Mental Health Practice Exam

A nurse on an acute mental health facility is receiving change of shift report for four clients. Which of the following client should the nurse assess first?

A client who is experiencing delusions of persecution

A nurse is caring for a group of clients. Which of the following findings should the nurse report?

A client who is taking lamotrigine and has developed a rash.

A nurse is caring for a group of clients. Which of the following findings is the nurse required to report?

A client who has borderline personality disorder threatened to harm their roommate

A nurse in a clinic is assessing a client whose partner died 4 months ago. Which of the following statements indicates that the client is at risk for complicated grief?

"I feel so empty without my wife that it's hard to get up every morning."

A nurse is teaching a newly licensed nurse about nursing care plans for clients who have depressive disorders. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

"I will update the plan of care as a clients manifestations of depression change"

A nurse in a community health center is counseling a family of two parents and two children. Which of the following statements by a family member indicates manipulative behavior?

"If you do my homework for me, I won't bother you for the rest of the day."

A nurse is planning care for a client who has depression and has made frequent suicide attempts. Which of the following statements indicates the client has a decreased risk for suicide?

"It is easier to talk about my feelings now."

A nurse is caring for an older adult client who begins to cry and states, "I knew God would punish me, and I deserve this horrible sickness!" Which of the following responses should the nurse make?

"Let's talk about what's upsetting you"

A nurse is caring for a client who has a personality disorder. Which of the following actions should the nurse take? Select all that apply. Document the client's condition every 30 min. Maintain continuous observation of the client while in restraints. Remove two restraints at a time as the client regains control. Maintain the client NPO during time in restraints. Ensure the client is in prone position. Conduct debriefing with the client and other staff.

- Maintain continuous observation of the client while in restraints. - Conduct debriefing with the client and other staff.

Select the 6 findings in the client's medical record that are manifestations of the client's diagnosed personality disorder.

- Married multiple times - Incidences of self-injury - Physical altercations -Hypersexualization -Anxious if left alone -Stealing money from family to cover credit card charges

Click to highlight the findings in the medical record that indicate maladaptive uses of defense mechanisms.

- Returned from exercise class in agitated state. - Client tells the nurse, "That exercise instructor was one of my favorite people here. We had so much in common. But now I know their true nature. She's evil!"

A nurse is preparing to administer diazepam 7.5 mg IV bolus to a client for alcohol withdrawal. Available is diazepam injection 5 mg/mL. How many mL should the nurse administer?

1.5mL

A nurse is caring for a group of clients. For which of the following situations should the nurse complete the incident report?

A client was administered one-half of the prescribed dose of medication.

A nurse is reviewing the electronic medical record of a client who has scizophrenia and is taking clozapine. Which of the following lab results should the nurse review prior to administering clozapine?

Absolute neutrophil count

A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse document as a negative symptom of this disorder?

Anhedonia

A nurse is caring for a client who has a personality disorder. For each potential nursing intervention click to specify if the potential intervention is anticipated, nonessential are contraindicated for the client.

Anticipated • haloperidol 2 mg IM • approach the client and state "you seem agitated. Let's sit quietly and talk about it" Nonessential • Request change of diet to mechanical soft Contraindicated • hold the next dose of buspar • Request prescription for digoxin 1 mg IV bolus stat

A nurse is caring for a client who has impaired cognitionA nurse is updating the client's plan of care. For each of the following potential nursing interventions, click to specify if the potential intervention is anticipated, nonessential, or contraindicated for the client.

Anticipated: - When addressing the client, approach them from the front when possible. - Give directions to the client slowly and in a moderate tone of voice. - Decrease sensory stimulation. - Assign the client to a room near the nurses' station. Contraindicated: - Use a vest restraint to keep the client in a medical recliner. - Ensure the bed is kept at a working height for the nurse. - Keep the lights off in the client's bedroom and bathroom at night. Nonessential: - Provide the client with high-calorie protein drinks hourly.

A nurse is planning discharge teaching for a client who has severe schizoaffective disorder. The nurse should identify that which of the following treatment options can offer interdisciplinary services for the client at home?

Assertive community treatment

A nurse on a medical surgical unit is assessing a client who sustained injuries 12 hr ago following a motor vehicle crash. The clients admission blood alcohol level was 325 mg/dL. Which of the following finding should indicate to the nurse that the client is experiencing alcohol withdrawal?

Blood pressure 154/96

A nurse on a mental health unit observes a client who has acute mania hit another client. Which of the following action should the nurse take first?

Call a team of staff members to help with the situation.

