Question

A nurse is caring for a client who is in the emergency department.

Answer 1

Correct Highlights :

Ask the client if they have been hit. slapped. or kicked within the past year.

Rationale :

💠 Behavior-specific screening questions (hit/slapped/kicked) are evidence-based and reduce ambiguity, increasing disclosure.

💠 Direct, nonjudgmental wording validates safety concerns without blaming or pressuring the client.

💠 Private, standardized screening is the expectation; it focuses on prevalence behaviors rather than explanations.

💠 Opens the door to further assessment (injury patterns, fear, safety planning) if the client discloses.

💠 Meets legal/ethical duties to screen for IPV while maintaining therapeutic neutrality.

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Answer 2

Correct Answers

Blank 1 Correct Option: heart rate
Blank 2 Correct Option: temperature

Rationale :

🔷 High temperature (39.5 °C) points to neuroleptic malignant syndrome (NMS) risk with antipsychotics.

🔷 Tachycardia (HR 124/min) reflects autonomic instability, another NMS hallmark.

🔷 Haloperidol is a typical antipsychotic associated with NMS; early recognition is critical.

🔷 Life-threatening trajectory requires urgent actions (hold med, notify provider, cooling, fluids, possible ICU).

🔷 Anticholinergic complaints (dry mouth, blurry vision) are less emergent than fever + tachycardia combo.

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Answer 3

Correct Answers:

A client who is taking fluoxetine and exhibits muscle rigidity and tachycardia

Rationale :

💎 Fluoxetine is an SSRI (Selective Serotonin Reuptake Inhibitor), and the combination of muscle rigidity and tachycardia suggests serotonin syndrome, a potentially life-threatening adverse effect.

💎 Serotonin syndrome occurs due to excess serotonin accumulation in the CNS, often characterized by neuromuscular hyperactivity, autonomic instability, and altered mental status.

💎 Immediate action is to withhold the medication and notify the provider—early recognition prevents progression to hyperthermia, seizures, or shock.

💎 Monitoring vital signs, muscle tone, reflexes, and temperature is essential while providing supportive care and discontinuing serotonergic agents.

💎 Mild side effects (e.g., yawning, dry mouth, or mild nausea) are expected with other antidepressants, but rigidity and tachycardia indicate a medical emergency.

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Answer 4

Correct Answers:

“I will practice replacing negative thoughts with positive self-statements."

Rationale :

🔶 Cognitive reframing targets maladaptive thoughts and substitutes balanced, adaptive statements.

🔶 It reduces stress reactivity by changing appraisal of events, not the events themselves.

🔶 Skill-based, repeatable strategy that clients can apply across contexts.

🔶 Distinct from biofeedback, PMR, or guided imagery, which address physiologic arousal/attention.

🔶 Core CBT technique with strong evidence for anxiety and stress management.

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Answer 5

Correct Answers:

“You have the right to refuse to attend group therapy."

Rationale :

🟦 Respect for autonomy and patient rights is foundational in mental health care.

🟦 Non-coercive stance preserves therapeutic alliance and trust.

🟦 Accurate education on rights often reduces resistance and opens future engagement.

🟦 Allows nurse to explore barriers (anxiety, stigma) after rights are affirmed.

🟦 Supports shared decision-making, a best practice in recovery-oriented care.

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Answer 6

Correct Answers:

“Tell me about your support system."

Rationale :

🟣 Open-ended, therapeutic prompt that gathers actionable data (family, friends, community).

🟣 Mobilizing supports is evidence-based for stress buffering and outcomes.

🟣 Avoids false reassurance or premature advice-giving.

🟣 Client-centered: invites narrative, validates experience, and guides planning.

🟣 Transitions naturally into referrals (therapy, groups) based on what the client identifies.

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Answer 7

Correct Answers:

Clients can refuse to attend group therapy.

Rationale :

🟠 Right to refuse treatment (with safety/commitment exceptions) applies to most non-emergent therapies.

🟠 Advance directives and legal counsel rights are maintained when competent/entitled.

🟠 Consent withdrawal does not have to be only in writing; verbal withdrawal is valid.

🟠 Teaching staff correct rights prevents coercion and improves ethical practice.

🟠 Aligns with patient-centered, recovery-oriented standards.

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Answer 8

Correct Answers:

Muscle distress

Rationale :

🟥 During ECT, the induced seizure risks fractures/myalgias without a neuromuscular blocker.

🟥 Succinylcholine provides brief paralysis, minimizing muscle contractions.

🟥 Airway/aspiration is addressed by NPO status and anesthesia, not succinylcholine specifically.

🟥 Bradycardia/HTN are managed by other peri-ECT meds and monitoring, not this agent.

🟥 Proper use reduces post-ECT soreness and injury risk, enhancing safety.

