 15 minutes

The nurse is caring for a client with schizophrenia who experiences auditory hallucinations. The client appears to be
listening to someone who isn't visible. He gestures, shouts angrily, and stops shouting in mid-sentence. Which nursing
intervention is the least appropriate? *
Ask the client to describe what the voices are saying.
Encourage the client to go to his room where he'll experience fewer distractions.
Acknowledge that the client is hearing voices but make it clear that the nurse doesn't hear these voices.
. Approach the client and touch him to get his attention.

A client with schizophrenia tells the nurse, "My intestines are rotted from the worms chewing on them." This statements
least likely indicates the appropriate type of delusion: Select All that Apply. *
Somatic delusion.
Jealous delusion.
Delusion of grandeur.
Delusion of persecution

The client presents to the ER with acute vomiting after eating at a fast-food restaurant. There has not been any
diarrhea. The nurse suspects botulism poisoning. Which nursing problem is the highest priority for this client?  *
Fluid volume loss.
Risk for respiratory paralysis.
Abdominal pain.
Anxiety.

A client with paranoid schizophrenia has been experiencing auditory hallucinations for many years. The approaches
that has proven to be ineffective for hallucinating clients is/are to: Select All that Apply  *
sing loudly to drown out the voices and provide a distraction
practice saying "Go away" or "Stop" when they hear voices.
go to their room until the voices go away
take an as-needed dose of psychotropic medication whenever they hear voices

What is not the definition of nihilistic delusions: Select All that Apply. *
The inability to carry out motor activities.
A false belief about the functioning of the body.
Belief that the body is deformed or defective in a specific way.
False ideas about the self, others, or the world

Mr. Parker has been diagnosed with Paranoid Schizophrenia and has stated that he believes that other patients are out
to get him. Mr. Parker has escalated to the point where he is threatening others, and he is having difficulty staying in his
room. The decision is made to assist Mr.Parker by having him spend some time in the quiet room. Which of the
following interventions will most likely promote safety? *
Approach Mr. Parker with several other staff members in a quiet manner and escort him to the quiet room.
Force-medicate him according to hospital
Approach Mr. Parker alone as he may feel more threatened with more than one staff member.
Place Mr. Parker in 4-point restraints and check on him every 15 minutes.

A client involved in a one-car rollover comes in with multiple injuries. What are the nursing interventions that must be
initiated for this client. Select All that Apply. *
Secure two large-bore IV lines and infuse normal saline.
Use the chin lift or jaw thrust maneuver to open the airway.
Assess for spontaneous respirations.
Give supplemental oxygen via mask.
Obtain a full set of vital sign measurements.
Remove or cut away the client's clothing.

Medication teaching about clozapine should include which of the following: *

Notifying the physician immediately about lip-smacking or vermiform movements of the tongue
The importance of being compliant with having a complete blood count drawn at least monthly
Cautioning the patient to report any signs of infection including sore throat, flu-like symptoms and fever
Notifying the physician immediately at the onset of diarrhea and hand tremors

Mr. Brown continues to remark that the CIA is following him and that they are waiting outside the door to the emergency
room. Your best response would be: *
“Mr. Brown, the CIA is not following you.”
“Why do you think the CIA is out there?”
“I understand you feel that they are outside, but the CIA is not there and you’re safe here.”
“We’ve told the CIA to leave you alone.”

The nurse is working in the triage area of an emergency department, and the following four clients approach the triage
desk at the same time. Choose which the nurse will assess. Select all that Apply *
An ambulatory, dazed 25-year-old man with a bandaged head wound
An irritable newborn with a fever, petechiae, and nuchal rigidity
A 35-year-old jogger with a twisted ankle who has a pedal pulse and no deformity
A 50-year-old woman with moderate abdominal pain and occasional vomiting

The nurse is teaching a class on bioterrorism. What is the scientific rationale for designating a specific area for
decontamination? *
Showers and privacy can be provided to the client in this area.
This area isolates the clients who have been exposed to the agent.
It provides a centralized area for stocking the needed supplies.
It prevents secondary contamination to the health-care providers.

