The client is responsive and able to fully respond by opening their eyes
and attending to a normal tone of voice and speech. What is the level of
consciousness? - correct answers - Alert
The client is able to open their eyes and respond but is drowsy and falls
asleep readily. What is the level of consciousness? - correct answers -
Lethargic
The client requires vigorous or painful stimuli (pinching a tendon or
rubbing the sternum) to elicit a brief response. They might not be able to
respond verbally. What is the level of consciousness? - correct answers -
Stuporous
The client is unconscious and does not respond to painful stimuli. What is
the level of consciousness? - correct answers - Comatose
How to test a client's immediate memory - correct answers - Ask the
client to repeat a series of numbers or a list of objects
How to test a client's recent memory - correct answers - Ask the
client to recall recent events, such as visitors from the current day, or
the purpose of the current mental health appointment or admission
How to test a client's remote memory - correct answers - Ask the client
to state a fact from his past that is verifiable, such as his birth date or his
mother's maiden name
How to assess a client's ability to calculate - correct answers - Ask
the client to count backward from 100 in sevens
How to assess a client's ability to think abstractly - correct answers - Ask
the client to interpret something complex such as, "A bird in the hand is
worth two in the bush."
Glasgow coma scale - correct answers - Used to obtain a baseline
assessment of a client's level of consciousness; highest score is 15 and
indicates that the client is awake and responding appropriately; a score of
7 or less indicates that the client is in a coma
Serious mental illness - correct answers - Includes disorders classified as
GRADED
severe
A+
and persistent mental illnesses; clients often have difficulty with
ADLs; can be chronic or recurrent
,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. Counting
backward by sevens is an appropriate technique to assess a client's
cognitive ability.
B. Observing a client's facial expression is appropriate when assessing
affect.
C. Writing a sentence is an indication of language ability.
Remote language is tested by asking the client to state a fact from his
past that his verifiable (date of birth). Abstract thinking is tested by
asking the client to interpret something.
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?
A. Assist the client with systematic desensitization therapy.
B. Teach the client appropriate coping mechanisms.
C. Assess the client for comorbid health conditions.
D. Monitor the client for adverse effects of the medications. - correct
answers - D. Monitoring for adverse effects of medications is an
example of a psychobiological intervention.
Systematic desensitization is cognitive and behavioral. Teaching coping
mechanisms is a counseling or health teaching. Assessing for comorbid
conditions is health promotion and maintenance.
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?
A. Coordinate holistic care with social services.
B. Identify the client's perception of her mental health status.
GRADED
C.
A+ Include the client's family in the interview.
,D. Teach the client about her current mental health disorder. - correct
answers - B. Assessment is the priority action. Identifying the client's
perception of her mental health status provides important information
about the client's psychosocial history.
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?
A. The client arouses briefly in response to a sternal rub.
B. The client has a glasgow coma scale score less than 7.
C.The client exhibits decorticate rigidity.
D.The client is alert but disoriented to time and place. - correct answers
- A. A client who is stuporous requires vigorous or painful stimuli to elicit a
response.
B & C occur with comatose patients.
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)
E. The DSM-5 includes client education handouts for mental health
disorders.
F. The DSM-5 establishes diagnostic criteria for individual mental health
disorders.
G.The DSM-5 indicates recommended pharmacological treatment for
mental health disorders.
H.The DSM-5 assists nurses in planning care for client's who have
mental health disorders.
I.The DSM-5 indicates expected assessment findings of mental health
disorders. - correct answers - B, D, & E. The DSM-5 establishes
diagnostic criteria, assists nurses in planning care, and identifies expected
findings for mental health disorders.
The DSM-5 does not contain client education handouts or
recommended pharmacological treatment.
Beneficence - correct answers - The quality of doing good, can be
described as charity
Autonomy - correct answers - The client's right to make their own
decisions Justice - correct answers - Fair and equal treatment for
all
GRADED
A+
Fidelity - correct answers - Loyalty and faithfulness to the client and to
one's duty Veracity - correct answers - Honesty when dealing with a
client
, Requirements for restraining a patient - correct answers - Provider must
prescribe the restraint in writing; time limits are based on age, 4 hr for
adults, 2 hr for ages 9-17, 1 hr for age 8 and younger; must be reviewed
every 24 hr; documentation must be done every 15-30 min
False imprisonment - correct answers - Confining a client to a specific
area if the reason for such confinement is for the convenience of the
staff
Assault - correct answers - Making a threat to a client's person
Battery - correct answers - Touching a client in a harmful or offensive
way
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?
A. A client who has schizophrenia with delusions of grandeur
B. A client who has manifestations of depression and attempted suicide
a year ago
C. A client who has borderline personality disorder and assaulted a
homeless man with a metal rod
D. A client who has bipolar disorder and paces quickly around the room
while talking to himself - correct answers - C. A client who is a current
danger to self or others is a candidate for a temporary emergency
admission.
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. Secluding a client for the convenience of
the staff is 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?
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.
GRADED
B.
