21. A client with borderline personality disorder says to the nurse,”I feel so comfortable talking with you. You seem to have a special way about you that really helps me.” Which would be the most appropriate response by the nurse?A.           “I cannot be your friend. We need to be clear on that.”B.           “You feel others don’t understand you?”C.          “I’m here to help you just as all the staff members are.”D.          “I’m glad you feel comfortable with me.” 22. When establishing a relationship with a client who has borderline personality disorder, which is most important for the nurse to do?A.           Limit interactions to 10 minutes at a time.B.           Aggressively confront the client about boundary violations.C.          Respect the client’s boundaries at all times.D.          Tell the client the relationship will last as long as the client wishes. 23. A client is brought to the emergency room and is talkative and grandiose. When taking the client’s blood pressure, the nurse discovers that the client’s blood pressure is elevated. The nurse suspects that the client may be intoxicated with which substance?A.           OpioidsB.           CannabisC.          AlcoholD.          Cocaine 24. A client reports drinking one to two drinks when drinking behavior first began. Now the client reports drinking at least six drinks with every episode in order to “have a good time.” Which term would best describe this phenomenon?A.           Rebound effectB.           WithdrawalC.          DependenceD.          Tolerance 25. When assessing a client who is withdrawing from opioids, the nurse may expect to find which of the following signs and symptoms? Select all that apply.A.           RhinorrheaB.           Aching back and legsC.          YawningD.          HallucinationsE.           Fever 26. When assessing a client who is withdrawing from alcohol, which of the following signs and symptoms would the nurse expect to find? Select all that apply.A.           Elevated blood pressureB.           Muscle crampsC.          DiaphoresisD.          Hand tremorsE.           Diarrhea 27. A client presents to the emergency room with respiratory depression, pupil constriction, slurred speech, and severe drowsiness. Which medication should be administered immediately to reverse the intoxication?A.           NitroglycerinB.           NaloxoneC.          LorazepamD.          Methadone 28. Which medication is commonly used to help clients safely withdraw from heroin by tapering doses gradually? A.           ClonidineB.           LorazepamC.          MethadoneD.          Buprenorphine/naloxone 29. A client is being discharged from treatment for addiction to cocaine. Which statement made by the client would cause the most concern for the nurse?A.           “I’m not very comfortable with being alone yet.”B.           “Shooting baskets helps me not think about getting high.”C.          “I can still hang out with my old friends. I am just not going to use.”D.          “I am going to take up a new hobby. It’s time to start something new.” 30. A client is being discharged on disulfiram. Which instruction for disulfiram should the client receive?A.           Skip the daily dose of disulfiram on days when consumption of alcoholic beverages is likely.B.           Take disulfiram with food to avoid stomach upset.C.          Read product labels carefully to avoid all products containing alcohol.D.          Disulfiram will prevent the desire to drink alcoholic beverages. 31. The nurse is talking with the friend of a client with alcoholism. The friend tells the nurse that the friend’s relationship with the client was codependent and enabling. Which is an example of codependent behavior?A.           The friend calling the client every night to make sure the client got home safely.B.           The friend confronted the client on the effect of the client’s drinking on their relationship.C.          The friend refused to go out drinking with the client to celebrate the client’s birthday.D.          The friend called Alcoholics Anonymous when the client expressed a need to stop drinking. 32. A client is admitted for a drug overdose with a barbiturate. Which is the priority nursing action when planning care for this client?A.           Prepare a dose of ipecac, an emetic.B.           Check the client’s belongings for additional drugs.C.          Monitor respiratory function.D.          Pad the side rails of the bed because seizures are likely. 33. When planning care for a client with anorexia nervosa, which intervention should be included in the plan of care?A.           Allowing the client to eat whenever the client feels hungry.B.           Permitting the client to eat any food the client chooses, as long as the client is eating.C.          Insisting the client sit in the dining room until all food is eaten.D.          Weighing the client daily in uniform clothing. 34. Which nursing diagnosis would be most difficult to successfully resolve in a client who had anorexia nervosa?A.           Imbalanced nutrition-less than body requirementsB.           Deficient knowledge (nutritious eating patterns)C.          Social isolationD.          Disturbed body image 35. A client is being admitted to the in-patient psychiatric unit with a diagnosis of bulimia nervosa. The nurse would expect this client to fall within which age range? A.           18 to 22 years oldB.           5 to 10 years oldC.          25 to 35 years oldD.          10 to 14 years old 36. The nurse is assessing a client with bulimia nervosa. Which symptoms would the nurse expect to find? Select all that apply. A.           Normal weight for heightB.           HypotensionC.          Electrolyte imbalancesD.          Cold intoleranceE.           Dental erosion 37. A client diagnosed with bulimia nervosa has been attending a mental health clinic for several months. Which factor should a nurse identify as an appropriate indicator of a positive client behavioral change?A.           The client demonstrates healthy coping mechanisms that decrease anxietyB.           The client gains 2 pounds in 1 weekC.          The client verbalizes they have a unrealistic body imageD.          The client focuses conversations on nutritious foods 38. A client diagnosed with anorexia nervosa is newly admitted to an in-patient psychiatric unit. Which nursing intervention takes priority?A.           Assessment of early disturbances in mother-daughter interactionsB.           Assessment of the client’s knowledge of selective serotonin reuptake inhibitors used in treatmentC.          Assessment and monitoring of vital signs and lab values to recognize and anticipate medical problemsD.          Assessment of family issues and health concerns 39. The nurse is assessing a client with anorexia nervosa. Which symptoms would the nurse expect to find? Select all that apply.A.           Elevated blood pressureB.           BradycardiaC.          DiarrheaD.          Pedal edemaE.           Lanugo 40. While assessing the family dynamics of a client with an eating disorder, which of the following will the nurse most likely discover?A.           Supportive and encouraging relationshipsB.           Multiple siblingsC.          Over Controlling parentsD.          Lack of interest in the client by other family members Health ScienceScienceNursing MENTAL HEA NUR4445

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