ATI RN MENTAL HEALTH PROCTORED EXAM REAL EXAM(UPDATED)

  1. A client is fearful of driving and enters a behavioral therapy program to help him overcome his anxiety. Using systematic desensitization, he is able to drive down a familiar street without experiencing a panic attack. The nurse should recognize that to continue positive results, the client should participate in which of the following? a. Biofeedback or d. Positive reinforcement 2. A nurse is counseling a client following the death of the client’s partner 8 months ago. Which of the following client statements indicates maladaptive grieving? d. “I still don’t feel up to returning to work.” 3. A nurse in an inpatient mental health facility is assessing a client who has schizophrenia and is taking haloperidol (antipsychotic, 1st gen). Which of the following clinical findings is the nurse’s priority? d. High fever (Complication → agranulocytosis) 4. A nurse is planning care for a client who has obsessive compulsive disorder. Which of the following recommendations should the nurse include in the client’s plan of care? c. Thought Stopping 4. A nurse is providing teaching to the daughter of an older client who has obsessive-compulsive disorder. Which of the following statements by the daughter indicates an understanding of the teaching? b. “I will limit my mother’s clothing choices when she is getting dressed.” 5. A nurse is caring for a client who is in the manic phase of bipolar disorder. Which of the following actions should the nurse take? c. Avoid power struggles by remaining neutral 6. A nurse is providing behavioral therapy for a client who has OCD. The client repeatedly checks that the doors are locked at night. Which of the following instructions should the nurse give the client when using thought stopping technique? d. “Snap a rubber band on your wrist when you think about checking the locks.” 7. A nurse is caring for a client who has a cocaine use disorder. Which of the following manifestations should the nurse expect the client to have during withdrawal? b. Fatigue 8. A nurse is reviewing the medical record of a client who is taking clozapine. For which of the following findings should the nurse withhold the medication and notify the provider? a. WBC 9. A nurse is creating a plan of care for a client who has major depressive disorder. Which of the following interventions should the nurse include in the plan? b. Encourage physical activity for the client during the day 10. A nurse is assessing a client who is experiencing acute alcohol withdrawal. Which of the following findings should the nurse expect? c. Insomnia 11. A nurse is caring for a client who has schizophrenia and displays severe symptoms of the disorder. Which of the following actions should the nurse take? d. Direct the client to perform her own daily hygiene and grooming tasks 12. A nurse is caring for a client who was involuntarily committed and is scheduled to receive electroconvulsive therapy. The client refuses the treatment and will discuss why with the healthcare team. Which of the following actions should the nurse take? a. Document the client’s refusal of the treatment in the medication record 13. A nurse is providing crisis intervention for a client who was involved in a violent mass casualty situation in the community. Which of the following actions should the nurse take during the initial session with the client? a. Identify the client’s usual coping style. 14. A nurse in the emergency department is caring for a client who reports feeling sad, worthless, and hopeless 9 months after the death of her son. Which of the following actions should the nurse take first? d. Ask the client if she has thought about harming herself given -. 15. A nurse is planning care for an adolescent who has autism spectrum disorder. Which of the following outcomes should the nurse include in the plan of care? c. Initiate social interactions with caregiver 16. A nurse is caring for a client who is experiencing active auditory hallucination. Which of the following should the nurse take? d. Focus the client on reality based activities 17. A nurse is conducting an admission interview with a client who is experiencing mania. Which of the following findings the nurse reports to the provider? a. Reports eating twice in the past week 't bathed in 2 days 18. A nurse is caring for a client who has anorexia nervosa. Which of the following findings requires immediate intervention by the nurse? c. +2 edema of the lower extremities 19. A nurse is planning care for a client who has a recent diagnosis of antisocial personality disorder. Which of the following outcomes should the nurse in the care plan? a. The client treats others with respect 20. A nurse is caring for a client who is prescribed massage therapy to treat panic disorder. The client states “I can't stand to be touched by another person”. Which of the following response should the nurse make? c. I will tell your provider know that you would like a treat other than a message (avoid triggers) ??(doubled)21. A nurse in a group home facility is caring for a client who is developmentally disabled. The client has been stealing belongings from the other clients. Which of the following techniques should the nurse use? b. Positive reinforcement 22. A nurse in a mental facility is caring for a newly admitted client. Which of the following resources should the nurse recommend to help the client adapt to the healthcare setting? a. A Community meeting 23. A nurse is teaching the caregiver of a client who has advanced Alzheimer’s disease about home safety. Which of the following statements by the caregiver indicates an understanding of the teaching? b. I will place a sliding bolt lock just above the doorknob 24. A nurse is beginning a therapeutic relationship with a client. The nurse should plan to accomplish which of the following tasks during the working phase? b. Evaluate progress toward predetermined goals 25. A nurse Is planning care for a client who has anorexia nervosa and is admitted to an inpatient eating disorder unit. Which of the following is an appropriate intervention? (p. 167) c. Initiate a relationship built on trust with the client. 