The client states, "Who is confused? He said I should go, but I didn't. Is that weird?" Which response by the nurse would be best to clarify the client's
... [Show More] statement?
A. How did you feel before you talked to him?
B. When did you first notice yourself feeling confused?
C. Did he indicate to you exactly what he meant?
D. I don't understand. Can you explain in another way? - correct answer D
During the initial interview with a client, the nurse begins to feel uncomfortable and realizes the client's behavior and mannerisms remind the nurse of the nurse's abusive parent. The nurse concludes that the current situation represents which phenomenon?
A. Transference
B. Countertransference
C. Denial
D. Reaction formation - correct answer B
A client asks the nurse what to do about leaving the spouse. The nurse replies "Why are you having trouble making a decision? It's easy to see that you should file for divorce." The nurse manager overhearing the conversation would counsel this nurse because the nurse's response: (Select all that apply)
A. Restricts the client's opportunity for self-exploration & problem solving skills
B. Belittles the client & the client's indecisiveness
C. Challenges the client's belief system
D. Assumes that t - correct answer A,B,D
While communicating with a client, the nurse decides to provide the client with feedback. The primary reason for this is that giving appropriate feedback makes it possible for the nurse to:
A. Present advice
B. Explore feelings
C. Provide information
D. Explain behavior - correct answer C
The nurse assesses a client as being on the mental health end of the mental health/mental illness continuum. Which statement by the client best supports this assessment? (Select all that apply)
A. I am satisfied with my life and life choices
B. My family thinks that I am a good person
C. I'm an average person leading a normal average life.
D. I've always thought I should have been more sucessful - correct answer A,C
A newly admitted adult client says, "No, I don't want that medicine. I won't take it." The nurse says, "Take it. It's good medicine." The nurse then places the cup in front of the client's mouth and forcefully presses it against the client's lips. In counseling this nurse, what important legal principles can be applied to the nurse's action? (Select all that apply)
A. If a client does not object a second time, a nurse can administer the medication
B. If treatment is given without consent, legal - correct answer B,D
A client presents at a crisis clinic with reports of having crying spells and overwhelming feelings of loss. The client further relates that this extreme distress began one week ago when the client's parent developed an acute physical illness & died. The client speaks clearly and descriptively about the illness & death & verbalizes feelings readily. The nurse interprets that the client's behaviors suggest the client:
A. Has suffered irreversible psychological damage
B. Is a candidate for long-te - correct answer D
A client has purposefully attempted to embarrass a nurse by making a sexually explicit comment. The best response by the nurse is to:
A. Clarify the intention of the client
B. Leave the situation altogether
C. Refuse to talk with the client any further
D. Continue to interact as if the comments did not cause embarrassment - correct answer A
An emergency psychiatric client presents with amnesia, hyperthermia, & unexplained loss of appetite. Accompanying family members state that the client suffered a head injury while falling from a ladder several days before. The nurse concludes that the client's symptoms are consistent with trauma to which area of the brain?
A. Thalamus
B. Hypothalamus
C. Cerebrum
D. Cerebellum - correct answer B
The nurse has explained to a client the biologic theories of depression. the nurse concludes that the teaching has been effective if the client says, "I now know that my depression may be caused from: (Select all that apply)
A. Excessive serotonin activity level in the CNS
B. Insufficient serotonin activity in the CNS
C. Excessive acetylcholine in the CNS.
D. Insufficient acetylcholine activity in the CNS - correct answer B,D
A client was quite upset the entire time she was pregnant and made it clear she did not want her unborn child. However, since the birth, she has become overly protective and refuses to let anyone else near the infant. Which ego defense mechanism does the nurse recognize in the client's behavior?
A. Denial
B. Projection
C. Reaction formation
D. Displacement - correct answer C
The client has an elective abortion. The nurse wishes to assist the client to manage post-abortion emotional responses. Which nursing approach is most appropriate?
A. Reassure the client that having an abortion was the best possible decision
B. Teach the client how to use effective methods of birth control
C. Encourage the client to express feelings of loss and grief
D. Suggest that the client rely on a higher power for spiritual support - correct answer C
A 63-year-old male client expresses feelings of hopelessness and helplessness about his spouse's illness and anticipated death. On which of the following issues should the nurse initially assist the client to focus?
A. The nature of the spouse's present illness
B. The client's response to past losses
C. The dying spouse's feelings about impending loss and death
D. The client's relationship with the spouse - correct answer A
The mental health nurse is conducting an assessment with a client who has a history of anxiety. The nurse concludes that the client's use of defense mechanisms is adaptive when the client remains psychologically and physically safe and the client:
A Experiences fewer direct manifestations of anxiety
B. Seeks social isolation to avoid stress
C. Displaces anxiety onto other persons or situations
D. Identifies the personal level of anxiety - correct answer A
The mental health client who experienced a brief psychotic reaction was treated as an inpatient for one week and then discharge to outpatient day hospital program for follow-up treatment. The nurse explains to the client's family that the outpatient treatment setting approach is based on the principle of providing which of the following?
