1. A male client with bipolar disorder who began taking lithium carbonate five days ago is
complaining of excessive thirst, and the RN finds him
... [Show More] attempting to drink water from
the bathroom sink faucet. Which intervention should the RN implement?
A. Report the client’s serum lithium level to the HCP.
B. Encourage the client to suck on hard candy to relieve the symptoms.
C. No action is needed since polydipsia is a common side effect.
D. Tell the client that drinking from the faucet is not allowed.
2. A mental health worker is caring for a client with escalating aggressive
behavior. Which action by the MHW warrant immediate intervention by the RN?
A. Is attempting to physically restrain the patient.
B. Tells the client to go to the quiet area of the unit.
C. Is using a loud voice to talk to the client.
D. Remains at a distance of 4 feet from the client.
3. A client is admitted to the mental health unit and reports taking extra
antianxiety medication because, “I’m so stressed out. I just want to go to sleep.”
The RN should plan one-on-one observation of the client based on which
statement?
A. “What should I do? Nothing seems to help.”
B. “I have been so tired lately and needed to sleep.”
C. “I really think that I don’t need to be here.”
D. “I don’t want to walk. Nothing matters anymore.”
4. The RN is performing intake interviews at a psychiatric clinic. A female
client with a known history of drug abuse reports that she had a heart attack four
years ago. Useof which substance places the client at highest risk for myocardial
infarction?
A. Benzodiazepine
B. Alcohol
C. Methamphetamine
D. Marijuana
5. A male client comes to the emergency center because he has an erection
that will not resolve. The client reports that he is taking trazodone (Desyrel) for
insomnia. Which information is most important for the nurse ask the client?
A. When was the last time you drank alcoholic beverage?
B. Have you taken any medications for erectile dysfunction?
C. Are you having any other sexual dysfunctions or problems?
D. Do you have a history of angina or high blood pressure?
6. The RN on the day shift receive report about a client with depression who
was in bed most of the weekend. The RN walks into the client’s room in the morning
and finds the client in bed. What intervention is best for the RN to implement?
A. Monitor the client’s appetite and pattern of sleep.
B. Assess the client’s feelings about the hospital stay.
C. Assist the client to get out of bed and involved in an activity.
D. Explain that staff will check on the client every 30 minutes.
7. A female client admitted to the mental health unit starts to shout and
scream at the RN. What is the best approach for the RN to take?
A. Stay quietly with the patient
B. Tell her that she is out of control.
C. Distract her by offering her finger foods.
D. Ignore the client’s acting out behavior.
8. A young adult female visits the mental health clinic complaining of
diarrhea, headache, and muscle aches. She is afebrile, denies chills, and all
laboratory findings are within normal limits. During the physical assessment, the
client tells the RN that her sister thinks she is neurotic and calls her a
hypochondriac. Which response is best for the RN to provide?
A. Unless your sister has a medical education, ignore her comments.
B. I can hear that your sister's comments are overwhelmingyou.
C. Do you think it’s possible that you might be ahypochondriac?
D. Besides your sister’s comments, what in your life is troubling you?
9. A mental health worker is caring for a client with escalating aggressive
behavior. Which action by the mental health worker warrants immediate
intervention by theRN?
A. Is attempting the physically restrain the patient.
B. Remains at a distance of 4 feet from the client.
C. Tells the client to go to the quiet area of the unit.
D. Is using a load voice to talk to the client.
10. When developing a plan of care for a client admitted to the psychiatric
unit following aspiration of a caustic material related to a suicide attempt,
which nursing problem has the highest priority?
A. Impaired comfort.
B. Risk for injury.
C. Ineffective breathing pattern.
D. Ineffective coping.
11. A female client on a psychiatric unit is sweating profusely while she
vigorously does push-ups and then runs the length of the corridor several times
before crashing into furniture in the sitting room. Picking herself up, she begins to
toss chairs aside, looking for a red one to sit in. When another client objects to the
disturbance, the client shouts, “I am the boss here. I do what I want.” Which nursing
problem best supports these observations?
A. Deficient diversional activity related to excess energy level.
B. Risk for other related violence related to disruptive behavior.
C. Risk for activity intolerance related to hyperactivity.
D. Disturbed personal identity related to grandiosity.
12. A RN is preparing the physical environment to interview a new client for
admission to the mental health unit. Which environmental setting facilitates the best
outcome of the interview?
A. Dim the lights in the room to help the patient feel calm.
B. Sit within two feet of the client to enhance level of safety and security.
C. Reduce the noise level in the room by turning off the television and radio.
D. Position table between the client and the RN for extra personal space.
13. The RN is providing education about strategies for a safety plan for a female
client who is a victim of intimate partner violence. Which strategies should be
included in the safety plan? (SOA)
A. Purchase a gun to use for protection.
B. Establish a code with family and friends to signify violence.
C. Take a self-defense course that retaliates the abuser with injury.
D. Have a bag ready that has extra clothes for self and children.
E. Plan an escape route to use if the abuser blocks the main exit.
14. The RN is admitting a male client who takes lithium carbonate (Eskalith)
twice a day. Which information should the RN report to the HCP immediately?
A. Short term memory loss.
B. Five pound weight gain
C. Decreased affect.
D. Nausea and vomiting.
15. A homeless client who reports feeling sad and depressed tells the mental
health nurse that in the past 2 days she has only had 4 hours of sleep. Which
action is most important for the RN to implement within the first 24 hours after
treatment isinitiated?
A. Allow the client to rest and sleep.
B. Ensure client attend groups addressing coping skills for dealing withdepression.
C. Begin planning for the clients discharge.
D. Encourage verbalization of feelings.
16. A RN is teaching a client about initiation of a prescribed abstinence
therapy using Disulfiram (Antabuse). What information should the client
acknowledge understanding?
A. Admit to others that he is a substance abuser.
B. Remain alcohol free for 12 hours prior to firstdose.
C. Attend monthly meetings of alcoholicsanonymous.
D. Completely sustain from heroin or cocaine use.
17. Which client statement suggests the RN that the client is using a
defense mechanism of projection to deal with anxiety related to admission to a
psychiatricunit?
A. At least I hit the wall instead of hitting the psychiatric aide.
B. I am here because the police thought I was doing something wrong.
C. I want to be here because I know it is the best psychiatric facility.
D. Don’t believe everything my family tells you, I am not crazy.
18. The RN documents the mental status of a female client who has been
hospitalized for several days by court order. The client states” I don’t need to be
here,” and tells the RN that she believes that the T.V. talks to her. The RN should
document these assessment statements in which section of the mental status
exam?
A. Insight and judgement.
B. Mood and affect.
C. Remote [Show Less]