A nurse in a provider;s office is collecting a health history from the guardian of a school-age child who has been taking atomoxetine. Which of the following adverse effects reported by the guardian is the priority for the nurse to report to the provider?

Dark urine

The nurse is caring for the client, who is in seclusion and under mechanical restraints. For each potential assessment finding, click to specify if the finding indicates the client's condition has improved, not changed, or has declined.

Declined: - Client attempts to bite nursing staff when offered water. Improved: - Client follows instructions of the nurse. - Client verbalizes precipitating factors to violent outburst. No change: Client is silent and glaring at staff.

A nurse is educating the parent of a child who has a new diagnosis of autism spectrum disorder. Which of the following manifestations of this disorder should the nurse include in the teaching?

Early identification of changes, such as decreased social involvement, is important

A nurse is performing a cognitive assessment to distinguish delirium from dementia in a client whose family reports episodes of confusion. Which of the following assessment finding supports the nurses suspicion of delirium?

Easily distracted

A nurse assessing a client who has borderline personality disorder. Which of the following findings should the nurse expect?

Emotional lability

A nurse is admitting a client who has anorexia nervosa and is at 60% of ideal body weight. Which of the following interventions should the nurse include in the plan of care?

Encourage the client to drink 125 mL of fluid each hour while awake.

A nurse in a mental health facility is caring for a client who requires the use of restraints. Which of the following actions should the nurse take when caring for the client?

Ensure a staff member checks on the client every 15 min.

A nurse in an inpatient mental health facility is caring for a client. The client begins pacing with their fists clenched and is verbally abusing the staff. Which of the following actions should the nurse take?

Ensure security personnel are available in the background to assist if the client's behavior escalates.

A nurse is planning prevention strategies for partner violence in the community. Which of the following strategies should the nurse include as a method of secondary prevention?

Establish screening programs to identify at-risk clients.

A nurse in a community health center is teaching families of clients who have PTSD about expected clinical manifestations. Which of the following manifestations should the nurse include?

Experiences feelings of isolation

A nurse in the emergency department is caring for a client who has alcohol toxicity and is unresponsive. Which of the following interventions should the nurse take?

Gather supplies for endotracheal intubation.

A nurse in a community health center is working with a group of clients who have post-traumatic stress disorder. Which of the following intervention should the nurse include to reduce anxiety among the group members?

Guided imagery

A nurse is assessing a client who recently used cocaine. Which of the following findings should the nurse expect?

Hypertension

A nurse is teaching a partner of a client who has bipolar disorder how to identify manifestations of acute mania. Which of the following findings should the client's partner report to the provider?

Inability to sleep

A nurse is performing an admission assessment on a client and notices that the client appears withdrawn and fearful. To establish a trusting nurse client relationship which of the following action, should the nurse take first?

Inform the client that this admission is confidential.

A school nurse is assessing a school- age child who is experienced the traumatic loss of a parent 8 months ago. Which of the following findings should the nurse identify as an indications that the child is experiencing post traumatic stress disorder?

Lack of interest in an upcoming holiday

A nurse is educating the parent of a child who has a new diagnosis of autism spectrum disorder. Which of the following manifestations of this disorder should the nurse include in the teaching?

Language Delay

A nurse is planning care for a client who has generalized anxiety disorder. At which of the following levels of anxiety, should the nurse plan to teach the client relaxation techniques?

Mild

A nurse is planning care for a client who is to undergo electroconvulsive therapy (ECT). Which of the following actions should the nurse include in the plan?

Monitor the client's cardiac rhythm during the procedure

A client who has a recent diagnosis of bipolar disorder is placed in a room with a client who has severe depression. The client who has depression reports to the nurse, "my roommate never sleeps, and keeps me up, two". Which of the following action should the nurse take?

Move the client who has bipolar disorder to a private room

A nurse is planning care for a client who has made repeated physical threat towards others on the unit. Although the client does not want to leave the unit, the nurse request the provider to transfer the client to a unit that is equipped to manage violent behavior. Which of the following ethical principles should the nurse apply in the situation?

Nonmaleficence

A nurse is caring for a client who has a personality disorder.For each potential providers prescription, click to specify if the prescribe therapy is expected with obsessive compulsive disorder dementia, or borderline personality disorder.

OCD - systematic desensitization - Fluoxetine 20 mg PO daily Dementia - Validation therapy - donepezil 5 mg PO daily Borderline personality disorder - dialectical behavioral therapy - Fluoxetine 20 mg PO daily

A nurse is planning care for a newly admitted client who has bipolar disorder and is experiencing mania. Which of the following?

