1 :

Hint : Divide the prescribed dose by the dose per tablet

Correct Answers:

  • 2


Rationale :
Working: Number of tablets= Desired dose (mg)÷Dose per tablet (mg) Desired dose = 150 mg Dose per tablet = 75 mg/tablet Therefore, Number of tablets= 150mg÷ 75mg/tablet =2tablet(s) Hence, the nurse should administer 2 tablets per dose.

Distractor Analysis :

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2 :

Hint : safety for both the client and staff

Correct Answers:

  • The client must be calm and cooperative


Rationale :
Physical restraints should only be used when absolutely necessary and discontinued as soon as the client demonstrates self-control and no longer poses a danger to themselves or others. The nurse must assess that the client is calm and cooperative before removing restraints, ensuring the safety of the client and staff.

Distractor Analysis :

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3 :

Hint : Safety and support.

Correct Answers:

  • Offer the client a quiet space and remain with them


Rationale :
During a panic-level anxiety episode, the priority is to provide safety and support. Offering a quiet space helps reduce stimuli, and staying with the client ensures they feel secure.

Distractor Analysis :

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4 :

Hint : Added behaviors in schizophrenia

Correct Answers:

  • Auditory hallucinations and delusions


Rationale :
Positive symptoms of schizophrenia involve additions or exaggerations to normal behavior, such as hallucinations, delusions, and disorganized thinking.

Distractor Analysis :

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5 :

Hint : Panic Disorder

Correct Answers:

  • Panic Attack due to Panic Disorder


Rationale :
The symptoms of sweating, trembling, increased heart rate, and chest pain are hallmark signs of a panic attack

Distractor Analysis :

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6 :

Hint : Benzodiazepines in alcohol withdrawal management

Correct Answers:

  • Benzodiazepines


Rationale :
Benzodiazepines, such as diazepam or lorazepam, are the first-line treatment for alcohol withdrawal. They help reduce withdrawal symptoms, prevent seizures, and provide a calming effect

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7 :

Nurses’ Notes

0800

Client observed at breakfast wearing hospital scrubs with the bottom of the pants rolled up and shirt arranged like a halter top. Client sat for less than 5 min and consumed half a piece of toast. Client took the juice box when leaving the table. Observed consuming juice and then dropping the box on the counter. The client reports not sleeping for 2 days.

1300:

Client arrived at group. Moved chairs into a cluster and found a seat in the middle. Talkative, interrupting others despite reminders to allow all members to take a turn. After 10 min, client stood, paced quickly around the day room, and eventually left the group. Observed client entering another client's room, yelling out, "Yoo-hoo! Are you here?" Redirected by staff out of room and led to day room. Invited to a one-on-one as an alternative to group. "Oh, I can't do that, I have a meeting with the mayor shortly."

1730

Client at nurse's desk and continuing to pace around the desk. Talking about the day, moving closer to nurse with each sentence. Offered to walk away from the nurse's desk. Client states, "You want to be alone with me." As client quickly walked to day room, they stated "Oh, I am feeling hot," and was observed taking off scrub top. Client's oral intake 2000 mL.

History and Physical

o   Bipolar disorder

o   Borderline personality disorder

o   Alcohol use disorder, in remission

Provider Prescriptions

o   Lithium 300 mg PO three times a day

o   Aripiprazole 10 mg PO daily

Laboratory Results

o   Lithium level 1.3 mEq/L

o   Sodium 136 mEq/L


Complete the following sentence by using the lists of options. The client is at highest risk for developing,)as evidence by .


Hint : Manic hyperactivity

Correct Answers

  • Blank 1 Correct Option: exhaustion
  • Blank 2 Correct Option: excessive physical activity

Rationale :
The client is displaying hyperactive behaviors, such as pacing, lack of sleep, and increased movement throughout the day. These behaviors, common in mania associated with bipolar disorder, put the client at risk for physical exhaustion.

Distractor Analysis :

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8 :

Hint : Gradual exposure-relaxation.

Correct Answers:

  • Modeling


Rationale :
Systematic desensitization involves gradually exposing the client to the feared object or situation (in this case, snakes) while teaching them relaxation techniques to manage their anxiety.

Distractor Analysis :

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9 :

Hint : PTSD SSRI treatment.

Correct Answers:

  • Paroxetine


Rationale :
Paroxetine is a selective serotonin reuptake inhibitor (SSRI) commonly prescribed for PTSD. It helps manage symptoms such as anxiety, depression, and intrusive thoughts by improving serotonin levels in the brain.

Distractor Analysis :

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10 :

Hint : Safety first.

Correct Answers:

  • Initiate suicide precautions and provide a safe environment.


Rationale :
The client’s statement about hopelessness and lack of purpose in living suggests a risk for self-harm or suicide, making safety the nurse's immediate priority.

Distractor Analysis :

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Total Questions: 10

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