AGACNP study set for exam
A charge nurse is discussing the care of a client who has major depressive disorder (MDD) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching? A. "Care during the continuation phase focuses on treating continued manifestations of MDD." B. "The goal of treatment during the maintenance phase is prevention of future episodes of MDD." C. "The client is at greatest risk for suicide during the first weeks of an MDD episode." D. "Medication and psychotherapy are used to prevent a relapse of MDD."
A. "Care during the continuation phase focuses on treating continued manifestations of MDD."
A nurse is teaching a client about stress-reduction techniques. Which of the following client statements indicates understanding of the teaching? A. "Cognitive reframing will help me change my irrational thoughts to something positive." B. "Progressive muscle relaxation uses a mechanical device to help me gain control over my pulse rate." C. "Biofeedback causes my body to release endorphins so that I feel less stress and anxiety." D. "Mindfulness allows me to prioritize the stressors that I have in my life so that I have less anxiety."
A. "Cognitive reframing will help me change my irrational thoughts to something positive."
A nurse manager is discussing the care of a client who has a personality disorder with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching? A. "I can promote my client's sense of control by establishing a schedule." B. "Self-assessment will help me cope with emotional reactions to client care." C. "I should practice limit-setting to help prevent client manipulation." D. "Maintaining professional boundaries is a priority of client care."
A. "I can promote my client's sense of control by establishing a schedule."
A nurse is caring for a client who has avoidant personality disorder. Which of the following statements is expected from a client who has this type of personality disorder? A. "I'm scared that you're going to leave me." B. "I'll go to group therapy if you'll let me smoke." C. "I need to feel that everyone admires me." D. "I sometimes feel better if I cut myself."
A. "I'm scared that you're going to leave me."
A nurse is caring for an adolescent client who has anorexia nervosa with recent rapid weight loss and a current weight of 90 lb. Which of the following statements indicates the client is experiencing the cognitive distortion of catastrophizing? A. "Life isn't worth living if I gain weight." B. "Don't pretend like you don't know how fat I am." C. "If I could be skinny, I know I'd be popular." D. "When I look in the mirror, I see myself as obese."
A. "Life isn't worth living if I gain weight."
A nurse is caring for a client who has acute stress disorder and is experiencing severe anxiety. Which of the following statements by the nurse is appropriate? A. "Tell me about how you are feeling right now." B. "You should focus on the positive things in your life to decrease your anxiety." C. "Why do you believe you are experiencing this anxiety?" D. "Let's discuss the medications your provider is prescribing to decrease your anxiety."
A. "Tell me about how you are feeling right now."
A charge nurse is discussing mirtazapine (Remeron) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding? A. "This medication increases the release of serotonin and norepinephrine." B. "I will need to monitor the client for hyponatremia while taking this medication." C. "This medication is contraindicated for clients who have an eating disorder." D. "Sexual dysfunction is a common adverse effect of this medication."
A. "This medication increases the release of serotonin and norepinephrine."
A nurse is preparing to obtain a nursing history from a client who has a new diagnosis of anorexia nervosa. Which of the following questions are appropriate for the nurse to include in the assessment? (Select all that apply.) A. "What is your relationship like with your family?" B. "Why do you want to lose weight?" C. "Would you describe your current eating habits?" D. "At what weight do you believe you will look better?" E. "Can you discuss your feelings about your appearance?"
A. "What is your relationship like with your family?" C. "Would you describe your current eating habits?" E. "Can you discuss your feelings about your appearance?"
A nurse is caring for a client who is experiencing a panic attack. Which of the following is an appropriate nursing intervention? A. Discuss new relaxation techniques. B. Show the client how to change his behavior. C. Distract the client with a television show. D. Stay with the client, and remain quiet.
D. Stay with the client, and remain quiet.
A nurse is preparing to implement cognitive reframing techniques for a client who has an anxiety disorder. Which of the following are appropriate to include in the plan of care? (Select all that apply.) A. Priority restructuring B. Monitoring thoughts C. Diaphragmatic breathing D. Journal keeping E. Meditation
A. Priority restructuring B. Monitoring thoughts D. Journal keeping
A nurse is assessing a client 4 hr after receiving an initial dose of fluoxetine (Prozac). Which of the following findings should the nurse report to the provider as an indication of serotonin syndrome? (Select all that apply.) A. Hypothermia B. Hallucinations C. Muscular flaccidity D. Diaphoresis E. Agitation
B. Hallucinations D. Diaphoresis E. Agitation
A nurse is caring for a client who has substance-induced psychotic disorder and is experiencing auditory hallucinations. The client states, "The voices won't leave me alone!" Which of the following statements by the nurse are appropriate? (Select all that apply.) A. "When did you start hearing the voices?" B. "The voices are not real, or else we would both hear them." C. "It must be scary to hear voices." D. "Are the voices telling you to hurt yourself?" E. "Why are the voices talking to only you?"
