MH - ATI Book questions

4. A nurse is planning care for a client who has body dysmorphic disorder. Which of the following actions should the nurse plan to take first? A. Assessing the client's risk for self-harm B. instilling hope for positive outcomes C. encouraging the client to participate in group therapy sessions D. encouraging the client to participate in treatment decisions

4. A. CORRECT: the greatest risk to a client who has an anxiety or obsessive-compulsive disorder is self-harm or suicide. therefore, the first action the nurse should plan to take is to assess the client's risk for self-harm to ensure that the client is provided with a safe environment.

5. A nurse is caring for a client who has acute stress disorder and is experiencing severe anxiety. Which of the following statements actions should the nurse make? 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. CORRECT: Asking an open-ended question is therapeutic and assists the client in identifying anxiety.

a nurse is caring for a client who has a new prescription for disulfiram for treatment of alcohol use disorder. the nurse informs the client that this medication can cause nausea and vomiting if he drinks alcohol. Which of the following types of treatment is this method an example? a. aversion therapy b. Flooding c. Biofeedback d. dialectical behavior therapy

A. CORRECT: Aversion therapy pairs a maladaptive behavior with unpleasant stimuli to promote a change in behavior

1. A nurse working in an acute mental health facility is caring for a 35‑year‑old female client who has manifestations of depression. The client lives at home with her partner and two young children. she currently smokes and has a history of chronic asthma. Which of the following factors put the client at risk for depression? (select all that apply.) A. Age B. Gender C. History of chronic asthma D. smoking E. Being married

A. CORRECT: Depressive disorders are more prevalent in adults between the ages of 15 and 40. B. CORRECT: Depressive disorders are twice as common in women than men. C. CORRECT: Depressive disorders are more common in clients who have a chronic medical illness. D. CORRECT: Depressive disorders are more common in clients who have a substance use disorder, such as nicotine use disorder.

3. A home health nurse is making a visit to a client who has Alzheimer's disease to assess the home for safety. Which of the following suggestions should the nurse make 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. CORRECT: Door locks that are difficult to open are appropriate to reduce the risk of the client wandering outside without supervision. D. CORRECT: Placing the client's mattress on the floor reduces the risk for falls out of bed. e. CORRECT: stairs should have adequate lighting to reduce the risk for falls.

3. A nurse is assessing a client who has generalized anxiety disorder. Which of the following findings should the nurse expect? (select all that apply.) A. excessive worry for 6 months B. impulsive decision making C. Delayed reflexes D. restlessness e. need for reassurance

A. CORRECT: Generalized anxiety disorder is characterized by uncontrollable, excessive worry for more than 3 months. D. CORRECT: Generalized anxiety disorder is characterized by restlessness. E. CORRECT: Generalized anxiety disorder is characterized by the need for repeated reassurance.

2. 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 actions is the nurse's priority? 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 effect

A. CORRECT: The greatest risk for a client who has MDD and comorbid anxiety is injury due to self‑harm. The highest priority intervention is placing the client on one‑to‑one observation.

2. 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. CORRECT: hallucinations are an example of a positive symptom. c. CORRECT: Alterations in speech are an example of a positive symptom. D. CORRECT: Delusions are an example of a positive symptom. e. CORRECT: Bizarre motor movements are an example of a positive symptom.

1. 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 should the nurse make? (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. CORRECT: the nurse should ask the client directly about the hallucination. c. CORRECT: the nurse should focus on the client's feelings rather than agreeing with the client's hallucination. D. CORRECT: the nurse should assess for command hallucinations and the client's risk for injury to self or others.

4. 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 actions should the nurse take first? 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. CORRECT: A client who is experiencing a command hallucination is at risk for injury to self or others. safety is the priority, and initiating one‑to‑one observation is the first action the nurse should take.

1. A nurse is caring for a client who has early stage Alzheimer's disease and a new prescription for donepezil. the nurse should include which of the following statements when teaching the client about the medication? 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. CORRECT: Donepezil slows the cognitive deterioration of Alzheimer's disease.

4. a nurse is assessing a client 4 hr after receiving an initial dose of fluoxetine Which of the following findings should the nurse report to the provider as indications of serotonin syndrome? (select all that apply.) a. Hypothermia B. Hallucinations c. Muscular flaccidity d. diaphoresis e. agitation

B. CORRECT: Hallucinations are an indication of serotonin syndrome d. CORRECT: diaphoresis is an indication of serotonin syndrome. e. CORRECT: agitation is an indication of serotonin syndrome.