The nurse is teaching CPR to a class. Which statement best explains the definition of sudden cardiac death?  *
Cardiac death occurs after being removed from a mechanical ventilator.
Cardiac death is the time that the physician officially declares the client dead.
Cardiac death occurs within one (1) hour of the onset of cardiovascular symptoms.
The death is caused by myocardial ischemia resulting from coronary artery disease.

A schizophrenic client with delusions tells the nurse, "There is a man wearing a red coat who's out to get me." The client
exhibits increasing anxiety when focusing on the delusions. Which of the following would be the inappropriate response
by the nurse? Select All that Apply *
"There is no need to be concerned with a man who isn't even real."
"Describe the man who's out to get you. What does he look like?"
"There is no reason to be afraid of that man. This hospital is very secure."
"This subject seems to be troubling you. Let's walk to the activity room."

A common hypothesis regarding the biologic origin of schizophrenia is: *

Norepinephrine hypothesis, which states that schizophrenia is due to an excess of this neurotransmitter, which causes hallucinations
Dopamine hypothesis, which postulates that some cases may be due to excess of dopamine in the brain and/or an excessive number
of dopamine receptors
Disease is caused by enlarged lateral ventricles in the brain.
All cases of schizophrenia are caused by viruses contracted in utero.

Which equipment must be immediately brought to the client’s bedside when a code is called for a client who has
experienced a cardiac arrest? *
A ventilator.
A crash cart.
A gurney.
Portable oxygen.

Which is the primary goal of the ER nurse in caring for a client who has ingested poison? *
Remove or inactivate the poison before it is absorbed.
Provide long-term supportive care to prevent organ damage.
Administer an antidote to increase the effects of the poison.
Implement treatment that prolongs the elimination of the poison.

A client with a diagnosis of paranoid schizophrenia comments to the nurse, "How do I know what is really in those
pills?" Which of the following are the unlikely responses of the nurse? Select All that Apply *
Ignore the comment because it's probably a joke.
Allow him to open the individual wrappers of the medication.
Say, "Don't worry about what is in the pills. It's what is ordered."
Say, "You know it's your medicine."

Which is the most important intervention for the nurse to implement when participatingin a code?  *
Elevate the arm after administering medication.
Maintain sterile technique throughout the code.
Treat the client’s signs/symptoms; do not watch the monitor.
Be sure to provide accurate documentation of what happened in the code.

When John, a 25-year-old graduate student diagnosed with Paranoid Schizophrenia, is ready for discharge, which of
the following is importantfor the client and his family? *
To set up a plan to improve the outlook of the client that includes daily rules for acceptable behaviors
To understand that all activity is to be avoided, so that John will not get upset
To understand all of the causal explanations of the illness so they can be discussed at home
To understand the treatment plan, including prescribed medication, expectations concerning effects and plans for continuity of care,
and professional resources

According to genetic studies of schizophrenia: *

Genetic factors are not important to one’s risk of developing schizophrenia.
A twin of a monozygotic (identical) twin with schizophrenia has a greater chance of having schizophrenia than the general population.
Genetic inheritance is most likely the only cause of schizophrenia since family interactional patterns cannot be empirically studied.
A twin of a monozygotic (identical) twin with schizophrenia has a lesser chance of having schizophrenia than the general population.

According to the triage system, which situation would be considered a level red (Priority 1)?  *
Injuries are extensive and chances of survival are unlikely.
Injuries are minor and treatment can be delayed hours to days.
Injuries are significant but can wait hours without threat to life or limb.
Injuries are life threatening but survivable with minimal interventions.

Which of the following events would be considered a “natural disaster?” (Select all that apply.)  *
Flood
Meteorological phenomena
Fire
Nuclear event

The nurse is teaching a class on biological warfare. Which information should the nurse include in the presentation?  *
Contaminated water is the only source of transmission of biological agents.
Vaccines are available and being prepared to counteract biological agents.
Biological weapons are less of a threat than chemical agents.
Biological weapons are easily obtained and result in significant mortality.

A chemical exposure has just occurred at an airport. An off-duty nurse, knowledgeable about biochemical agents, is
giving directions to the travelers. Which direction shouldthe nurse provide to the travelers? *
Hold their breath as much as possible.
Stand up to avoid heavy exposure.
Lie down to stay under the exposure.
Attempt to breathe through their clothing.