A. "When did you start hearing the voices?" C. "It must be scary to hear voices." D. "Are the voices telling you to hurt yourself?"
A nurse is discussing routine follow-up needs for a client who has a new prescription for valproic acid (Depakote). The nurse should inform the client of the need for routine monitoring of which of the following? A. AST/ALT and LDH B. Creatinine and BUN C. WBC and granulocyte counts D. Serum sodium and potassium
A. AST/ALT and LDH
A nurse working in an acute mental health facility is caring for a 35-year-old female client who has clinical findings of depression. The client lives at home with her husband and two young children. She currently smokes and has a history of chronic asthma. The nurse should identify which of the following as risk factors for depression for this client? (Select all that apply.) A. Age of 35 years old B. Female gender C. History of chronic asthma D. Currently smokes E. Being married
A. Age of 35 years old B. Female gender C. History of chronic asthma D. Currently smokes
A nurse is completing an admission assessment for a client who has schizophrenia. Which of the following findings should the nurse document as positive symptoms? (Select all that apply.) A. Auditory hallucination B. Lack of motivation C. Use of clang associations D. Delusion of persecution E. Constantly waving arms F. Flat affect
A. Auditory hallucination C. Use of clang associations D. Delusion of persecution E. Constantly waving arms
A nurse is caring for a client who has a new prescription for disulfiram (Antabuse) for the treatment of his alcohol use disorder. The nurse informs the client that this medication can cause nausea and vomiting if he drinks alcohol. This form of treatment is an example of which of the following? A. Aversion therapy B. Flooding C. Biofeedback D. Dialectical behavior therapy
A. Aversion therapy
A nurse is discussing acute vs. prolonged stress with a client. Which of the following should the nurse identify as an acute stress response? (Select all that apply.) A. Decreased appetite B. Depressed immune system C. Increased blood pressure D. Panic attacks E. Unhappiness
A. Decreased appetite B. Depressed immune system C. Increased blood pressure E. Unhappiness
A nurse working on an acute mental health unit is admitting a client who has major depressive disorder and comorbid anxiety disorder. Which of the following is the highest priority action by the nurse? A. Placing the client on one-to-one observation B. Assisting the client to perform ADLs C. Encouraging the client to participate in counseling D. Teaching the client about medication adverse effects
A. Placing the client on one-to-one observation
A charge nurse is preparing a staff education session on personality disorders. Which of the following should be included as personality characteristics associated with all of the personality disorders? (Select all that apply.) A. Difficulty in getting along with other members of a group B. Belief in the ability to become invisible during times of stress C. Display of defense mechanisms when routines are changed D. Claiming to be more important than other persons E. Difficulty understanding why it is inappropriate to have a personal relationship with staff
A. Difficulty in getting along with other members of a group C. Display of defense mechanisms when routines are changed E. Difficulty understanding why it is inappropriate to have a personal relationship with staff
A nurse is planning care for the termination phase of a nurse-client relationship. Which of the following actions is appropriate to include in the plan of care? A. Discussing ways to use new behaviors B. Practicing new problem-solving skills C. Developing goals D. Establishing boundaries
A. Discussing ways to use new behaviors
A nurse is working in a community mental health facility. Which of the following services are appropriate for clients to receive? (Select all that apply). A. Educational groups B. Medication dispensing programs C. Individual counseling programs D. Detoxification programs E. Crisis intervention
A. Educational groups B. Medication dispensing programs C. Individual counseling programs
A nurse is preparing to provide an educational seminar on stress to other nursing staff. Which of the following is appropriate to include in the discussion? A. Excessive stressors cause the client to experience distress. B. The body's initial adaptive response to stress is denial. C. The absence of stressors results in homeostasis. D. Negative, rather than positive, stressors produce a biological response.
