NURS 222 Mental Health Exam
1. A nurse is obtaining a medical history from a client who is requesting a prescription for
bupropion for smoking
... [Show More] cessation. Which of the following assessment findings in a client's
history should the nurse report to provider?
a. Recent head injury - risk for seizures
b. Hypothyroidism
c. Hippie infection
d. Knee arthroplasty 1 month ago
2. A nurse is planning care for a client who has narcissistic personality disorder. Which of the
following actions is appropriate for the nurse to include in the plan of care?
a. Request an anti-psychotic medication from the provider
b. Ask the client to sign a no suicide contract
c. Remain neutral when communicating with the client
d. Provide the client with high calorie finger foods
3. A nurse is preparing for an interprofessional team meeting regarding client who has major
depressive disorder. Which of the following findings obtained during the initial assessment
is a priority to report to other disciplines?
a. Significant weight loss
b. Neglected hygiene
c. Psychomotor retardation
d. Problem solving skills
4. A nurse in a mental health facility is reviewing a client's medical record. Which of the
following actions should the nurse take first? EXHIBIT
a. Initiate 0.9% sodium chloride with 40 mil equivalent potassium chloride
b. Encourage the client to attend group therapy sessions
c. Teach the client about nutritional needs
d. Administer acetaminophen 500 mg PO
5. A nurse is planning care for a client who demonstrates prolonged depression related to the
loss of her partner 6 months ago. Which of the following actions should the nurse take?
a. Suggest that the client avoid social interactions that remind her of her partner
b. Discourage the client from reliving the events surrounding her loss
c. Explain that it can take a year or more to learn to live with a loss
d. The client to maintain an unstructured daily routine
6. A nurse is teaching a client who has a new prescription for disulfiram. Which of the
following statements by the client indicates an understanding of the teaching?
a. I can continue to eat age cheese and chocolate
b. I can wear my cologne on special occasions
c. When I bake my favorite cookies, I can use pure vanilla extract for flavoring
d. If I cut myself I can clean the wound with isopropyl alcohol
i. Avoid everything that has alcohol
7. A nurse is caring for a client who has schizophrenia and is experiencing auditory
hallucinations. Which of the following actions should the nurse take first?
a. Focus the client on reality-based topics
b. Monitor the client for indication of anxiety
c. Ask the client what she is hearing
d. Encourage the client to listen to music
8. A nurse is assessing a client who has delirium. Which of the following findings requires
immediate intervention by the nurse?
a. Rapid mood swings
b. Inappropriate speech patterns
c. Command hallucinations
d. Impaired memory
9. A nurse in an emergency department is assessing a client who recently reported using
cocaine. Which of the following clinical manifestations should the nurse?
a. Lethargy
b. Bradycardia
c. Hypertension
d. Hypothermia
10. A nurse is teaching a client about the use of cognitive reframing for Stress Management.
Which of the following statements been a client indicates an understanding of the
teaching?
a. I will practice replacing negative thoughts with positive self statements
b. I will progressively relax each of my muscle groups when feeling stressed
c. I will focus on a mental image while concentrating on my breathing
d. I will learn how to voluntarily control my blood pressure and heart rate
11. A nurse in an inpatient mental health facility is assessing a client who has schizophrenia
and is taking haloperidol. Which of the following clinical findings is the nurse’s priority?
a. High fever
b. Urinary hesitancy
c. Insomnia
d. Headache
12. A nurse is interviewing a client who was recently sexual assaulted. The client cannot recall
the attack. The nurse should identify the the client is using which of the following defense
mechanisms?
a. Suppression
b. Reaction Formation
c. Sublimation
d. Repression
13. A nurse is caring for a client who has Alzheimer's disease. Which of the following findings
should the nurse expect?
a. Excessive motor activity
b. Altered LOC
c. Failure to recognize familiar objects
d. Rapid mood swings
14. A nurse in a mental health facility is caring for a client who is being aggressive toward
other clients. Which of the following actions is a priority for the nurse to take?
a. Ask the client if he intends to harm others
b. Role model healthy ways to express anger
c. Assist the client to explore techniques to reduce stress
d. Suggest that the client make a list of things that make him angry
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15. A nurse is assisting with obtaining informed consent for a client who has been declared
legally incompetent. Which of the following actions should the nurse take?