Your patient on a conventional neuroleptic medication complains of dizziness. Your initial intervention would be:  *
Forcing fluids
Prompt discontinuation of the medication and notifying the physician
Taking the patient’s blood pressure sitting and standing
Instructing patient to place their head between knees

Ms. Smith was recently admitted to an in patient psychiatric facility. During the assessment she seems to be mimicking
your body movements.This is an example of: *
Mirroring the therapist
Akathisia
Echopraxia
Echolalia

A patient is admitted to the inpatient unit of the Southern Philippines Medical Center - Institute of Psychiatry and
Behavioral Medicine (SPMC - IPBM) with a diagnosis of paranoid schizophrenia. He's shouting that the government of
China is trying to assassinate him. Which of the following responses is least likely appropriate? Select All that Apply  *
"A foreign government is trying to kill you? Please tell me more about it."
. "I find it hard to believe that a foreign government or anyone else is trying to hurt you. You must feel frightened by this."
"You're wrong. Nobody is trying to kill you."
"I think you're wrong. China is a friendly country and an ally of the Philippines. Their government wouldn't try to kill you."

Cary, a schizophrenic client states, "I hear the voice of King Budoy." Which responses by the nurse would be least
therapeutic? Select All that Apply. *
"I don't hear the voice, but I know you hear what sounds like a voice."
"King Budoy has been dead for years."
"Don't worry about the voice as long as it doesn't belong to anyone real.
"You shouldn't focus on that voice."

The nurse is teaching a class on disaster preparedness. Which are components of an Emergency Operations Plan
(EOP)? Select all that apply. *
A plan for practice drills.
A deactivation response.
A plan for internal communication only.
A pre-incident response.
A security plan.

Mr. Williams who has been hospitalized for over a month due to exacerbation of schizophrenia will soon be discharged
to his home wherehe will live with his parents and one younger brother. Which of the following recommendations will be
most helpful to the family? *
Do not encourage spending time alone as this will increase a sense of isolation from the family.
Provide Mr. Williams with a structured routine, including chores and other responsibilities.
Set goals for Mr. Williams as he may have difficulty doing this for himself.
Encourage Mr. Williams to take complete responsibility for medications and follow-up appointments.

Which of the following groups of characteristics would the nurse least expect to see in a client with schizophrenia?  *
Loose associations, grandiose delusions, and auditory hallucinations
Periods of hyperactivity and irritability alternating with depression
Delusions of jealousy and persecution, paranoia, and mistrust
Sadness, apathy, feelings of worthlessness, anorexia, and weight loss

The nurse formulates a nursing diagnosis of Impaired social interaction related to disorganized thinking for a client with
schizotypal personality disorder. Based on this nursing diagnosis, which nursing intervention takes the least priority?
Select All that Apply. *
Establishing a one-on-one relationship with the client
Developing a schedule for the client's participation in social interactions
Exploring the effects of the client's behavior on social interactions
Helping the client to participate in social interactions

The nurse is discharging a client diagnosed with accidental carbon monoxide poisoning. Which statement made by the
client indicates the need for further teaching? *
“I should install carbon monoxide detectors in my home.”
“Having a natural bright-red color to my lips is good.”
“You cannot smell carbon monoxide, so it can be difficult to detect.”
“I should have my furnace checked for leaks before turning it on.”

Which intervention is the most important for the nurse to implement when performingmouth-to-mouth resuscitation on a
client who has pulseless ventricular fibrillation? *
Perform the jaw thrust maneuver to open the airway.
Use the mouth to cover the client’s mouth and nose.
Insert an oral airway prior to performing mouth to mouth.
Use a pocket mouth shield to cover client’s mouth.

A client is admitted to a psychiatric facility with a diagnosis of chronic schizophrenia. The history indicates that the client
has been taking neuroleptic medication for many years. Assessment reveals unusual movements of the tongue, neck,
and arms. Which conditions should the nurse least suspect? Select All that Apply *
Neuroleptic malignant syndrome
Dystonia
Akathisia
Tardive dyskinesia

Ms. Williams has difficulty trusting the staff members on the unit. Which of the following interventions is most likely to
promote trust? *
Assigning the same staff to work with Ms. Williams as often as possible
Encouraging patient to engage in a one-to one session for an hour on both morning and evening shifts to convey acceptance of her
Encouraging Ms. Williams to play a game of cards with the other patients
Using therapeutic touch in order to convey caring and concern for Ms. Williams

The client has ingested a corrosive solution containing lye. Which intervention should the nurse implement?  *
Administer syrup of ipecac to induce vomiting.
Insert a nasogastric tube and connect to wall suction.
Assess for airway compromise.
Immediately administer water or milk.