A. Excessive stressors cause the client to experience distress.
A nurse observes a client who is pacing and wringing his hands. The client states, "I don't know why, but I've worried every day for over a year that my son will die a horrible death." The nurse identifies that this finding is consistent with which of the following disorders? A. Generalized anxiety disorder B. Panic disorder C. Posttraumatic stress disorder D. Acute stress disorder
A. Generalized anxiety disorder
A nurse working on an acute mental health unit is caring for a client who has posttraumatic stress disorder (PTSD). Which of the following is an expected finding? (Select all that apply.) A. Hallucinations B. Obsessive need to talk about the traumatic event C. Exaggerated displays of emotion D. Recurring nightmares E. Diminished reflexes
A. Hallucinations D. Recurring nightmares
A nurse is making a home visit to a client who has Alzheimer's disease to assess the home for safety. Which of the following are appropriate suggestions to decrease the client's risk for injury? A. Install childproof door locks. B. Place rugs over electrical cords. C. Mark cleaning supplies with colored tape. D. Place the client's mattress on the floor. E. Install light fixtures above stairs.
A. Install childproof door locks. D. Place the client's mattress on the floor. E. Install light fixtures above stairs.
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 planning a peer group discussion about the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (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
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 care for a client following surgical implantation of a vagus nerve stimulation (VNS) device. The nurse should plan to monitor for which of the following adverse effects? (Select all that apply.) A. Voice changes B. Seizure activity C. Disorientation D. Dysphagia E. Neck pain
A. Voice changes D. Dysphagia E. Neck pain
A nurse is teaching a client who has a new prescription for imipramine (Tofranil) how to minimize anticholinergic effects. Which of the following should the nurse include in the teaching? (Select all that apply.) A. Void just before taking the medication. B. Increase the dietary intake of potassium. C. Wear sunglasses when outside. D. Change positions slowly when getting up. E. Chew sugarless gum.
A. Void just before taking the medication. C. Wear sunglasses when outside. E. Chew sugarless gum.
A nurse is caring for a client in restraints. Which of the following statements are appropriate documentation? (Select all that apply.) A. "Client ate most of his breakfast." B. "Client was offered 8 oz of water every hr." C. "Client shouted at assistive personnel." D. "Client received chlorpromazine (Thorazine) 15 mg by mouth at 1000." E. "Client acted out after lunch."
B. "Client was offered 8 oz of water every hr." C. "Client shouted at assistive personnel." D. "Client received chlorpromazine (Thorazine) 15 mg by mouth at 1000." E. "Client acted out after lunch."
A nurse is caring for a client who has bipolar disorder. The client states, "I am very rich, and I feel I must give my money to you." Which of the following is an appropriate response by the nurse? A. "Why do you think you feel the need to give money away?" B. "I am here to provide care and cannot accept this from you." C. "I can request that your case manager discuss appropriate charity options with you." D. "You should know that giving away your money is inappropriate."
B. "I am here to provide care and cannot accept this from you."
A nurse is caring for a client who has schizoaffective disorder. Which of the following statements indicates the client is experiencing depersonalization? A. "I am a superhero and am immortal." B. "I am no one, and everyone is me." C. "I feel monsters pinching me all over." D. "I know that you are stealing my thoughts."
B. "I am no one, and everyone is me."
A nurse is providing teaching to a client who has a new prescription for amitriptyline (Elavil). Which of the following client statements indicates understanding of the teaching? A. "While taking this medication, I'll need to stay out of the sun to avoid a skin rash." B. "I may feel drowsy for a few weeks after starting this medication." C. "I cannot eat my favorite pizza with pepperoni while taking this medication." D. "This medication will help me lose the weight that I have gained over the last year."
B. "I may feel drowsy for a few weeks after starting this medication."
A charge nurse is discussing transcranial magnetic stimulation (TMS) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching? A. "TMS is indicated for clients whose depression is not relieved by medication." B. "I will provide postanesthesia care following TMS." C. "TMS is usually performed as an outpatient procedure." D. "I will schedule the client for daily TMS treatments for the first several weeks."
B. "I will provide postanesthesia care following TMS."
A nurse is caring for a client who is on lithium therapy. The client states that he wants to take ibuprofen for osteoarthritis pain relief. Which of the following statements by the nurse is appropriate? A. "That is a good choice. Ibuprofen does not interact with lithium." B. "Regular aspirin would be a better choice than ibuprofen." C. "Lithium decreases the effectiveness of ibuprofen." D. "The ibuprofen will make your lithium level fall too low."
B. "Regular aspirin would be a better choice than ibuprofen.
A nurse is teaching a client who has an anxiety disorder and is scheduled to begin classical psychoanalysis. Which of the following client statements indicates an understanding of this form of therapy? A. "Even if my anxiety improves, I will need to continue this therapy for 6 weeks." B. "The therapist will focus on my past relationships during our sessions." C. "Psychoanalysis will help me reduce my anxiety by changing my behaviors." D. "This therapy will address my conscious feelings about stressful experiences."