a. Request of the client’s guardian sign the consent
b. Ask the charge nurse to obtain informed consent
c. Contact the social worker to obtain the consent
d. Explain implied consent to the client’s family
16. A nurse is developing a plan of care for school-age child has autism spectrum disorder.
Which of the following interventions should the nurse include in the plan?
a. Assign a child to a room with another child of the same age
b. Discourage the child from making eye contact with caregivers
c. Allow flexibility in the child's daily schedule
d. Use a reward system for appropriate behavior
17. A nurse in an outpatient clinic is assessing a client who has anorexia nervosa. Which of the
following findings indicates a need for hospitalization?
a. Potassium 3.8
b. HR 56/min
c. Temperature 96.1 F
d. Weight 10% below ideal weight
18. A nurse is caring for a client who has severe depression and is scheduled to receive
electroconvulsive therapy. The nurse should recognize that the client will receive
succinylcholine to prevent which of the following adverse effects?
a. Muscle distress
b. Aspiration
c. Elevated blood pressure
d. Decrease heart rate
19. A nurse is developing a plan of care for a client who has paranoid personality disorder.
Which of the following actions should the nurse include in the plan?
a. Provide written information about the client’s treatment plan
b. Monitor the client for splitting behaviors
c. Encourage countertransference when developing the nurse client relationship
d. Isolate the client from social or group interactions
20. A nurse is caring for a client who has schizophrenia. The client’s employer calls to discuss
the client's condition. Which of the following is appropriate nursing action?
a. Consult the client's family
b. Contact the facility legal department
c. Contact the provider
d. Consult the client
21. A nurse in the emergency department is caring for a client who has serotonin syndrome.
The nurse should assess the client for which of the following manifestations?
a. Bradycardia - tachycardia
b. Priapism
c. Paresthesia
d. Hyperpyrexia - temp >104F
22. A nurse is caring for a client who has bipolar disorder. The client is walking in and out of
rooms, speaking inappropriately, and giggling. Which of the following actions should the
nurse take?
a. Tell the client will be negative consequences for her behavior
b. Have the client return to her room to read a book
i. Do not involve client w/ something that requires high level of
concentration
c. Lead the client outside for a walk - “provide outlet for physical activity”
d. Take the client to the day room to watch a movie with other clients
23. A nurse is admitting a client who has a new diagnosis of schizophrenia and history of
aggression. Which of the following actions should the nurse include in the client’s initial
plan of care?
a. Ignore the clients hallucinations - should assess
b. Agree with the client when he's upset until he can calm down - never agree
c. Avoid eye contact with the client for the first few days - therapeutic comm
d. Provide a physical exercise activity for the client - distracts the client
24. A nurse is caring for a client who begins yelling and pacing around the room. Which of the
following actions should the nurse take? SATA
a. Stand directly in front of the client
b. Speak to the client in a loud voice
c. Request that security guards restrain the client
d. Identify the clients stressors
e. Talk to the client using short, simple sentences
25. A nurse is observing a newly licensed nurse administer an IM medication to a client who is
manic and refuses the medication. Which of the following actions should the nurse take
first?
a. Talk to the newly licensed nurse about the incident
b. Call the provider for an alternate medication route
c. Stop the newly licensed nurse from administering the medication
d. Report the occurrence to the nurse manager
26. A nurse is teaching the family of a client who has Alzheimer's disease about safety
interventions for nighttime wandering. Which of the following interventions should the
nurse include?
a. Install locks at the bottom of the exit doors - top
b. Place a client's mattress on the floor
c. Encourage the client to take naps during the day - noooo
d. Place rubber back throw rugs on the tile floors - fall risk
27. A nurse is assessing a client who has schizophrenia. The client tells the nurse, “My heart
exploded and my blood is draining out.” The nurse should interpret the statement as
which of the following manifestations?
a. A somatic delusion
b. A visual hallucination
c. Concrete thinking
d. Paranoia
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28. A nurse is preparing to administer methylphenidate 25 mg PO to school age child who has
ADHD. Avail is 10 mg/5mL. How many mL? ( Round to the nearest tenth )
a. 12.5 mL
29. A nurse is creating a plan of care for a client who has major depressive disorder. Which of
the following interventions should the nurse include in the plan?