Identify the five most critical elements in performing disaster triage for multiple victims.  *
Obtain past medical and surgical histories.
Check airway, breathing, and circulation.
Assess the level of consciousness.
Visually inspect for gross deformities, bleeding, and obvious injuries.
Note the color, presence of moisture, and temperature of the skin.
Check vital signs, including pulse and respirations

The nurse in a disaster is triaging the following clients. Which client would be triaged as an Expectant Category, Priority
4, and color black? *
The client with a sucking chest wound who is alert.
The client with a head injury who is unresponsive.
The client with an abdominal wound and stable vital signs.
The client with a sprained ankle that may be fractured.
A man is brought to the hospital by his wife, who states that for the past week her husband has refused all meals and
accused her of trying to poison him. During the initial interview, the client's speech, only partly comprehensible, reveals
that his thoughts are controlled by delusions that he is possessed by the devil. The physician diagnoses paranoid
schizophrenia. Schizophrenia is least described as a disorder characterized by: Select All that Apply.  *
severe mood swings and periods of low to high activity.
auditory and tactile hallucinations
multiple personalities, one of which is more destructive than the others.
disturbed relationships related to an inability to communicate and think clearly.

The nurse is planning care for a client admitted to the psychiatric unit with a diagnosis of paranoid schizophrenia. Which
nursing diagnosis should receive the least priority? Select All that Apply. *
Risk for violence toward self or others
Ineffective family coping
. Impaired verbal communication
Imbalanced nutrition: Less than body requirements

A client tells the nurse that the television newscaster is sending a secret message to her. The nurse suspects the client
is least likely to experience: Select All that Apply *
a delusion.
ideas of reference.
a hallucination.
flight of ideas.

Mr. Jones has not been eating and has difficulty bringing food to his mouth. The most appropriate intervention would be
to: *
Allow patient to eat in his room as he will be more comfortable away from the other patients
Place the patient on a liquid supplement as this may be more easily tolerated
Place the spoon in the patient’s hand, scoop food into it and say, “Eat a bite of this apple
Spoon feed the patient

The nurse is caring for a client with multiple injuries sustained during a head-on car collision. Which assessment finding
takes priority? *
A deviated trachea
Unequal pupils
Ecchymosis in the flank area
Irregular apical pulse

A group of people arrive at the emergency department by private car. They all have extreme periorbital swelling,
coughing, and tightness in the throat. There is a strong odor emanating from their clothes. They report exposure to a
“gas bomb” that was set off in their house. What is the priority action? *
Measure vital signs and listen to lung sounds.
Direct clients to the decontamination area.
Alert security about possible terrorism activity.
Direct clients to cold or clean zones for immediate treatment.

The health-care facility has been notified that an alleged inhalation anthrax exposure has occurred at the local post
office. Which category of personal protective equipment(PPE) would the response team wear? *
Level A
Level B
Level C
Level D

A client is receiving Haloperidol (Haldol) to reduce psychotic symptoms. As he watches television with other clients, the
nurse notes that he has trouble sitting still. He seems restless, constantly moving his hands and feet and changing
position. When the nurse asks what is wrong, he says he feels jittery. How should the nurse would least likely manage
this situation? Select All that Apply. *
Ask the client to sit still or leave the room because he is distracting the other clients.
Administer an as needed dose of haloperidol to decrease agitation
Give an as needed dose of a prescribed anticholinergic agent to control akathisia.
Ask the client if he is nervous or anxious about something.