B. "The therapist will focus on my past relationships during our sessions."
A nurse is caring for a client who has Alzheimer's disease and is beginning to experience noticeable short-term memory loss. When discussing a new prescription for donepezil (Aricept), the nurse should include which of the following in the teaching? A. "You should avoid taking over-the-counter acetaminophen while on donepezil." B. "You can expect the progression of cognitive decline to slow with donepezil." C. "You will be screened for underlying kidney disease prior to starting donepezil." D. "You should stop taking donepezil if you experience nausea or diarrhea."
B. "You can expect the progression of cognitive decline to slow with donepezil."
A nurse is caring for a group of clients. Which of the following clients should a nurse consider for referral to an assertive community treatment (ACT) group? A. A client in an acute care mental health facility who has fallen several times while running down the hallway B. A client who lives at home and keeps "forgetting" to come in for his monthly antipsychotic injection for schizophrenia C. A client in a day treatment program who says he is becoming more anxious during group therapy D. A client in a weekly grief support group who says she still misses her deceased husband who has been dead for 3 months
B. A client who lives at home and keeps "forgetting" to come in for his monthly antipsychotic injection for schizophrenia
A nurse is speaking with a client who has schizophrenia when he suddenly seems to stop focusing on the nurse's questions and begins looking at the ceiling and talking to himself. Which of the following actions should the nurse take? A. Stop the interview at this point, and resume later when the client is better able to concentrate. B. Ask the client, "Are you seeing something on the ceiling?" C. Tell the client, "You seem to be looking at something on the ceiling. I see something there, too." D. Continue the interview without comment on the client's behavior.
B. Ask the client, "Are you seeing something on the ceiling?"
A nurse is planning group therapy for clients dealing with bereavement. Which of the following should the nurse include in the initial phase? (Select all that apply.) A. Encourage the group to work toward goals. B. Define the purpose of the group. C. Discuss termination of the group. D. Identify informal roles of members within the group. E. Establish an expectation of confidentiality within the group.
B. Define the purpose of the group. C. Discuss termination of the group. E. Establish an expectation of confidentiality within the group.
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. Denial
A nurse is discussing relapse prevention with a client who has bipolar disorder. Which of the following should the nurse include in the teaching? (Select all that apply.) A. Use caffeine in moderation to prevent relapse. B. Difficulty sleeping can indicate a relapse. C. Begin taking your medications as soon as a relapse begins. D. Participating in psychotherapy can help prevent a relapse. E. Anhedonia is a clinical manifestation of a depressive relapse.
B. Difficulty sleeping can indicate a relapse. D. Participating in psychotherapy can help prevent a relapse. E. Anhedonia is a clinical manifestation of a depressive relapse.
A nurse is performing an admission assessment for a client who has delirium related to an acute urinary tract infection. Which of the following are expected findings? (Select all that apply.) A. History of gradual memory loss B. Family report of personality changes C. Hallucinations D. Unaltered level of consciousness E. Restlessness
B. Family report of personality changes C. Hallucinations E. Restlessness
A nurse is assessing a client who has alcohol use disorder and is experiencing withdrawal. Which of the following is an expected finding? (Select all that apply.) A. Bradycardia B. Fine tremors of both hands C. Hypotension D. Vomiting E. Restlessness
B. Fine tremors of both hands D. Vomiting E. Restlessness
A nurse is performing an admission assessment of a client who has bulimia nervosa with purging behavior. Which of the following is an expected finding? (Select all that apply.) A. Amenorrhea B. Hypokalemia C. Mottling of the skin D. Slightly elevated body weight E. Presence of lanugo on the face
B. Hypokalemia D. Slightly elevated body weight
A nurse working in an emergency department is caring for a client who has bezodiazepine toxicity due to an overdose. Which of the following is the priority nursing action? A. Administer flumazenil (Romazicon) B. Identify the client's level of orientation C. Infuse IV fluids D. Prepare the client for gastric lavage
B. Identify the client's level of orientation
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 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 mental health status.
A nurse is caring for a client on an acute mental health unit. The client reports hearing voices that are telling her to "kill your doctor." Which of the following is the priority action for the nurse to take? A. Use therapeutic communication to discuss the hallucination with the client. B. Initiate one-to-one observation of the client. C. Focus the client on reality. D. Notify the provider of the client's statement.
