A charge nurse is discussing mental status exams with a newly licensed nurse. Which of the following
statements by the newly licensed nurse indicates an ... [Show More] 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 client repeat a list of objects."
E. "To assess the client's abstract thinking, I should ask the client to identify our most recent presidents."
- 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 a mental health disorder. Which of the following actions
should the nurse include as a psychobiological intervention?
A. Assist the client with systematic desensitization therapy.
B. Teach the client appropriate coping mechanisms
C. Assess the client for comorbid health conditions.
D. Monitor the client for adverse effects of the medications. - D. Monitor the client for adverse effects of
the medications.
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 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 about her current mental health disorder. - 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
of the following findings should the nurse expect?
A. The client arouses briefly in response to a sternal rub.
B. The client has a glasgow coma scale score less than 7.
C. The client exhibits decorticate rigidity.
D. The client is alert but disoriented to time and place. - A. The client arouses briefly in response to a
sternal rub.
A nurse is planning a peer group discussion about the DSM-5. Which of the following information is
appropriate to include in the discussion? (Select all that apply)
A. The DSM-5 includes client education handouts 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 in planning care for client's who have mental health disorders.
E. The DSM-5 indicates expected assessment findings of mental health disorders. - B. The DSM-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 a temporary 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 while talking to himself - 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
very 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. False imprisonment
C. Assault
D. Battery - B. 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?
A. Keep the client's communication confidential, but talk to the client daily, using therapeutic
communication to convince him to admit to hiding the knife
B. Keep the client's communication confidential, but watch the client and his roommate closely.
C. 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.
D. Report the incident to the health care team, but do not inform the client of the intention to do so. - D.
Report the incident to the health care team, but do not inform the client of the intention to do so.
A nurse is caring for a client who is in mechanical restraints. Which of the following statements should
the nurse include in the documentation? (Select all that apply)
A. "Client ate most of his breakfast."
B. "Client was offered 8 oz of 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." - B. "Client was offered 8 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 nurse discussing a client's hallucinations in the hallway with another
nurse. Which of the following actions should the 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. - 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
the mother of the child asks the nurse for reassurance about her son's condition, which of the following
responses should the nurse make?
A. "I think your son is getting better. What have you noticed."
B. "I'm sure everything will be okay. It just takes time to heal."
C. "I'm not sure whats wrong. Have you asked the doctor about your concerns?"
D. "I understand you're concerned. Let's discuss what concerns you specifically." - D. "I understand
you're concerned. 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 - B. Denial
A nurse is providing preoperative teaching for a client who was just informed that she requires
emergency surgery. The client has a respiratory rate 30/min and says, "This is difficult to comprehend. I
feel shaky and nervous." The nurse should identify that the client is experiencing which of the following
levels of anxiety?
A. Mild
B. Moderate
C. Severe
D. Panic - B. Moderate
A nurse is caring for a client who is experiencing moderate anxiety. Which of the following actions
should the nurse take when trying to give necessary information to the client? (Select all that apply.)
A. Reassure the client that everything will be okay.
B. Discuss prior use of coping mechanisms with the client.
C. Ignore the client's anxiety so that she will not be embarrassed.
D. Demonstrate a calm manner while using simple and clear directions.
E. Gather information from the client using closed-ended questions. - B. Discuss prior use of coping
mechanisms with the client.
D. Demonstrate a calm manner while using simple and clear directions.
A nurse is talking with a client who is at risk for suicide following the death of his spouse. Which of the
following statements should the nurse make?
A. "I feel very sorry for the loneliness you must be experiencing."
B. "Suicide is not the appropriate way to cope with loss."
C. "Losing someone close to you must be very upsetting."
D. "I know how difficult it is to lose a loved one." - C. "Losing someone close to you must be very
upsetting."
A charge nurse is discussing the characteristics of a nurse-client relationship with a newly licensed nurse.
Which of the following characteristics should the nurse include in the discussion? (Select all that apply)
A. The needs of both participants are met.
B. An emotional commitment exists between the participants.
C. It is goal-directed.
D. Behavioral change is encouraged.
E. A termination date is established. - C. It is goal-directed.
D. Behavioral change is encouraged.
E. A termination date is established.
A nurse is in the working phase of a therapeutic relationship with a client who has methamphetamine
use disorder. Which of the following actions indicates transference behavior?
A. The client asks the nurse whether she will go out to dinner with him.
B. The client accuses the nurses of telling him what to do just like his ex-girlfriend.
C. The client reminds the nurse of a friend who died from a substance overdose.
D. The client becomes angry and threatens to harm himself. - B. The client accuses the nurses of telling
him what to do just like his ex-girlfriend.
A nurse is planning care for the termination phase of a nurse-client relationship. Which of the following
actions should the nurse include in the plan of care?
A. Discussing ways to use new behaviors
B. Practicing new problem-solving skills
C. Developing goals
D. Establishing boundaries - A. Discussing ways to use new behaviors
A nurse is orienting a new client to a mental health unit. When explaining the unit's community
meetings, which of the following statements should the nurse make?
A. "You and a group of other clients will meet to discuss your treatment plans.
B. "Community meetings have a specific agenda that is established by staff.
C. "You and the other clients will meet with staff to discuss common problems.
D. "Community meetings are an excellent opportunity to explore your personal mental health issues." -
C. "You and the other clients will meet with staff to discuss common problems. [Show Less]
