2
Saunder Mental health
The nurse is creating a plan of care for a client in a crisis state. When developing the plan, the nurse
should consider which factor?
The home care nurse is visiting an older client whose spouse died 6 months ago. Which
behaviors by the client indicates effective coping? Select all that apply.
Neglecting personal grooming.
Looking at old snapshots of family.
Participating in a senior citizens program.
Visiting the spouse's grave once a month
Decorating a wall with the spouse's pictures and awards received
A client with a diagnosis of depression who has attempted suicide says to the nurse, "I
should have died. I've always been a failure. Nothing ever goes right for me." Which
response by the nurse demonstrates therapeutic communication?
You have everything to live for."
"Why do you see yourself as a failure?".
"Feeling like this is all part of being
depressed.".
"You've been feeling like a failure for a while?"
The nurse visits a client at home. The client states, "I haven't slept at all the last couple
of nights." Which response by the nurse demonstrates therapeutic communication?
I see."
"Really?"
"You're having difficulty sleeping?"
"Sometimes I have trouble sleeping too."
A client experiencing disturbed thought processes believes that his food is being
poisoned. Which communication technique should the nurse use to encourage the client
to eat?
Using open-ended questions and silence (encourage the client to express feelings)
Sharing personal preference regarding food choices
Documenting reasons why the client does not want to eat
Offering opinions about the necessity of adequate nutrition
P a g e 1 | 44
, 2
The nurse should plan which goals of the termination stage of group
development? Select all that apply.
The group evaluates the experience.
The real work of the group is accomplished.
Group interaction involves superficial conversation.
Group members become acquainted with one
another.
Some structuring of group norms, roles, and responsibilities takes place.
The group explores members' feelings about the group and the impending separation.
A client diagnosed with terminal cancer says to the nurse, "I'm going to die, and I wish
my family would stop hoping for a cure! I get so angry when they carry on like this. After
all, I'm the one who's dying." Which response by the nurse is therapeutic?
Have you shared your feelings with your family?"
"I think we should talk more about your anger with your family."
"You're feeling angry that your family continues to hope for you to be cured?"
"You are probably very depressed, which is understandable with such a
diagnosis."
On review of the client's record, the nurse notes that the admission was voluntary.
Based on this information, the nurse plans care anticipating which client behavior?
Fearfulness regarding treatment measures
Anger and aggressiveness directed toward others
An understanding of the pathology and symptoms of the diagnosis.
A willingness to participate in the planning of the care and treatment plan
When reviewing the admission assessment, the nurse notes that a client was admitted
to the mental health unit involuntarily. Based on this type of admission, the nurse
should provide which intervention for this client?
Monitor closely for harm to self or others.
Assist in completing an application for admission.
Supply the client with written information about his or her mental illness.
Provide an opportunity for the family to discuss why they felt the admission was
needed.
P a g e 2 | 44
, 2
When a client is admitted to an inpatient mental health unit with the diagnosis of
anorexia nervosa, a cognitive behavioral approach is used as part of the treatment plan.
The nurse plans care based on which purpose of this approach?
Providing a supportive environment
Examining intrapsychic conflicts and past issues
Emphasizing social interaction with clients who withdraw
Helping the client to examine dysfunctional thoughts and beliefs
A client is preparing to attend a Gamblers Anonymous meeting for the first time. The
nurse should tell the client that which is the first step in this 12-step program?
Admitting to having a problem.
Substituting other activities for gambling.
Stating that the gambling will be stopped.
Discontinuing relationships with people who gamble
The nurse in the mental health unit plans to use which therapeutic communication
techniques when communicating with a client? Select all that apply.
Restating
Listening
Asking the client "Why?".
Maintaining neutral responses
Providing acknowledgment and feedback
Giving advice and approval or disapproval
What is the most appropriate nursing action to help manage a manic client who is
monopolizing a group therapy session?
Ask the client to leave the group for this session only.
Refer the client to another group that includes other manic clients.
Tell the client to stop monopolizing in a firm but compassionate manner.
Thank the client for the input, but inform the client that others now need a chance to contribute.