a. Encourage physical activity for the client during the day - yay endorphins
b. Discourage the client from expressing feelings of anger
c. Keep a bright light on in the client’s room at night
d. Identify and schedule alternate group activities for the client
30. A nurse is caring for a client who has generalized anxiety disorder and a history of
substance use disorder. Which of the following medications should the nurse expect the
provider to prescribe?
a. Clonazepam - benzo/seizures/prevention and tx of alch w/drawals
b. Buspirone - anxiolytic/OCD/GAD
c. Alprazolam - benzo/seizures/prevention and tx of alch w/drawals
d. Chlordiazepoxide - benzo/seizures/prevention and tx of alch w/drawals
31. A nurse in a mental health facility is interviewing a new client. Which of the following
outcomes must occur if the nurse is to establish a therapeutic nurse client relationship?
a. A written contract is established to clarify the steps of the treatment plan
b. The nurse is seen as an authority figure
c. The nurse is seen as a friend
d. The nurse maintains confidentiality unless the client's safety is
compromised - first establish trust
32. 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, “I am so worried that my mother is depressed.” Which of the following
responses should the nurse make?
a. Tell me the reasons you think your mother is depressed
b. You shouldn't worry about this, because depressive disorder is easily treated
c. Everyone gets depressed from time to time
d. Older adults are usually diagnosed with depressive disorder as they age
33. A nurse in a mental health facility is making plans for client discharge. Which of the
following interdisciplinary team members should the nurse contact to assist a client with
housing placement?
a. Clinical nurse specialist
b. Recreational therapist
c. Occupational therapist
d. Social worker
34. A nurse is reviewing the medication administration record of a client who has major
depressive disorder and a new prescription for selegiline. The nurse should recognize that
which of the following client medications is contraindicated when taking with selegiline?
a. Warfarin
b. Calcium carbonate
c. Acetaminophen
d. Fluoxetine - SSRI: contraindicated when taking MAOI = hypertensive crisis
35. A nurse is planning to lead a support group for clients have alcohol use disorder. One of
the group members is a client who speaks a different language than the nurse. The nurse
should ask which of the following individuals to assist with communication?
a. A translator of the same gender as the client
b. A unit secretary who speaks the same language as the client
c. A family member of the client - never
d. Another client who speaks the same language as the client - no
36. A nurse on a mental health unit is leading a therapy session for group of clients. One client
challenges the nurse and shows no empathy for others in the group. Which of the
following actions should the nurse take?
a. Request of the client leave the therapy session immediately
b. Ask the client privately what is causing the anger
c. Place the client in seclusion
d. Reassign the client to another group
37. A nurse is caring for a client who states, “Things will never work out.” Which of the
following responses should the nurse make?
a. Why do you feel like things will never work out?
b. You should try to focus on yourself for a change
c. Have you been thinking about harming yourself?
d. Maybe an antidepressant will make you feel better
38. A nurse in an emergency department is creating a plan of care for a client who reports
experiencing intimate partner violence. Which of the following interventions should the
nurse include as a priority?
a. Refer the client to a support group
b. Follow the facility’s protocol for reporting the abuse
c. Teach the client stress reduction techniques
d. Help the client devise a safe plan
39. A nurse is providing teaching to a client who is prescribed methylphenidate for ADHD.
Which of the following statements by the client indicates an accurate understanding of this
medication’s effects?
a. I know that I will be able to think more clearly now - stimulates CNS
b. I need to tell my doctor if I start gaining weight - weight loss
c. I'll take my medicine at bedtime because it will make me drowsy
i. Take last dose before 4pm
d. This medicine will help me relax and feel less anxious
i. Used to increase ability to focus, complete tasks, interact w peers
and manage impulsivity
40. A nurse is developing a safety plan for client who has experience intimate-partner abuse.
Which of the following items should the nurse include in the plan that will provide
immediate safety for the client and her children?
a. The phone number of the local shelter
b. A code phrase to use when it is time to leave the house
c. The phone numbers for law enforcement agency
d. A referral to a support group
41. A nurse in a long-term care facility is assessing an older client for depression. Which of
the following findings should the nurse expect?
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a. Rambling speech
b. Sundowning
c. Rapid mood swings
d. Insomnia?