Yesterday, a client with schizophrenia began treatment with haloperidol (Haldol). Today, the nurse notices that the
client is holding his head to one side and complaining of neck and jaw spasms. What should the nurse least do? Select
All that Apply. *
Yesterday, a client with schizophrenia began treatment with haloperidol (Haldol). Today, the nurse notices that the client is holding his
head to one side and complaining of neck and jaw spasms. What should the nurse do?
Put the client on the list for the physician to see tomorrow
Tell the client to lie down and relax.
Evaluate the client for adverse reactions to haloperidol

A 24-year-old client is experiencing an acute schizophrenic episode. He has vivid hallucinations that are making him
agitated. The nurse's least responses at this time would be to: Select All that Apply *
Tell him his fear is unrealistic.
Take the client's vital signs.
Explore the content of the hallucinations.
Engage the client in reality-oriented activities.

The nurse knows that the physician has ordered the liquid form of the drug Chlorpromazine (Thorazine) rather than the
tablet form because the liquid least likely: Select All that Apply *
produces fewer drug interactions
produces fewer anticholinergic effects.
has a more predictable onset of action.
has a longer duration of action.

The nurse and group of friends are at the lake. Suddenly, someone says, “Look across the lake! It looks like someone
might be drowning out there!” What is the nurse's first action? *
Determine who is the strongest swimmer in the group.
Direct someone to locate a cell phone and call 911.
Find a boat, raft, or some type of flotation device.
Use a pair of binoculars and look across the lake

Nursing actions during a dystonic reaction may include: *

Administration of IM physostigmine and bethanecol
Decreasing stimulation in environment as dystonia and agitation may appear similar
Notifying physician, administration of cogentin, and making certain respiratory support equipment is available
Turning patient on side

The nurse is teaching a class on bioterrorism and is discussing personal protective equipment (PPE). Which statement
is the most important fact that must be sharedwith the participants? *
Health-care facilities should keep masks at entry doors.
No single combination of PPE protects against all hazards.
The EPA has divided PPE into four levels of protection.

The triage nurse in a large trauma center has been notified of an explosion in a major chemical manufacturing plant.
Which action should the nurse implement first whenthe clients arrive at the emergency department?  *
Triage the clients and send them to the appropriate areas.
Thoroughly wash the clients with soap and water and then rinse.
Remove the clients’ clothing and have them shower.
Assume the clients have been decontaminated at the plant.

When a primary survey of a trauma client is conducted, what is one of the priority actions that would be performed
first? *
Obtain a complete set of vital sign measurements.
Palpate and auscultate the abdomen.
Perform a brief neurologic assessment.
Check the pulse oximetry reading.

You are caring for a patient who suffers from epilepsy and has been diagnosed recently a shaving schizophrenia.
Teaching should include which of the following: *
Antipsychotic medications should be used cautiously as they decrease seizure threshold.
Antipsychotic medications are contraindicated.
Antipsychotic medications do not affect seizure threshold.
Antipsychotic medications should be used cautiously as they increase seizure threshold.

The client diagnosed with septic shock has hypotension, decreased urine output, and cool, pale skin. Which phase of
septic shock is the client experiencing? *
hypodynamic phase.
compensatory phase.
hyperdynamic phase.
progressive phase.

A client with catatonic schizophrenia is mute, can't perform activities of daily living, and stares out the window for hours.
What are the nurse's least priority? Select All that Apply. *
Encourage socialization with peers.
Assist the client with feeding.
Reassure the client about safety.
Assist the client with showering

A gastric lavage has been ordered for a client who is comatose and who ingested a full bottle of acetaminophen, a
nonnarcotic analgesic. Which should be included in the procedure? Select all that apply. *
Place the client on the left side with the head 15 degrees lower than the body.
Insert a small bore feeding tube into the nare.
Have standby suction available.
Withdraw all stomach contents and then instill an irrigating solution.
Send samples of the stomach contents to the lab for analysis.

The client diagnosed with septicemia has the following health-care provider orders. Which order has the highest
priority? *
Provide clear liquid diet.
Initiate IV antibiotic therapy.
Obtain a STAT chest x-ray.
Perform hourly glucometer checks.

Which signs/symptoms would the nurse assess in the client who has been exposed tothe anthrax bacillus via the
skin? *
A scabby, clear fluid–filled vesicle.
Edema, pruritus, and a 2-mm ulcerated vesicle.
Irregular brownish-pink spots around the hairline.
Tiny purple spots flush with the surface of the skin

Which assessment data would warrant immediate intervention for the client diagnosed with septic shock?  *
Vital signs T 100.4F, P 104, R 26, and BP 102/60.
A white blood cell count of 18,000 mm.
A urinary output of 90 mL in the last four (4) hours.
The client complains of being thirsty.

