QUESTIONS WITH CORRECT DETAILED ANSWERS ||
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A charge nurse is discussing mental status exams with a newly licensed nurse. Which of the following statem
ents by the newly licensed nurse indicates an understandingJof the teaching? (SelectJall that apply).
A. "To assessJcognitiveJability, I shouldJask theJclient to count backwardJby sevens."
B. "To assess affect, I should observeJthe client's facial expression.
C. "To assess language ability, IJshould instruct the client to writeJa sentence."
D. "To assessJremote memory, IJshould have the cJ- correct answer-
A. "To assess cognitiveJability, I should ask theJclient to count backward by sevens."
B. "To assess affect, I should observeJthe client'sJfacial expression.
C. "To assess language ability, IJshould instruct the clientJto writeJa sentence."
A nurse is planningJcare for a client who has a mental health disorder. Which of the followingJactions should
theJnurse include as aJpsychobiological intervention?
A. Assist the client with systematic desensitization therapy.
B. Teach the client appropriate coping mechanisms
C. Assess theJclient for comorbid health conditions.
D. Monitor the client for adverse effects of theJmedications. - correct answer-
D. Monitor the client for adverse effects of theJmedications.
A nurse inJan outpatient mental health clinic is preparing to conductJan initial client interview. WhenJconduct
ing theJinterview, which of the following actions shouldJthe nurse identify as the priority?
A. Coordinate holistic care with social services
B. Identify theJclient's perception of her mental health status.
C. Include theJclient's family in the interview.
D. Teach the client about her current mental health disorder. - correct answer-
B. Identify theJclient's perception of her mental health status.
,A nurse is told during change of shiftJreport that a clientJis stuporous. WhenJassessing the client, which of the
following findings should theJnurse expect?
A. The client arouses briefly in responseJto a sternal rub.
B. The client has a glasgow comaJscaleJscore less than 7.
C. The client exhibits decorticate rigidity.
D. The client isJalert but disoriented toJtime and place. - correct answer-
A. The client arouses briefly in responseJto a sternal rub.
A nurse is planningJaJpeer group discussion about theJDSM-
5. Which of the following information is appropriate toJinclude inJthe discussion? (Select all thatJapply)
A. The DSM-5 includes client educationJhandouts for mental health disorders.
B. The DSM-5 establishes diagnostic criteria for individual mental health disorders.
C. The DSM-5 indicates recommended pharmacological treatment for mental health disorders.
D. The DSM-5 assists nurses inJplanning care for client'sJwho have mental health dJ- correctJanswer-
B. The DSM-5 establishes diagnostic criteria for individual mental health disorders.
D. The DSM-5 assists nurses in planning care for client'sJwho have mental health disorders.
E. TheJDSM-5 indicates expected assessment findings of mental healthJdisorders.
A nurse in an emergency mental health facility is caring for a group of clients. The nurse should identify that
which of theJfollowing clients requires a temporary emergency admission?
A. A client who has schizophrenia with delusions of grandeur
B. A clientJwho has manifestations of depression and attemptedJsuicideJaJyear ago
C. A client who has borderline personality disorder and assaulted a homeless manJwith a metal rod
D. A client who has bipolar disorder andJpaces quickly aroundJthe room wh - correctJanswer-
C. A clientJwho has borderline personality disorder and assaulted a homeless manJwith a metal rod
A nurse decides to put a clientJwho has a psychotic disorder inJseclusion overnightJbecause the unit is very sh
ort-
,staffed, and the client frequently fights with otherJclients. The nurse's actions areJan example of which of the
following torts?
A. Invasion of privacy
B. False imprisonment
C. Assault
D. Battery - correct answer-B. False imprisonment
A clientJtells aJnurse, "Don'tJtell anyone but I hid a sharp knife under my mattress in order to protect myself fr
om my roommate, who is always yelling at me and threatening me." Which of the followingJactionsJshould t
heJnurse take?
A. Keep the client's communication confidential, but talk toJthe client daily, using therapeutic communicatio
nJto convince him to admitJto hiding the knife
B. Keep the client's communication confidential, but watch the client and his roommate closely.
C. Tell theJcl - correct answer-
D. Report the incidentJto the health careJteam, butJdoJnotJinform the client of theJintention to do so.
A nurse is caring for a client who is in mechanical restraints. Which of the following statements should the n
urseJinclude in the documentation? (SelectJall that apply)
A. "Client ate most of his breakfast."
B. "ClientJwas offered 8 oz of water every hr."
C. "ClientJshouted 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 offeredJ8 oz of water every hr."
C. "Client shouted obscenities at assistive personnel."
D. "Client received chlorpromazine 15 mg by mouth at 1000.
A nurse hears a newly licensed nurseJdiscussing a client's hallucinations in the hallway with another nurse.
WhichJof the following actions should theJnurse takeJfirst?
, A. Notify the nurse manager.
B. Tell theJnurse to stop discussing the behavior.
C. Provide an in-service program about confidentiality.
D. CompleteJan incident report. - correct answer-B. Tell the nurse to stop discussingJthe behavior
A nurse is caring for the parents of aJchild who has demonstrated changes in behavior and mood. When theJm
other of the child asks theJnurse for reassurance about herJson's condition, which of the followingJresponses s
hould theJnurse make?
A. "I think yourJson is gettingJbetter. What have you noticed."
B. "I'm sure everything will beJokay. ItJjustJtakes timeJto heal."
C. "I'm not sure whats wrong. Have you asked theJdoctor about your concerns?"
D. "I understand you're concerned. Let's discussJwh -Jcorrect answer-
D. "I understand you're concerned. Let's discussJwhat concerns youJspecifically."
A nurse is caring for a client who smokes and has lungJcancer. The client reports, "I'm coughingJbecause I ha
veJthat cold that everyoneJhas been getting." The nurseJshould identify thatJthe client isJusing which of the fol
lowing defense mechanisms?
A. Reaction formation
B. Denial
C. Displacement
D. Sublimation - correct answer-B. Denial
A nurse is providing preoperative teaching for a client who was just informed that she requires emergency su
rgery. The clientJhas a respiratory rate 30/min and says, "This is difficult to comprehend. I feel shaky and ner
vous." The nurse should identify that the client is experiencing which of the following levels of anxiety?
A. Mild
B. Moderate
C. Severe
D. Panic - correct answer-B. Moderate