26. A nurse is providing discharge teaching about manifestations of relapse to the family of a client who has schizophrenia. Which of the following information should the nurse include in the teaching a. The client develops an inability to concentrate 27. A nurse in a mental health facility is caring for a client. Which of the following actions should the nurse take during the working phase of the nurse-client relationship? c. Promote problem- solving skills. 28. A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse include in the plan? d. Provide finger food to enhance caloric intake (ensure adequate food/fluid intake) 29. A nurse is developing a teaching plan for the family of an older adult client who is to receive transcranial magnetic stimulation. Which of the following information should the nurse include in the teaching plans? a. The client might have a headache after treatment (a/e mild discomfort and tingling sensation at the site of the electromagnet) 30. A nurse overhears a client saying, “I am a spy, a spy for the FBI. I am an I, an eye for an eye, an eye in the sky. Sky is up high. The nurse should document the client’s statement as which of the following speech alterations? a. Clang association 31. A nurse is assessing a client who has neuroleptic malignant syndrome. Which of the following clinical findings should the nurse expect? b. Temperature 40 (104F) (sudden high fever) 32. A nurse in an acute care mental health facility is planning discharge care for a client who sustained a traumatic brain injury. For which of the following needs should the nurse collaborate with a clinical psychologist? a. The client needs to begin a group therapy program prior to discharge 33. A nurse is caring for a client who reports that he is angry with his partner because she is thinking he is just trying to gain attention. When the nurse attempts to talk to the client, he becomes angry and tells her to leave. Which of the following defense mechanisms is the client demonstrating? b. Displacement ???34. A nurse is teaching a client who has schizophrenia about her new prescription for risperidone. Which of the following statements should be included in the teaching? a. You should discontinue this medication if you develop muscle rigidity 35. A nurse is talking to a client following a group therapy session. The client tells the nurse that one of the other clients in the group made an inappropriate comment. Which of the following responses should the nurse make? a. You sound upset about today’s session 36. A nurse is reviewing the laboratory report of a client who is taking carbamazepine for bipolar disorder. Which of the following laboratory results should the nurse report to the provider? b. Platelets 90,000/mm 37. A nurse is providing teaching about disorder management for a client who has PTSD. Which of the following statements should the nurse include in the teaching?c. Talking about the traumatic experience is recommended 37.A nurse is providing teaching about disulfiram to a client who has a history of alcohol use. Which of the following instructions should the nurse include in the teaching? a. You will need to take the medication once daily e. You should avoid using mouthwash that contain alcohol 38. A nurse in a mental health facility is making plans for a client's discharge. Which of the following interdisciplinary team members should the nurse contact to assist the client with housing placement? a. Social worker 39. A nurse is providing teaching to a client who has depressive disorder and a new prescription for doxepin. Which of the following instructions should the nurse include in the teaching? b. Sit on the side of the bed for a few minutes before standing 40. A nurse is caring for a client who has borderline personality disorder and has been engaging in self-mutilation. The nurse should encourage the client to participate in which of the following groups? d. Dialectical Behavior Treatment 41. A nurse is caring for a client following a physical assault. The client states, “I don't remember what happened to me.” The nurse should recognize that the client is using which of the following defense mechanisms? b.Repression 42. A nurse is preparing to administer haloperidol 7mg IM to a client who is severely agitated. Available is haloperidol injection 5mg/mL. How many mL should the nurse administer? 1.4 mL 43. A charge nurse is discussing the care of a client who has a substance use disorder with a staff nurse. Which of the following statements by the staff nurse should the charge nurse identify as countertransference? a. The client is just like my brother who finally overcome his habit 44. A nurse is teaching a client who has a new prescription for phenelzine to treat depression. The nurse instructs the client to avoid foods with tyramine to prevent which of the following?b. Hypertensive crisis 45. A nurse is caring for a client who has a personality disorder and is using transference to cope. Which of the following behaviors should the nurse expect? b. Reaction to the nurse as though she were his mother ***46. A nurse is admitting a client who has generalized anxiety disorder. Which of the following actions should the nurse plan to take first? a. Determine how the client handles stress I’m just thinking this cuz it said first and this seems like an assessment which is what you do first b. Ask the client to identify her strengths c. Provide the client with a quiet environment at the same time it is important to provide them with a calm quiet environment, but I think this one is if they are experiencing panic-level anxiety. Idk. I might be overthinking d. Teach the client to use guided imagery 47. A nurse is teaching a client who has bipolar disorder and a new prescription for lithium carbonate. Which of the following statements by the client indicates an understanding of the teaching? d. I will call my doctor if I have a diarrhea **48. A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take? a. Place the client in seclusion c. breathe into paper bag 49. A nurse is caring for a client who is starting treatment for substance use disorder. Which of the following actions indicates the nurse is practicing the ethical principle of nonmaleficence? b. Withholding a prescribed meds that is causing adverse effects for the client 50. A nurse is caring for a client who has just returned to the unit after receiving electroconvulsive therapy treatments. Which of the following assessments is the nurse’s priority? d. Presence of gag reflex ***51. A nurse in the emergency department is counseling a client who reports experiencing intimate partner violence. Which of the following actions should the nurse take? a. Request permission from the client to take photographs of the injuries. b. Offer to help the client escape from the partner the next time violence occurs c. determine what the client did to trigger the violent incident. d. Tell the client that staying with the partner shows a lack of judgment. 