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A client who was wandering aimlessly around the streets acting inappropriately and appeared disheveled and admitted to a psychiatric unit and is experiencing auditory and visual hallucinations. The nurse would develop a plan of care based on: * A. borderline personality disorder * B. anxiety disorder * C. schizophrenia * D. depression
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In assessing a clients suicide potential, which statement by the client would give the nurse the highest cause for concern? * A. My thoughts of hurting my self are scary to me * B. I would like to go to sleep and not wake up * C. I have thought about taking pills and alcohol until I pass out * D. I would like to be free from all these worries
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A client with paranoid schizophrenia has persecutory delusions and auditory hallucinations and is extremely agitated. He has been given a PRN dose of Thorazine IM. Which of the following would indicate to the nurse that the medication is having the desired effect?
* A. Complains of dry mouth * B. State he feels restless in his body * C. Stops pacing and sits with the nurse * D. Exhibits increase activity and speech
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A decision is made to discharge a client with obsessive-compulsive disorder. Of the following abilities the client has demonstrated, the one that probably most influenced the decision not to hospitalize him is his ability to: * a. Hold a job. * b. Relate to his peers. * c. Perform activities of daily living. * d. Behave in an outwardly normal
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The client is taking Tofranil. The nurse should closely monitor the patient: * a. Hypertension * b. Hypothermia * c. Increase Intra Ocular Pressure * d. Increase Intra Cranial Pressure
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A client was hospitalized with major depression with suicidal ideation for 1 week. He is taking venlafaxine (Effexor), 75 mg three times a day, and is planning to return to work. The nurse asks the client if he is experiencing thoughts of self-harm. The client responds, "I hardly think about it anymore and wouldn't do anything to hurt myself." The nurse judges: * A. The client to be decompensates and in need have being readmitted to the hospital * B. The client to need an adjustment or increase in his dose of antidepressant * C. The depression to be improving and the suicidal ideation to be lessening * D. The presence of suicidal ideation to warrant a telephone call to the client's physician
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Client with a history of schizophrenia has been admitted for suicidal ideation. The client states "God is telling me to kill myself right now." The nurses best response is: * A. I understand that god’s voice is real to you, but I do not hear anything. I will stay with you. * B. The voices are part of your illness; it will stop if you take medication * C. the voices are all in your imagination, think of something else and till go away * D. Do not think of anything right now, just go, and relax.
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If a Patient complaints about vomiting, diarrhea, and restlessness after taking lithane, then the nurses initial intervention is: * a. Recognize that this is a sign of toxicity and withhold the next medication. * b. Notify the physician. * c. Check V/S to validate patient’s concerns * d. Recognize that this is a normal side effect of lithium and continue the drug.
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A client is admitted to the inpatient psychiatric unit. He is unshaven, has body odor, and has spots on his shirt and pants. He moves slowly, gazes at the floor, and has a flat affect. The nurses highest priority in assessing the client on admission would be to ask him: * A. How he sleeps at night. * B. If he is thinking about hurting himself * C. About recent stresses * D. How he feels about himself
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The nurse should know that the normal therapeutic level of lithium is * A. .6 to 1.2 meq/L * B. 6 to 12 meq/L * C. .6 to .12 cc/ml * D. .6 to .12 cc3/L
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