A client is participating in a therapy group and focuses on viewing all team members as
equally important in helping the clients to meet their goals. The nurse is implementing
which therapeutic approach?
Milieu therapy.
Interpersonal therapy.
Behavior modification.
Support group therapy
P a g e 3 | 44
, 2
The nurse is working with a client who despite making a heroic effort was unable to
rescue a neighbor trapped in a house fire. Which client-focused action should the nurse
engage in during the working phase of the nurse-client relationship?
Exploring the client's ability to function
Exploring the client's potential for self-harm.
Inquiring about the client's perception or appraisal of why the rescue was unsuccessful.
Inquiring about and examining the client's feelings for any that may block adaptive coping
A client says to the nurse, "The federal guards were sent to kill me." Which
is the best response by the nurse to the client's concern?
I don't believe this is true."
"The guards are not out to kill you."
"Do you feel afraid that people are trying to hurt you?".
"What makes you think the guards were sent to hurt you?"
A client diagnosed with delirium becomes disoriented and confused at night. Which
intervention should the nurse implement initially?
Move the client next to the nurses' station.
Use an indirect light source and turn of f the television.
Keep the television and a soft light on during the night.
Play soft music during the night, and maintain a well-lit room.
A client is admitted to the mental health unit with a diagnosis of depression. The nurse
should develop a plan of care for the client that includes which intervention?
Encouraging quiet reading and writing for the first few days.
Identification of physical activities that will provide exercise
No socializing activities, until the client asks to participate in milieu
A structured program of activities in which the client can participate
When planning the discharge of a client with chronic anxiety, the nurse directs the goals
at promoting a safe environment at home. Which is the most
appropriate maintenance goal?
Suppressing feelings of anxiety
Identifying anxiety-producing situations
Continuing contact with a crisis counselor.
Eliminating all anxiety from daily situations
A client is unwilling to go to his church because his ex-girlfriend goes there and he feels
that she will laugh at him if she sees him. Because of this hypersensitivity to a reaction
P a g e 4 | 44
Saunder Mental health
The nurse is creating a plan of care for a client in a crisis state. When developing the plan, the nurse
should consider which factor?
The home care nurse is visiting an older client whose spouse died 6 months ago. Which
behaviors by the client indicates effective coping? Select all that apply.
Neglecting personal grooming.
Looking at old snapshots of family.
Participating in a senior citizens program.
Visiting the spouse's grave once a month
Decorating a wall with the spouse's pictures and awards received
A client with a diagnosis of depression who has attempted suicide says to the nurse, "I
should have died. I've always been a failure. Nothing ever goes right for me." Which
response by the nurse demonstrates therapeutic communication?
You have everything to live for."
"Why do you see yourself as a failure?".
"Feeling like this is all part of being
depressed.".
"You've been feeling like a failure for a while?"
The nurse visits a client at home. The client states, "I haven't slept at all the last couple
of nights." Which response by the nurse demonstrates therapeutic communication?
I see."
"Really?"
"You're having difficulty sleeping?"
"Sometimes I have trouble sleeping too."
A client experiencing disturbed thought processes believes that his food is being
poisoned. Which communication technique should the nurse use to encourage the client
to eat?
Using open-ended questions and silence (encourage the client to express feelings)
Sharing personal preference regarding food choices
Documenting reasons why the client does not want to eat
Offering opinions about the necessity of adequate nutrition
P a g e 1 | 44
, 2
The nurse should plan which goals of the termination stage of group
development? Select all that apply.
The group evaluates the experience.
The real work of the group is accomplished.
Group interaction involves superficial conversation.
Group members become acquainted with one
another.
Some structuring of group norms, roles, and responsibilities takes place.
The group explores members' feelings about the group and the impending separation.
A client diagnosed with terminal cancer says to the nurse, "I'm going to die, and I wish
my family would stop hoping for a cure! I get so angry when they carry on like this. After
all, I'm the one who's dying." Which response by the nurse is therapeutic?
Have you shared your feelings with your family?"
"I think we should talk more about your anger with your family."