52. A nurse is reviewing the medication administration record of a client who has schizophrenia. The nurse should plan to initiate the abnormal involuntary movement scale to monitor for adverse effects of which of the following medications? a. Amantadine b. Benztropine c. Diphenhydramine d. Haloperidol (Antipsychotic) 53. A nurse is planning overall strategies to address problems for a client who has borderline personality disorder. Which of the following strategies is the priority for the nurse to incorporate in the plan of care? c. Implement measures to prevent intentional self-inflicted injury 54. A nurse is obtaining a medical history from a client who is requesting a prescription for bupropion for smoking cessation. Which of the following assessment findings in the client’s history should the nurse report to the provider? c. Recent head injury 55. A nurse is caring for a client who has bipolar disorder and is experiencing a manic episode. Which of the following actions should the nurse take? c. Dim the lights in the client’s room 56. A nurse is caring for a client who is admitted to a mental health facility after attempting suicide. Which of the following actions should the nurse take first? a. Implement continuous one to one observation 57. A nurse in an outpatient clinic is assessing a client who has anorexia nervosa. Which of the following findings indicates the need for hospitalization? a. Temperature 35.6 (96.1) Temp less than 36C (96.8F) 58. A nurse is providing teaching for a newly licensed nurse about the constructive use of defense mechanisms. Which of the following examples should the nurse include in the teaching? d. A student who is upset with her teacher writes a story about an excellent student 59. A nurse is caring for a client who has a prescription phenelzine. The nurse should instruct the client to avoid which of the following over the counter medications? d. Pseudoephedrine (Increases Hypertension) 60. An older adult client is brought to the mental health clinic by her daughter. The daughter reports that her mother is not eating and seems uninterested in routine activities. The daughter states, “I’m so worried that my mother is depressed.” Which of the following responses should the nurse make? a. “Tell me the reasons you think your mother is depressed.” 61. A nurse is planning care for a newly admitted client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan? c. Notify the client about designated times for meals 62. A nurse in a community health facility is interviewing a client who recently lost his job. The client states “I was fired because my boss doesn't like me”. Which of the following defense mechanisms is the client displaying? b. Rationalizations 63. A nurse in an alcohol treatment facility is caring for a client who states, “My job is so stressful that the only way I can cope is to drink.“ The nurse should recognize that the client is displaying which of the following defense mechanisms? c. Rationalization 64. A nurse is providing counseling for a family that consists of two parents and their two adolescents’ children. Which of the following family members should the nurse identify as acting in the role of monopolizer? d. The adolescent daughter who attempts to dominate the discussion 65. A nurse is caring for a client in a mental health facility. The client is agitated and threatens to harm herself and others. Which of the following is the nurse’s priority intervention? d. Set limits on the client’s behavior 66. A nurse is assessing a client who has bipolar disorder and is taking lamotrigine. Which of the following findings is the nurse’s priority? d. Skin rash 67. A nurse is assessing a young adult female client for schizophrenia. Which of the following findings should the nurse identify as a risk factor for this condition? r b. Environmental stress 68. A nurse is caring for a client in an inpatient mental health facility. The client tells the nurse that the government is reading her mail. Which of the following responses should the nurse make? c. “ It must be frightening to think that someone is reading your mail.” 69. A nurse is assessing a client who is restless and constantly mutters to himself. Which of the following findings should lead the nurse to suspect delirium? c. The client’s manifestation developed suddenly 70. A nurse is leading a crisis intervention group for adolescents who witnessed the suicide of a classmate. Which of the following actions should the nurse take first? d. Identify prior coping skills 71. A nurse is providing crisis intervention for a client who was involved in a violent mass casualty situation in the community. Which of the following actions should the nurse take during the initial session with the client? a. Identify the client’s usual coping style. 72. A nurse is caring for a client who has borderline personality disorder. Which of the following outcomes should the nurse include in the treatment plan? b. The client will verbalize improve mood ***73. A nurse is assisting with obtaining informed consent for a client who has been legally incompetent. Which of the following actions should the nurse take? a. Explain implied consent to the client’s family. b. Contact the facility social work to obtain the consent. c. Request that the client’s guardian sign the consent d. Ask the charge nurse to obtain informed consent. Client who has been judged incompetent has a temporary or permanent guardian appointed by the court. The guardian can sign the informed consent for the client. SINGLE QUESTIONS 1. 