Mental Health CMS Prep Part 2
A nurse is performing an admission assessment for a client who has restricting type anorexia nervosa.
The nurse should expect which of the following findings? - (answer)Decreased caloric intake
A nurse is assessing a client who takes phenelzine for the treatment of depression. Which of the
following findings is the priority for the nurse to report to the provider? - (answer)Elevated BP
A nurse is assessing a client who experienced a sexual assault 6 months ago. Which of the following
findings should the nurse report to the provider as an indication of rape-trauma syndrome? - (answer)A
report of intense guilt
A nurse is an acute substance disorder unit is assessing a client who received treatment in the
emergency department for a heroin overdose. Which of the following findings should the nurse
anticipate during heroin withdrawal? - (answer)Muscle aches
A nurse in an emergency room is assessing a client who has cocaine intoxication. Which of the following
findings should the nurse expect? - (answer)Dilated pupils
A nurse is caring for a client who has Wernicke-Korsakoff syndrome due to alcohol use disorder. Which
of the following findings should the nurse expect? - (answer)Confusion
A charge nurse is discussing mental status examinations with a newly licensed nurse. Which of the
following statements by the newly licensed nurse indicates an understanding of the teaching? -
(answer)To assess cognitive ability, I should ask the client to count backward by sevens.
To assess affect, I should obscure the client's facial expression.
To assess language ability, I should instruct the client to write a sentence
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? - (answer)Monitor the client for adverse
effects of medications
, Mental Health CMS Prep Part 2
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 a priority? -
(answer)Identify client's perception of her mental health status
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? - (answer)The client arouses briefly in response to
sternal rub
A nurse is planning a peer group discussion about the Diagnostic and Statistical Manual of Mental
Disorders, 5th edition. Which of the following information is appropriate to include in the discussion? -
(answer)The DSM-5 establishes diagnostic criteria for individual mental health disorders.
The DSM-5 assists nurses in planning care for client's who have mental health disorders.
The DSM-5 indicates expected assessment findings of mental health disorders.
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? - (answer)A client who
has borderline personality disorder and assaulted a homeless man with a metal rod
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? - (answer)False Imprisonment
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? - (answer)Tell the client that this must be reported to the health care
team because it concerns the health and safety of the client and others
A Nurse is caring for a client who is in mechanical restraints. Which of the following statements should
the nurse include in the documentation? - (answer)"Client was offered 8oz of water every hour".
A nurse is performing an admission assessment for a client who has restricting type anorexia nervosa.
The nurse should expect which of the following findings? - (answer)Decreased caloric intake
A nurse is assessing a client who takes phenelzine for the treatment of depression. Which of the
following findings is the priority for the nurse to report to the provider? - (answer)Elevated BP
A nurse is assessing a client who experienced a sexual assault 6 months ago. Which of the following
findings should the nurse report to the provider as an indication of rape-trauma syndrome? - (answer)A
report of intense guilt
A nurse is an acute substance disorder unit is assessing a client who received treatment in the
emergency department for a heroin overdose. Which of the following findings should the nurse
anticipate during heroin withdrawal? - (answer)Muscle aches
A nurse in an emergency room is assessing a client who has cocaine intoxication. Which of the following
findings should the nurse expect? - (answer)Dilated pupils
A nurse is caring for a client who has Wernicke-Korsakoff syndrome due to alcohol use disorder. Which
of the following findings should the nurse expect? - (answer)Confusion
A charge nurse is discussing mental status examinations with a newly licensed nurse. Which of the
following statements by the newly licensed nurse indicates an understanding of the teaching? -
(answer)To assess cognitive ability, I should ask the client to count backward by sevens.
To assess affect, I should obscure the client's facial expression.
To assess language ability, I should instruct the client to write a sentence
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? - (answer)Monitor the client for adverse
effects of medications
, Mental Health CMS Prep Part 2
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 a priority? -
(answer)Identify client's perception of her mental health status
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? - (answer)The client arouses briefly in response to
sternal rub
A nurse is planning a peer group discussion about the Diagnostic and Statistical Manual of Mental
Disorders, 5th edition. Which of the following information is appropriate to include in the discussion? -
(answer)The DSM-5 establishes diagnostic criteria for individual mental health disorders.
The DSM-5 assists nurses in planning care for client's who have mental health disorders.
The DSM-5 indicates expected assessment findings of mental health disorders.
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? - (answer)A client who
has borderline personality disorder and assaulted a homeless man with a metal rod
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? - (answer)False Imprisonment
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? - (answer)Tell the client that this must be reported to the health care
team because it concerns the health and safety of the client and others
A Nurse is caring for a client who is in mechanical restraints. Which of the following statements should
the nurse include in the documentation? - (answer)"Client was offered 8oz of water every hour".