3. 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. CORRECT: Hypokalemia is an expected finding of purging‑type bulimia nervosa. D. CORRECT: Most clients who have bulimia nervosa maintain a weight within a normal range or slightly higher

2. a nurse is providing preoperative teaching for a client who was just informed that she requires emergency surgery. the client, has a respiratory rate 30/min, and says, "this is difficult to comprehend. i feel shaky and nervous." the nurse should identify that the client is experiencing which of the following levels of anxiety? a. Mild B. Moderate c. Severe d. Panic

B. CORRECT: Moderate anxiety decreases problem‑solving and may hamper the client's ability to understand information. Vital signs may increase somewhat, and the client is visibly anxiou

2. a nurse is involved in a serious and prolonged mass casualty incident in the emergency department. Which of the following strategies should the nurse use to help prevent developing a trauma‑related disorder? (Select all that apply) a. avoid thinking about the incident when it is over. B. Take breaks during the incident for food and water. C. debrief with others following the incident. d. Hold emotions in check in the days following the incident. e. Take advantage of offered counseling

B. CORRECT: Taking breaks and remembering to drink water and eat nutritious foods while working during a traumatic incident can help prevent development of a trauma‑related disorder. C. CORRECT: debriefing with others following a traumatic incident can help prevent development of a trauma‑related disorder. e. CORRECT: Taking advantage of counseling offered by an employer or others can help prevent development of a trauma‑related disorder.

5. a nurse is discussing relapse prevention with a client who has bipolar disorder. Which of the following information 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. CORRECT: The client should be alert for sleep disturbances, which can indicate a relapse. D. CORRECT: The client who has bipolar disorder can participate in psychotherapy to help prevent a relapse. e. CORRECT: The client who has bipolar disorder should be aware of manifestations, including anhedonia, which is a depressive characteristic that can indicate a relapse.

4. 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 responses should the nurse make? 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. CORRECT: This statement is matter‑of‑fact and concise and is a therapeutic response to a client who has bipolar disorder.

3. a nurse is in the working phase of a therapeutic relationship with a client who has methamphetamine use disorder. Which of the following actions 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. CORRECT: When a client views the nurse as having characteristics of another person who has been significant to his personal life, such as his ex-girlfriend, this indicates transference.

2. a nurse decides to put a client who has a psychotic disorder in seclusion overnight because the unit is very short‑staffed, and the client frequently fights with other clients. the nurse's actions are an example of which of the following torts? a. invasion of privacy B. False imprisonment c. assault d. Battery

B. CORRECT: a civil wrong that violates a client's civil rights is a tort. in this case, it is false imprisonment, which is the confining of a client to a specific area, such as a seclusion room, if the reason for such confinement is for the convenience of staff

2. a nurse is discussing acute vs. prolonged stress with a client. Which of the following effects should the nurse identify as an acute stress response? (Select all that apply.) a. Chronic pain B. Depressed immune system C. Increased blood pressure D. Panic attacks e. Unhappiness

B. CORRECT: a depressed immune system is an indicator of acute stress. C. CORRECT: Increased blood pressure is an indicator of acute stress e. CORRECT: Unhappiness is an indicator of acute stress

5. 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. CORRECT: an act group works with clients who are nonadherent with traditional therapy, such as the client in a home setting who keeps "forgetting" his injection

1. a nurse is discussing the risk factors for somatic symptom disorder with a newly licensed nurse. Which of the following risk factors should the nurse include? (Select all that apply.) a. age older than 65 years B. anxiety disorder c. Female gender d. coronary artery disease e. obesity

B. CORRECT: anxiety disorder is a risk factor for somatic symptom disorder. c. CORRECT: Female gender is a risk factor for somatic symptom disorder.

4. 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." Which of the following recommendations should the nurse make 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. CORRECT: assertive communication allows the client to assert her feelings and then make a change in the situation

3. a nurse in an outpatient mental health clinic is preparing to conduct an initial client interview. When conducting the interview, which of the following actions should the nurse identify as the priority? a. coordinate holistic care with social services. 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. CORRECT: assessment is the priority action when using the nursing process approach to client care. identifying the client's perception of her mental health status provides important information about the client's psychosocial history.

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. CORRECT: classical psychoanalysis places a common focus on past relationships to identify the cause of the anxiety disorder.

3. a nurse is caring for a client who is experiencing moderate anxiety. Which of the following actions should the nurse take when trying to give necessary information to the client? (Select all that apply.) a. reassure the client that everything will be okay. B. discuss prior use of coping mechanisms with the client. c. ignore the client's anxiety so that she will not be embarrassed. d. demonstrate a calm manner while using simple and clear directions. e. Gather information from the client using closed‑ended questions.

