NGN MENTAL HEALTH FORM A
1. A nurse is contributing to the plan of care for a client who has
borderlinepersonality disorder and exhibits manipulative behaviors.Which of the
following interventions should the nurse include in the plan to address limit setting?
Answer: Establish and explain consequences for the client'sbehavior.
The nurse should communicate desired behavior and expectationsas well as detailed
consequences for not meeting those expectations to a client who has borderline
personality disorder.
These expectations and consequences should beincluded in theplan of care when
addressing limit setting with the client.
2. A nurse is caring for an adult client who has visible injuries as aresult of intimate
partner violence. Which of the following actions should the nursetake?
Answer: Encourage the client to develop a safety plan.
The nurse should encourage the client to develop a safety plan toaid in
escapingfurther violence if necessary.
3. A nurse in an urgent care clinic is collecting data from a clientwhosefriend
reports a suspicion of cocaine use. The nurse should identify that which of the
following manifestations is an indicatorof the client's use ofthis substance?
Answer: Hypertension
Cocaine is a central nervous system stimulant. Therefore,hypertension is
anexpected finding.
4. A nurse in a mental health facility is caring for a client who has dementia. The
client's agitation is increasing. Which of the followingactions should thenurse take first?
Answer: Offer diversionary activities
When providing client care, the nurse should first use the least restrictive
intervention. Therefore, the nurse should offer diversionary activities to distract the
client and redirect energy intomore appropriate behaviors.
5. A nurse is caring for a client who has bipolar disorder.The clientsuddenlyappears
agitated and begins pacing at the end of the hallway with clenchedfists. Which of the
following actions shouldthe nurse take first?
Answer: Determinethe client's intentions.
The first action the nurse should take when using the nursing process is to collect
data from the client. By determining the client's intentions, the nurse can de-escalate
the situation by talkingto the client in a calm manner. This interventionwill assist the
nursein establishing a trusting relationship with the client.
,6. A nurse is reinforcing teaching with a client who has a new prescriptionfor
alprazolam.Which of the following instructions is thepriority for the nurseto include?
Answer: "Do not drive until your reaction to the medication is determined." The
greatest risk to this client is injury to himself.Therefore, the priority
informationthe nurse should include is toinform the client not to drive or handle
major mechanical equipment while taking alprazolam.
7. A nurse is caring for a client who is 2 days postoperative following a hip
arthroplasty. When a news report about militaryaction 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 responses shouldthe nurse make? (Selectall that apply.)
Answer: "This must be a very difficult time for you"
This statement demonstrates the use of reflecting. Reflecting expresses the nurse's
observations of the client's verbal and nonverbal behaviors when dis- cussing
sensitive issues. This therapeutic communication technique encouragesclients to
acceptand embrace their own feelings.
"Your child's death must be a terrible loss"
This statement demonstrates the use of reflecting. Reflecting expresses the nurse's
observations of the client's verbal and nonverbal behaviors when dis- cussing
sensitive issues. This therapeutic communication technique encouragesclients to
acceptand embrace their own feelings.
"Tell me something you remember about your child"
This statement demonstrates the use of exploring. Exploring acknowledges
theclient's feelings and facilitates communicationbetween the client and the nurse.
8. A nurse is contributing to the plan of care for a client who hasbipolar disorder
and is exhibiting mania. Which of the following interventions shouldthe nurse
include to improve the nutritional status of the client?
Answer: Have the client's favorite snacks available at all times. The client is often
too busy to sit and consume meals during themanic phase of bipolar disorder. The
nurse should ask the client fora list of food likes and
dislikes, and then coordinate with the dietitian to ensure the client's favorite foods and
beverages are available around the clock. The client is more likely to eat foods he
enjoys, which will improve the nutritional status of the client.
9. A nurse is collecting data from a client who has paranoid personality disorder.
Which of the following manifestations shouldthe nurse expect?
Answer: -Projects blame onto others
The nurse should expect clients who have paranoid personality disorder to project
blame onto others rather than taking responsibility for their own actions.
, 10. A nurse on an outpatient 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?
Answer: - "When you raise your voice, it makes me feeluncomfortable
and unsafe."
Using "I feel" messages models the sharing and owning of personalfeelings andhelps
minimize defensive responses.
11. A nurse is caring for a client who has schizophrenia. Which ofthe following
actions by the nurse is a violation of the client's confidentiality?
Answer: Thenurse places the client's diagnosis on the white boardin the client's
room. Writing information about the client's diagnosis or medical condition on the
white-board in the client's room is a violation of HIPAA. However, message boards
in the client's room can be used to post nursing care information.
12. A nurse in a mental health facility is collecting data from a client who has
schizophrenia. The nurse should identify that which of the following findings is
referred to as a negative symptom of schizophrenia?
Answer: Apathy
Negative symptoms of schizophrenia are deficits in the client's
ability to experience emotions. Apathy is a negative symptom of schizophrenia that is
manifested by a loss of interest in one's surroundings.
13. A nurse is collecting data from a client who has bulimia nervosa. Which of the
following manifestations should the nurse expect?
Answer: Dental caries
The nurse should expect manifestations of bulimia nervosa to include dental caries, which
can lead to tooth erosion. Dental caries are caused by the increased acid in the stomach
that is found in the vomitus of clients who purge repeatedly.
14. A nurse is collecting data from a client who has bipolar disorder and a history of
mania. Which of the following findings should the nurse identify as an indication that
the client is relapsing?
Answer: Pressured speech
The nurse should identify that rapid or pressured speech, provocative behavior,and
insomnia are indications of potential relapse in a client who has bipolar disorder and
a history of mania.
