1. A nurse is performing an admission assessment for a client who voluntary entered an outpatient mental health crisis facility. The client states,
... [Show More] “I’ve lost control of everything in my life!” which of the following questions should the nurse ask first?
a. “What has helped you to cope with a crisis in the past?”
b. “Who can we call to support you during this crisis?”
c. “Are you having thoughts about harming yourself today?”
d. “What event brought on this crisis?”
2. A nurse in a mental health facility is assessing the use of defense mechanisms in a client show has bulimia nervosa. Which of the following client behaviors should the nurse identify as displacement?
a. The client reports a headache each day when group therapy is scheduled
b. The client criticizes the nurse at each medication administration time
c. The client continually talks about the benefits of healthy eating habits
d. The client complains about the taste of the food
3. A nurse in a community mental health clinic is planning staff education about the levels of prevention of intimate partner abuse. Which of the following should the nurse identify as a strategy for primary prevention?
a. Referring a client who left a violent relationship to a legal advocacy program
b. Administering pharmacotherapy to minimize long-term effects of violence
c. Promoting self-esteem by having a client identify personal strengths
d. Establishing a support group for survivors to foster emotional healing
4. A nurse is admitting a client who has schizophrenia and has recently attempted to commit suicide. The client is angry over this admission and wants to go home. Which of the following interventions should the nurse anticipate implementing? (Select all that apply.)
a. Place the client in seclusion
b. Obtain a no-suicide contract
c. Institute one-to-one observation
d. Administer an antidepressant medication
e. Restrain the client during change of shift
5. A nurse in a community health center is obtaining a health history of an older adult client who reports being abused by a caregiver. Which of the following actions is appropriate for the nurse to take?
a. Arrange for admission to a long-term care facility
b. Notify a protective agency
c. Inform the client’s family
d. Discuss the concerns with the caregiver
6. A nurse is providing discharge teaching for a client who has a prescription for buspirone. Which of the following should the nurse include in the teaching?
a. Taking the medication with grapefruit juice can intensify the effects of the medication
b. It may take up to a week for the medication to reach its full therapeutic effect
c. Avoid sudden discontinuation of this medication to prevent withdrawal symptoms
d. When filling the prescription for this medication it is limited to a 90-day supply
7. A nurse in a mental health facility is admitting a client who is at risk for suicide. Which of the following nursing intervention should be included in the plan of care?
a. Search the client’s personal belongings daily for potentially harmful objects
b. Minimize talking about the client’s future plans
c. Assess the client for manifestations of psychosis on a regular basis
d. Initiate discussion regarding the client’s thoughts about suicide
8. A nurse is caring for a client who is in hospice for an inoperable brain tumor. When completing a spiritual assessment as part of end-of-life care, which of the following interventions should the nurse implement?
a. Discuss spiritual issues in a conversational manner
b. Engage in a formal discussion of the client’s religious beliefs
c. Prompt the client to the specific when asking question related to his own spirituality
d. Offer suggestions based on personal spiritual values
9. A nurse is planning care for a newly admitted client who has bipolar disorder. Which of the following is the priority action by the nurse?
a. Schedule the client for group therapy sessions
b. Maintain consistent rules
c. Provide frequent high-carlorie snacks
d. Avoid the use of value judgments
10. A nurse is caring for a client who was sexually assaulted in her home. The nurse should recognize that the client is recovering when she
a. Moves to a different residence
b. Seeks out different groups of friends
c. States a plan to revise her daily schedule
d. Expresses interest intimate relationships
11. A nurse is planning to interview an older adult client to obtain a mental health history. Which of the following techniques is appropriate?
a. Interview the client in private setting
b. Begin the interview by explaining the plan of care
c. Use open-ended questions throughout the interview
d. Ask the client to complete a detailed questionnaire
12. A nurse is planning care for a client who has obsessive compulsive disorder. Which of the following is the highest priority intervention by the nurse?
a. Develop a structured activity schedule for the client
b. Help the client to identify sources of anxiety
c. Teach the client focused relaxation techniques
d. Encourage nonritualistic behavior with positive reinforcement
13. A nurse is planning to develop a relationship with a new client. Order the phases of the nurse- client relationship by placing all of the letters in the letters in the correct sequence.
a. Recognize safety risks
b. Set the parameters of the relationship
c. Promote problem-solving skills
d. Summarize relationship goals
14. A nurse is planning care for four clients in a mental health facility. Which of the following clients is at greatest risk for injury when performing ADLs?
a. The client who has stage 6 Alzheimer’s disease
b. The client who is in the maintenance phase of schizophrenia
c. The client who has obsessive-compulsive disorder
d. The client who has dysthymic disorder
15. A nurse is planning care for a preschool-age child who has ADHD. Which of the following interventions is the highest priority?
a. Decrease distractions during meal times
b. Provide positive feedback when the child completes a task
c. Clearly identify consequences for unacceptable behavior
d. Remove unnecessary equipment from the child’s surroundings.
16. A nurse working in a community mental health facility is teaching a client who has alcohol use disorder and is considering attending Alcoholics Anonymous (AA). Which of the following statements by the client demonstrates an understanding of the teaching?
a. “I can have an occasional drink with dinner after completing AA.”
b. “AA can also help me with my addiction to pain medication.”
c. “AA will allow me to confront family members who also have alcohol use disorder.”
d. “In AA, I will play a role in the recovery of others who are addicted to alcohol.”
17. A nurse is reviewing the laboratory values for a client who has been taking clozapine for schizophrenia for the last 3 months. Which of the following laboratory finding should the nurse report to the provider?
a. Serum chloride 3.8 mEq/L
b. WBC count 2500/mm³
c. Total serum bilirubin 0.8 mg/dL
d. Alanine aminotransferase 16 units/L
18. A nurse is caring for a client who has end stage pancreatic cancer. The nurse overhears the client say to her sister, “I love our time together. I am going to miss you.” Which of the following grief reactions is the client experiencing?
a. Anticipatory
b. Inhibited
c. Disenfranchised
d. distorted
19. A nurse is admitting a client who is experiencing alcohol withdrawal delirium. The nurse plans a room assignment. Which of the following clients is the most appropriate roommate for this client?
a. A client who has insomnia
b. A client who receives frequent visitors
c. A client who is hypervigilant
d. A client who has depressive disorder
20. A case manager is implementing a program to help client increase adherence to their treatment regime. Which of the following actions should the nurse take?
a. Provide care for a client’s physical health needs
b. Track the outcomes of client care
c. Develop community based program goals
d. Promote client use of a crisis hotline
21. A nurse is admitting a client who has of alcohol use and a new diagnosis of Korsakoff’s syndrome. Which of the following should the nurse include in the client’s plan of care?
a. Initiate contact precautions
b. Provide assistance with ambulation
c. Teach stress-management techniques
d. Administer lithium therapy
22. A nurse is planning care for an older adult client who is experiencing delirium. Which of the following interventions will meet the needs of this client?
a. Offer the client various choices for meal selection
b. Assign different nursing personnel for each shift
c. Permit the client daily rituals to decrease anxiety
d. Maintain an environment that has low lighting
23. A nurse in a 24-hr mental health facility is planning discharge for a client who has a long history of alcohol use disorder. Which of the following postdischarge activities should the nurse plan to include?
a. Taking the oral medication buprenorphine to prevent alcohol use
b. Attending a relapse prevention group several times each week
c. Beginning a methadone treatment program at a local center
d. Living with her mother, who has promised to keep her away from alcohol [Show Less]