B. CORRECT: discussing the prior use of coping mechanisms assists the client in identifying ways of effectively coping with the current stressor. d. CORRECT: Providing a calm presence assists the client in feeling secure and promotes relaxation. clients experiencing moderate levels of anxiety often benefit from the direction of others.

4. a nurse is caring for a client who is in mechanical restraints. Which of the following statements should the nurse include in the 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 obscenities at assistive personnel." d. "client received chlorpromazine 15 mg by mouth at 1000." e. "client acted out after lunch."

B. CORRECT: how much water was offered and how often it was offered is objective data that the nurse should document when caring for a client in mechanical restraints. c. CORRECT: a description of the client's verbal communication is objective data that the nurse should document when caring for a client in mechanical restraints. d. CORRECT: the dosage and time of medication administration is objective data that the nurse should document when caring for a client in mechanical restraints e. the nurse should document objective information regardi

1. a nurse is planning care for a client who has bipolar disorder and is experiencing a manic episode. Which of the following interventions should the nurse 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. CORRECT: offering concise explanations improves the client's ability to focus and comprehend the information. C. CORRECT: establishing consistent limits decreases the risk for client manipulation. e. CORRECT: Using a firm approach with client communication promotes structure and minimizes inappropriate client behaviors.

1. a nurse is providing teaching to a client who has a new prescription for amitriptyline. Which of the following statements by the client indicates an 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. CORRECT: sedation is an adverse effect of amitriptyline during the first few weeks of therapy.

3. 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. CORRECT: splitting occurs when a person is unable to see both positive and negative qualities at the same time. the client who has borderline personality disorder tends to see a person as all bad one time and all good another time.

5. 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 information is appropriate to include in the discussion? (select all that apply.) a. the DsM‑5 includes client education handouts for mental health disorders. B. the DsM‑5 establishes diagnostic criteria for individual mental health disorders. c. the DsM‑5 indicates recommended pharmacological treatment for mental health disorders. D. the DsM‑5 assists nurses in planning care for client's who have mental health disorders. e. the DsM‑5 indicates expected assessment findings of mental health disorders.

B. CORRECT: the DsM‑5 establishes diagnostic criteria for mental health disorders. D. CORRECT: nurses use the DsM‑5 to plan, implement, and evaluate care for client's who have mental health disorders e. CORRECT: the DsM‑5 identifies expected findings for mental health disorders.

5. A nurse is performing an admission assessment for a client who has delirium related to an acute urinary tract infection. Which of the following findings should the nurse expect? (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. CORRECT: the client who has delirium can experience rapid personality changes. c. CORRECT: the client who has delirium can have perceptual disturbances, such as hallucinations and illusion e. CORRECT: the client who has delirium commonly exhibits restlessness and agitation

5. 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. CORRECT: the greatest risk to this client is an invasion of privacy through the sharing of confidential information in a public place. the first action the nurse should take is to tell the newly licensed nurse to stop discussing the client's hallucinations in a public location.

5. 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. CORRECT: the nurse should ask the client directly about the hallucination to identify client needs and assess for a potential risk for injury.

2. a nurse is caring for a client who is taking phenelzine for which of the following adverse effects should the nurse monitor? (select all that apply.) a. elevated blood glucose level B. orthostatic hypotension c. priapism d. Headache e. Bruxism

B. CORRECT: the nurse should observe for orthostatic hypotension, which is an adverse effect of phenelzine. d. CORRECT: the nurse should observe for a headache which is an adverse effect of phenelzine.

3. 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. CORRECT: this comment indicates the client is experiencing a loss of identity or depersonalization.

1. 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." the nurse should identify that the client is using which of the following defense mechanisms? a. reaction formation B. denial c. displacement d. Sublimation

B. CORRECT: this is an example of denial, which is pretending the truth is not reality to manage the anxiety of acknowledging what is real.

3. 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 minutes 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. CORRECT: A clinical finding of pMDD is emotional lability. The client can experience rapid changes in mood.

1. 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 underlying reasons? A. narcissistic behavior B. Fear of rejection from staff C. Attempt to reduce anxiety D. Adverse effect of antidepressant medication

C. CORRECT: Clients who have oCD demonstrate repetitive behavior in an attempt to suppress persistent thoughts or urges that cause anxiety.