42. A nurse is caring for a client who is under observation for suicidal ideation and has
verbalized a suicide plan. The client demands privacy and to be left alone. Which of the
following statements should the nurse make?
a. We are concerned about you and need to keep you safe
b. Since you are trying to follow the treatment plan, we can submit your request
to the provider
c. If you complete a no-suicide contract that states you will not harm yourself,
you can be alone.
d. Until your medication has reached therapeutic levels, you will need constant
observation
43. A nurse a mental health clinic is assessing a client who has borderline personality disorder.
Which of the following findings should the nurse expect?
a. Avoidance of interpersonal relationships
b. Reluctance to discard worthless objects
c. Inability to maintain employment
d. Intense efforts to avoid abandonment - fear of abandonment
44. A nurse is caring for a client who has bipolar disorder and is exhibiting mania. Which of
the following findings should the nurse expect?
a. Disorganized speech
b. Hypersomnia
c. Heightened concentration
d. Agoraphobia
45. A nurse is caring for a client who receives Lamotrigine daily for bipolar disorder and
reports a rash on his arm. Which of the following actions should the nurse take?
a. Explain that the medication causes of temporary rash
b. Apply hydrocortisone cream on the clients rash
c. Withhold the next dose of the medication
d. Ask the client about a recent change in laundry detergent
46. A nurse is assessing a client who has bulimia nervosa. Which of the following findings
should the nurse expect?
a. Acrocyanosis
b. Lanugo (anorexia)
c. Hyponatremia - purging = loss of electrolytes
d. Amenorrhea (anorexia)
47. A nurse is caring for a client who has schizophrenia and has been taking promazine for 5
years. Which of the following assessment tools should the nurse use to determine if the
client is experiencing adverse effects of the medication?
a. Abnormal involuntary movement scale AIMS - Tardive
b. Hamilton depression scale
c. Mood disorder questionnaire MDQ
d. Addiction severity index ASI
48. A nurse in an acute care facility is planning care for a client who has a history of alcohol
use disorder and is admitted while intoxicated. Which of the following interventions
should the nurse plan for the client?
a. Implement seizure precautions
b. Acidify the client’s urine
c. Monitor for orthostatic hypotension
d. Administer methadone hydrochloride
49. A nurse is caring for a client who has PTSD. Which of the following clinical findings is
associated with this disorder?
a. Hyper-vigilance
b. Depersonalization
c. Pressured speech
d. Compulsive Behavior
50. A nurse in the ED is admitting a client who has a history of alcohol use disorder. The
client has a blood alcohol level of 0.26 g/dL. the nurse should anticipate a prescription for
which of the following medications?
a. Acamprosate - alcohol abstinence
b. Naltrexone - alcohol abstinence
c. Chlordiazepoxide - w/drawal sx
d. Disulfiram - maintains abstinence from alcohol
51. A nurse is developing a teaching plan for the family of an older client who is to receive
transcranial magnetic stimulation. Which of the following information should the nurse
include in the teaching plan?
a. The client might have a headache after treatment
b. The client will experience a seizure during treatment
c. The client will require intubation after treatment
d. The client is at risk for aspiration during treatment
52. A nurse is caring for a school-age child who has a fractured arm. The child has other
injuries that cause the nurse to suspect abuse. Which of the following actions is
appropriate for the nurse to take when assessing the child’s situation?
a. Ask clarifying questions as a child explains how the injuries occurred
b. Direct the parents to the waiting room before interviewing the child
c. Interview the child with the provider and social worker present
d. Ask the parents directly if the child's fracture is due to physical abuse
53. A nurse in a mental health facility is assessing a client for suicide risk factors using the
SAD PERSONS scale. Which of the following findings indicates the risk for suicide?
a. The client is 50 years old
b. Client has diabetes mellitus
c. Female
d. Married
54. A nurse is providing behavioral therapy for a client who has OCD. The client repeatedly
checks that the doors unlocked at night. Which of the following instructions should the
nurse give the client when using thought stopping technique?
