RASMUSSEN MENTAL HEALTH FINAL REVIEW EXAM
QUESTIONS AND ANSWERS VERIFIED 100% CORRECT
C
A nurse is caring for a client who is having difficulty sleeping and is pacing the floor. The client's head
down, and he is wringing his hands. Which of the following actions should the nurse take? A.
Encourage the client to go back to bed.
B. Give the client a PRN sleeping medication.
C. Remain with the client.
D. Explore alternatives to pacing the floor with the client.
B
A nurse is caring for a 9-year-old boy who has a new diagnosis of diabetes mellitus and is eager to return
to school and participate in social events. The mother tells the nurse she is afraid to let him take part in
physical activities at school. Which of the following responses should the nurse make?
A. "You might want to use tutors to home-school him."
B. "Tell me more about how you are feeling about your son's activities."
C. "I agree. His well-being is the most important."
D. "You sound overprotective. Let's talk about this some more."
D
A nurse on a mental health unit is caring for clients who have various depressive disorders. The nurse
should identify which of the following client diagnoses as presenting the greatest risk for suicide?
A. Premenstrual dysphoric disorder
B. Seasonal affective disorder
C. Persistent depressive disorder
D. Major depressive disorder
A, B, E
A nurse is providing a community health education class about suicide prevention. Which of the
following should the nurse identify as risk factors for suicide? Select All That Apply
A. substance use disorder
B. age greater than 45 years old
C. female gender
D. currently married
E. schizophrenia
C
A nurse is caring for a client following a recent suicide attempt. Which of the following actions should
the nurse take?
A. Place metal utensils on the client's meal tray.
,B. Assign the client to a private room.
C. Inspect the client's personal belongings.
D. Tuck bedcovers over client's hands and arms.
A
A nurse is providing teaching about confidentiality with a newly licensed nurse. which of the ff
statements by the newly licensed nurse indicates an understanding of the teaching?
A. "The court might require me to discuss confidential information"
B. "I am required to provide confidential information to insurance companies"
C. "if questioned during a police investigation, I am required to divulge confidential information" D. "I
am legally allowed to discuss confidential information with the client's former therapist" C
A nurse is caring for a client who professes a deep and everlasting love for his girlfriend one day, and the
next day refuses to speak to her or allow her to visit. The nurse recognizes this client behavior which of
the following defense mechanisms?
A. Repression
B. Splitting
C. Undoing
D. Sublimation
B, C, D
A nurse is caring for a client who is experiencing a crisis related to anxiety. Which of the following
actions should the nurse take? select all that apply A. Avoid eye contact to prevent escalation of
anxiety.
B. Establish rapport with the client.
C. Identify the cause of the anxiety.
D. Validate the client's feelings.
E. Develop a flexible crisis intervention plan.
B
A nurse notices that a client who has moderate anxiety is pacing the hall and mumbling. As the nurse
approaches the client, he states, "I am at the end of my rope. I don't think I can take any more bad
news." Which of the following responses should the nurse make?
A. "Most clients with anxiety issues benefit from lying down."
B. "Come with me to an area where we can talk without interruption."
C. "Providers usually recommend relaxation exercises for clients who are as upset as you are." D. "An
antianxiety pill works best for situations like these."
D
A nurse is making a home visit for a 16-year old adolescent who attempted suicide. Which of the
following behaviors should alert the nurse that the adolescent still has suicidal intent? A. Telling
his parents that he doesn't want to talk about the suicide attempt.
B. Stating that he wants to be with his peers more than with his parents.
C. Preferring to eat his meals while watching TV.
, D. Planning to give his CD collection to his girlfriend.
A
A nurse in an emergency department is assessing a client who has traumatic injuries following an
assault. The client sits quietly and calmly in the examination room and states, "I'm fine." The nurse
should recognize the client's behavior as which of the following reactions?
A. Denial
B. Displacement
C. Projection
D. Undoing
B
A nurse in an acute mental health facility is caring for a client who jumps out of her chair and begins to
shout angrily at the clients around her. Which of the following actions should the nurse take first? A.
Call for assistance to place the client in restraints.
B. Speak to the client calmly, giving simple directions.
C. Escort the client to an unlocked seclusion room.
D. Offer the client a PRN antianxiety medication.
C
A nurse working in suicide prevention is discussing suicide interventions with a newly hired nurse. Which
of the following statements indicates that the newly hired nurse understands when a tertiary
intervention is needed?
A. "I should perform screenings to identify clients at risk for suicide."
B. "I should recognize the lethality of the suicide plan."
C. "I should provide counseling for the family following the suicide of a client."
D. "I should provide a safe environment to prevent the client from committing suicide." C
A nurse reviews the laboratory report for a client who is receiving lithium three times daily PO. The
client's current blood lithium level is 1.8 mEq/L. The nurse identifies that this lab value indicates which
of the following?
A. A blood lithium level of 1.8 mEq/L is not within the maintenance treatment level.
B. The lithium level is below the therapeutic treatment level.
C. The lithium level is at the toxic level.
D. The lithium level is within the therapeutic level for initial treatment.
D
A nurse is caring for a client who is exhibiting severe manifestations of serotonin syndrome. Which of
the following is the priority nursing intervention? A. Administering an anticonvulsant.