A+ 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 health care
team because it concerns the health and safety of the client and
others.
and attending to a normal tone of voice and speech. What is the level of
consciousness? - correct answers - Alert
The client is able to open their eyes and respond but is drowsy and falls
asleep readily. What is the level of consciousness? - correct answers -
Lethargic
The client requires vigorous or painful stimuli (pinching a tendon or
rubbing the sternum) to elicit a brief response. They might not be able to
respond verbally. What is the level of consciousness? - correct answers -
Stuporous
The client is unconscious and does not respond to painful stimuli. What is
the level of consciousness? - correct answers - Comatose
How to test a client's immediate memory - correct answers - Ask the
client to repeat a series of numbers or a list of objects
How to test a client's recent memory - correct answers - Ask the
client to recall recent events, such as visitors from the current day, or
the purpose of the current mental health appointment or admission
How to test a client's remote memory - correct answers - Ask the client
to state a fact from his past that is verifiable, such as his birth date or his
mother's maiden name
How to assess a client's ability to calculate - correct answers - Ask
the client to count backward from 100 in sevens
How to assess a client's ability to think abstractly - correct answers - Ask
the client to interpret something complex such as, "A bird in the hand is
worth two in the bush."
Glasgow coma scale - correct answers - Used to obtain a baseline
assessment of a client's level of consciousness; highest score is 15 and
indicates that the client is awake and responding appropriately; a score of
7 or less indicates that the client is in a coma
Serious mental illness - correct answers - Includes disorders classified as
GRADED
severe
A+
and persistent mental illnesses; clients often have difficulty with
ADLs; can be chronic or recurrent
,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. Counting
backward by sevens is an appropriate technique to assess a client's
cognitive ability.
B. Observing a client's facial expression is appropriate when assessing
affect.
C. Writing a sentence is an indication of language ability.
Remote language is tested by asking the client to state a fact from his
past that his verifiable (date of birth). Abstract thinking is tested by
asking the client to interpret something.
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?
A. Assist the client with systematic desensitization therapy.
B. Teach the client appropriate coping mechanisms.
C. Assess the client for comorbid health conditions.
D. Monitor the client for adverse effects of the medications. - correct
answers - D. Monitoring for adverse effects of medications is an
example of a psychobiological intervention.
Systematic desensitization is cognitive and behavioral. Teaching coping
mechanisms is a counseling or health teaching. Assessing for comorbid
conditions is health promotion and maintenance.
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?
A. Coordinate holistic care with social services.
B. Identify the client's perception of her mental health status.
GRADED
C.
A+ Include the client's family in the interview.
,D. Teach the client about her current mental health disorder. - correct
answers - B. Assessment is the priority action. Identifying the client's
perception of her mental health status provides important information
about the client's psychosocial history.
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?
A. The client arouses briefly in response to a sternal rub.
B. The client has a glasgow coma scale score less than 7.
C.The client exhibits decorticate rigidity.
D.The client is alert but disoriented to time and place. - correct answers
- A. A client who is stuporous requires vigorous or painful stimuli to elicit a
response.
B & C occur with comatose patients.
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)
E. The DSM-5 includes client education handouts for mental health
disorders.
F. The DSM-5 establishes diagnostic criteria for individual mental health
disorders.
G.The DSM-5 indicates recommended pharmacological treatment for
mental health disorders.
H.The DSM-5 assists nurses in planning care for client's who have
mental health disorders.
I.The DSM-5 indicates expected assessment findings of mental health
disorders. - correct answers - B, D, & E. The DSM-5 establishes
diagnostic criteria, assists nurses in planning care, and identifies expected
findings for mental health disorders.
The DSM-5 does not contain client education handouts or
recommended pharmacological treatment.
Beneficence - correct answers - The quality of doing good, can be
described as charity
Autonomy - correct answers - The client's right to make their own
decisions Justice - correct answers - Fair and equal treatment for
all
GRADED
A+
Fidelity - correct answers - Loyalty and faithfulness to the client and to
one's duty Veracity - correct answers - Honesty when dealing with a
client
, Requirements for restraining a patient - correct answers - Provider must
prescribe the restraint in writing; time limits are based on age, 4 hr for
adults, 2 hr for ages 9-17, 1 hr for age 8 and younger; must be reviewed
every 24 hr; documentation must be done every 15-30 min
False imprisonment - correct answers - Confining a client to a specific
area if the reason for such confinement is for the convenience of the
staff
Assault - correct answers - Making a threat to a client's person
Battery - correct answers - Touching a client in a harmful or offensive
way
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?
A. A client who has schizophrenia with delusions of grandeur
B. A client who has manifestations of depression and attempted suicide
a year ago
C. A client who has borderline personality disorder and assaulted a
homeless man with a metal rod
D. A client who has bipolar disorder and paces quickly around the room
while talking to himself - correct answers - C. A client who is a current
danger to self or others is a candidate for a temporary emergency
admission.
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. Secluding a client for the convenience of
the staff is 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?
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.
GRADED
B.
A+ 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 health care
team because it concerns the health and safety of the client and
others.
