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QUESTIONS AND ANSWERS
A charge nurse is discussing mental status exams with a newly licensed nurse. Which of
the following statements by the newly licensed nurse indicates an understanding of the
teaching? (Select all that apply)
a. To assess cognitive ability, I should ask the client to count backward by sevens.
b. To assess affect, I should observe the client's facial expression.
c. To assess language ability, I should instruct the client to write a sentence.
d. To assess remote memory, I should have the client repeat a list of objects.
e. To assess the client's abstract thinking, I should ask the client to identify our most
recent presidents.
✔️ Correct Answer: A, B, C
Rationale:
Counting backward by sevens assesses cognitive ability (concentration and calculation).
Observing facial expression assesses affect (emotional expression). Writing a sentence
assesses language ability. Option D describes assessment of immediate memory, not
remote memory. Option E describes assessment of orientation or memory, not abstract
thinking; abstract thinking is assessed by interpreting proverbs.
,A nurse is planning care for a client who has a mental health disorder. Which of the
following actions should the nurse include as a psychobiological intervention?
a. Assist the client with systematic desensitization therapy.
b. Teach the client appropriate coping mechanisms.
c. Assess the client for comorbid health conditions.
d. Monitor the client for adverse effects of the medications.
✔️ Correct Answer: D
Rationale:
Psychobiological interventions address the biological aspects of mental health disorders,
including medication administration and monitoring for adverse effects. Systematic
desensitization (Option A) is a behavioral therapy. Teaching coping mechanisms (Option
B) is a psychosocial intervention. Assessing for comorbid conditions (Option C) is part of
comprehensive assessment but not specifically psychobiological.
A nurse in an outpatient mental health clinic is preparing to conduct an initial client
interview. When conducting the interview, which of the following actions should the
nurse identify as the priority?
a. Coordinate holistic care with social services.
b. Identify the client's perception of her mental health status.
c. Include the client's family in the interview.
d. Teach the client about her current mental health disorder.
✔️ Correct Answer: B
Rationale:
The priority during an initial client interview is to identify the client's perception of her
mental health status. Understanding the client's perspective is essential for establishing
rapport, building trust, and developing an effective treatment plan. Coordinating care
(Option A), including family (Option C), and teaching (Option D) are important but
secondary to the initial assessment.
,A nurse is told during change of shift report that a client is stuporous. When assessing
the client, which of the following findings should the nurse expect?
a. The client arouses briefly in response to a sternal rub.
b. The client has a Glasgow Coma Scale score less than 7.
c. The client exhibits decorticate rigidity.
d. The client is alert but disoriented to time and place.
✔️ Correct Answer: A
Rationale:
A stuporous client is difficult to arouse and requires vigorous stimulation (such as a
sternal rub) to elicit a brief response. Option B describes coma (GCS <7). Option C
describes abnormal posturing, which is not specific to stupor. Option D describes
confusion or disorientation, not stupor.
A nurse is planning a peer group about the DSM-5. Which of the following information is
appropriate to include in the discussion? (Select all that apply)
a. The DSM-5 includes client education handouts for mental health disorders.
b. The DSM-5 establishes diagnostic criteria for individual mental health disorders.
c. The DSM-5 indicates recommended pharmacological treatment for mental health
disorders.
d. The DSM-5 assists nurses in planning care for clients who have mental health
disorders.
e. The DSM-5 indicates expected assessment findings of mental health disorders.
✔️ Correct Answer: B, D, E
Rationale:
The DSM-5 establishes diagnostic criteria (Option B), assists in care planning (Option D),
and indicates expected assessment findings (Option E). It does not include client
education handouts (Option A) or recommend pharmacological treatment (Option C).
A nurse in an emergency mental health facility is caring for a group of clients. The nurse
should identify that which of the following clients requires a temporary emergency
admission?
, a. A client who has schizophrenia with delusions of grandeur
b. A client who has manifestations of depression and attempted suicide a year ago
c. A client who has borderline personality disorder and assaulted a homeless man with a
metal rod
d. A client who has bipolar disorder and paces quickly around the room while talking to
himself
✔️ Correct Answer: C
Rationale:
A client who has assaulted someone poses an immediate danger to others and requires
temporary emergency admission for safety. Delusions of grandeur (Option A) do not
necessarily indicate imminent danger. A suicide attempt a year ago (Option B) is not an
immediate risk. Pacing and talking to oneself (Option D) are concerning but do not
indicate immediate danger to self or others.
A nurse decides to put a client who has a psychotic disorder in seclusion overnight
because the unit is very short-staffed, and the client frequently fights with other clients.
The nurse's actions are an example of which of the following torts?
a. Invasion of privacy
b. False imprisonment
c. Assault
d. Battery
✔️ Correct Answer: B
Rationale:
False imprisonment is the unlawful confinement of a person without consent or legal
justification. Placing a client in seclusion for staff convenience (short-staffing) rather than
for safety reasons constitutes false imprisonment. Invasion of privacy (Option A) involves
unauthorized disclosure of personal information. Assault (Option C) is threatening harm.
Battery (Option D) is harmful or offensive contact.
A client tells a nurse, "Don't tell anyone but I hid a sharp knife under my mattress in order
to protect myself from my roommate, who is always yelling at me and threatening me."
Which of the following actions should the nurse take?