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 Answers --A, B, C
A charge nurse is discussing the care of a client who has MDD with a newly licensed nurse.
Which of the following statements by the newly licensed nurse indicates an understanding of
the teaching?
A) Care during the continuation phase focuses on treating continued manifestations of MDD
B) The treatment of MDD during the maintenance phase lasts for 6-12 weeks
C) The client is at greatest risk for suicide during the first weeks of an MDD episode
D) Medication and psychotherapy are most effective during the acute phase of MDD --
Correct Answers --C
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)
A) The needs of both participants are met
B) An emotional commitment exists between the participants
C) It is goal-directed
D) Behavioral change is encouraged
E) A termination date is established -- Correct Answers --C, D, E
A charge nurse is discussing TMS with a newly licensed nurse. Which of the following
statements by the newly licensed nurse indicates an understanding of the teaching?
,A) TMS is indicated for clients who have schizophrenia spectrum disorders
B) I will provide postanesthia care following TMS
C) TMS treatments usually last 5-10 minutes
D) I will schedule the client for daily TMS treatments for the first several weeks -- Correct
Answers --D
A client says she is experiencing increased stress because her significant other is "pressuring
me and my kids to go live with him. I love him, but I'm not ready to do that." Which of the
following recommendations should the nurse make to promote a change in the client's
situation?
A) Learn to practice mindfulness
B) Use assertiveness techniques
C) Exercise regularly
D) Rely on the support of a close friend -- Correct Answers --B
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?
A) Keep the client's communication confidential, but talk to the client daily, using therapeutic
communication to convince him to admit to hiding the knife.
B) Keep the client's communication confidential, but watch the client and his roommate
closely.
C) Tell the client that this must be reported to the healthcare team because it concerns the
health and safety of the client and others.
D) Report the incident to the health care team, but do not inform the client of the intention to
do so. -- Correct Answers --D
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?
A) Educating clients on health promotion techniques to reduce the risk of depression
B) Performing screenings for depression at community health programs
C) Establishing rehabilitation programs to decrease the effects of depression
D) Providing support groups for clients at risk for depression -- Correct Answers --C
, A home health nurse is making a visit to a client who has Alzheimer's disease to assess the
home for safety. Which of the following suggestions should the nurse make to decrease the
client's risk for injury? (Select all that apply)
A) Install childproof door locks
B) Place rugs over electrical cords
C) Mark cleaning supplies with colored tape
D) Place the client's mattress on the floor
E) Install light fixtures above stairs -- Correct Answers --A, D, E
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 Answers --B
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?
A) Notify the nurse manager
B) Tell the nurse to stop discussing the behavior
C) Provide an in-service program about confidentiality
D) Complete an incident report -- Correct Answers --B
A nurse in a long-term care facility is caring for a client who has major neurocognitive
disorder and attempts to wander out of the building. The client states, "I have to get home."
Which of the following statements should the nurse make?
A) You have forgotten that this is your home
B) You cannot go outside without a staff member
C) Why would you want to leave? Aren't you happy with your care?
D) I am your nurse. Let's walk together to your room -- Correct Answers --D