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? ans: Guided imagery 2. 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? ans: Move the client who has bipolar disorder to a private room. 3. 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? ans: WBC count, 2,500/mm3 4. A nurse is caring for four clients in the emergency department. The nurse should identify which of the following clients can give informed consent? ans: A 35-year-old client who has major depressive disorder 5. A nurse is facilitating a community meeting for acute care clients. One client is constantly talking and using the majority of the group's time. Which of the following interventions should the nurse implement? ans: Ask group members to discuss their feelings about the clients monopolizing behavior 6. A nurse in a community health center teaching families of clients who have post traumatic stress disorder about expected clinical manifestations. Which of the following manifestations should the nurse include? ans: Experiences feelings of isolation 7. 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.) ans: 1.5 8. 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? ans: Establish screening programs to identify at risk clients. 9. 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? ans: The client has COPD 10. A nurse is preparing to discharge to home an older adult client who attempted suicide. The client lives alone and has difficulty performing ADs. Which of the following referrals should the nurse initiate? (select all that apply.) ans: Occupational therapy, Meal delivery services, Physical therapy, Home health sérvices 1. A nurse is caring for a school-aged child who has conduct disorder and is being physically aggressive toward other children in the unit. Which of the following actions should the nurse take first? a. Place the child in seclusion 2. A nurse is caring for a client who has a new diagnosis of bulimia nervosa. Which of the following diagnosis procedures should the nurse anticipate the provider should describe during the medical evaluation? b. ECG 3. A nurse is caring for a client who exhibits excessive compliance, passivity, and self-denial. The nurse should recognize that these findings are associated with which of the following personality disorders? a. Dependent 4. A nurse is caring for a client who is involuntarily admitted for major depressive disorder and refuses to take prescribed antianxiety medication. Which of the following actions should the nurse take? c. Offer the client the medication at the next scheduled dose time 5. A nurse is caring for a client in the emergency department who states she was beaten and sexually assault by her partner. After a rapid assessment, which of the following actions should the nurse plan to take next? d. Offer prophylactic medication to prevent STI’s 6. A nurse is caring for a client who has major depressive disorder. After discussing the treatment with his partner, the client verbally agrees to electroconvulsive therapy (ECT) but will not sign the consent form. Which of the following actions should the nurse take? b.Cancel the scheduled ECT procedure 7. A nurse is caring for a client who reports that he is angry with his partner because she thinks he is just trying to gain attention. When the nurse attempts to talk to the client, he becomes angry and tells her to leave. Which of the following defense mechanisms is the client demonstrating? d. Displacement 8. A nurse is advising an assistive personnel (AP) on the care of a client who has major depressive disorder. The AP states that he is irritated by the client’s depression. Which of the following statements by the nurse is appropriate? b. It’s important that the client feel safe verbalizing how she is feeling 9. 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. 10. 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? D. Monitor the client for adverse effects of the medications 11. 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? B. Identify the client's perception of her mental health status. 12. 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 dient arouses briefly in response to a sternal rub ??13. A nurse is teaching a client with schizophrenia about her new prescription for risperidone. Which of the following statements should the nurse include in the teaching? B. You will experience weight loss while taking this medication 14. A nurse is admitting à client who has generalized anxiety disorder. Which of the following actions should the nurse plan to take first? a. Provide the client with a quiet environment 15. A nurse is conducting an admission interview with a client who is experiencing mania. Which of the following findings should the nurse report to the provider? B. Reports eating twice in the past week 16. A nurse is planning care for a client who has OCD. Which of the following recommendations should the nurse include in the client's plan of care? B. Thought stopping 17. A nurse is caring for a client who has bipolar disorder and experiencing a manic episode. Which of the following actions should the nurse take? B. Dim the lights in the client's room 18. A nurse is leading a grisis intervention group for adolescents who witnessed the suicide of a classmate, Which of the following actions should the nurse take first? C. Identify prior coping skills 19. A nurse overhears a client saying. "I am a spy, a spy for the FBI. I am an I, an eye for an eye, and eye in the sky. Sky is up high." The nurse should document the dient statement as which of the following speech alterations? D. Clang Association 20. A nurse is talking with a group of parents who have recently experienced the death of a child. Which of the following actions should the nurse take? Suggest forming a weekly support group for parents who have experienced the death of a child. 