B. Initiate one-to-one observation of the client.
A nurse is conducting a family therapy session. The adolescent son tells the nurse that he plans ways to make his sister look bad so his parents will think he's the better sibling, which he believes will give him more privileges. The nurse should identify this dysfunctional behavior as which of the following? A. Placation B. Manipulation C. Blaming D. Distraction
B. Manipulation
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. Moderate
A nurse is planning care for a client who has bipolar disorder and is experiencing a manic episode. Which of the following is appropriate for the nurse to include in the plan of care? (Select all that apply.) A. Provide flexible client behavior expectations B. Offer concise explanations C. Establish consistent limits D. Disregard client complaints E. Use a firm approach with communication
B. Offer concise explanations C. Establish consistent limitsE. Use a firm approach with communication
A nurse is caring for a client who is taking phenelzine (Nardil). For which of the following adverse effects should the nurse observe? (Select all that apply.) A. Elevated blood glucose level B. Orthostatic hypotension C. Priapism D. Headache E. Bruxism
B. Orthostatic hypotension
A nurse is discussing early indications of toxicity with a client who has a new prescription for lithium carbonate for bipolar disorder. The nurse should include which of the following in the teaching? (Select all that apply.) A. Constipation B. Polyuria C. Rash D. Muscle weakness E. Tinnitus
B. Polyuria D. Muscle weakness
A nurse is caring for a client who has borderline personality disorder. The client says, "The nurse on the evening shift is always nice! You are the meanest nurse ever!" The nurse should recognize the client's statement as an example of which of the following defense mechanisms? A. Regression B. Splitting C. Undoing D. Identification
B. Splitting
A nurse hears a newly licensed nurse discussing a client's hallucinations in the hallway with another nurse. Which of the following actions should the nurse take first? A. Notify the nurse manager. B. Tell the nurse to stop discussing the behavior. C. Provide an in-service program about confidentiality. D. Complete an incident report.
B. Tell the nurse to stop discussing the behavior.
A nurse is in the working phase of a therapeutic relationship with a client who has methamphetamine use disorder. Which of the following indicates transference behavior? A. The client asks the nurse whether she will go out to dinner with him. B. The client accuses the nurse of telling him what to do just like his ex-girlfriend. C. The client reminds the nurse of a friend who died from a substance overdose. D. The client becomes angry and threatens harm to himself.
B. The client accuses the nurse of telling him what to do just like his ex-girlfriend.
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 client says she is experiencing increased stress because her significant other is "pressuring me and my kids to go live with him. I love him, but I'm not ready to do that." She also states that her significant other "keeps nagging at my oldest son, which makes me mad, since he's my son, not his." Which of the following should the nurse recommend to promote a change in the client's situation? A. Learn to practice mindfulness. B. Use assertiveness techniques. C. Exercise regularly. D. Rely on the support of a close friend.
B. Use assertiveness techniques.
A nurse decides to put a client who has psychosis in seclusion overnight because the unit is very short‑staffed, and the client frequently fights with other clients. This is an example of A. beneficence. B. a tort. C. a facility policy. D. justice.
B. a tort.
A nurse is teaching a newly licensed nurse about the use of electroconvulsive therapy (ECT) for the treatment of bipolar disorder. Which of the following statements by the newly licensed nurse indicates understanding? A. "ECT is the recommended initial treatment for bipolar disorder." B. "ECT is contraindicated for clients who have suicidal ideation." C. "ECT is effective for clients who are experiencing severe mania." D. "ECT is prescribed to prevent relapse of bipolar disorder."
C. "ECT is effective for clients who are experiencing severe mania."
A nurse working in an outpatient clinic is providing teaching to a client who has a new diagnosis of premenstrual dysphoric disorder (PMDD). Which of the following statements by the client indicates understanding of the teaching? A. "I can expect my problems with PMDD to be worst when I'm menstruating." B. "I will use light therapy 30 min a day to prevent further recurrences of PMDD." C. "I am aware that my PMDD causes me to have rapid mood swings." D. "I should increase my caloric intake with a nutritional supplement when my PMDD is active."
C. "I am aware that my PMDD causes me to have rapid mood swings."
A nurse is caring for a client who has bulimia nervosa and who has stopped purging behavior. The client tells the nurse that she is afraid she is going to gain weight. Which of the following is an appropriate response by the nurse? A. "Many clients are concerned about their weight. However, the dietitian will ensure that you don't get too many calories in your diet." B. "Instead of worrying about your weight, try to focus on other problems at this time." C. "I understand you have concerns about your weight, but first, let's talk about your recent accomplishments." D. "You are not overweight, and the staff will ensure that you do not gain weight while you are in the hospital. We know that is important to you."