A. Compliance with the Americans with disabilities act as it applies to mental health clients
B. Mental health care in the least restrictive setting possible
C. - correct answer B
A nurse completing a cultural assessment of the client recognizes a personal tendency to engage in stereotyping in countertransference responses. The nurse should further recognize that these behaviors are likely to lead the nurse to do which of the following?
A. Anticipate the unmet needs of the individual client
B. Be open and honest while responding to the client's concerns
C. Fail to recognize unmet needs of the individual client
D. Facilitate the treatment process - correct answer C
In order to deal effectively with the spiritual needs of a client, what should be the nurse's initial strategy?
A. Refer the client to an appropriate clergy
B. Clarify own spiritual beliefs and values
C. Use a spiritual assessment tool
D. Discuss on religiosity with the client - correct answer B
During a team meeting, the nurse develops the outcomes of care for a depressed male client. Which of the following is the most appropriately stated outcome for the client within 3 days?
A. Feel less depressed
B. Reduce self-rating on a depression scale by 10%
C. State he has significantly more insight into his problems
D. Feel supported as he deals with grief issues - correct answer B
In older adult grieving the loss of a family member reports all of the following symptoms to the nurse. To plan appropriate nursing interventions, the nurse needs to determine which symptoms need to be addressed first. Put the following client symptoms in order from highest to lowest priority.
A. Occasional feelings of tightness in the chest
B. Expressed thoughts of being better off dead
C. Statements of guilt about a loved one's death
D. Morbid preoccupation with feelings of worthlessness - correct answer B,D,A,C
An elderly African-American woman is admitted for sepsis and pneumonia. She immediately calls for her minister to be at her bedside to pray with her. The nurse recognises this as a(n):
A. Indication that she feels she may die soon
B. Positive coping mechanism in the African-American culture
C. Indication that the client is lonely
D. Signal that the client does not trust the hospital staff - correct answer B
The client says, "I feel like I've been abandoned." The nurse who chooses to which communication technique might reply, "You feel alone...?"
A. Focusing
B. Summarizing
C. Reflecting
D. Restating - correct answer C
A new staff nurse asks the experienced psychiatric-mental health nurse to explain the primary purpose for which nurses use the DSM-IV-TR. The response should be:
A. Determine functional categories of physical disabilities of the client
B.Understand the clients psychiatric-mental health medical diagnosis
C. Define categories of nursing diagnoses for the client
D. Specify individualized outcomes for nursing care of the client - correct answer B
When teaching new staff members about mental illness/mental health treatment approaches developed during the 1900's, the nurse should indicate that which therapeutic approaches were developed at approximately the same point in time? Select all that apply.
A. Community mental health centers
B. Antipsychotic medications
C. Nurse-client relationship theory
D. Psychoanalysis - correct answer B,C
A new staff nurse asks the experienced psychiatric-mental health nurse to explain the primary purpose for which the psychiatric-mental health nurse uses the DSM-IV-TR. The response of the more experienced nurse should be, "Nurses use the DSM IV-TR to:"
A. Determine functional categories of physical disabilities of the client
B. Understand the clients psychiatric-mental heals medical diagnosis(es)
C. Define categories of nursing diagnoses for the clients
D. Specify individualized outcomes for nur - correct answer B
The treatment team has recommended that an individual be committed to a psychiatric inpatient unit. When the family of this individual asks about possible adverse effects or arguments against commitment, the nurse should tell them that:
A. The family may not be able to care for an acutely ill member
B. Interventions will ease suffering, and in some cases, save lives
C. It is the only way to obtain treatment from the public healthcare system
D. It reinforces the stigma that mentally ill people ar - correct answer D
A new staff nurse asks the experienced psychiatric-mental health nurse about the origins of the community mental health movement. The experienced nurse should respond that the community mental health movement resulted primarily from:
A. Destruction of asylums
B. Lack of government housing
C. Deinstitutionalization
D. The need of society to spread the mentally ill all over the country - correct answer C
When planning nursing care, the nurse uses the approach of which theorist when considering motivation and behavior by utilizing a schematic hierarchy of needs?
A. Sigmund Freud
B. Harry Stack Sullivan
C. Jean Piaget
D. Abraham Maslow - correct answer D
The nurse is planning to conduct reminiscence therapy for a group of older adults. The nurse implements this by doing which of the following?
A. Encouraging each member to socialize with every other member of the group
B. Role-modeling adaptive was to cope with aging
C. Encouraging each group member to recall and discuss earlier life experiences
D. Validating clients' positive feelings about aging - correct answer C
While an older client is completing a life review with the nurse, the client shows despair over life events and injustices that occurred, personal inability to find any meaning in own life, and feelings of hopelessness about the future. The nurse should formulate which of the following as the most appropriate nursing diagnosis?