5. a nurse is orienting a new client to a mental health unit. When explaining the unit's community meetings, which of the following statements should the nurse make? 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. CORRECT: Community meetings are an opportunity for clients to discuss common problems or issues affecting all members of the unit

5. A nurse is interviewing a 25‑year‑old client who has a new diagnosis of dysthymic disorder. Which of the following findings should the nurse expect? A. Wide fluctuations in mood B. report of a minimum of five clinical findings of depression C. presence of manifestations for at least 2 years D. inflated sense of self‑esteem

C. CORRECT: Manifestations of dysthymic disorder last for at least 2 years in adults.

4. a nurse is caring for a client who has derealization disorder. Which of the following findings should the nurse identify as an indication of derealization? a. The client explains that her body seems to be floating above the ground. B. The client has the idea that someone is trying to kill her and steal her money. C. The client states that the furniture in the room seems to be small and far away. d. The client cannot recall anything that happened during the past 2 weeks

C. CORRECT: Stating that one's surroundings are far away or unreal in some way is an example of derealization.

4. 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 an understanding of the teaching? A. "Care during the continuation phase focuses on treating continued manifestations of MDD." B. "The treatment of MDD during the maintenance phase lasts for 6 to 12 weeks." C. "The client is at greatest risk for suicide during the first weeks of an MDD episode." D. "Medication and psychotherapy are most effective during the acute phase of MDD."

C. CORRECT: The client is at greatest risk for suicide during the acute phase of MDD.

1. 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 an understanding of the teaching? a. "i can promote my client's sense of control by establishing a schedule." B. "i should encourage clients who have a schizoid personality disorder to increase socialization." C. "i should practice limit‑setting to help prevent client manipulation." D. "i should implement assertiveness training with clients who have antisocial personality disorder."

C. CORRECT: When caring for a client who has a personality disorder, limit‑setting is appropriate to help prevent client manipulation.

2. a charge nurse is discussing the characteristics of a nurse-client relationship with a newly licensed nurse. Which of the following characteristics should the nurse 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. CORRECT: a therapeutic nurse-client relationship is goal-directed. d. CORRECT: a therapeutic nurse-client relationship encourages positive behavioral change. e. CORRECT: a therapeutic nurse-client relationship has an established termination date.

2. 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. CORRECT: eCT is appropriate for the treatment of severe mania associated with bipolar disorder.

4. a nurse is leading a peer group discussion about the indications for eCt. Which of the following indications should the nurse include in the discussion? a. Borderline personality disorder B. acute withdrawal related to a substance use disorder C. Bipolar disorder with rapid cycling D. Dysphoric disorder

C. CORRECT: eCt is indicated for the treatment of bipolar disorder with rapid cycling.

4. a nurse is assisting with a court‑ordered evaluation of a client who has antisocial personality disorder. Which of the following findings should the nurse expect? (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. CORRECT: exploitation and manipulation of others is an expected finding of antisocial personality disorder. e. CORRECT: Failure to accept personal responsibility is an expected finding of clients who have antisocial personality disorder.

5. a nurse is caring for a client who has bulimia nervosa and has stopped purging behavior. the client tells the nurse that she is afraid she is going to gain weight. Which of the following response should the nurse make? 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. CORRECT: this statement acknowledges the client's concern and then focuses the conversation on the client's accomplishments, which can promote client self‑esteem and self‑image.

1. a nurse is talking with a client who is at risk for suicide following the death of his spouse. Which of the following statements should the nurse make? 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. CORRECT: this statement is an empathetic response that attempts to understand the client's feelings.

3. a nurse is assessing a client immediately following an eCt procedure. Which of the following findings should the nurse expect? (Select all that apply.) a. hypotension B. paralytic ileus C. memory loss D. nausea e. Confusion

C. CORRECT: transient short‑term memory loss is an expected finding immediately following eCt. D. CORRECT: nausea is an expected finding immediately following eCt. e. CORRECT: Confusion is an expected finding immediately following eCt.

2. a nurse working in an emergency department is caring for a client who has benzodiazepine toxicity due to an overdose. Which of the following actions is the nurse's priority? a. administer flumazenil. B. identify the client's level of orientation. c. infuse iV fluids. d. Prepare the client for gastric lavage.

CORRECT: When taking the nursing process approach to client care, the initial step is assessment. identifying the client's level of orientation is the priority action.

2. A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take? 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. CORRECT: During a panic attack, the nurse should quietly remain with the client. this promotes safety and reassurance without additional stimuli.

