MH FINAL Exam – Questions With Complete Solutions
A nurse is caring for a client who has a history of alcohol use disorder and has
been hospitalized for detox. The nurse enters the room and finds the client
shouting in a terrified voice, "Get these bugs off of me!" Which of the following
responses by the nurse is appropriate?
A) "I'm sure that the bugs you see will not harm you."
B) "Tell me more about the bugs that you see in your room."
C) "I don't see any bugs, but you seem very frightened."
D) "I do not see anything. This is part of the withdrawal process." Right Ans
- C) "I don't see any bugs, but you seem very frightened."
This client is experiencing a tactile hallucination, which is common during
alcohol withdrawal. This response by the nurse presents reality and shows
empathy by acknowledging the client's feelings.
A nurse is caring for an adolescent who is experiencing indications of
depression. Which of the following findings should the nurse expect? Right
Ans - constant pain
A nurse in an emergency department is assessing a client for suspected
cocaine intoxication. Which of the following findings should the nurse expect?
Right Ans - Dilated pupils
A nurse is caring for a client who has severe manifestations of schizophrenia
and is medicated PRN for agitation with haloperidol. The nurse should assess
the client for which of the following adverse effects?
a. Dysrhythmias
b. Cataracts
c. Pancreatitis
d. Bleeding Right Ans - a. Dysrhythmias
A nurse is admitting a client who has experienced a weight loss of 11kg (25 lb)
in 3 months. The client weighs 40 kg (88 lb) and believes she is fat. Which of
the following aspects of care should the nurse consider the first priority for
this client?
, a) Identify the client's nutritional status.
b) Request a mental health console.
c) Plan a therapeutic diet for the client.
d) Provide a structured environment for the client. Right Ans - a. Identify
the client's nutritional status.
A nurse in an emergency department is caring for an adolescent client who
reports being sexually assaulted just prior to admission. Which of the
following actions should the nurse take?
a. Discuss self-defense techniques with the client.
b. Inform the client photographs of injuries are required for a police report.
c. Ask the client to describe the situation.
d. Give the client a bed bath prior to physical examination. Right Ans - c.
Ask the client to describe the situation.
A nurse is providing discharge teaching to a client who has bipolar disorder
and will be discharged with a prescription for lithium. The nurse should teach
the client that which of the following factors puts her at risk for lithium
toxicity.
a. The client runs 4 miles outdoors every afternoon.
b. The client drinks 2 liters of liquids daily.
c. The client eats 2 to 3 gm of sodium-containing foods daily.
d. The client eats foods high in tyramine. Right Ans - a. The client runs 4
miles outdoors every
afternoon.
Strenuous exercise in outdoor heat, which can lead to dehydration, puts the
client at risk for lithium toxicity. Mild to moderate exercise will not lead to
lithium toxicity, but if the client engages in strenuous exercise during hot
weather, she should take care to replace any water and sodium that have been
lost through profuse sweating. This also applies to other factors that can cause
the client to become dehydrated, such as having diarrhea or taking diuretics.
A nurse is planning care for a client newly admitted with major depressive
disorder. Which of the following actions should the nurse plan to take?
A. Ask the client to create her own schedule of daily activities.
A nurse is caring for a client who has a history of alcohol use disorder and has
been hospitalized for detox. The nurse enters the room and finds the client
shouting in a terrified voice, "Get these bugs off of me!" Which of the following
responses by the nurse is appropriate?
A) "I'm sure that the bugs you see will not harm you."
B) "Tell me more about the bugs that you see in your room."
C) "I don't see any bugs, but you seem very frightened."
D) "I do not see anything. This is part of the withdrawal process." Right Ans
- C) "I don't see any bugs, but you seem very frightened."
This client is experiencing a tactile hallucination, which is common during
alcohol withdrawal. This response by the nurse presents reality and shows
empathy by acknowledging the client's feelings.
A nurse is caring for an adolescent who is experiencing indications of
depression. Which of the following findings should the nurse expect? Right
Ans - constant pain
A nurse in an emergency department is assessing a client for suspected
cocaine intoxication. Which of the following findings should the nurse expect?
Right Ans - Dilated pupils
A nurse is caring for a client who has severe manifestations of schizophrenia
and is medicated PRN for agitation with haloperidol. The nurse should assess
the client for which of the following adverse effects?
a. Dysrhythmias
b. Cataracts
c. Pancreatitis
d. Bleeding Right Ans - a. Dysrhythmias
A nurse is admitting a client who has experienced a weight loss of 11kg (25 lb)
in 3 months. The client weighs 40 kg (88 lb) and believes she is fat. Which of
the following aspects of care should the nurse consider the first priority for
this client?
, a) Identify the client's nutritional status.
b) Request a mental health console.
c) Plan a therapeutic diet for the client.
d) Provide a structured environment for the client. Right Ans - a. Identify
the client's nutritional status.
A nurse in an emergency department is caring for an adolescent client who
reports being sexually assaulted just prior to admission. Which of the
following actions should the nurse take?
a. Discuss self-defense techniques with the client.
b. Inform the client photographs of injuries are required for a police report.
c. Ask the client to describe the situation.
d. Give the client a bed bath prior to physical examination. Right Ans - c.
Ask the client to describe the situation.
A nurse is providing discharge teaching to a client who has bipolar disorder
and will be discharged with a prescription for lithium. The nurse should teach
the client that which of the following factors puts her at risk for lithium
toxicity.
a. The client runs 4 miles outdoors every afternoon.
b. The client drinks 2 liters of liquids daily.
c. The client eats 2 to 3 gm of sodium-containing foods daily.
d. The client eats foods high in tyramine. Right Ans - a. The client runs 4
miles outdoors every
afternoon.
Strenuous exercise in outdoor heat, which can lead to dehydration, puts the
client at risk for lithium toxicity. Mild to moderate exercise will not lead to
lithium toxicity, but if the client engages in strenuous exercise during hot
weather, she should take care to replace any water and sodium that have been
lost through profuse sweating. This also applies to other factors that can cause
the client to become dehydrated, such as having diarrhea or taking diuretics.
A nurse is planning care for a client newly admitted with major depressive
disorder. Which of the following actions should the nurse plan to take?
A. Ask the client to create her own schedule of daily activities.