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Answer 9

Correct Answers:

Schedule the client for a morning group fitness class at the facility.

Rationale :

🟩 Daytime activity improves sleep drive and circadian alignment in dementia.

🟩 Avoid late-day naps; long afternoon naps worsen sleep initiation.

🟩 Limit caffeine (ideally avoid, not “≤4 drinks”); morning exercise is more sleep-friendly.

🟩 Evening exertion close to bedtime can be activating; mornings are preferable.

🟩 Consistency and structured routine aid sleep and reduce nighttime wandering.

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Answer 10

Correct Answers:

Fatigue

Rationale :

🔵 Stimulant withdrawal typically causes fatigue, hypersomnia, anhedonia, depression.

🔵 Rapid speech/seizures/tremor fit intoxication or other syndromes, not classic withdrawal.

🔵 Crash phase follows cessation due to dopamine depletion.

🔵 Monitoring mood is vital due to post-use dysphoria/suicidality risk.

🔵 Supportive care, rest, and sleep normalization are mainstays initially.

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QLexNursing

1 :
A nurse is caring for a client who is in the emergency department.

Correct Highlights :

2 :
A nurse as caring for a client.

Correct Answers

3 :
A nurse is reviewing the medical records for a group of clients prior to administering the clients' medications. For which of the following clients should the nurse withhold the prescribed medication and notify the provider?

4 :
A nurse is teaching a client about the use of cognitive reframing for stress management. Which of the following statements by the client indicates an understanding of the teaching?

5 :
A nurse is caring for a client who refuses to attend group therapy. Which of the following statements should the nurse make?

6 :
A nurse is caring for a client who reports difficulty coping with several recent stressors. Which of the following responses should the nurse make?

7 :
A charge nurse on a mental health unit is preparing an in-service about client rights for staff members. Which of the following information should the nurse include?

8 :
A nurse is caring for a client who has severe depression and is scheduled to receive electroconvulsive therapy. The nurse should recognize that the client will receive succinylcholine to prevent which of the following adverse effects?

9 :
A nurse in a long-term care facility is caring for a client who has dementia and reports difficulty falling asleep at night. Which of the following actions should the nurse take to promote adequate rest?

10 :
A nurse is caring for a client who has cocaine use disorder. Which of the following manifestations should the nurse expect the client to have during withdrawal?

QLexNursing

1 : A nurse is caring for a client who is in the emergency department.

Correct Highlights :

2 : A nurse as caring for a client.

Correct Answers

3 : A nurse is reviewing the medical records for a group of clients prior to administering the clients' medications. For which of the following clients should the nurse withhold the prescribed medication and notify the provider?

4 : A nurse is teaching a client about the use of cognitive reframing for stress management. Which of the following statements by the client indicates an understanding of the teaching?

5 : A nurse is caring for a client who refuses to attend group therapy. Which of the following statements should the nurse make?

6 : A nurse is caring for a client who reports difficulty coping with several recent stressors. Which of the following responses should the nurse make?

7 : A charge nurse on a mental health unit is preparing an in-service about client rights for staff members. Which of the following information should the nurse include?

8 : A nurse is caring for a client who has severe depression and is scheduled to receive electroconvulsive therapy. The nurse should recognize that the client will receive succinylcholine to prevent which of the following adverse effects?

9 : A nurse in a long-term care facility is caring for a client who has dementia and reports difficulty falling asleep at night. Which of the following actions should the nurse take to promote adequate rest?

10 : A nurse is caring for a client who has cocaine use disorder. Which of the following manifestations should the nurse expect the client to have during withdrawal?

1 :
A nurse is caring for a client who is in the emergency department.

2 :
A nurse as caring for a client.

3 :
A nurse is reviewing the medical records for a group of clients prior to administering the clients' medications. For which of the following clients should the nurse withhold the prescribed medication and notify the provider?

4 :
A nurse is teaching a client about the use of cognitive reframing for stress management. Which of the following statements by the client indicates an understanding of the teaching?

5 :
A nurse is caring for a client who refuses to attend group therapy. Which of the following statements should the nurse make?

6 :
A nurse is caring for a client who reports difficulty coping with several recent stressors. Which of the following responses should the nurse make?

7 :
A charge nurse on a mental health unit is preparing an in-service about client rights for staff members. Which of the following information should the nurse include?

8 :
A nurse is caring for a client who has severe depression and is scheduled to receive electroconvulsive therapy. The nurse should recognize that the client will receive succinylcholine to prevent which of the following adverse effects?

9 :
A nurse in a long-term care facility is caring for a client who has dementia and reports difficulty falling asleep at night. Which of the following actions should the nurse take to promote adequate rest?

10 :
A nurse is caring for a client who has cocaine use disorder. Which of the following manifestations should the nurse expect the client to have during withdrawal?