"You're feeling angry that your family continues to hope for you to be cured?"
"You are probably very depressed, which is understandable with such a
diagnosis."
On review of the client's record, the nurse notes that the admission was voluntary.
Based on this information, the nurse plans care anticipating which client behavior?
Fearfulness regarding treatment measures
Anger and aggressiveness directed toward others
An understanding of the pathology and symptoms of the diagnosis.
A willingness to participate in the planning of the care and treatment plan
When reviewing the admission assessment, the nurse notes that a client was admitted
to the mental health unit involuntarily. Based on this type of admission, the nurse
should provide which intervention for this client?
Monitor closely for harm to self or others.
Assist in completing an application for admission.
Supply the client with written information about his or her mental illness.
Provide an opportunity for the family to discuss why they felt the admission was
needed.
P a g e 2 | 44
, 2
When a client is admitted to an inpatient mental health unit with the diagnosis of
anorexia nervosa, a cognitive behavioral approach is used as part of the treatment plan.
The nurse plans care based on which purpose of this approach?
Providing a supportive environment
Examining intrapsychic conflicts and past issues
Emphasizing social interaction with clients who withdraw
Helping the client to examine dysfunctional thoughts and beliefs
A client is preparing to attend a Gamblers Anonymous meeting for the first time. The
nurse should tell the client that which is the first step in this 12-step program?
Admitting to having a problem.
Substituting other activities for gambling.
Stating that the gambling will be stopped.
Discontinuing relationships with people who gamble
The nurse in the mental health unit plans to use which therapeutic communication
techniques when communicating with a client? Select all that apply.
Restating
Listening
Asking the client "Why?".
Maintaining neutral responses
Providing acknowledgment and feedback
Giving advice and approval or disapproval
What is the most appropriate nursing action to help manage a manic client who is
monopolizing a group therapy session?
Ask the client to leave the group for this session only.
Refer the client to another group that includes other manic clients.
Tell the client to stop monopolizing in a firm but compassionate manner.
Thank the client for the input, but inform the client that others now need a chance to contribute.
A client is participating in a therapy group and focuses on viewing all team members as
equally important in helping the clients to meet their goals. The nurse is implementing
which therapeutic approach?
Milieu therapy.
Interpersonal therapy.
Behavior modification.
Support group therapy
P a g e 3 | 44
, 2
The nurse is working with a client who despite making a heroic effort was unable to
rescue a neighbor trapped in a house fire. Which client-focused action should the nurse
engage in during the working phase of the nurse-client relationship?
Exploring the client's ability to function
Exploring the client's potential for self-harm.
Inquiring about the client's perception or appraisal of why the rescue was unsuccessful.
Inquiring about and examining the client's feelings for any that may block adaptive coping
A client says to the nurse, "The federal guards were sent to kill me." Which
is the best response by the nurse to the client's concern?
I don't believe this is true."
"The guards are not out to kill you."
"Do you feel afraid that people are trying to hurt you?".
"What makes you think the guards were sent to hurt you?"
A client diagnosed with delirium becomes disoriented and confused at night. Which
intervention should the nurse implement initially?
Move the client next to the nurses' station.
Use an indirect light source and turn of f the television.
Keep the television and a soft light on during the night.
Play soft music during the night, and maintain a well-lit room.
A client is admitted to the mental health unit with a diagnosis of depression. The nurse
should develop a plan of care for the client that includes which intervention?
Encouraging quiet reading and writing for the first few days.
Identification of physical activities that will provide exercise
No socializing activities, until the client asks to participate in milieu
A structured program of activities in which the client can participate
When planning the discharge of a client with chronic anxiety, the nurse directs the goals
at promoting a safe environment at home. Which is the most
appropriate maintenance goal?
Suppressing feelings of anxiety
Identifying anxiety-producing situations
Continuing contact with a crisis counselor.
Eliminating all anxiety from daily situations
A client is unwilling to go to his church because his ex-girlfriend goes there and he feels
that she will laugh at him if she sees him. Because of this hypersensitivity to a reaction
P a g e 4 | 44
