1. While caring for an older client, the nurse observes multiple bruises over the client’s legs, arms,

back, and gluteal areas. When the client contact, the nurse suspects elder abuse. What action should

the nurse indicate?

➢ Measure and documentsize,shape and color of the bruised areas.

2. A client who is homeless is diagnosed with schizophrenia and admitted on an involuntary basis to e

mental health hospital 4 days ago. The client stopped taking prescribed antipsychotic drugs

approximately one month ago. Since hospitalization the client continuesto have poorjudgment and

refuses all medications. What action should the nurse take?

➢ Administer a long acting antipsychotic medication so that the client can be discharged to a

shelter. ?

3. Afterreceiving treatment for anorexia, a student asksthe school nurse for permission to work in the

school cafeteria as part of the school’s wok study program. What action should the nurse take?

➢ Recommend assignment to the receptionist’s office.

4. A male client comesto the emergency center because he has an erection that will not resolve. The

client reports that he is taking trazodone (desyrel) for insomnia. Which information is most

important for the nurse to ask this client?

➢ Have you taken any medication for erectile dysfunction?

5. On admission to the mental health unit, a client diagnosed with schizophrenia tellsthe nurse that he

is the son of God. Based on this statement, which intervention should the nurse include in this

client’s plan of care?

➢ Confront his delusion as not consistent with reality.

6. The nurse on the day shift receives report about a client with depression who was in bed most of the

weekend. The nurse walks into the client’s room in the morning and finds the client in bed. What

intervention I best for the nurse to implement?

➢ Assist the client to get out of bed and involved in an activity.

7. Which client information indicatesthe need forthe nurse to use the CAGE questionnaire during the

admission interview?

➢ Describes self as a social drinker who drinks alcoholic beverages daily.

8. A female client admitted to the mental health unitstats to shout and scream at the nurse. What is he

best approach for the nurse to take?

➢ Stay quietly with the client.

9. A woman is brought to the psychiatric clinic by her husband. He reportsthat his wife isreluctant to

leave home because of what she describes as a fear of open places and crows. Which nursing

problems applies to the client’s behavior?

➢ Anxiety related to real or perceived threat to physical integrity.

10. A clientisreceiving benztropine mesylate (Cogentin) for drug-induced extrapyramidalsyndrome

(EPS). Which finding indicates that the RN should further evaluate the client?

➢ Presence of a dry mouth.

11. A male client in the mental health unit is guarded and vaguely answers the nurse’s questions. He

isolates in his room and sometimes opensthe door to peek into the hall. Which problem can the RN

anticipate?

➢ Delusions of persecution.