C. "I understand you have concerns about your weight, but first, let's talk about your recent accomplishments."
A nurse is caring for a client who is to begin taking fluoxetine (Prozac) for treatment of generalized anxiety disorder. Which of the following statements indicates the client understands the use of this medication? A. "I will take the medication at bedtime." B. "I will follow a low-sodium diet while taking this medication." C. "I will need to discontinue this medication slowly." D. "I will be at risk for weight loss with long-term use of this medication."
C. "I will need to discontinue this medication slowly."
A nurse is talking with a client who is at risk for suicide following the death of his spouse. Which of the following statements by the nurse is appropriate? A. "I feel very sorry for the loneliness you must be experiencing." B. "Suicide is not the appropriate way to cope with loss." C. "Losing someone close to you must be very upsetting." D. "I know how difficult it is to lose a loved one."
C. "Losing someone close to you must be very upsetting."
A nurse is providing teaching to the family of a client who has a substance use disorder. Which of the following statements by a family member indicates a need for further teaching? A. "We need to understand that she is not responsible for her disorder." B. "Eliminating any codependent behavior will promote her recovery." C. "She should participate in an Al-Anon group to help her recover." D. "The primary goal of her treatment is abstinence from substance use."
C. "She should participate in an Al-Anon group to help her recover."
A nurse is orienting a new client to a mental health unit. When explaining the unit's community meetings, which of the following statements by the nurse is appropriate? A. "You and a group of other clients will meet to discuss your treatment plans." B. "Community meetings have a specific agenda that is established by staff." C. "You and the other clients will meet with staff to discuss common problems." D. "Community meetings are an excellent opportunity to explore your personal mental health issues."
C. "You and the other clients will meet with staff to discuss common problems."
A nurse is caring for several clients who are attending community-based mental health programs. Which of the following clients should the nurse plan to visit first? A. A client who recently burned her arm while using a hot iron at home B. A client who requests that her antipsychotic medication be changed due to some new side effects C. A client who says he is hearing a voice that tells him he is not worthy of living anymore D. A client who tells the nurse he experienced symptoms of severe anxiety before and during a job interview
C. A client who says he is hearing a voice that tells him he is not worthy of living anymore
Which of the following is an example of a client who requires emergency admission to a mental health facility? A. A client with schizophrenia who has frequent hallucinations B. A client with symptoms of depression who attempted suicide a year ago C. A client with borderline personality disorder who assaulted a homeless man with a metal rod D. A client with bipolar disorder who paces quickly down the sidewalk while talking to himself
C. A client with borderline personality disorder who assaulted a homeless man with a metal rod
A nurse is working with an established group and identifies various member roles. Which of the following should the nurse identify as an individual role? A. A member who praises input from other members B. A member who follows the direction of other members C. A member who brags about accomplishments D. A member who evaluates the group's performance toward a standard
C. A member who brags about accomplishments
A nurse wants to use democratic leadership with a group whose purpose is to learn appropriate conflict resolution techniques. The nurse is correct in implementing this form of group leadership when she demonstrates which of the following actions? A. Observes group techniques without interfering with the group process B. Discusses a technique and then directs members to practice the technique C. Asks for group suggestions of techniques and then supports discussion D. Suggests techniques and asks group members to reflect on their use
C. Asks for group suggestions of techniques and then supports discussion
A nurse observes a client who has OCD repeatedly applying, removing, and then reapplying makeup. The nurse identifies that repetitive behavior in a client who has OCD is due to which of the following? A. Narcissistic behavior B. Fear of rejection from staff C. Attempt to reduce anxiety D. Adverse effect of antidepressant medication
C. Attempt to reduce anxiety
A nurse is assisting with a court-ordered evaluation of a client who has antisocial personality disorder. When assessing this client, which of the following are expected findings? (Select all that apply.) A. Demonstrates extreme anxiety when placed in a social situation B. Has difficulty making even simple decisions C. Attempts to convince other clients to give him their belongings D. Becomes agitated if his personal area is not neat and orderly E. Blames others for his past and current problems
C. Attempts to convince other clients to give him their belongings E. Blames others for his past and current problems
A nurse in an acute mental health facility is caring for a client who has a severe mental illness and soon will be ready for discharge but still requires supervision much of the time. The client's wife works all day but is home by late afternoon. Which of the following should the nurse suggest as appropriate follow-up care? A. Receiving daily care from a home health aide B. Having a weekly visit from a nurse case worker C. Attending a partial hospitalization program D. Visiting a community mental health center on a daily basis
