NSG 221
Mental Health Nursing
Pre-Assessment Version 2
Questions & Answers
2025
A nurse in a community Health center is working with a group of clients who have
posttraumatic stress disorder. Which of the following interventions should the nurse
include to reduce anxiety among the group members?
Guided imagery
A client who has a recent diagnosis of bipolar disorder is placed in a room with a client
who has severe depression. The client who has depression reports to the nurse, " my
roommate never sleeps and keeps me up, too."Which of the following actions should
the nurse take?
Move the client who has bipolar disorder to a private room.
A nurse is reviewing laboratory results for a client who has schizophrenia and is taking
clozapine. Which of the following values should the nurse identify as a contraindication
for receiving clozapine?
WBC count, 2,500/mm3
A nurse is caring for four clients in the emergency department. The nurse should identify
that which of the following clients can give informed consent?
A 35-year-old client who has major depressive disorder
A nurse is facilitating a community meeting for acute care clients. One client is
constantly talking and using the majority of the groups time. Which of the following
intervention should the nurse implement?
Ask group members to discuss their feelings about the clients
monopolizing behavior
A nurse in a community health centers teaching families of clients who have post
,traumatic stress disorder about expected clinical manifestations. Which of the following
manifestation should the nurse include?
Experiences feelings of isolation
A nurse is preparing to administer diazepam 7.5 MG Bolus to a client for alcohol
withdrawal. Available is diazepam injection 5 mg/ml. How many ML should the nurse
administer? (round the answer to the nearest 10th. Using a leading zero if it applies. Do
not use a trailing zero.)
1.5
A nurse is planning prevention strategies for a partner violence in the community. Which
of the following strategies should the nurse include as a method of secondary
prevention?
Establish screening programs to identify at risk clients.
A nurse is assessing a client for risk factors for the development of depression. The
nurse should identify that which of the following factors places the client at increased
risk for depression?
The client has COPD
A nurse is preparing to discharge to home an older adult client who attempted suicide.
The client lives alone and has difficulty performing ADLs. Which of the following
referrals should the nurse initiate? (select all that apply.)
Occupational therapy
Meal delivery services
Mental health practice b 2019
Physical therapy
Home health services
A nurse is receiving change of shift report for four clients. Which of the following should
the nurse plan to see first?
A client who is taking clozapine and reports a sore throat and
chills
A nurse in a mental health clinic is planning care for four clients. Which of the following
Should the nurse delegate to an assistive personnel?
Stay with a client who has anorexia nervosa for one hour after
meal times
A nurse on a mental health unit observes a client who has acute mania hit another
client.Which of the following actions should the nurse take first?
Call for a team of staff members to help with the situation.
A nurse is teaching a group of newly licensed nurses about the use of mechanical
restraints. Which of the following information should the nurse include in the teaching?
Apply restraints when other means of managing the clients
behavior have failed.
A nurse is teaching the guardians of a client about their adolescent child diagnosis of
bulimia nervosa
Which of the following statements made by the guardians indicates an understanding of
their child's illness?
It is important for our child to have regular dental check ups
A nurse is teaching coping strategies to a client who is experiencing depression related
, to partner violence. Which of the following statements by the client indicates an
understanding of the teaching?
I will talk about my feelings with a close friend
A nurse is caring for an older adult client who is experiencing delirium. Which of the
following intervention should the nurse include in the clients plan of care?
Permit the client to perform daily rituals to decrease anxiety.
A nurse in a mental health clinic is caring for a client who has post-traumatic stress
disorderAfter returning from military deployment. Which of the following is the priority
action for the nurse to take?
Stay with a client when flashbacks occur.
A nurse is caring for a client who gave birth to a stillborn baby. Which of the following
statements should the nurse make?
I'll stay with you just in case you want to talk.
A nurse is caring for a child who has conduct disorder and is behaving in a destructive
manner,Throwing objects, and kicking others. Which of the following therapeutic nursing
interventions is the priority?
Reduce environmental stimuli
A nurse is caring for an older adult client who begins to cry and states, " I knew God
would punish me and I deserve this horrible sickness!"Which of the following responses
should the nurse make?
Let's talk about what is upsetting you
A nurse is performing a cognitive assessment to distinguish delirium from dementia and
a client whose family reports episodes of confusion. Which of the following assessment
findings supports the nurses suspicion of delirium?
Easily distracted
A nurse on a medical surgical unit is assessing a client who sustained injuries 12 hours
ago following a motor vehicle crash. The clients admission blood alcohol level was 325
mg/dL . Which of the following findings should indicate to the nurse that the client is
experiencing alcohol withdrawal?
Blood pressure 154/96 mm hg
A nurse is teaching the partner of a client who has bipolar disorder how do identify
manifestations of acute mania. Which of the following findings should the clients partner
report to the provider?
Inability to sleep
A nurse on a mental health unit is caring for a group of clients. Which of the following
actions by the nurse is an example of ethical principle of justice?
Spending adequate time with a client who is verbally abusive.
A nurse is planning care for a client who has made repeated physical threats towards
others on the unit. Although the client does not want to leave the unit, the nurse request
the provider to transfer the client to a unit that is equipped to manage violent behavior.
Which of the following ethical principles should the nurse apply in this situation?
Nonmaleficence
A nurse is caring for a client who is in An abusive relationshipAnd is assisting in the
development of a safety plan. Which of the following actions is the first component of a
safety plan?
Identify signs of escalation of violence.