The patient remarks repeatedly that he believe she is Jesus Christ and has come to save the world. This can best be
described as: *
Defense of identification
An idea of reference
A delusion of grandeur
An illusion

The nurse is caring for a client with schizophrenia who experiences auditory hallucinations. The client appears to be
listening to someone who isn't visible. He gestures, shouts angrily, and stops shouting in mid-sentence. Which nursing
interventions are the least likely appropriate? Select All that Apply *
Approach the client and touch him to get his attention.
Ask the client to describe what the voices are saying
Encourage the client to go to his room where he'll experience fewer distractions.
Acknowledge that the client is hearing voices but make it clear that the nurse doesn't hear these voices.

The nurse is caring for a client in the prodromal phase of radiation exposure. Which signs/symptoms would the nurse
assess in the client? *
Anemia, leukopenia, and thrombocytopenia.
Sudden fever, chills, and enlarged lymph nodes.
Nausea, vomiting, and diarrhea.
Flaccid paralysis, diplopia, and dysphagia.

Which statement explains the scientific rationale for having emergency suction equipment available during resuscitation
efforts? *
Gastric distention can occur as a result of ventilation.
It is needed to assist when intubating the client.
This equipment will ensure a patent airway.
It keeps the vomitus away from the health-care provider.

In the work setting, what is the nurse's primary responsibility in preparing for management of disasters, including natural
disasters and bioterrorism incidents? *
Knowing the agency's emergency response plan
Being aware of the signs and symptoms of potential agents of bioterrorism
Knowing how and what to report to the Centers for Disease Control and Prevention
Making ethical decisions about exposing self to potentially lethal substances

The client is diagnosed with neurogenic shock. Which signs/symptoms would the nurseassess in this client?  *
Cool moist skin.
Bradycardia.
Wheezing.
Decreased bowel sounds.

The nurse is providing care for a female client with a history of schizophrenia who's experiencing hallucinations. The
physician orders 200 mg of haloperidol (Haldol) orally or I.M. every 4 hours as needed. What are the nurse's unlikely
least actions? *
Call the physician to clarify whether the haloperidol should be given orally or I.M.
Call the physician to clarify the order because the dosage is too high.
Administer the haloperidol orally if the client agrees to take it.
Withhold haloperidol because it may worsen hallucinations.

The triage nurse is working in the emergency room. Which client should be assessed first? *
The 10-year-old child whose dad thinks the child’s leg is broken.
The 45-year-old male who is diaphoretic and clutching his chest.
The 58-year-old female complaining of a headache and seeing spots.
The 25-year-old male who cut his hand with a hunting knife.

Which of the following symptoms is considered a “negative symptom” of schizophrenia? *

Delusions
Both Auditory hallucinations and Auditory hallucinations
Auditory hallucinations
Flat affect

The nurse is providing first aid to a victim of a poisonous snakebite. Which should bethe nurse’s first action?  *
Apply a tourniquet to the affected limb.
Cut an X in across the bite and suck out the venom.
Administer a corticosteroid medication.
Have the client lie still and remove constrictive items.

A client with borderline personality disorder becomes angry when he is told that today's psychotherapy session with the
nurse will be delayed 30 minutes because of an emergency. When the session finally begins, the client expresses
anger. Which response by the nurse would be least likely helpful in dealing with the client's anger?  *
. "I really care about you and I'll never let this happen again."
. "If it had been your emergency, I would have made the other client wait."
"You had to wait. Can we talk about how this is making you feel right now?"
"I know it's frustrating to wait. I'm sorry this happened."

The nurse is caring for a client with frostbite to the feet - an injury caused by freezing of the skin and underlying
tissues . What are the following correct interventions. Select All that Apply. *
Apply a loose, sterile, bulky dressing.
Give pain medication.
Remove the client from the cold environment.
Immerse the feet in warm water of 105° to 115°F (40.6° to 46.1°C).
Monitor for compartment syndrome.