C. Attending a partial hospitalization program
A nurse is leading a peer group discussion about the indications for electroconvulsive therapy (ECT). Which of the following is appropriate to include in the discussion? A. Borderline personality disorder B. Acute withdrawal related to a substance use disorder C. Bipolar disorder with rapid cycling D. Dysthymic disorder
C. Bipolar disorder with rapid cycling
A nurse is caring for a client who has alcohol use disorder. The client is no longer experiencing withdrawal manifestations. Which of the following medications should the nurse anticipate administering to assist the client with maintaining abstinence from alcohol? A. Chlordiazepoxide (Librium) B. Bupropion (Zyban) C. Disulfiram (Antuse) D. Carbamazepine (Tegretol)
C. Disulfiram (Antuse)
A nurse is assisting with systematic desensitization for a client who has an extreme fear of elevators. Which of the following is appropriate when implementing this form of therapy? A. Demonstrate riding in an elevator, and then ask the client to imitate the behavior. B. Advise the client to say "stop" out loud every time he begins to feel an anxiety response related to an elevator. C. Gradually expose the client to an elevator while practicing relaxation techniques. D. Stay with the client in an elevator until his anxiety response diminishes.
C. Gradually expose the client to an elevator while practicing relaxation techniques.
A nurse is planning care for a client who is experiencing benzodiazepine withdrawal. Which of the following is the priority nursing intervention? A. Orient the client frequently to time, place, and person. B. Offer fluids and nourishing diet as tolerated. C. Implement seizure precautions. D. Encourage participation in group therapy sessions.
C. Implement seizure precautions.
A charge nurse is discussing the characteristics of a nurse-client relationship with a newly licensed nurse. Which of the following are appropriate to include in the discussion? (Select all that apply.) A. The needs of both participants are met. B. An emotional commitment exists between the participants. C. It is goal-directed. D. Behavioral change is encouraged. E. A termination date is established.
C. It is goal-directed. D. Behavioral change is encouraged. E. A termination date is established.
A nurse is assessing a client immediately following an electroconvulsive therapy (ECT) procedure. Which of the following are expected findings? (Select all that apply.) A. Hypotension B. Paralytic ileus C. Memory loss D. Nausea E. Tachycardia
C. Memory loss D. Nausea E. Tachycardia
A nurse is planning a staff education program on substance use in older adults. Which of the following is appropriate for the nurse to include in the presentation? A. Older adults require higher doses of a substance to achieve a desired effect. B. Older adults commonly use rationalization to cope with a substance use disorder. C. Older adults are at a higher risk for substance use following retirement. D. Older adults develop substance use to mask signs of dementia.
C. Older adults are at a higher risk for substance use following retirement
A nurse is making a home visit to a client who is in the late stage of Alzheimer's disease. The client's spouse, who is the primary caregiver, wishes to discuss concerns about the client's nutrition and the stress of providing care. Which of the following is an appropriate action by the nurse? A. Verify that a current power of attorney document is on file. B. Instruct the client's spouse to offer finger foods to increase oral intake. C. Provide information on resources for respite care. D. Schedule the client for placement of an enteral feeding tube.
C. Provide information on resources for respite care
A client tells a student nurse, "Don't tell anyone, but I hid a sharp knife under my mattress in order to protect myself from my roommate, who is always yelling at me and threatening me." Which of the following actions should the nurse take? A. Keep the client's communication confidential, but talk to the client daily, using therapeutic communication to convince him to admit to hiding the knife. B. Keep the client's communication confidential, but watch the client and his roommate closely. C. Tell the client that this must be reported to health care staff because it concerns the health and safety of the client and others. D. Report the incident, but do not inform the client of the intention to do so.
C. Tell the client that this must be reported to health care staff because it concerns the health and safety of the client and others.
A nurse is working on promotion of healthy coping skills with older adult clients who had all previously been hospitalized for severe depression and are now in a residential care facility. The nurse should recognize that this is an example of which of the following? A. Primary prevention B. Secondary prevention C. Tertiary prevention D. Mental status examination
C. Tertiary prevention
A nurse is reviewing the medical record of a client who has a new prescription for bupropion (Wellbutrin) for depression. Which of the following findings is the highest priority for the nurse to report to the provider? A. The client has a family history of seasonal pattern depression. B. The client currently smokes 1.5 packs of cigarettes per day. C. The client had a motor vehicle crash last year and sustained a head injury. D. The client has a BMI of 25 and has gained 10 lb over the last year.
