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A charge nurse is discussing mental status exams with a newly licensed nurse. Which of the following st
atements 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."
D. "To assess remote memory, I should have the c - correct answer-
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."
A nurse is planning care for a client who has aZmental health disorder. Which of the following actions sh
ould the nurse include as a psychobiological intervention?
A. Assist the client withZsystematic desensitization therapy.
B. Teach the client appropriate coping mechanisms
C. Assess the client for comorbid health conditions.
D. Monitor theZclient for adverse effects of theZmedications. - correct answer-
D. Monitor theZclient for adverse effects of the medications.
A nurse in an outpatient mental health clinic is preparing to conduct an initial client interview. When con
ducting the interview, which of the following actions should the nurse identify as the priority?
A. Coordinate holistic care with social services
B. Identify the client's perception of her mental health status.
C. Include the client's family in the interview.
D. Teach the client aboutZher current mental health disorder. - correct answer-
B. Identify the 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 o
f the following findings should the nurse expect?
A. The client arouses briefly in response to a sternal rub.
B. TheZclient has a glasgow coma scale score less than 7.
C. TheZclient exhibits decorticate rigidity.
D. The client is alert but disoriented to time and place. - correct answer-
A. The client arouses briefly in response to a sternal rub.
A nurse is planning a peer group discussion about theZDSM-
5. Which of theZfollowing information is appropriate to include in the discussion? (SelectZall that apply)
A. The DSM-5 includes client education handouts for mental health disorders.
B. TheZDSM-5 establishes diagnostic criteria for individual mental health disorders.
C. TheZDSM-5 indicates recommended pharmacological treatment for mental health disorders.
D. The DSM-5 assists nurses in planning care for client's who have mental health d - correct answer-
B. TheZDSM-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.
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 aZtemporary emergency admission?
A. A client who has schizophrenia with delusions of grandeur
B. A client who has manifestations of depression and attempted suicide a year ago
C. A client who has borderline personality disorder and assaulted a homeless man with a metal rod
D. A client who has bipolar disorder and paces quickly around the room wh - correct answer-
C. 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 ve
ry short-
staffed, and the client frequently fights with other clients. The nurse's actions are an example of which of
the following torts?
,A. Invasion of privacy
B. FalseZimprisonment
C. Assault
D. Battery - correct answer-B. False imprisonment
A client tells a nurse, "Don't tell anyone but I hid a sharp knife under my mattress in order Zto protect my
self fromZmy roommate, who is always yelling at me and threatening me." Which of the following action
s should the nurse take?
A. Keep the client's communication confidential, but talk to the client daily, using therapeutic communic
ation to convince him to admit to hiding the knife
B. KeepZthe client's communication confidential, but watch the client and his roommate closely.
C. Tell the cl - correct answer-
D. Report the incident toZthe health care team, but do not inform the client of theZintention to do so.
A nurse is caring for a client who is in mechanical restraints. Which of the following statements should Zt
he nurseZinclude inZthe documentation? (Select all thatZapply)
A. "Client ate most of his breakfast."
B. "Client was offered 8 ozZof water every hr."
C. "Client shouted obscenities at assistive personnel."
D. "Client received chlorpromazine 15 mg by mouth at 1000."
E. "Client acted out after lunch." - correct answer-B. "Client was offered 8 oz of waterZevery hr."
C. "Client shouted obscenities at assistive personnel."
D. "Client received chlorpromazine 15 mg by mouth at 1000.
A nurse hears a newly licensed nurse discussing a client's hallucinations in the hallway with another nurs
e. Which of the following actions shouldZthe nurse take first?
A. Notify the nurse manager.
B. Tell the nurse to stop discussing the behavior.
, C. Provide an in-service program about confidentiality.
D. Complete an incident report. - correct answer-B. Tell the nurse to stop discussing the behavior
A nurse is caring for the parents of a child who has demonstrated changes in behavior and mood. When t
he mother of theZchild asks the nurse for reassurance about her son's condition, which of the following re
sponses should the nurse make?
A. "I think your son is getting better. WhatZhave you noticed."
B. "I'm sure everythingZwill be okay. ItZjust takes time to heal."
C. "I'm not sure whats wrong. Have you asked the doctor about your concerns?"
D. "I understandZyou'reZconcerned. Let'sZdiscuss wh - correct answer-
D. "I understand you'reZconcerned. Let's discuss what concerns you specifically."
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?
A. Reaction formation
B. Denial
C. Displacement
D. Sublimation - correct answer-B. Denial
A nurse is providing preoperative teaching for aZclient who was just informedZthat she requires emergenc
y surgery. The client has a respiratory rate 30/min and says, "This is difficult to comprehend. I Zfeel shaky
and nervous." TheZnurse should identify that the clientZis experiencing which of the following levels of a
nxiety?
A. Mild
B. Moderate
C. Severe
D. Panic - correct answer-B. Moderate