Offer the client high-calorie finger foods frequently.

A nurse is caring for an older adult client who is experiencing delirium. Which of the following intervention should the nurse include in the clients plan of care?

Permit the client to perform daily rituals to decrease anxiety.

For each potential assessment finding, click to specify if the finding is consistent with positive or negative symptoms of schizophrenia.

Positive: - Delusions of grandeur - Clang associations - Catatonia Negative: -Alogia - Withdrawal from social activities

A nurse is planning care for a client who has schizophrenia and reports auditory hallucinations. Which of the following interventions should the nurse include in the plan?

Promote the use of music to compete with the client's auditory hallucinations.

A nurse is caring for a child who has conduct disorder, and he's behaving in a destructive manner, throwing objects and kicking others. Which of the following therapeutic nursing interventions is the priority?

Reduce environmental stimuli

A nurse is establishing a therapeutic relationship with a client who has antisocial personality disorder. Which of the following strategies should the nurse use when communicating with this client?

Set realistic limits on the client's behavior

A nurse on a mental health unit is caring for a group of clients. Which of the following actions by the nurse is an example of the ethical principle of justice?

Spending adequate time with a client who is verbally abusive.

A nurse is talking with a group of parents who have recently experienced the death of a child. Which of the following actions should the nurse take?

Suggest forming a weekly support group for parents who have experienced the death of a child.

A nurse is caring for a child who is taking methylphenidate. The nurse and monitor the child for which of the following findings as an adverse effect of methylphenidate?

Tachycardia

A nurse is assessing a client for risk factors for the development of depression. The nurse should identify that which of the following factors places the client at an increased risk for depression?

The client has COPD.

36-year-old well-nourished female presenting with recurrence of labile behavior involving episodes of self-injury (cutting arms and legs) and hypersexualization, recent arrest for stealing money from family to cover credit card charges and instigating physical altercations with current spouse. Axis 1: major depressive disorder; Axis 2: borderline personality disorder Client attends a group exercise class twice a week and eats a well-balanced diet. Employed as legal secretary for past 12 years. The client is at risk for developing _____________ as evidenced by the client's ______________.

The client is at risk for developing violent behavior as evidenced by the client's increased agitation.

Client diagnosed with major depressive disorder 15 years ago. Visits clinic twice a week for outpatient group therapy with social worker and follow-up with nurse. Client actively participates in therapy. Acknowledges that relationship with family members has improved and there are fewer verbal altercations. Thursday: Client presents with irritability, diaphoresis, and severe headache, and states, "I am really feeling bad. My heart is pounding." Was excited to share they had met a friend for lunch before coming to the clinic. "Maybe it's something I ate, but we both had the same thing - corned beef sandwich with Swiss cheese. Do you think it is food poisoning?" The client is at risk of developing ___________________ due to _____________?

The client is at risk of developing hypertensive crisis due to consuming foods high in tyramine.

During a client's initial interview in a mental health inpatient setting, a nurse identifies that the client is maintaining eye contact and leaning forward. Which of the following assumptions should the nurse make based on the client's nonverbal behaviors?

The client is interested in what the nurse is saying.

While observing group therapy, a nurse recognizes that a client is behaving in a way suggestive of dependent personality disorder. Which of the following behaviors is consistent with this condition?

The client needs excessive external input to make everyday decisions.

A nurse is discussing a 12-step program with a client who has alcohol use disorder and is in an acute care facility undergoing detoxification. Which of the following information should the nurse include in the teaching?

The client should obtain a sponsor before discharge for an increased chance of recovery.

A nurse is reviewing laboratory results for a client who has schizophrenia and is taking clozapine. Which of the following values should the nurse identify as a contra indication for receiving clozapine?

WBC count 2,500/mm³

After reviewing the client's medical record, the nurse should notify the provider of which of the following findings related to clozapine?

When taking actions, the nurse should identify an elevated temperature, hypoactive bowel sounds, a decreased ANC level, myalgia along with an increased heart rate can be adverse effects of the medication clozapine. Therefore, the nurse should report these findings to the client's provider.

A nurse is monitoring a client who began taking sertraline 3 days ago. Which of the following findings should the nurse report to the provider as potential adverse effects of this new medication? Select all that apply.

When taking actions, the nurse should identify that an increased temperature, decreased sodium level, diaphoresis, insomnia, headache, and elevated blood pressure can be adverse effects of the medication sertraline. Therefore, the nurse should report these findings to the provider.