21. A nurse in a community Health Center & working with a group of clients who have post- traumatic stress disorder. Which of the following interventions should the nurse include to reduce anxiety among the group members? Guided imagery 22. A nurse is planning care for a client who is to undergo electroconvulsive therapy (ECT). Which of the following actions should the nurse include in the plan? Monitor the client's cardiac rhythm during the procedure 23. A nurse is planning prevention strategies for 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 24. A nurse in a mental health facility is caring for a client who has schizophrenia. Which of the following findings places the client at a greater risk for self-directed injury or injuring others? command hallucinations 25. 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) B. The DSM-5 establishes diagnostic criteria for individual 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. ***26. A nurse in an emergency mental health facility is caring for a group of clients. The nurse should identify which of the following clients requires a temporary emergency admission? C. A client who has borderline personality disorder and assaulted a homeless man with a metal rod 27. A nurse is teaching a client who has a depressive disorder about fluoxetine. Which of the following information should the nurse include in the teaching? a. You may experience a decreased sex drive while taking medication 28. A nurse is teaching a client about adverse effects of zolpidem. Which of the following adverse effects should the nurse include in the teaching? a. Daytime sleepiness 29. A nurse is assessing a client who is taking bupropion. The nurse should recognize which of the following findings as an indication that the medication is effective? a. Decreased urge to smoke 30. A nurse is preparing to administer benztropine 2 mg IM every 12 hr to a client who is experiencing an extrapyramidal reaction. Available is 1 mg/mL a. 2 mL 31. A nurse is providing discharge teaching to a client with a new prescription for phenelzine. The nurse should instruct the client to avoid which of the following foods when taking this medication? a. salami 32. A nurse is teaching a client who has bipolar disorder about lithium. Which of the following statements should the nurse include in the teaching? a. Notify your provider if you experience vomiting or diarrhea 33. A nurse is preparing to administer fluoxetine 40 mg PO daily. The amount available is fluoxetine 20 mg/5 mL. a. 10 mL 34. A nurse is caring for a client who has generalized anxiety disorder and is taking buspirone. Which of the following adverse effects should the nurse report to the provider? a. sweating 35. a nurse is providing discharge teaching to a client who has bipolar disorder and will be discharged with a prescription for lithium. The nurse should teach the client which of the following factors puts her at risk for lithium toxicity? a. The client runs 4 miles outdoors every afternoon 36. A nurse is developing a plan of care for a client who has a depressive disorder and is taking amitriptyline. Which of the following actions should the nurse include in the plan of care? a. Weigh the client weekly 37. A nurse is planning care for a client who is scheduled to receive ECT. Which of the following medications should the nurse anticipate administering prior to the procedure? a. atropine 38. A nurse in the emergency department is planning care for a client who is admitted for an - overdose of phencyclidine. Which of the following actions should the nurse plan to take? a. Administer ammonium chloride 39. A nurse is reinforcing teaching with an older adult client who has major depressive disorder and a prescription for nortriptyline 25 mg daily. Which of the following client statements indicates understanding of the teaching? a. I should sit on the side of the bed before standing up in the morning 40. 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? B. False imprisonment 41. 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? D. Report the incident to the health care team, but do not inform the client 42. 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) B. "Client was offered 8 oz of water every hr." C. "Client shouted obscenities at assistive personnel." D. "Client received chlorpromazine 15 mg by mouth at 1000. 43. 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? B. Tell the nurse to stop discussing the behavior. 44. 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? D. "I understand you're concerned. Let's discuss what concerns you specifically." 45. 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? B. Denial 46. 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? B. Moderate 47. 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.) B. Discuss prior use of coping mechanisms with the client. D. Demonstrate a calm manner while using simple and clear directions. 48. 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? C. "Losing someone close to you must be very upsetting." 49. 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) C. It is goal-directed. D. Behavioral change is encouraged E. A termination date is established ****50. A nurse is in the working phase of a therapeutic relationship with a client who has methamphetamine use disorder. Which of the following actions….what to do just like ex girlfriend 51. A nurse is caring for a client who is starting treatment for substance use disorder. Which of the following actions indicate the nurse is practicing the ethical principle of nonmaleficence? C. Withholding the prescribed medication that is causing adverse effects for the client. 52. A nurse in a group home facility is caring for a client who is developmentally disabled. The client has been stealing belongings from other clients. Which of the following techniques should the nurse use? c. Positive reinforcement to increase desired behavior. 