1. A nurse in an urgent care clinic is collecting data from a client whose friend reports a

suspicion ofcocaine use. The nurse should identify that which of the following

manifestations is an indicator of the client’s use of this substance?

Answer: Hypertension

2. A nurse in a mental health facility is caring for a client who has dementia. The

client’sagitation is increasing. Which of the following actions should the

nurse take first?

Answer: Offer diversionary activities

3. A nurse is caring for a client who has bipolar disorder. The client suddenly appears

agitated and begins pacing at the end of the hallway with clenched fists. Which of the

following actions should the nurse take first?

Answer: Determine the client’s intentions

4. A nurse is reinforcing discharge teaching with a client who has a new prescription for

alprazolam.Which of the following instructions is the priority for the nurse to include?

Answer: Do not drive until your reaction to the medication is determined

5. A nurse is caring for a client who is 2 days postoperative following a hip arthroplasty.

When a news report about military action comes on the television, the client says to the

nurse, “My youngest child died 6 months ago while serving in the military.” Which of

the following responsesshould the nurse make?

Answer:

-This must be very difficult time for you

-Your child’s death must be a terrible loss

-Tell me something you remember about your child

6. A nurse is caring for an adult client who has visible injuries as a result of

intimate partnerviolence. Which of the following actions should the nurse take?

Answer: Encourage the client to develop a safety plan

7. A nurse is contributing to the plan of care for a client who has bipolar disorder and is

exhibiting mania,Which of the following interventions should the nurse include to improve

the nutritional status of the client?

Answer: Have the client’s favorite snacks available at all times.

8. A nurse is collecting data from a client who has paranoid personality disorder. Which of

thefollowing manifestations should the nurse expect?

Answer: Projects blame onto others

9. A nurse on and inpatient unit is assisting with a group therapy session. During the

session, a client begins to shout using aggressive language. Which of the following

statements should thenurse make to the client?