Question

A nurse in an acute mental health unit is caring for a group of clients. For which of the following clients is seclusion contraindicated?

Answer 1

Correct Answers:

An adult client following a suicide attempt

Rationale :

🟢 Seclusion is contraindicated for clients who are at risk for self-harm, such as those recovering from a suicide attempt.

🟢 Isolation could increase suicidal ideation, promote feelings of hopelessness, and reduce supervision.

🟢 These clients require close observation, one-to-one monitoring, and supportive care, not seclusion.

🟢 The goal is to reduce risk and enhance safety, not intensify distress.

🟢 Seclusion is typically used for agitation or aggression, not suicidal behavior.

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Answer 2

Correct Answers:

Dysrhythmias

Rationale :

🟢 Haloperidol can prolong the QT interval, which increases the risk of developing cardiac dysrhythmias.

🟢 It is especially important to monitor clients with cardiac conditions or who are on other QT-prolonging drugs.

🟢 ECG monitoring should be considered for clients receiving high doses or IV forms of haloperidol.

🟢 Symptoms of dysrhythmias may include dizziness, palpitations, or syncope.

🟢 This adverse effect is life-threatening and should be addressed immediately.

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Answer 3

Correct Answers:

7

Rationale :

🟢 Use the formula:

(Desired dose ÷ Available dose) × Volume

(350 mg ÷ 250 mg) × 5 mL

7 mL.

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Answer 4

Correct Answers:

A client runs 4 miles outdoors every afternoon.

Rationale :

🟢 Excessive sweating and fluid loss during exercise can lower sodium levels, increasing the risk of lithium toxicity.

🟢 Lithium and sodium are excreted through the kidneys, and dehydration can concentrate lithium in the blood.

🟢 Clients should be instructed to maintain adequate hydration and moderate activity levels.

🟢 Symptoms of lithium toxicity include tremors, nausea, ataxia, and confusion.

🟢 This is a preventable risk factor with appropriate patient education.

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Answer 5

Correct Answers:

The partner has lost 20 lb in the past 2months.

Rationale :

🟢 Unintentional weight loss is a classic indicator of caregiver role strain and stress.

🟢 It may reflect poor self-care, depression, or overwhelming burden from caregiving responsibilities.

🟢 This warrants further assessment, support, and possibly referral to social services.

🟢 Caregivers of clients with Alzheimer’s disease are at high risk of burnout.

🟢 Physical symptoms like weight loss suggest unsustainable caregiver burden.

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Answer 6

Correct Answers:

0.75

Rationale :

🟢 Use the formula:

(Desired dose ÷ Available concentration)

(75 mg ÷ 100 mg/mL)

0.75 mL.

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Answer 7

Correct Answers:

"It sounds like you're having a difficult time."

Rationale :

🟢 This response demonstrates therapeutic communication by showing empathy and validation of the client’s emotions.

🟢 It encourages the client to continue expressing their concerns and builds rapport.

🟢 Open-ended and non-judgmental statements are preferred for clients with anxiety.

🟢 The goal is to provide a safe environment for emotional exploration.

🟢 Avoid asking “why” or giving premature advice early in assessment.

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Answer 8

Correct Answers:

"Tell me more about your feelings about what happened to your partner."

Rationale :

🟢 This response uses open-ended therapeutic communication to allow the partner to express emotions.

🟢 It helps the nurse assess for guilt, trauma, or risk of depression, while offering support.

🟢 Avoiding judgment and offering space to talk promotes healing and trust.

🟢 The question focuses on feelings, not assumptions or minimizing statements.

🟢 Encouraging emotional exploration can help in crisis intervention.

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Answer 9

Correct Answers:

"l may have a dry mouth while taking this medication."

Rationale :

🟢 Chlorpromazine, a first-generation antipsychotic, has anticholinergic effects like dry mouth, constipation, and blurred vision.

🟢 Educating clients about expected side effects helps improve medication adherence.

🟢 This knowledge prepares the client to manage symptoms with comfort measures, such as sips of water or sugar-free gum.

🟢 Anticholinergic effects are common but manageable.

🟢 Knowing these side effects improves safety and confidence with new prescriptions.

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Answer 10

Correct Answers:

Remain with the client.

Rationale :

🟢 Staying with the client demonstrates presence and support, which is crucial during acute anxiety or agitation.

🟢 The client’s nonverbal signs (head down, wringing hands, pacing) show emotional distress.

🟢 Physical presence can help reduce feelings of isolation and panic.

🟢 It also allows the nurse to monitor for worsening symptoms or risk of self-harm.

🟢 This approach is non-invasive and therapeutic, enhancing trust.

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QLexNursing

1 :
A nurse in an acute mental health unit is caring for a group of clients. For which of the following clients is seclusion contraindicated?

2 :
A nurse is caring for a client who has severe manifestations of schizophrenia and is medicated PRN for agitation with haloperidol. The nurse should assess the client for which of the following adverse effects?

