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 answers - -To assess cognitive ability, I should ask the client to
count backward by sevens."
-To assess affect, I should observe the client's facial expression.
-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 answers - 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
answers - 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 answers
- 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 answers - The DSM-5 establishes
diagnostic criteria for individual mental health disorders.
-The DSM-5 assists nurses in planning care for client's who have
mental health disorders.
-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 answers - 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
GRADED
overnight because the unit is very short-staffed, and the client frequently
A+
fights with other clients. The nurse's actions are an example of which of
the following torts? -
correct answers - 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
answers - 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 answers - -Client was offered 8 oz of
water every hr."
-Client shouted obscenities at assistive personnel."
-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 answers - 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 answers - 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 answers - 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 answers - 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
answers - -Discuss prior use of coping mechanisms with the client.
-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 answers
GRADED
-A+-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 answers - -It is goal-directed.
-Behavioral change is encouraged.
-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 answers - 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 answers - 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 answers - 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 answers - 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 answers - 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 answers
- -Educational groups
-Medication dispensing programs
-Individual counseling programs
-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 answers - Attending a
GRADED
partial
A+ hospitalization program
nurse. Which of the following statements by the newly licensed nurse
indicates an understanding of the teaching? (Select all that apply). -
correct answers - -To assess cognitive ability, I should ask the client to
count backward by sevens."
-To assess affect, I should observe the client's facial expression.
-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 answers - 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
answers - 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 answers
- 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 answers - The DSM-5 establishes
diagnostic criteria for individual mental health disorders.
-The DSM-5 assists nurses in planning care for client's who have
mental health disorders.
-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 answers - 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
GRADED
overnight because the unit is very short-staffed, and the client frequently
A+
fights with other clients. The nurse's actions are an example of which of
the following torts? -
correct answers - 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
answers - 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 answers - -Client was offered 8 oz of
water every hr."
-Client shouted obscenities at assistive personnel."
-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 answers - 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 answers - 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 answers - 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 answers - 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
answers - -Discuss prior use of coping mechanisms with the client.
-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 answers
GRADED
-A+-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 answers - -It is goal-directed.
-Behavioral change is encouraged.
-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 answers - 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 answers - 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 answers - 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 answers - 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 answers - 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 answers
- -Educational groups
-Medication dispensing programs
-Individual counseling programs
-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 answers - Attending a
GRADED
partial
A+ hospitalization program