53. A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take? d. Have the client breathe into a paper bag. 54. The nurse is caring for a client following a physical assault. The client states "I don't remember what happened to me." The nurse should recognize that the client is using which of the following defense mechanisms? a. Repression ***55. A nurse is providing behavior therapy for a client who has obsessive-compulsive disorder. The client repeatedly checks that the doors are locked at night. Which of the following instructions should the nurse give the client when using thought stopping technique? a. Snap a rubber band on your wrist when you think about checking the locks. c. Focus on abdominal breathing whenever you go to check the locks. 56. A nurse is admitting a client who has generalized anxiety disorder. Which of the following actions should the nurse plan to take first? a. Provide the client with a quiet environment 57. A nurse is caring for a client whose child has a terminal illness. The client requests information about how to deal with the upcoming loss. Which of the following statements should the nurse make a. "It is not uncommon to feel angry toward yourself or others 58. A nurse is teaching a client who has bipolar disorder and a prescription for lithium. Which of the following instructions should the nurse include in the teaching a. "Take this medication with food 59. A nurse is planning care for four clients in a mental health facility. Which of the following clients is at the greatest risk for injury when performing ADLs a. A client who has severe Alzheimer's disease 60. A nurse is updating the plan of care for a client who has bulimia nervosa and is 5% above his ideal body weight. Which of the following interventions should the nurse include in the plan a. Identify the client's trigger foods 61. A nurse who works with newborns is assessing the potential for abuse or neglect. Which of the following family groups should the nurse identify as the highest potential for future child abuse a. A family where one or both parents witnessed intimate partner violence in the home as children 62. A nurse is performing an admission assessment on a client and notices that the client appears withdrawn and fearful. To establish a trusting nurse-client relationship, which of the following actions should the nurse take first a. Inform the client that her admission is confidential 63. A nurse is caring for four clients in an inpatient mental health facility. Which of the following clients can give informed consent a. A 35-year-old client who has major depressive disorder 64. A nurse is admitting a client who has schizophrenia to an acute care setting. When the nurse questions the client regarding his admission, the client states, "I'm red, in the head, and I'm going to bed!" The nurse should document the client's speech pattern as which of the following a. Clang association 65. A nurse is educating the parent of a child who has a new diagnosis of autism spectrum disorder. Which of the following manifestations of this disorder should the nurse include in the teaching a. Language delay 66. A nurse in a mental health unit is admitting a client who is anxious because he often hears voices telling him what to do. Which of the following actions should the nurse take a. Ask the client what the voices are saying 67. 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 a. "Let's talk about what is upsetting you 68. A nurse is talking with a client who is beginning chemotherapy. The client tells the nurse that she is mourning the loss of her hair. Which of the following actions should the nurse take first a. Discuss the importance of hair with the client 69. A nurse is providing care for a client who has bipolar disorder and is experiencing acute mania. The client's morning lithium level is 1.5 mEq/L. Which of the following laboratory findings should the nurse report to the provider? (Click on the "Exhibit" button below for additional client information. There are three tabs that contain separate categories of data a. Sodium level 125 mEq/l ***70. A nurse in an emergency department is caring for an 18-month-old toddler who has a fractured left femur. Which of the following statements by the toddler's parent should cause the nurse to suspect child abuse 71. A client is fearful of driving and enters a behavioral therapy program to help him overcome his anxiety. Using systematic desensitization, he is able to drive down a familiar street without experiencing a panic attack. The nurse should recognize that to continue positive results, the client should participate in which of the following? a. Biofeedback 72. A nurse is counseling a client following the death of the client's partner 8 months ago. Which of the following client statements indicates maladaptive grieving? d"I still don't feel up to returning to work." 73. A nurse in an inpatient mental health facility is assessing a client who has schizophrenia and is taking haloperidol (antipsychotic, 1st gen). Which of the following clinical findings is the nurse's priority? d. high fever 74. A nurse is providing teaching to the daughter of an older client who has obsessive- compulsive disorder. Which of the following statements by the daughter indicates an understanding of the teaching? b. "I will limit my mother's clothing choices when she is getting 75.A nurse is caring for a client who is in the manic phase of bipolar disorder. Which of the following actions should the nurse take? Avoid power struggles by remaining neutral 76. A nurse is caring for a client who has a cocaine use disorder. Which of the following manifestations should the nurse expect the client to have during withdrawal? b. Fatigue 77. A nurse is reviewing the medical record of a client who is taking clozapine. For which of the following findings should the nurse withhold the medication and notify the provider? a. WBC count 78. A nurse is creating a plan of care for a client who has major depressive disorder. Which of the following interventions should the nurse include in the plan? b. Encourage physical activity for the client during the day 79. A nurse in a group home facility is caring for a client who is developmentally disabled. The client has been stealing belongings from other clients. Which of the following techniques should the nurse use? c. Positive reinforcement to increase desired behavior. 