A. Spiritual distress
B. Chronic sorrow
C. Chronic low self-esteem
D. Risk for violence, self-directed - correct answer A
A client with a history of drug abuse verbalizes the need for help during the nursing history. When planning treatment for the client, what is the most important initial information the nurse should obtain?
A. How the client has supported the drug use
B. The client's current height and weight
C. The client's family response to the drug use
D. The types and quantities of drugs involved - correct answer D
A 6-year-old child was recently admitted to the hospital with a diagnosis of autism. The child picks up a toy and begins to hit another child. What is the most appropriate response by the nurse?
A. Isolate the child for 24 hours
B. Encourage the client to explain his angry thoughts
C. Assume a nonpunitive stance and stop the behavior
D. Call the client's parents for their input - correct answer C
The nurse wishes to encourage the client to express personal feelings and to develop increased awareness about what those feelings mean. Which approach by the nurse would be best?
A. Challenge the client
B. Offer reassurance
C. Give advice
D. Offer empathy - correct answer D
While the nurse and client are talking, the client states "You are just like my mother; you don't trust me or like me. The two of you wish I were dead." The nurse interprets this statement as indicating which of the following processes?
A. Psychosis
B. Countertransference
C. Transference
D. Projection - correct answer C
During the orientation phase of the therapeutic nurse-client relationship, the nurse gathers information from the client. The main purpose of doing so is to allow the nurse to do which of the following?
A. Keep the client focused
B. Become aware of the client's feelings
C. Elicit the client's commitment to treatment
D. Have the client give examples of behaviors discussed - correct answer B
The nurse wants to assess the client's current level of independence and competence in caring for self while living in the community. The nurse should choose which of the following as the best assessment tool?
A. Psychiatric assessment
B. Functional assessment
C. Social assessment
D. Cultural assessment - correct answer B
A nurse is conducting a psychoeducational group regarding the interplay of neurotransmitters and circadian rhythms. The nurse evaluates that the clients understood the teaching if members of the group say, "Circadian rhythms are most related to:"
A. Acetylcholine
B. Norepinephrine
C. Serotonin
D. Dopamine - correct answer C
A client says to the nurse, "Where did you come from? Venus is in outer space. Are you with the FBI? I like the staff on this unit. What are we going to do today?" The nurse should document this as:
A. Loose association
B. Tangential speech
C. Circumstantial speech
D. Concrete thinking - correct answer A
A newly admitted client has been self inflicting cuts to the arms when angry. Which is the priority nursing diagnosis for this client?
A. Defensive coping
B. Risk for self-directed violence
C. Ineffective coping
D. Anxiety - correct answer B
While talking with the nurse, the schizophrenic client begins to stare upward in an attentive posture as if listening to something that the nurse doesn't hear. The nurse says, "Look at me. I'm your nurse. Listen to me, not the sounds you hear." What intervention principle is the nurse using?
A. Assisting the client to reduce current level of anxiety
B. Helping the client refocus from internal to external stimuli
C. Using therapeutic communication to reduce delusional thinking
D. Using calming te - correct answer B
A client who failed to complete a craft project during group activities becomes upset, accuses the group leader of not giving assistance, and berates the other clients for hoarding all the supplies. The nurse interprets this behavior as which of the following?
A. Compensation
B. Projection
C. Introjection
D. Minimization - correct answer B
A member of the staff asks the nurse to explain the primary purposes of therapeutic communication. Which of the following should the nurse include in a reply? "Therapeutic communication is commonly designed to:" (Select all that apply.)
A. Assist with problem solving
B. Provide satisfying social interaction
C. Provide opportunities to express and clarify feelings
D. Manage feelings of rejection - correct answer A,C
During the nursing assessment of a physically frail elderly client, the nurse can enhance communication by doing which of the following? Select all that apply.
A. Speaking loudly and using many gestures
B. Restating terms or phrases if the client indicates lack of understanding
C. Interviewing the client with family present to verify responses to questions
D. Reducing the amount of time for the interview, as the client will tire easily - correct answer B,D
The nurse is assessing a 72-year-old widowed client who is experiencing depression. When formulating a plan of care, the nurse keeps in mind that depression in older adults is:
A. Primarily a problem of nursing home clients
B. An expected reaction to the potential multiple losses of old age
C. Unlikely to respond well to treatment
D. Often undetected by healthcare professionals - correct answer D
During an interview, a client is unable to remain focused and shares unnecessary details and unusual thoughts before getting to the central idea. How should the nurse refer to this when documenting?
A. Incoherence
B. Tangential speech
C. Neologisms
D. Circumstantiality - correct answer D
A client with bipolar disorder approaches the nurse and demands that the staff members assist with locating post-discharge lodging for the client. What is the best action by the nurse?
A. Determine whether something in the nurse-client relationship is leading to the demanding behavior
B. Assess whether the client can manage this situation independently
C. Comply with the client's demands and then discuss the situation later
D. Confront the client about the demanding behavior - correct answer B [Show Less]