15. A nurse is developing countertransference toward a client during the working
phase of the nurse-client relationship.To correctthe situation, whichof the following
1. A nurse is contributing to the plan of care for a client who has
borderlinepersonality disorder and exhibits manipulative behaviors.Which of the
following interventions should the nurse include in the plan to address limit setting?
Answer: Establish and explain consequences for the client'sbehavior.
The nurse should communicate desired behavior and expectationsas well as detailed
consequences for not meeting those expectations to a client who has borderline
personality disorder.
These expectations and consequences should beincluded in theplan of care when
addressing limit setting with the client.
2. A nurse is caring for an adult client who has visible injuries as aresult of intimate
partner violence. Which of the following actions should the nursetake?
Answer: Encourage the client to develop a safety plan.
The nurse should encourage the client to develop a safety plan toaid in
escapingfurther violence if necessary.
3. A nurse in an urgent care clinic is collecting data from a clientwhosefriend
reports a suspicion of cocaine use. The nurse should identify that which of the
following manifestations is an indicatorof the client's use ofthis substance?
Answer: Hypertension
Cocaine is a central nervous system stimulant. Therefore,hypertension is
anexpected finding.
4. A nurse in a mental health facility is caring for a client who has dementia. The
client's agitation is increasing. Which of the followingactions should thenurse take first?
Answer: Offer diversionary activities
When providing client care, the nurse should first use the least restrictive
intervention. Therefore, the nurse should offer diversionary activities to distract the
client and redirect energy intomore appropriate behaviors.
5. A nurse is caring for a client who has bipolar disorder.The clientsuddenlyappears
agitated and begins pacing at the end of the hallway with clenchedfists. Which of the
following actions shouldthe nurse take first?
Answer: Determinethe client's intentions.
The first action the nurse should take when using the nursing process is to collect
data from the client. By determining the client's intentions, the nurse can de-escalate
the situation by talkingto the client in a calm manner. This interventionwill assist the
nursein establishing a trusting relationship with the client.
,6. A nurse is reinforcing teaching with a client who has a new prescriptionfor
alprazolam.Which of the following instructions is thepriority for the nurseto include?
Answer: "Do not drive until your reaction to the medication is determined." The
greatest risk to this client is injury to himself.Therefore, the priority
informationthe nurse should include is toinform the client not to drive or handle
major mechanical equipment while taking alprazolam.
7. A nurse is caring for a client who is 2 days postoperative following a hip
arthroplasty. When a news report about militaryaction 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 responses shouldthe nurse make? (Selectall that apply.)
Answer: "This must be a very difficult time for you"
This statement demonstrates the use of reflecting. Reflecting expresses the nurse's
observations of the client's verbal and nonverbal behaviors when dis- cussing
sensitive issues. This therapeutic communication technique encouragesclients to
acceptand embrace their own feelings.
"Your child's death must be a terrible loss"
This statement demonstrates the use of reflecting. Reflecting expresses the nurse's
observations of the client's verbal and nonverbal behaviors when dis- cussing
sensitive issues. This therapeutic communication technique encouragesclients to
acceptand embrace their own feelings.
"Tell me something you remember about your child"
This statement demonstrates the use of exploring. Exploring acknowledges
theclient's feelings and facilitates communicationbetween the client and the nurse.
8. A nurse is contributing to the plan of care for a client who hasbipolar disorder
and is exhibiting mania. Which of the following interventions shouldthe nurse
include to improve the nutritional status of the client?
Answer: Have the client's favorite snacks available at all times. The client is often
too busy to sit and consume meals during themanic phase of bipolar disorder. The
nurse should ask the client fora list of food likes and
dislikes, and then coordinate with the dietitian to ensure the client's favorite foods and
beverages are available around the clock. The client is more likely to eat foods he
enjoys, which will improve the nutritional status of the client.
9. A nurse is collecting data from a client who has paranoid personality disorder.
Which of the following manifestations shouldthe nurse expect?
Answer: -Projects blame onto others
The nurse should expect clients who have paranoid personality disorder to project
blame onto others rather than taking responsibility for their own actions.
, 10. A nurse on an outpatient 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?
Answer: - "When you raise your voice, it makes me feeluncomfortable
and unsafe."
Using "I feel" messages models the sharing and owning of personalfeelings andhelps
minimize defensive responses.
11. A nurse is caring for a client who has schizophrenia. Which ofthe following
actions by the nurse is a violation of the client's confidentiality?
Answer: Thenurse places the client's diagnosis on the white boardin the client's
room. Writing information about the client's diagnosis or medical condition on the
white-board in the client's room is a violation of HIPAA. However, message boards
in the client's room can be used to post nursing care information.
12. A nurse in a mental health facility is collecting data from a client who has
schizophrenia. The nurse should identify that which of the following findings is
referred to as a negative symptom of schizophrenia?
Answer: Apathy
Negative symptoms of schizophrenia are deficits in the client's
ability to experience emotions. Apathy is a negative symptom of schizophrenia that is
manifested by a loss of interest in one's surroundings.
13. A nurse is collecting data from a client who has bulimia nervosa. Which of the
following manifestations should the nurse expect?
Answer: Dental caries
The nurse should expect manifestations of bulimia nervosa to include dental caries, which
can lead to tooth erosion. Dental caries are caused by the increased acid in the stomach
that is found in the vomitus of clients who purge repeatedly.
14. A nurse is collecting data from a client who has bipolar disorder and a history of
mania. Which of the following findings should the nurse identify as an indication that
the client is relapsing?
Answer: Pressured speech
The nurse should identify that rapid or pressured speech, provocative behavior,and
insomnia are indications of potential relapse in a client who has bipolar disorder and
a history of mania.
15. A nurse is developing countertransference toward a client during the working
phase of the nurse-client relationship.To correctthe situation, whichof the following
