A nurse in the emergency department is caring for a client who has alcohol toxicity

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client regarding his admission, the client states, “I’m red, in the head, and I’m going to bed!” The nurse should document the client’s speech pattern as which of the following?
Clang association
Word salad
Neologism
Echolalia
A nurse is caring for an older adult client who is experiencing delirium. Which of the following interventions should the nurse include in the client’s plan of care?
Offer the client various choices for meal selection
Assign different nursing personnel for each shift
Permit the client to perform daily rituals to decrease anxiety
Maintain an environment that has low lighting
A nurse in the emergency department is admitting a client who reports a headache along with heart palpitations after having a glass of wine with dinner a few hours ago. The client has a history of depression and has a blood pressure of 210/105 mm Hg. Which of the following questions should the nurse ask first?
“Do you have a family history of hypertension?”
“When did you last see your primary provider?”
“What medications are you currently taking?” 
“Do you currently use relaxation techniques for increased stress?”
A nurse is caring for a client who was admitted following an overdose of amitriptyline. The nurse should monitor the client for which of the following adverse effects associated with this medication?
Loose stools
Urinary retention
Fever
Dyspnea
A nurse who works with newborns is assessing the potential for abuse or neglect. Which of the following family groups should the nurse identify as the highest potential for future child abuse?
A family in which both parents are adolescents
A family in which the parents respond indifferently toward their newborn
A family where one or both parents witnessed intimate partner violence in the home as children
A family in which one or both parents has a developmental disability
A client who has paranoid schizophrenia is attending a treatment planning conference with a family member. During the discussion of the medication adherence portion of the plan, the nurse notices that the family member seems distracted. Which of the following actions should the nurse take?
Call the family member to the side to inquire if she has questions or concerns about the treatment plan
Advise the family member that this treatment plan has been developed specifically for the client to follow
Ask the family member if she has any thoughts or questions about the treatment plan
Document that the family member does not support the medication treatment plan
A nurse is reviewing the medication administration record for a client who is experiencing the adverse effects of chlorpromazine. The nurse should administer benztropine to relieve which of the following adverse effects?
Blurred vision
Orthostatic hypotension
Dry mouth
Acute dystonia
A nurse is caring for a client who is receiving hospice care for an inoperable brain tumor. When completing a spiritual assessment as part of end-of-life care, which of the following interventions should the nurse implement?
Discuss spiritual issues in a conversational manner
Engage in a formal discussion of the client’s religious beliefs
Prompt the client to be specific when asking questions related to his own spirituality
Offer suggestions based on personal spiritual values
A nurse is assessing a school-age child who has conduct disorder. Which of the following characteristics should the nurse expect the child to demonstrate?
Feelings of remorse
Extended periods of depression
Deficits in intellectual functioning
Aggression toward animals
A nurse is caring for a client who is taking clozapine. For which of the following findings should the nurse withhold the medication?
The client reports a sore throat
The client reports being constipated for 2 days. 
The client reports feeling dizzy when getting out of bed.
The client has gained 1.4 kg (3 lb) in the past month
A nurse is caring for a client who has alcoholic cardiomyopathy. Which of the following laboratory findings should the nurse expect?
Increased creatinine phosphokinase (CPK)
Increased low-density lipoproteins (LDL)
Decreased fasting blood glucose (FBG)
Decreased aspartate aminotransferase (AST)
A nurse is planning care for a newly admitted client who has bipolar disorder. Which of the following is the priority action by the nurse?
Schedule the client for group therapy sessions
Maintain consistent rules
Provide frequent high-calorie snacks
Avoid the use of value judgments
A nurse is admitting a client who has alcohol use disorder. Which of the following statements by the client indicates that the client is using denial as a defense mechanism?
“I put in extra hours at work, so I won’t think about drinking.”
“I know that wine is good for my heart, so that’s why I drink some each evening.”
“I make up for my drinking by taking my partner on nice vacations.”
“I am able to go to work every day, so I don’t have a problem.”
A nurse in a clinic is assessing a client whose partner died 4 months ago. Which of the following statements indicates that the client is at risk for complicated grief?
“I wish I had been nicer and more generous with my wife before she died.”
“I told my wife to go to the doctor, but she wouldn’t listen to me.”
“I think about my wife all the time when I go on outings with my family.”
“I feel so empty without my wife that it’s hard to get up every morning,”
A nurse is caring for a client who has moderate Alzheimer’s disease. Which of the following nursing interventions assists in orienting the client to reality?
Discourage the client from reminiscing about her past
Overlook the client’s frustration with communication
Talk with the client about scheduled daily activities
Present multiple options when offering the client choices
A nurse is planning care for a client who constantly threatens others on the unit. Although the client does not want to leave the unit, the nurse requests the provider to transfer the client to a unit that is equipped to manage violent behavior. Which of the following ethical principles should the nurse apply in this situation?
Nonmaleficence
Veracity
Justice
Autonomy
A nurse is communicating with a client in an inpatient mental health facility. Which of the following actions by the nurse demonstrates the use of active listening?
Offering self
Use of silence
Attention to body language
Reflection of feelings
A school nurse is assessing a school-age child who experienced the traumatic loss of a parent 8 months ago. Which of the following findings should the nurse identify as an indication that the child is experiencing post-traumatic stress disorder (PTSD)?
Clinging behaviors directed toward a teacher
Increased time spent sleeping
Intense focus on school work
Lack of interest in an upcoming holiday
A nurse is caring for four clients in an inpatient mental health facility. Which of the following clients can give informed consent?
A 17-year-old client who lives with friends
A 50-year-old who has a blood alcohol level of 0/08
A 35-year-old client who has major depressive disorder
A 65-year-old client who just received a dose of morphine
A nurse in the emergency department is caring for a client who has alcohol toxicity and is unresponsive. Which of the following interventions should the nurse take?
Gather supplies for endotracheal intubation
Administer a beta blocker intravenously
Position the client in low fowler’s position
Place a cooling blanket over the client
A nurse in a community health center is counseling a family of two parents and two children. Which of the following statements by a family member indicates manipulative behavior?
“If you do my homework for me, I won’t bother you for the rest of the day”
“Mom is always upset”
“It’s not the children’s fault. It’s mine.”
“It’s your fault that we’re having problems as a family”
A nurse in a mental health facility is planning discharge for a client who has a long history of alcohol use disorder. Which of the following post discharge activities should the nurse plan to include?
Taking the oral

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