80. A nurse is caring for a client who is experiencing a panic attack. Which of the followi ng actions should the nurse take? d. Have the client breathe into à paper bag. 81. The nurse is caring for a client following a physical assault. The client states "I don't remember what happened to me." The nurse should recognize that the client is using which of the following defense mechanisms? a. Repression 82. A nurse is teaching a client who has schizophrenia about her new prescription for risperidone. Which of the following statements should the nurse include in the teaching? a.You should continue this medication if you develop muscle rigidity". 83. A nurse is planning care for an adolescent who has autism spectrum disorder. Which of the following outcomes should the nurse include in the plan care? b. Initiates social interactions with caregivers. 1. A nurse is creating a plan of care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan? d. Encourage the client to participate in family therapy 2. A school nurse is caring for an adolescent client whose teacher reports changes in school performance and withdrawal from interaction with classmates. Which of the following interventions is the nurse's priority at this time?a. Contact the adolescent's parents b. Determine when the adolescent's change in behavior began 3. A nurse is assessing a client who is withdrawing from heroin. Which of the following manifestations should the nurse expect? a. Slurred speech 4. A nurse is assessing a client who has histrionic personality disorder. Which of the following finds should the nurse expect? b. Attention seeking 5. A nurse is providing teaching to the daughter of an older client who has obsessive- compulsive disorder. Which of the following statements by the daughter indicates an understanding of the disorder? a. I will limit my mother's clothing choices when she is getting dressed 6. A nurse in a mental health facility is caring for a client who has borderline personality disorder. Which of the following should the nurse expect? a.Self-mutation 7. A nurse in an emergency mental health facility is caring for a group of clients. The nurse should identify which of the following clients requires a temporary emergency admission? C. A client who has borderline personality disorder and assaulted a homeless man with a metal rod 8. 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? D. "I understand you're concerned. Let's discuss what concerns you specifically. 9. 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? B. Denial 10. 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? B. The client accuses the nurses of telling him what to do just like his ex-girlfriend 11. A nurse is caring for a client whose child has a terminal illness. The client requests information about how to deal with the upcoming loss. Which of the following statements should the nurse make: d. "It is not uncommon to feel angry toward yourself or others." 13. A nurse is teaching a client who has bipolar disorder and a prescription for lithium. Which of the following instructions should the nurse include in the teaching? a. "Take this medication with food." 14. A nurse is planning care for four clients in a mental health facility. Which of the following clients is at the greatest risk for injury when performing ADLs a. A client who has severe Alzheimer's disease 15. A nurse who works with newborns is assessing the potential for abuse or neglect. Which of the following family groups should the nurse identify as the highest potential for future child abuse? A family where one or both parents witnessed intimate partner violence in the home as children 16. A nurse is performing an admission assessment on a client and notices that the client appears withdrawn and fearful. To establish a trusting nurse-client relationship, which of the following actions should the nurse take first a. Inform the client that her admission is confidential. 17. A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse include in the plan? A. give detailed instructions for completion of self-care activities 18. A nurse is planning overall strategies to address problems for a client who has borderline personality disorder. Which of the following strategies is the priority for the nurse to incorporate in the plan of care? C. assist the client to maintain awareness of her thoughts and feelings 19. A nurse is providing discharge teaching about expected adverse effects to a client who has a new prescription for lithium. Which of the following adverse effects should the nurse include? (Select all that apply). 1. Thirst 2. Sedation 5. Dry skin 20. A nurse is assessing a client who has schizophrenia. Which of the following finding should the nurse document as positive symptoms of schizophrenia? (Select all that apply.) 1. Flight of ideas 2. Delusions of grandeur 4. Auditory hallucinations 21. A nurse is caring for a client whose partner died 6 months ago. Which of the following findings is the nurse's priority? A. The client says he feels guilty about not spending more time with his partner 22. A nurse is caring for a client who has bipolar disorder and is refusing to take prescribed medications. Which of the following ethical principles to the nurse displaying when he supports the clients refusal of medication? b. Autonomy 23. A nurse in an outpatient clinic is assessing a client who has anorexia nervosa. Which of the following findings indicates the need for hospitalization? B. Temp below 96.7? 24. A nurse us obtaining a medical history from a client who is requesting a prescription for bupropion for smoking cessation. Which of the following assessment finding in the client’s history should the nurse report to the provider? D. Recent head injury 25. A nurse is providing crisis intervention for a client who was involved in a violent mass causality situation in the community. Which of the following actions should the nurse take during the initial session with the client? B. identify the client’s usual coping style 26. A nurse in the community health facility is interviewing a client who recently lost his job. The client states “I was fired because my boss doesn’t like me” Which of the following defense mechanisms is the client displaying? A. Rationalization 27. A nurse is assessing a client who recently experienced the loss of their partner. Which of the following question is the priority for for nurse to ask during situational crisis? c. Who do you talk to when you need help? 28. A nurse is caring for a client who was involuntarily committed and is scheduled to receive ECT. The client refuses treatment and will not discuss why with the healthcare team. Which of the following actions should the nurse take? c. Document the refusal of the treatment in the medical record. 