3 :
A nurse is preparing to minister amoxicillin 350 mg PO. Available is amoxicillin 250 mg/5 mL. How many mL should the nurse administer? (Round to the nearest whole number.)

4 :
A nurse is providing discharge teaching to a client who has bipolar disorder and will be discharged with a prescription for lithium. The nurse could teach the client which of the following factors puts her at risk for lithium toxicity?

5 :
A nurse is making a home visit to a client who has Alzheimer's disease and the client's partner. Which of the following observations indicates to the nurse that the partner is experiencing caregiver role strain?

6 :
A nurse is preparing to administer haloperidol 75 mg 1M per week. Available is haloperidol decanoate 100mg/ml for injection. How many ml should the nurse administer per dose? (Round the answer to the nearest hundredth. Use a leading zero if it applies.)

7 :
A nurse is caring for a young adult client who says he is experiencing increased anxiety and an inability to concentrate. Which of the following responses should the nurse make?

8 :
A nurse is admitting a client who has multiple injuries following a motor vehicle crash. Shortly after admission, the clients partner arrives. He is distraught and blames himself for the accident. Which of the following responses should the nurse make?

9 :
A nurse is teaching a client who has a new prescription for chlorpromazine. Which of the following client statements indicates an understanding of the teaching?

10 :
A nurse is caring for a client who is having difficulty sleeping and is pacing the floor. The client's head down, and he is wringing his hands. Which of the following actions should the nurse take?

QLexNursing

1 : A nurse in an acute mental health unit is caring for a group of clients. For which of the following clients is seclusion contraindicated?

2 : A nurse is caring for a client who has severe manifestations of schizophrenia and is medicated PRN for agitation with haloperidol. The nurse should assess the client for which of the following adverse effects?

3 : A nurse is preparing to minister amoxicillin 350 mg PO. Available is amoxicillin 250 mg/5 mL. How many mL should the nurse administer? (Round to the nearest whole number.)

4 : A nurse is providing discharge teaching to a client who has bipolar disorder and will be discharged with a prescription for lithium. The nurse could teach the client which of the following factors puts her at risk for lithium toxicity?

5 : A nurse is making a home visit to a client who has Alzheimer's disease and the client's partner. Which of the following observations indicates to the nurse that the partner is experiencing caregiver role strain?

6 : A nurse is preparing to administer haloperidol 75 mg 1M per week. Available is haloperidol decanoate 100mg/ml for injection. How many ml should the nurse administer per dose? (Round the answer to the nearest hundredth. Use a leading zero if it applies.)

7 : A nurse is caring for a young adult client who says he is experiencing increased anxiety and an inability to concentrate. Which of the following responses should the nurse make?

8 : A nurse is admitting a client who has multiple injuries following a motor vehicle crash. Shortly after admission, the clients partner arrives. He is distraught and blames himself for the accident. Which of the following responses should the nurse make?

9 : A nurse is teaching a client who has a new prescription for chlorpromazine. Which of the following client statements indicates an understanding of the teaching?

10 : A nurse is caring for a client who is having difficulty sleeping and is pacing the floor. The client's head down, and he is wringing his hands. Which of the following actions should the nurse take?

1 :
A nurse in an acute mental health unit is caring for a group of clients. For which of the following clients is seclusion contraindicated?

2 :
A nurse is caring for a client who has severe manifestations of schizophrenia and is medicated PRN for agitation with haloperidol. The nurse should assess the client for which of the following adverse effects?

3 :
A nurse is preparing to minister amoxicillin 350 mg PO. Available is amoxicillin 250 mg/5 mL. How many mL should the nurse administer? (Round to the nearest whole number.)

4 :
A nurse is providing discharge teaching to a client who has bipolar disorder and will be discharged with a prescription for lithium. The nurse could teach the client which of the following factors puts her at risk for lithium toxicity?

5 :
A nurse is making a home visit to a client who has Alzheimer's disease and the client's partner. Which of the following observations indicates to the nurse that the partner is experiencing caregiver role strain?

6 :
A nurse is preparing to administer haloperidol 75 mg 1M per week. Available is haloperidol decanoate 100mg/ml for injection. How many ml should the nurse administer per dose? (Round the answer to the nearest hundredth. Use a leading zero if it applies.)

7 :
A nurse is caring for a young adult client who says he is experiencing increased anxiety and an inability to concentrate. Which of the following responses should the nurse make?

8 :
A nurse is admitting a client who has multiple injuries following a motor vehicle crash. Shortly after admission, the clients partner arrives. He is distraught and blames himself for the accident. Which of the following responses should the nurse make?

9 :
A nurse is teaching a client who has a new prescription for chlorpromazine. Which of the following client statements indicates an understanding of the teaching?

10 :
A nurse is caring for a client who is having difficulty sleeping and is pacing the floor. The client's head down, and he is wringing his hands. Which of the following actions should the nurse take?