C. The client had a motor vehicle crash last year and sustained a head injury.
A nurse is interviewing a 25-year-old client who has a new diagnosis of dysthymia. Which of the following findings should the nurse expect? A. There are wide fluctuations in mood. B. The report of a minimum of five clinical findings of depression. C. The presence of manifestations for at least 2 years. D. There is an inflated sense of self-esteem.
C. The presence of manifestations for at least 2 years.
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.
A nurse in a long-term care facility is caring for a resident who has major neurocognitive disorder and attempts to wander out of the building. The client states, "I have to get home." Which of the following is an appropriate response by the nurse? A. "You have forgotten that this is your home." B. "You cannot go outside without a staff member." C. "Why would you want to leave? Aren't you happy with your care?" D. "I am your nurse. Let's walk together to your room."
D. "I am your nurse. Let's walk together to your room."
A nurse is discussing free association as a therapeutic tool with a client who has major depressive disorder. Which of the following client statements indicates understanding of this technique? A. "I will write down my dreams as soon as I wake up." B. "I may begin to associate my therapist with important people in my life." C. "I can learn to express myself in a nonaggressive manner." D. "I should say the first thing that comes to my mind."
D. "I should say the first thing that comes to my mind
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 providing teaching for a client who is scheduled to receive electroconvulsive therapy (ECT) for the treatment of major depressive disorder. Which of the following client statements indicates understanding of the teaching? A. "It is common to treat depression with ECT before trying medications." B. "I can have my depression cured if I receive a series of ECT treatments." C. "I will have seizures lasting 1½ to 2 min during ECT." D. "I will receive a muscle relaxant to protect me from injury during ECT."
D. "I will receive a muscle relaxant to protect me from injury during ECT."
A charge nurse is discussing mental status examinations with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching? A. "To assess cognitive ability, I should ask the client to count backward 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 caring for a client who states, "I'm so stressed at work because of my coworker. He expects me to finish his work because he's too lazy!" When discussing appropriate communication, which of the following statements by the client to his coworker indicates client understanding? A. "You really should complete your own work. I don't think it's right to expect me to complete your responsibilities." B. "Why do you expect me to finish your work? You must realize that I have my own responsibilities." C. "It is not fair to expect me to complete your work. If you continue, then I will report your behavior to our supervisor." D. "When I have to pick up extra work, I feel very overwhelmed. I need to focus on my own responsibilities."
D. "When I have to pick up extra work, I feel very overwhelmed. I need to focus on my own responsibilities."
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? A. Reassure the client that everything will be okay. B. Use a low-pitched voice and speak slowly. C. Ignore the client's anxiety so that she will not be embarrassed. D. Demonstrate a calm manner while using simple and clear language.
D. Demonstrate a calm manner while using simple and clear language.
A nurse working on an acute mental health unit forms a group to focus on self-management of medications. At each of the meetings, two of the members use the opportunity to discuss their common interest in gambling on sports. This is an example of which of the following? A. Triangulation B. Group process C. Subgroup D. Hidden agenda
D. Hidden agenda
A nurse on an acute care unit is planning care for a client who has anorexia nervosa with binge-eating and purging behavior. Which of the following nursing actions is appropriate to include in the client's plan of care? A. Allow the client to select preferred meal times. B. Establish consequences for purging behavior. C. Provide the client with a high-fat diet at the start of treatment. D. Implement one-to-one observation during meal times.
D. Implement one-to-one observation during meal times.
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 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 acute mental health facility is caring for a client who is experiencing a mixed episode of bipolar disorder. Which of the following is the priority nursing action? A. Set consistent limits for expected client behavior. B. Administer prescribed medications as scheduled. C. Provide the client with step-by-step instructions during hygiene activities. D. Monitor the client for escalating behavior.
D. Monitor the client for escalating behavior.
A nurse working in a mental health clinic is providing teaching to a client who has a new prescription for diazepam (Valium) for generalized anxiety disorder. Which of the following is appropriate for the nurse to include in the teaching? A. 3 to 6 weeks of treatment is required to achieve therapeutic benefit. B. Combining alcohol with diazepam will produce a paradoxical response. C. Diazepam has a lower risk for dependency than other antianxiety medications. D. Report confusion as a potential indication of toxicity.
D. Report confusion as a potential indication of toxicity.