You are working with Mr. Green who has recently been prescribed Thorazine (chlorpromazine). He comes to the
nurses’ stations and complains of blurred vision and constipation. Your most appropriate response would be:  *
“Those are possible side effects to the medication and tolerance usually develops in several weeks. We can order a bulk diet for you.”
Administer an anticholinergic medication.
“I’ll notify the physician right away as your dose is probably too high.”
“I’ll notify the physician right away and see if we can try a different medication.”

During the initial interview, a client with schizophrenia suddenly turns to the empty chair beside him and whispers, "Now
just leave. I told you to stay home. There isn't enough work here for both of us!" What are the inappropriate responses
by the nurse to this situation? *
"There is no one else in the room. What are you doing?"
"I'm having a difficult time hearing you. Please look at me when you talk."
"When people are under stress, they may see things or hear things that others don't. Is that what just happened?"
"Who are you talking to? Are you hallucinating?"

While looking out the window, a client with schizophrenia remarks, "That school across the street has creatures in it that
are waiting for me." Which of the following terms least likely describes what the creatures represent?  *
Delusion
Anxiety attack
Hallucination
Projection

The client is admitted into the emergency department with diaphoresis, pale, clammy skin, and BP of 120/80. Thirty
minutes later the client’s B/P is 90/70. Which intervention should the nurse implement first?
Start an IV with an 18-gauge catheter.
Administer dopamine intravenous infusion.
Obtain arterial blood gases (ABGs).
Insert an indwelling urinary catheter.

Ms. Williams, who was admitted to the unit yesterday, is withdrawn and keeps to herself on theunit. An appropriate
intervention would be: *
Encouraging Ms. Williams to attend all activities as prescribed in order to integrate into the milieu and feel a part of the group
Encouraging Ms. Williams to spend all day and early evening on the unit and locking the door to her room
Electing Ms. Williams as the patient representative to increase her sense of confidence
Encouraging Ms. Williams to attend activities gradually with a supportive staff member

The individual with schizophrenia may benefit from a group-oriented approach. Which of the following groups would be
most appropriate? *
Cognitive-behavioral in order to assist with difficulties with self-care
Any of the above, depending on the individual patient
An instructive approach as well as supportive group that provides social skills training
Insight-oriented

Which statement best describes the role of the medical-surgical nurse during a disaster? *
The nurse may be assigned to ride in the ambulance.
The nurse may be assigned as a first assistant in the operating room.
The nurse may be assigned to crowd control.
The nurse may be assigned to the emergency department.
Ms. Smith displays paranoid behavior on the unit and becomes particularly suspicious. She comments that she
suspects the food is being poisoned. A possible intervention would be to: *
Have Ms. Smith eat away from the other patients
Have Ms. Smith prepare her own meals
Serve the food in sealed containers
Serve small, frequent meals

Which of the following statements about tardive dyskinesia is most accurate? *

All patients on long-term neuroleptic therapy are at risk.
Occurs most often in dehydrated patients.
Symptoms may appear 1–10 days following administration of neuroleptic medication.
Symptoms are generally reversible, particularly in younger patient population.

The nurse is preparing for the discharge of a client who has been hospitalized for paranoid schizophrenia. The client's
husband expresses concern over whether his wife will continue to take her daily prescribed medication. The nurse's
least response to address the husband's concern: Select All that Apply *
his wife can be given a long-acting medication that is administered every 1 to 4 weeks.
he can easily mix the medication in his wife's food if she stops taking it.
his concern is valid but his wife is an adult and has the right to make her own decisions.
. his wife knows she must take her medication as prescribed to avoid future hospitalizations.

A client with paranoid type schizophrenia becomes angry and tells the nurse to leave him alone. The nurse should not
do the following as a response to the clien'ts paranoia: Select All that Apply. *
tell him that she'll leave for now but will return soon.
ask him if it's okay if she sits quietly with him.
ask him why he wants to be left alone.
tell him that she won't let anything happen to him

After Chlorpromazine (Thorazine) administration. The nurse should least likely expect to see the elimination of the
client's delusional thoughts and hallucinations. Select All that Apply. *
Several days
Several minutes
Several weeks
Several hours

Which best describes the action of anti psychotic medications? *

They block dopamine receptors.
They decrease available amounts of serotonin and norepinephrine.
They block reuptake of dopamine to increase availability at receptor sites.
They enhance the availability of dopamine.