29. A nurse is leading a grief support group for a bereaved client. Which of the following statements should the nurse report to the provider as an indication of clincal depression. I feel like I am angry at the whole world right now 30. A nurse is caring for a client who is undergoing electroconvulsive therapy. Which of the following tasks should the nurse delegate to assistive personnel? A. Assist the client to ambulate for the first time following the procedure 31. A nurse is caring for a client who has depression following a recent job loss. Which of the following questions should the nurse ask to assess the client’s personal coping skills? A. “How have you deal with similar situations in the past?” 32. A nurse conducting an admission interview with a new client who tells the nurse. “My life is so stressful. I can’t take it anymore.” Which of the following responses should the nurse take first? B. “Let’s talk more about what you are experiencing.” 33. A nurse is caring for a client who is experiencing alcohol withdrawal and notes visible tremors and an elevated blood pressure and heart rate. Which of the following mediations should the nurse prepare to administer? A. Naltrexone 34. A nurse in a mental health facility is reviewing the laboratory results of a client who is taking lithium carbonate. Which of the following findings places the client at risk for lithium toxicity? C. Sodium 132 mEq/L 35. A nurse is leading a critical incident stress debriefing with a group of staff members following a mass trauma incident. Which of the following interventions should the nurse take first? D. Reassure staff members that the debriefing is confidential. 36. A nurse is caring for a client who has borderline personality disorder and has been engaging in self-mutilation. The nurse should encourage the client to participate in which of the following groups? D. Dialectical behavior treatment group 37. A nurse in an alcohol rehabilitation facility is creating a discharge plan for a client who has alcohol use disorder. Which of the following recommendations should the nurse include in the plan? B. Request a discharge prescription for buprenorphine for the client 1. A nurse is caring for a client whose child has a terminal illness. The client requests information about how to deal with the upcoming loss. Which of the following statements should the nurse make a. "It is not uncommon to feel angry toward yourself or others 2. A nurse is teaching a client who has bipolar disorder and a prescription for lithium. Which of the following instructions should the nurse include in the teaching a. "Take this medication with food 3. A nurse is planning care for four clients in a mental health facility. Which of the following clients is at the greatest risk for injury when performing ADLs a. A client who has severe Alzheimer's disease 4. A nurse is updating the plan of care for a client who has bulimia nervosa and is 5% above his ideal body weight. Which of the following interventions should the nurse include in the plan a. Identify the client's trigger foods 5. A nurse who works with newborns is assessing the potential for abuse or neglect. Which of the following family groups should the nurse identify as the highest potential for future child abuse a. A family where one or both parents witnessed intimate partner violence in the home as children 6. A nurse is performing an admission assessment on a client and notices that the client appears withdrawn and fearful. To establish a trusting nurse-client relationship, which of the following actions should the nurse take first a. Inform the client that her admission is confidential 7. A nurse is caring for four clients in an inpatient mental health facility. Which of the following clients can give informed consent a. A 35-year-old client who has major depressive disorder 8. A nurse is admitting a client who has schizophrenia to an acute care setting. When the nurse questions the client regarding his admission, the client states, "I'm red, in the head, and I'm going to bed!" The nurse should document the client's speech pattern as which of the following a. Clang association 9. A nurse is educating the parent of a child who has a new diagnosis of autism spectrum disorder. Which of the following manifestations of this disorder should the nurse include in the teaching a. Language delay 10. A nurse in a mental health unit is admitting a client who is anxious because he often hears voices telling him what to do. Which of the following actions should the nurse take a. Ask the client what the voices are saying 11. 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 a. "Let's talk about what is upsetting you 12. A nurse is talking with a client who is beginning chemotherapy. The client tells the nurse that she is mourning the loss of her hair. Which of the following actions should the nurse take first a. Discuss the importance of hair with the client 13. A nurse is providing care for a client who has bipolar disorder and is experiencing acute mania. The client's morning lithium level is 1.5 mEq/L. Which of the following laboratory findings should the nurse report to the provider? (Click on the "Exhibit" button below for additional client information. There are three tabs that contain separate categories of data a. Sodium level 125 mEq/l 14. A nurse in an emergency department is caring for an 18-month-old toddler who has a fractured left femur. Which of the following statements by the toddler's parent should cause the nurse to suspect child abuse? "My child was riding a bicycle and fell off