1. A nurse is planning overall strategies to address problems for a client who
has borderline personality disorder. Which of the following strategies is
... [Show More] the
priority for the nurse to incorporate in the plan of care?
a. discuss the appropriate use of assertive behavior with the client
b. encourage the client to attend weekly support group meetings
c. assist the client to maintain awareness of her thoughts and feelings
d. implement measures to prevent intentional self-inflicted injury
2) A nurse is admitting a client who has generalized anxiety disorder. Which
of the following actions should the nurse plan to take first?
a. Provide the client with a quiet environment
b. Determine how the client handles stress.
c. Teach the client to use guided imagery.
d. Ask the client to identify her strengths
3) A nurse is conducting an admission interview with a client who is
experiencing mania. Which of the following should the nurse report to the
provider?
a. States that he hasn’t bathed in 2 days
b. Reports eating twice in the past two weeks.
c. Makes inappropriate sexual comments.
d. Speaks in rhyming sentences.
4) A nurse is planning care for a client who has obsessive-compulsive
disorder. Which of the following recommendation should the nurse include in
the clients plan of care?
a. Validation therapy
b. Thought stopping
c. Operant conditioning
d. Reality orientation therapy
5) A nurse is caring for a client who has bipolar disorder and is experiencing
a manic episode. Which of the following actions should the nurse take?
a. Encourage the client to join group activities
b. Dim the lights in the client’s room
c. Provide detailed explanations to the client
d. Administer methylphenidate
6) A nurse is leading a crisis intervention group for adolescents who
witnessed the suicide of a classmate. Which of the following actions should
the nurse take first?
a. Initiate referrals
b. Review community resources
c. Identify prior coping skills
d. Discuss the importance of confidentiality
7) A nurse overhears a client saying"I am a spy, a spy for the FBI .I am an
I,an eye for an eye in the sky. Sky is up high." The nurse should document
the client’s statement as which of the following speech alterations?
a. Echolalia
b. Word salad
c. Neologism
d. Clang association
8) An older adult client is brought to the mental health clinic by her daughter.
The daughter reports that her mother is not eating and seems uninterested
in routine activities. The daughter states "Im so worried that my mother is
depressed" which of the following responses should the nurse make?
a. Everyone gets depressed from time to time.
b. You shouldnt worry about this because depressive disorder is easily
treated.
c. Older adults are usually diagnosed with depressive disorder as they
age.
d. Tell me the reasons you think your mother is depressed.
9) A nurse is planning care for an adolescent who has autism spectrum
disorder. Which of the following outcomes should the nurse include in the
plan care?
a. Meets own needs without manipulating others.
b. Initiates social interactions with caregivers.
c. Changes behavior as a result of peer pressure.
d. Acknowledges his delusions are not real.
10) A nurse is providing behavior therapy for a client who has obsessivecompulsive disorder. The client repeatedly checks that the doors are locked
at night. Which of the following instructions should the nurse give the client
when using thought stopping technique?
a. Snap a rubber band on your wrist when you think about checking
the locks.
b. Ask a family member to check the locks for you at night.
c. Focus on abdominal breathing whenever you go to check the locks.
d. Keep a journal of how often you check the locks each night.
11) A nurse is caring for a client who is starting treatment for substance use
disorder. Which of the following actions indicate the nurse is practicing the
ethical principle of nonmaleficence?
a. Provide the client with quality care regardless of their ability to pay
for treatment.
b. Educating the client about legal rights concerning treatment.
c. Withholding the prescribed medication that is causing adverse
effects for the client.
d. Being truthful with the client about the manifestations of withdrawal.
12) A nurse in a group home facility is caring for a client who is
developmentally disabled. The client has been stealing belongings from
other clients. Which of the following techniques should the nurse use?
a. Crisis intervention to decrease anxiety.
b. Aversion therapy to provide distraction
c. Positive reinforcement to increase desired behavior.
d. Systematic desensitization to extinguish the behavior.
13) A nurse is caring for a client who is experiencing a panic attack. Which of
the following actions should the nurse take?
a. Ask the client to discuss precipitating events
b. Speaks to the client in a high-pitched voice.
c. Place the client in seclusion
d. Have the client breathe into a paper bag.
14) The nurse is caring for a client following a physical assault. The client
states "I don't remember what happened to me." The nurse should recognize
that the client is using which of the following defense mechanisms?
a. Repression
b. Displacement
c. Rationalization
d. Denial
15) A nurse is caring for a client who has anorexia nervosa. Which of the
following findings require immediate intervention by the nurse?
a. +2 edema of the lower extremities
b. BUN 21 mg dL
c. Lanugo covering the body
d. Blood pH 7.60
16) A nurse is caring for a client in a mental health facility. The client is
agitated and threatens to harm herself and others. Which of the following is
the priority intervention?
a. Place the client in restraints
b. Administer an anti-anxiety medication to the client
c. Put the client in seclusion
d. Set limits on the clients behavior
17) Dosage Calculation: A nurse is preparing to administer Haloperidol 7mg
IM to a client who is severely agitated. Available is Haloperidol injection
5mg/mL. How many mL should the nurse administer?
1.4 mL
18) A nurse is caring for a client who was involuntarily committed and is
scheduled to receive electroconvulsive therapy (ECT). The client refuses the
treatment and will not discuss why with the health care team. Which of the
following actions should the nurse take?
a. Ask the clients family to encourage the client to receive ECT
b. Inform the client that ECT does not require a consent.
c. Document the clients refusal of the treatment in the medical record.
d. Tell the client he cannot refuse the treatment because he was
involuntarily committed.
19) A nurse in the emergency department is caring for a client who reports
feeling sad, worthless, and hopeless 9 months after the death of her son.
Which of the following actions should the nurse take first?
a. Request a mental health consult for the client.
b. Ask the client if she has thought about harming herself.
c. Encourage the client to attend a grief support group.
d. Discuss the clients coping skills.
20) A nurse is caring for a client who has borderline personality disorder and
has been engaging in self- mutilation. The nurse should encourage the client
to participate in which of the following groups.
a. Dual diagnosis treatment group
b. Dialectical Behavior treatment group
c. Desensitization therapy
21) The nurse is reviewing the medication administration record of a client
who has schizophrenia. The nurse should plan to initiate the Abnormal
Involuntary Movement Scale to monitor for adverse effects of which of the
following medications.?
a. Amantadine
b. Diphenhydramine
c. Benztropine
d. Haloperidol
22) A nurse is counseling a client following the death of a client’s partner 8
months ago. Which of the following client statements indicates maladaptive
grieving?
a. I am so sorry for the times I was angry with my partner.
b. I find myself thinking about my partner often.
c. I still don’t feel up to retu...........................................................CONTINUED [Show Less]