B. Padding side rails to prevent injury.
C. Applying a cooling blanket.
D. Preparing for artificial ventilation.
A
QUESTIONS AND ANSWERS VERIFIED 100% CORRECT
C
A nurse is caring for a client who is having difficulty sleeping and is pacing the floor. The client's head
down, and he is wringing his hands. Which of the following actions should the nurse take? A.
Encourage the client to go back to bed.
B. Give the client a PRN sleeping medication.
C. Remain with the client.
D. Explore alternatives to pacing the floor with the client.
B
A nurse is caring for a 9-year-old boy who has a new diagnosis of diabetes mellitus and is eager to return
to school and participate in social events. The mother tells the nurse she is afraid to let him take part in
physical activities at school. Which of the following responses should the nurse make?
A. "You might want to use tutors to home-school him."
B. "Tell me more about how you are feeling about your son's activities."
C. "I agree. His well-being is the most important."
D. "You sound overprotective. Let's talk about this some more."
D
A nurse on a mental health unit is caring for clients who have various depressive disorders. The nurse
should identify which of the following client diagnoses as presenting the greatest risk for suicide?
A. Premenstrual dysphoric disorder
B. Seasonal affective disorder
C. Persistent depressive disorder
D. Major depressive disorder
A, B, E
A nurse is providing a community health education class about suicide prevention. Which of the
following should the nurse identify as risk factors for suicide? Select All That Apply
A. substance use disorder
B. age greater than 45 years old
C. female gender
D. currently married
E. schizophrenia
C
A nurse is caring for a client following a recent suicide attempt. Which of the following actions should
the nurse take?
A. Place metal utensils on the client's meal tray.
,B. Assign the client to a private room.
C. Inspect the client's personal belongings.
D. Tuck bedcovers over client's hands and arms.
A
A nurse is providing teaching about confidentiality with a newly licensed nurse. which of the ff
statements by the newly licensed nurse indicates an understanding of the teaching?
A. "The court might require me to discuss confidential information"
B. "I am required to provide confidential information to insurance companies"
C. "if questioned during a police investigation, I am required to divulge confidential information" D. "I
am legally allowed to discuss confidential information with the client's former therapist" C
A nurse is caring for a client who professes a deep and everlasting love for his girlfriend one day, and the
next day refuses to speak to her or allow her to visit. The nurse recognizes this client behavior which of
the following defense mechanisms?
A. Repression
B. Splitting
C. Undoing
D. Sublimation
B, C, D
A nurse is caring for a client who is experiencing a crisis related to anxiety. Which of the following
actions should the nurse take? select all that apply A. Avoid eye contact to prevent escalation of
anxiety.
B. Establish rapport with the client.
C. Identify the cause of the anxiety.
D. Validate the client's feelings.
E. Develop a flexible crisis intervention plan.
B
A nurse notices that a client who has moderate anxiety is pacing the hall and mumbling. As the nurse
approaches the client, he states, "I am at the end of my rope. I don't think I can take any more bad
news." Which of the following responses should the nurse make?
A. "Most clients with anxiety issues benefit from lying down."
B. "Come with me to an area where we can talk without interruption."
C. "Providers usually recommend relaxation exercises for clients who are as upset as you are." D. "An
antianxiety pill works best for situations like these."
D
A nurse is making a home visit for a 16-year old adolescent who attempted suicide. Which of the
following behaviors should alert the nurse that the adolescent still has suicidal intent? A. Telling
his parents that he doesn't want to talk about the suicide attempt.
B. Stating that he wants to be with his peers more than with his parents.
C. Preferring to eat his meals while watching TV.
, D. Planning to give his CD collection to his girlfriend.
A
A nurse in an emergency department is assessing a client who has traumatic injuries following an
assault. The client sits quietly and calmly in the examination room and states, "I'm fine." The nurse
should recognize the client's behavior as which of the following reactions?
A. Denial
B. Displacement
C. Projection
D. Undoing
B
A nurse in an acute mental health facility is caring for a client who jumps out of her chair and begins to
shout angrily at the clients around her. Which of the following actions should the nurse take first? A.
Call for assistance to place the client in restraints.
B. Speak to the client calmly, giving simple directions.
C. Escort the client to an unlocked seclusion room.
D. Offer the client a PRN antianxiety medication.
C
A nurse working in suicide prevention is discussing suicide interventions with a newly hired nurse. Which
of the following statements indicates that the newly hired nurse understands when a tertiary
intervention is needed?
A. "I should perform screenings to identify clients at risk for suicide."
B. "I should recognize the lethality of the suicide plan."
C. "I should provide counseling for the family following the suicide of a client."
D. "I should provide a safe environment to prevent the client from committing suicide." C
A nurse reviews the laboratory report for a client who is receiving lithium three times daily PO. The
client's current blood lithium level is 1.8 mEq/L. The nurse identifies that this lab value indicates which
of the following?
A. A blood lithium level of 1.8 mEq/L is not within the maintenance treatment level.
B. The lithium level is below the therapeutic treatment level.
C. The lithium level is at the toxic level.
D. The lithium level is within the therapeutic level for initial treatment.
D
A nurse is caring for a client who is exhibiting severe manifestations of serotonin syndrome. Which of
the following is the priority nursing intervention? A. Administering an anticonvulsant.
B. Padding side rails to prevent injury.
C. Applying a cooling blanket.
D. Preparing for artificial ventilation.
A
