Axchargexnursexisxdiscussingxmentalxstatusxexamsxwithxaxnewlyxlicensedxnurse.xWhichxofxthexfollowing
xstatementsxbyxthexnewlyxlicensedxnursexindicatesxanxunderstandingxofxthexteaching?
x(Selectxallxthatxapply)
A)xToxassessxcognitivexability,xIxshouldxaskxthexclientxtoxcountxbackwardxbyxsevens.
B)xToxassessxaffect,xIxshouldxobservexthexclient'sxfacialxexpression
C)xToxassessxlanguagexability,xIxshouldxinstructxthexclientxtoxwritexaxsentence.
D)xToxassessxremotexmemory,xIxshouldxhavexthexclientxrepeatxaxlistxofxobjects.
E)xToxassessxthexclient'sxabstractxthinking,xIxshouldxaskxthexclientxtoxidentifyxourxmostxrecentxpresiden
ts.x-xANSWERxA,xB,xC
Axnursexisxplanningxcarexforxaxclientxwhoxhasxaxmentalxhealthxdisorder.xWhichxofxthexfollowingxactions
xshouldxthexnursexincludexasxaxpsychobiologicalxintervention?
A)xAssistxthexclientxwithxsystematicxdesensitizationxtherapy.
B)xTeachxthexclientxappropriatexcopingxmechanisms.
C)xAssessxthexclientxforxcomorbidxhealthxconditions.
D)xMonitorxthexclientxforxadversexeffectsxofxthexmedications.x-xANSWERxD
Axnursexinxanxoutpatientxmentalxhealthxclinicxisxpreparingxtoxconductxanxinitialxclientxinterview.xWhenx
conductingxthexinterview,xwhichxofxthexfollowingxactionsxshouldxthexnursexidentifyxasxthexpriority?
A)xCoordinatexholisticxcarexwithxsocialxservices.
B)xIdentifyxthexclient'sxperceptionxofxherxmentalxhealthxstatus.
C)xIncludexthexclient'sxfamilyxinxthexinterview.
D)xTeachxthexclientxaboutxherxcurrentxmentalxhealthxdisorderx-xANSWERxB
,Axnursexisxtoldxduringxchangexofxshiftxreportxthatxaxclientxisxstuporous.xWhenxassessingxthexclient,xwhi
chxofxthexfollowingxfindingsxshouldxthexnursexexpect?
A)xThexclientxarousesxbrieflyxinxresponsextoxaxsternalxrub.
B)xThexclientxhasxaxglasgowxcomaxscalexscorexlessxthanx7.
C)xThexclientxexhibitsxdecorticatexrigidity.
D)xThexclientxisxalertxbutxdisorientedxtoxtimexandxplace.x-xANSWERxA
AxnursexisxplanningxaxpeerxgroupxaboutxthexDSM-
5.xWhichxofxthexfollowingxinformationxisxappropriatextoxincludexinxthexdiscussion?
x(Selectxallxthatxapply).
A)xThexDSM-5xincludesxclientxeducationxhandoutsxforxmentalxhealthxdisorders.
B)xThexDSM-5xestablishesxdiagnosticxcriteriaxforxindividualxmentalxhealthxdisorders.
C)xThexDSM-5xindicatesxrecommendedxpharmacologicalxtreatmentxforxmentalxhealthxdisorders.
D)xThexDSM-5xassistsxnursesxinxplanningxcarexforxclient'sxwhoxhavexmentalxhealthxdisorders.
E)xThexDSM-5xindicatesxexpectedxassessmentxfindingsxofxmentalxhealthxdisorders.x-xANSWERxB,xD,xE
Axnursexinxanxemergencyxmentalxhealthxfacilityxisxcaringxforxaxgroupxofxclients.xThexnursexshouldxiden
tifyxthatxwhichxofxthexfollowingxclientsxrequiresxaxtemporaryxemergencyxadmission?
A)xAxclientxwhoxhasxschizophreniaxwithxdelusionsxofxgrandeur
B)xAxclientxwhoxhasxmanifestationsxofxdepressionxandxattemptedxsuicidexaxyearxago.
C)xAxclientxwhoxhasxborderlinexpersonalityxdisorderxandxassaultedxaxhomelessxmanxwithxaxmetalxrod.
D)xAxclientxwhoxhasxbipolarxdisorderxandxpacesxquicklyxaroundxthexroomxwhilextalkingxtoxhimself.x-
xANSWERxC
Axnursexdecidesxtoxputxaxclientxwhoxhasxaxpsychoticxdisorderxinxseclusionxovernightxbecausexthexunitxi
sxveryxshort-
staffed,xandxthexclientxfrequentlyxfightsxwithxotherxclients.xThexnurse'sxactionsxarexanxexamplexofxwhic
hxofxthexfollowingxtorts?
A)xInvasionxofxprivacy
, B)xFalseximprisonment
C)xAssault
D)xBatteryx-xANSWERxB
Axclientxtellsxaxnurse,x"Don'txtellxanyonexbutxIxhidxaxsharpxknifexunderxmyxmattressxinxorderxtoxprotect
xmyselfxfromxmyxroommate,xwhoxisxalwaysxyellingxatxmexandxthreateningxme."xWhichxofxthexfollowing
xactionsxshouldxthexnursextake?
A)xKeepxthexclient'sxcommunicationxconfidential,xbutxtalkxtoxthexclientxdaily,xusingxtherapeuticxcommu
nicationxtoxconvincexhimxtoxadmitxtoxhidingxthexknife.
B)xKeepxthexclient'sxcommunicationxconfidential,xbutxwatchxthexclientxandxhisxroommatexclosely.
C)xTellxthexclientxthatxthisxmustxbexreportedxtoxthexhealthcarexteamxbecausexitxconcernsxthexhealthxa
ndxsafetyxofxthexclientxandxothers.
D)xReportxthexincidentxtoxthexhealthxcarexteam,xbutxdoxnotxinformxthexclientxofxthexintentionxtoxdoxso
.x-xANSWERxD
Axnursexisxcaringxforxaxclientxwhoxisxinxmechanicalxrestraints.xWhichxofxthexfollowingxstatementsxshoul
dxthexnursexincludexinxthexdocumentation?x(Selectxallxthatxapply)
A)xClientxatexmostxofxhisxbreakfast
B)xClientxwasxofferedx8xozxofxwaterxeveryxhr
C)xClientxshoutedxobscenitiesxatxassistivexpersonnel
D)xClientxreceivedxchlorpromazinex15xmgxbyxmouthxatx1000
E)xClientxactedxoutxafterxlunchx-xANSWERxB,xC,xD
Axnursexhearsxaxnewlyxlicensedxnursexdiscussingxaxclient'sxhallucinationsxinxthexhallwayxwithxanotherxn
urse.xWhichxofxthexfollowingxactionsxshouldxthexnursextakexfirst?
A)xNotifyxthexnursexmanager
B)xTellxthexnursextoxstopxdiscussingxthexbehavior
C)xProvidexanxin-servicexprogramxaboutxconfidentiality