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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). - Correct answer 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."
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? - Correct
answer D. Monitor the client for adverse effects of the medications.
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? - Correct answer B. Identify the client's perception of her
mental health status.
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? - Correct answer A.
The client arouses briefly in response to a sternal rub.
A nurse is planning a peer group discussion about the DSM-5. Which of the following
information is appropriate to include in the discussion? (Select all that apply) - Correct
answer B. The DSM-5 establishes diagnostic criteria for individual mental health
disorders.
D. The DSM-5 assists nurses in planning care for client's who have mental health
disorders.
E. The DSM-5 indicates expected assessment findings of mental health disorders.
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? - Correct answer C. A client who has borderline personality disorder and
assaulted a homeless man with a metal rod
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? - Correct answer B.
False imprisonment
,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? - Correct answer D. Report
the incident to the health care team, but do not inform the client of the intention to do so.
A nurse is caring for a client who is in mechanical restraints. Which of the following
statements should the nurse include in the documentation? (Select all that apply) -
Correct answer B. "Client was offered 8 oz of water every hr."
C. "Client shouted obscenities at assistive personnel."
D. "Client received chlorpromazine 15 mg by mouth at 1000.
A nurse hears a newly licensed nurse discussing a client's hallucinations in the hallway
with another nurse. Which of the following actions should the nurse take first? - Correct
answer B. Tell the nurse to stop discussing the behavior
A nurse is caring for the parents of a child who has demonstrated changes in behavior
and mood. When the mother of the child asks the nurse for reassurance about her son's
condition, which of the following responses should the nurse make? - Correct answer D.
"I understand you're concerned. Let's discuss what concerns you specifically."
A nurse is caring for a client who smokes and has lung cancer. The client reports, "I'm
coughing because I have that cold that everyone has been getting." The nurse should
identify that the client is using which of the following defense mechanisms? - Correct
answer B. Denial
A nurse is providing preoperative teaching for a client who was just informed that she
requires emergency surgery. The client has a respiratory rate 30/min and says, "This is
difficult to comprehend. I feel shaky and nervous." The nurse should identify that the
client is experiencing which of the following levels of anxiety? - Correct answer B.
Moderate
A nurse is caring for a client who is experiencing moderate anxiety. Which of the
following actions should the nurse take when trying to give necessary information to the
client? (Select all that apply.) - Correct answer B. Discuss prior use of coping
mechanisms with the client.
D. Demonstrate a calm manner while using simple and clear directions.
A nurse is talking with a client who is at risk for suicide following the death of his
spouse. Which of the following statements should the nurse make? - Correct answer C.
"Losing someone close to you must be very upsetting."
A charge nurse is discussing the characteristics of a nurse-client relationship with a
newly licensed nurse. Which of the following characteristics should the nurse include in
the discussion? (Select all that apply) - Correct answer C. It is goal-directed.
D. Behavioral change is encouraged.
E. A termination date is established.
, A nurse is in the working phase of a therapeutic relationship with a client who has
methamphetamine use disorder. Which of the following actions indicates transference
behavior? - Correct answer B. The client accuses the nurses of telling him what to do
just like his ex-girlfriend.
A nurse is planning care for the termination phase of a nurse-client relationship. Which
of the following actions should the nurse include in the plan of care? - Correct answer A.
Discussing ways to use new behaviors
A nurse is orienting a new client to a mental health unit. When explaining the unit's
community meetings, which of the following statements should the nurse make? -
Correct answer C. "You and the other clients will meet with staff to discuss common
problems.
A nurse is caring several clients who are attending community-based mental health
programs. Which of the following clients should the nurse plan to visit first? - Correct
answer C. A client who says he is hearing a voice that tells him he is not worth living
anymore.
A community mental health nurse is planning care to address the issue of depression
among older adult clients in the community. Which of the following interventions should
the nurse plan as a method of tertiary prevention? - Correct answer C. Establishing
rehabilitation programs to decrease the effects of depression
A nurse is working in a community mental health facility. Which of the following services
does this type of program provide? (Select all that apply) - Correct answer A.
Educational groups
B. Medication dispensing programs
C. Individual counseling programs
E. Family therapy
A nurse in an acute mental health facility is assisting with discharge planning for a client
who has a severe mental illness and requires supervision much of the time. The client's
wife works all day but is home by late afternoon. Which of the following strategies
should the nurse suggest as appropriate follow-up care? - Correct answer C. Attending
a partial hospitalization program
A nurse is caring for a group of clients. Which of the following clients should a nurse
consider for referral to an assertive community treatment (ACT) group? - Correct
answer B. A client who loves at home and keeps "forgetting" to come in for his monthly
antipsychotic injection for schizophrenia
A nurse is teaching a client who has an anxiety disorder and is scheduled to begin
classical psychoanalysis. Which of the following client statements indicates an