questions and answer(A+).
A charge nurse is discussing mental status exams with a newly licensed nurse. Which of the following s
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tatements by the newly licensed nurse indicates an understanding of the teaching?
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(Select all that apply)
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A) To assess cognitive ability, I should ask the client to count backward by sevens.
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B) To assess affect, I should observe the client's facial expression
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C) To assess language ability, I should instruct the client to write a sentence.
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D) To assess remote memory, I should have the client repeat a list of objects.
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E) To assess the client's abstract thinking, I should ask the client to identify our most recent presidents.
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- (correct answer) - A, B, C
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A nurse is planning care for a client who has a mental health disorder. Which of the following actions s
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hould the nurse include as a psychobiological intervention?
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A) Assist the client with systematic desensitization therapy.
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B) Teach the client appropriate coping mechanisms.
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C) Assess the client for comorbid health conditions.
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D) Monitor the client for adverse effects of the medications. - (correct answer) - D
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A nurse in an outpatient mental health clinic is preparing to conduct an initial client interview. When c
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onducting the interview, which of the following actions should the nurse identify as the priority?
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A) Coordinate holistic care with social services.
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B) Identify the client's perception of her mental health status.
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C) Include the client's family in the interview.
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D) Teach the client about her current mental health disorder - (correct answer) - B
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,A nurse is told during change of shift report that a client is stuporous. When assessing the client, whic
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h of the following findings should the nurse expect?
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A) The client arouses briefly in response to a sternal rub.
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B) The client has a glasgow coma scale score less than 7.
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C) The client exhibits decorticate rigidity.
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D) The client is alert but disoriented to time and place. - (correct answer) - A
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A nurse is planning a peer group about the DSM-
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5. Which of the following information is appropriate to include in the discussion?
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(Select all that apply).
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A) The DSM-5 includes client education handouts for mental health disorders.
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B) The DSM-5 establishes diagnostic criteria for individual mental health disorders.
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C) The DSM-5 indicates recommended pharmacological treatment for mental health disorders.
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D) The DSM-5 assists nurses in planning care for client's who have mental health disorders.
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E) The DSM-5 indicates expected assessment findings of mental health disorders. - (correct answer) -
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B, D, E
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A nurse in an emergency mental health facility is caring for a group of clients. The nurse should identif
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y that which of the following clients requires a temporary emergency admission?
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A) A client who has schizophrenia with delusions of grandeur
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B) A client who has manifestations of depression and attempted suicide a year ago.
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C) A client who has borderline personality disorder and assaulted a homeless man with a metal rod.
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D) A client who has bipolar disorder and paces quickly around the room while talking to himself. -
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(correct answer) - C
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A nurse decides to put a client who has a psychotic disorder in seclusion overnight because the unit is
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very short- gh
staffed, and the client frequently fights with other clients. The nurse's actions are an example of which
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of the following torts?
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A) Invasion of privacy
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B) False imprisonment
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C) Assaultgh
, D) Battery - (correct answer) - B
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A client tells a nurse, "Don't tell anyone but I hid a sharp knife under my mattress in order to protect
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myself from my roommate, who is always yelling at me and threatening me." Which of the following a
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ctions should the nurse take?
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A) Keep the client's communication confidential, but talk to the client daily, using therapeutic commun
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ication to convince him to admit to hiding the knife.
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B) Keep the client's communication confidential, but watch the client and his roommate closely.
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C) Tell the client that this must be reported to the healthcare team because it concerns the health and
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safety of the client and others.
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D) Report the incident to the health care team, but do not inform the client of the intention to do so. -
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(correct answer) - D
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A nurse is caring for a client who is in mechanical restraints. Which of the following statements should
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the nurse include in the documentation? (Select all that apply)
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A) Client ate most of his breakfast
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B) Client was offered 8 oz of water every hr
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C) Client shouted obscenities at assistive personnel
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D) Client received chlorpromazine 15 mg by mouth at 1000
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E) Client acted out after lunch - (correct answer) - B, C, D
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A nurse hears a newly licensed nurse discussing a client's hallucinations in the hallway with another nu
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rse. Which of the following actions should the nurse take first?
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A) Notify the nurse manager
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B) Tell the nurse to stop discussing the behavior
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C) Provide an in-service program about confidentiality
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D) Complete an incident report - (correct answer) - B
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A nurse is caring for the parents of a child who has demonstrated changes in behavior and mood. Whe
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n the mother of the child asks the nurse for reassurance about her son's condition, which of the follow
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ing responses should the nurse make?
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A) I think your son is getting better. What have you noticed
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B) I'm sure everything will be okay. It just takes time to heal
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