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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
55. A nurse in a long term care facility is assessing a client who has dementia. Which of the
following findings should the nurse identify as a risk for the client?
a. The bed in the low position
b. The room has an area rug
c. Hallways are long distances
d. Outside doors have locks
56. A nurse is caring for a client who reports that he is angry with his partner because she
thinks he is just trying to gain attention. When the nurse attempts to talk to the client, he
becomes angry and tells her to leave. Which of the following defense mechanisms is the
client demonstrating?
a. Denial
b. Rationalization
c. Compensations
d. Displacement
57. A nurse is assessing a client for negative manifestations of schizophrenia. Which of the
following findings should the nurse expect?
a. Echopraxia
b. Tangentiality
c. Anergia - lack of energy
d. Delusions
58. A nurse is caring for a client who has physical restraints applied. The nurse determines that
the restraints should be removed when which of the following occurs?
a. The client is able to follow commands?
b. The client states that he will harm himself unless the restraints are removed
c. The client refuses to take his medication until he is released
d. The client demonstrates that he is oriented to person, place and time
59. A nurse is interviewing a client who has schizophrenia. The client states, “Aliens are going
to abduct me at midnight tonight.” Which of the following responses should the nurse
make?
a. Have you ever been abducted by aliens before?
b. You are safe from the aliens here
c. Why are the aliens going to abduct you?
d. Believing that aliens will abduct you must be scary
60. A nurse is building a therapeutic relationship with a client who has an eating disorder.
Which of the following activities would the nurse initiate during the relationship’s
orientation phase?
a. Teaching and encouraging the use of problem solving skills
b. Discussing the incorporation of new strategies into daily life
c. Using memories to validate the relationship experience
d. Mutually deciding and agreeing on the goals of the relationship
61. A nurse is reviewing the lab report of a client who is taking carbamazepine for bipolar
disorder. Which of the following lab results should the nurse report to the provider?
a. Urine specific gravity 1.029
b. Platelets 90,000/mm3
c. Urine pH 5.6
d. RBC 4.7/mm3
62. A nurse is caring for a client who reports smoking marijuana several times a day. The
client tells the nurse, “ I don’t know what the big deal is, it is a harmless herb.” The nurse
should identify that the client is displaying which of the following mechanisms?
a. Rationalization
b. Suppression
c. Reaction Formation
d. Compensation
63. After assessing a client in a crisis situation, a nurse determines the client is safe. Which of
the following actions should the nurse take first?
a. Teach the client specific coping skills to handle stressful situations
b. Help the client identify social support
c. Involve the client in planning interventions
d. Assist the client to lower his anxiety level
64. A nurse is assessing a client who has been taking thioridazine for 2 weeks. The client
reports an inability to sit still. Which of the following should the nurse suspect?
a. Tardive dyskinesia
b. Acute dystonia
c. Pseudoparkinsonism
d. Akathisia - unable to sit/stand still
65. A nurse is assessing a client who has antisocial personality disorder. Which of the
following client behaviors should the nurse expect?
a. Attention seeking
b. Manipulative
c. Anxious
d. Projects blame
66. A nurse in an ED is caring for a client who reports a recent sexual assault by her partner.
Which of the following statements is the priority for the nurse to make?
a. I want you to know that you are in a safe place here
b. I can provide info about an advocacy group in your area
c. A trained sexual assault nurse will be assigned to your care
d. I can contact a support person for you
67. A nurse is providing crisis intervention for a client who was involved in a violent mass
casualty situation in the community. Which of the following should the nurse take during
the initial session with the client?
a. Identify the client's usual coping style
b. Tell the client that his life will soon return to normal
c. Encourage the client to display anger toward the cause of the crisis
d. Help the client focus on a wide variety of topics regarding the crisis
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68. A nurse is providing teaching to a client who has a new prescription for tranylcypromine.
Which of the following OTC meds should the nurse instruct the client to avoid taking due
to adverse interactions?
a. Magnesium hydroxide
b. Pseudoephedrine
c. Ranitidine - h2 receptor
d. Ibuprofen
69. A nurse in a mental health facility is reviewing the lab results of a client who is taking
lithium carbonate. Which of the following findings places the client at risk for lithium
toxicity?
a. Sodium 132
b. Aspartate aminotransferase 40 units/L
c. WBC 6,000/mm3
d. Calcium 10.0 mg
70. A nurse is providing teaching about relapse prevention to a client who has schizophrenia.
Which of the following statements by the client indicates an understanding of the
teaching?
a. I shouldn’t worry about the voices because they are a part of my illness
b. I should let my counselor know if i am having trouble sleeping
c. I should avoid being around others if i think I’m having a relapse
d. I should increase my carb intake to maintain my energy level [Show Less]