A charge nurse is discussing mental status examinations with a newly licensed nurse. Which of the following statements by the newly licensed nurse
... [Show More] indicates a need for further teaching?
A. "To assess cognitive ability; I should ask the client to count backwards by 7."
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." - D. To assess remote memory; I should have the client repeat a list of objects."
A nurse is planning care for a client who has a mental health disorder. Which of the following is appropriate to 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 medications - D. Monitor the client for adverse effects of 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 is the highest priority action?
A. Respect the client's need for personal space
B. Identify the client's perception of her of her own 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 of her own 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 is an expected finding?
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 is appropriate to include in the discussion? (select all that apply)
A. The DSM-5 is used to identify mental health disorders
B. The DSM-5 establishes diagnostic criteria
C. The DSM-5 indicates recommended pharmacological treatment
D. The DSM-5 assists nurses in planning care
E. The DSM-5 indicates expected assessment findings - A. The DSM-5 is used to identify mental health disorders
B. The DSM-5 establishes diagnostic criteria
D. The DSM-5 assists nurses in planning care
E. The DSM-5 indicates expected assessment findings
Which of the following is an example of a client who requires emergency admission to a mental health facility? - C- A client with borderline personality disorder who assaulted a homeless man with a metal rod
A client tells a student nurse "don't tell, but I hid a knife under my mattress to protect myself from my room mate" which action should the nurse take? - C - Tell the client that this must be reported to health care staff because it concerns the health and safety of others
A nurse puts a client who has psychosis in seclusion overnight because the unit is short-staffed and the client fights with others, example of? - B - a tort, false imprisonment
A nurse is caring for a client in restraints. Which is appropriate documentation? - B,C,D - Client was offered 8 oz of water every hr, client shouted at assistive personnel, client received thorazine 15 mg by mouth at 1000
A nurse hears a newly licensed nurse discussing a clients hallucinations in the hallway with another nurse, which action should she take first? - B- tell the nurse to stop discussing the behavior
A charge nurse is conducting a class on therapeutic communication to a group of newly licensed nurses. Which of the following responses by the newly licensed nurse requires additional teaching regarding nonverbal communication?
A. Personal space
B. Posture
C. Eye contact
D. Intonation - D. Intonation
A nurse is communicating with a client on the acute mental health facility. The client states, "I can't sleep. I stay up all night." The nurse responds, "You are having difficulty sleeping?" Which of the following therapeutic communication techniques is the nurse demonstrating?
A. Offering general leads
B. Summarizing
C. Focusing
D. Restating - D. Restating
A nurse is communicating with a newly admitted client. Which of the following is a barrier to therapeutic communication?
A. Offering advice
B. Reflecting meaning
C. Listening attentively
D. Giving information - A. Offering advice
A nurse is conducting therapy with a several clients and their families. Effective communication with clients and families is based on
A. discussing in-depth topics with which the client feels comfortable.
B. using silence to avoid unpleasant or difficult topics.
C. attending to verbal and nonverbal behaviors.
D. requiring the client and family to ask for feedback. - C. attending to verbal and nonverbal behaviors.
When a family asks a nurse for reassurance about a client's condition, which of the following is an appropriate response?
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 what's 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." Which of the following defense mechanisms is the client using?
A.Reaction formation
B.Denial
C.Displacement
D.Sublimation - B.CORRECT: This is an example of denial, which is pretending the truth is not reality to manage the anxiety of acknowledging what is real.
A nurse is obtaining informed consent for a client who has just learned she must have a breast biopsy. The client is perspiring and pale, has a respiratory rate 30/min, and says, "I don't quite understand what you're trying to tell me." The nurse should assess the client's anxiety as which of the following?
A.Mild
B.Moderate
C.Severe
D.Panic - B.CORRECT: Moderate anxiety decreases problem-solving and may hamper one's ability to understand information. Vital signs may increase somewhat, and the person is visibly anxious.
A nurse is caring for a client who is experiencing moderate anxiety. Which of the following is an appropriate nursing intervention when trying to give necessary information to the client? [Show Less]