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 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?
F) Assist the client with systematic desensitization therapy.
G)Teach the client appropriate coping mechanisms.
H)Assess the client for comorbid health conditions.
I) Monitor the client for adverse effects of the medications. - correct
answers - D
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?
J) Coordinate holistic care with social services.
K) Identify the client's perception of her mental health status.
L) Include the client's family in the interview.
M)Teach the client about her current mental health disorder - correct
answers - B
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?
N)The client arouses briefly in response to a sternal rub.
O)The client has a glasgow coma scale score less than 7.
P) The client exhibits decorticate rigidity.
Q)The client is alert but disoriented to time and place. - correct answers -
A
GRADED
A+
A nurse is planning a peer group about the DSM-5. Which of the following
information is appropriate to include in the discussion? (Select all that
apply).
R) The DSM-5 includes client education handouts for mental health
disorders.
, C)The DSM-5 indicates recommended pharmacological treatment for
mental health disorders.
D)The DSM-5 assists nurses in planning care for client's who have
mental health disorders.
E)The DSM-5 indicates expected assessment findings of mental health
disorders. - correct answers - B, D, E
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?
F) A client who has schizophrenia with delusions of grandeur
G)A client who has manifestations of depression and attempted suicide
a year ago.
H)A client who has borderline personality disorder and assaulted a
homeless man with a metal rod.
I)A client who has bipolar disorder and paces quickly around the room
while talking to himself. - correct answers - C
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?
J) Invasion of privacy
K) False imprisonment
L) Assault
M)Battery - 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?
N)Keep the client's communication confidential, but talk to the
client daily, using therapeutic communication to convince him to
admit to hiding the knife.
O)Keep the client's communication confidential, but watch the client and
his roommate closely.
P)Tell the client that this must be reported to the healthcare team
because it concerns the health and safety of the client and others.
Q)Report the incident to the health care team, but do not inform
the client of the intention to do so. - correct answers - D
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)
R) Client ate most of his breakfast
S) Client was offered 8 oz of water every hr
T) Client shouted obscenities at assistive personnel
GRADED
U)
A+ Client received chlorpromazine 15 mg by mouth at 1000
V) Client acted out after lunch - correct answers - B, C, D
, 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 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?
E) I think your son is getting better. What have you noticed
F) I'm sure everything will be okay. It just takes time to heal
G)I'm not sure what's wrong. Have you asked the doctor about your
concerns?
H)I understand you're concerned. Let's discuss what concerns you
specifically - correct answers - D
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?
I) Reaction formation
J) Denial
K) Displacement
L) Sublimation - correct answers - B
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?
M)Mild
N)Moderate
O)Severe
P) Panic - correct answers - B
A nurse is caring for a client who is experiencing moderate anxiety.
Which of the following actions should the nurse trying to give necessary
information to the client? (Select all that apply)
Q)Reassure the client that everything will be okay
R) Discuss prior use of coping mechanisms with the client
S) Ignore the client's anxiety so that she will not be embarrassed
T) Demonstrate a calm manner while using simple and clear directions
U)Gather information from the client using closed-ended
GRADED
questions
A+ - correct answers - B, D
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 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?
F) Assist the client with systematic desensitization therapy.
G)Teach the client appropriate coping mechanisms.
H)Assess the client for comorbid health conditions.
I) Monitor the client for adverse effects of the medications. - correct
answers - D
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?
J) Coordinate holistic care with social services.
K) Identify the client's perception of her mental health status.
L) Include the client's family in the interview.
M)Teach the client about her current mental health disorder - correct
answers - B
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?
N)The client arouses briefly in response to a sternal rub.
O)The client has a glasgow coma scale score less than 7.
P) The client exhibits decorticate rigidity.
Q)The client is alert but disoriented to time and place. - correct answers -
A
GRADED
A+
A nurse is planning a peer group about the DSM-5. Which of the following
information is appropriate to include in the discussion? (Select all that
apply).
R) The DSM-5 includes client education handouts for mental health
disorders.
, C)The DSM-5 indicates recommended pharmacological treatment for
mental health disorders.
D)The DSM-5 assists nurses in planning care for client's who have
mental health disorders.
E)The DSM-5 indicates expected assessment findings of mental health
disorders. - correct answers - B, D, E
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?
F) A client who has schizophrenia with delusions of grandeur
G)A client who has manifestations of depression and attempted suicide
a year ago.
H)A client who has borderline personality disorder and assaulted a
homeless man with a metal rod.
I)A client who has bipolar disorder and paces quickly around the room
while talking to himself. - correct answers - C
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?
J) Invasion of privacy
K) False imprisonment
L) Assault
M)Battery - 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?
N)Keep the client's communication confidential, but talk to the
client daily, using therapeutic communication to convince him to
admit to hiding the knife.
O)Keep the client's communication confidential, but watch the client and
his roommate closely.
P)Tell the client that this must be reported to the healthcare team
because it concerns the health and safety of the client and others.
Q)Report the incident to the health care team, but do not inform
the client of the intention to do so. - correct answers - D
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)
R) Client ate most of his breakfast
S) Client was offered 8 oz of water every hr
T) Client shouted obscenities at assistive personnel
GRADED
U)
A+ Client received chlorpromazine 15 mg by mouth at 1000
V) Client acted out after lunch - correct answers - B, C, D
, 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 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?
E) I think your son is getting better. What have you noticed
F) I'm sure everything will be okay. It just takes time to heal
G)I'm not sure what's wrong. Have you asked the doctor about your
concerns?
H)I understand you're concerned. Let's discuss what concerns you
specifically - correct answers - D
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?
I) Reaction formation
J) Denial
K) Displacement
L) Sublimation - correct answers - B
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?
M)Mild
N)Moderate
O)Severe
P) Panic - correct answers - B
A nurse is caring for a client who is experiencing moderate anxiety.
Which of the following actions should the nurse trying to give necessary
information to the client? (Select all that apply)
Q)Reassure the client that everything will be okay
R) Discuss prior use of coping mechanisms with the client
S) Ignore the client's anxiety so that she will not be embarrassed
T) Demonstrate a calm manner while using simple and clear directions
U)Gather information from the client using closed-ended
GRADED
questions
A+ - correct answers - B, D