A nurse is caring for a client who has alcoholic cardiomyopathy. Which of the following
Mental Health Nursing
Pre-Assessment Version 2
Questions & Answers
2025
A nurse in a community Health center is working with a group of clients who have
posttraumatic stress disorder. Which of the following interventions should the nurse
include to reduce anxiety among the group members?
Guided imagery
A client who has a recent diagnosis of bipolar disorder is placed in a room with a client
who has severe depression. The client who has depression reports to the nurse, " my
roommate never sleeps and keeps me up, too."Which of the following actions should
the nurse take?
Move the client who has bipolar disorder to a private room.
A nurse is reviewing laboratory results for a client who has schizophrenia and is taking
clozapine. Which of the following values should the nurse identify as a contraindication
for receiving clozapine?
WBC count, 2,500/mm3
A nurse is caring for four clients in the emergency department. The nurse should identify
that which of the following clients can give informed consent?
A 35-year-old client who has major depressive disorder
A nurse is facilitating a community meeting for acute care clients. One client is
constantly talking and using the majority of the groups time. Which of the following
intervention should the nurse implement?
Ask group members to discuss their feelings about the clients
monopolizing behavior
A nurse in a community health centers teaching families of clients who have post
,traumatic stress disorder about expected clinical manifestations. Which of the following
manifestation should the nurse include?
Experiences feelings of isolation
A nurse is preparing to administer diazepam 7.5 MG Bolus to a client for alcohol
withdrawal. Available is diazepam injection 5 mg/ml. How many ML should the nurse
administer? (round the answer to the nearest 10th. Using a leading zero if it applies. Do
not use a trailing zero.)
1.5
A nurse is planning prevention strategies for a partner violence in the community. Which
of the following strategies should the nurse include as a method of secondary
prevention?
Establish screening programs to identify at risk clients.
A nurse is assessing a client for risk factors for the development of depression. The
nurse should identify that which of the following factors places the client at increased
risk for depression?
The client has COPD
A nurse is preparing to discharge to home an older adult client who attempted suicide.
The client lives alone and has difficulty performing ADLs. Which of the following
referrals should the nurse initiate? (select all that apply.)
Occupational therapy
Meal delivery services
Mental health practice b 2019
Physical therapy
Home health services
A nurse is receiving change of shift report for four clients. Which of the following should
the nurse plan to see first?
A client who is taking clozapine and reports a sore throat and
chills
A nurse in a mental health clinic is planning care for four clients. Which of the following
Should the nurse delegate to an assistive personnel?
Stay with a client who has anorexia nervosa for one hour after
meal times
A nurse on a mental health unit observes a client who has acute mania hit another
client.Which of the following actions should the nurse take first?
Call for a team of staff members to help with the situation.
A nurse is teaching a group of newly licensed nurses about the use of mechanical
restraints. Which of the following information should the nurse include in the teaching?
Apply restraints when other means of managing the clients
behavior have failed.
A nurse is teaching the guardians of a client about their adolescent child diagnosis of
bulimia nervosa
Which of the following statements made by the guardians indicates an understanding of
their child's illness?
It is important for our child to have regular dental check ups
A nurse is teaching coping strategies to a client who is experiencing depression related
, to partner violence. Which of the following statements by the client indicates an
understanding of the teaching?
I will talk about my feelings with a close friend
A nurse is caring for an older adult client who is experiencing delirium. Which of the
following intervention should the nurse include in the clients plan of care?
Permit the client to perform daily rituals to decrease anxiety.
A nurse in a mental health clinic is caring for a client who has post-traumatic stress
disorderAfter returning from military deployment. Which of the following is the priority
action for the nurse to take?
Stay with a client when flashbacks occur.
A nurse is caring for a client who gave birth to a stillborn baby. Which of the following
statements should the nurse make?
I'll stay with you just in case you want to talk.
A nurse is caring for a child who has conduct disorder and is behaving in a destructive
manner,Throwing objects, and kicking others. Which of the following therapeutic nursing
interventions is the priority?
Reduce environmental stimuli
A nurse is caring for an older adult client who begins to cry and states, " I knew God
would punish me and I deserve this horrible sickness!"Which of the following responses
should the nurse make?
Let's talk about what is upsetting you
A nurse is performing a cognitive assessment to distinguish delirium from dementia and
a client whose family reports episodes of confusion. Which of the following assessment
findings supports the nurses suspicion of delirium?
Easily distracted
A nurse on a medical surgical unit is assessing a client who sustained injuries 12 hours
ago following a motor vehicle crash. The clients admission blood alcohol level was 325
mg/dL . Which of the following findings should indicate to the nurse that the client is
experiencing alcohol withdrawal?
Blood pressure 154/96 mm hg
A nurse is teaching the partner of a client who has bipolar disorder how do identify
manifestations of acute mania. Which of the following findings should the clients partner
report to the provider?
Inability to sleep
A nurse on a mental health unit is caring for a group of clients. Which of the following
actions by the nurse is an example of ethical principle of justice?
Spending adequate time with a client who is verbally abusive.
A nurse is planning care for a client who has made repeated physical threats towards
others on the unit. Although the client does not want to leave the unit, the nurse request
the provider to transfer the client to a unit that is equipped to manage violent behavior.
Which of the following ethical principles should the nurse apply in this situation?
Nonmaleficence
A nurse is caring for a client who is in An abusive relationshipAnd is assisting in the
development of a safety plan. Which of the following actions is the first component of a
safety plan?
Identify signs of escalation of violence.
A nurse is caring for a client who has alcoholic cardiomyopathy. Which of the following