2. a nurse is planning care for a client who has a mental health disorder. Which of the following actions should the nurse 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. CORRECT: Monitoring for adverse effects of medications is an example of a psychobiological intervention.

3. a nurse in an acute mental health facility is caring for a client who has 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. CORRECT: Monitoring for escalating behavior addresses the client's priority need for safety and is therefore the priority nursing action.

2. a nurse in an acute mental health facility is communicating with a client. 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. CORRECT: Restating allows the nurse to repeat the main idea expressed.

1. a nurse is providing teaching for a client who is scheduled to receive 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 should receive ECT once a week for 6 weeks." D. "i will receive a muscle relaxant to protect me from injury during eCt."

D. CORRECT: a muscle relaxant, such as succinylcholine, is administered to reduce the risk for injury during induced seizure activity

2. A nurse in a long‑term care facility is caring for a client 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 statements should the nurse make? 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. CORRECT: it is appropriate for the nurse to introduce herself with each new interaction and to promote reality in a calm, reassuring manner.

4. 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 should the nurse 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. CORRECT: the nurse should closely monitor the client during and after meals to prevent purging.

1. a charge nurse is conducting a class on therapeutic communication to a group of newly licensed nurses. Which of the following aspects of communication should the nurse identify as a component of verbal communication? a. Personal space B. Posture c. Eye contact D. intonation

D. CORRECT: the nurse should identify intonation as a component of verbal communication. intonation is the tone of one's voice and can communicate a variety of feelings.

5. 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 effective 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. CORRECT: this response demonstrates assertive communication, which allows the client to state his feelings about the behavior and then promote a change.

5. a nurse is caring for the parents of a child who has demonstrated recent changes in behavior and mood. When the mother of the child asks the nurse for reassurance about her son's condition, which of the following responses should the nurse make? 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. CORRECT: this therapeutic response reflects upon, and accepts, the parents' feelings, and it allows them to clarify what they are feeling

2. a charge nurse is discussing tmS with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? a. "tmS is indicated for clients who have schizophrenia spectrum disorders." B. "i will provide postanesthesia care following TMS." C. "TMS treatments usually last 5 to 10 minutes." D. "i will schedule the client for daily TMS treatments for the first several weeks."

D. CORRECT: tmS is commonly prescribed daily for a period of 4 to 6 weeks.

2. 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. CORRECT: Clients who have avoidant personality disorder often have a fear of abandonment. this type of statement is expected.

3. 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. CORRECT: Cognitive reframing helps the client look at irrational cognitions (thoughts) in a more realistic light and to restructure those thoughts in a more positive way.

5. a charge nurse is preparing a staff education session on personality disorders. Which of the following personality characteristics associated with all of the personality disorders should the charge nurse include in the teaching? (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. CORRECT: Difficulty with social and professional relationships is a personality characteristic that can be seen with all personality disorder types C. CORRECT: Maladaptive response to stress is a personality characteristic that can be seen with all personality disorder types. e. CORRECT: Difficulty understanding personal boundaries is a personality characteristic that can be seen with all personality disorder types.

1. a nurse is preparing to provide an educational seminar on stress to other nursing staff. Which of the following information should the nurse 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. absence of stressors results in homeostasis. D. negative, rather than positive, stressors produce a biological response.

a. CORRECT: Distress is the result of excessive or damaging stressors, such as anxiety or anger.

a nurse is preparing to implement cognitive reframing techniques for a client who has an anxiety disorder. Which of the following techniques should the nurse 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. CORRECT: Priority restructuring is a cognitive reframing technique. B. CORRECT: Monitoring thoughts is a cognitive reframing technique. d. CORRECT: Journal keeping is a cognitive reframing technique

5. a nurse is planning care for a client following surgical implantation of a 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. CORRECT: Voice changes are a common adverse effect of VnS due to the proximity of the implanted lead on the vagus nerve to the larynx and pharynx. D. CORRECT: Dysphagia is a potential adverse effect of VnS. however, this usually subsides with time. e. CORRECT: neck pain is a potential adverse effect of VnS. however, this usually subsides with time.

4. a nurse is told during change‑of‑shift report that a client is stuporous. When assessing the client, which of the following findings should the nurse expect? 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. CORRECT: a client who is stuporous requires vigorous or painful stimuli to elicit a response.

1. 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 should 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. CORRECT: a nursing history of a client who has anorexia nervosa should include an assessment of family and interpersonal relationships. C. CORRECT: a nursing history of a client who has anorexia nervosa should include an assessment of the client's current eating habits. E. CORRECT: a nursing history of a client who has anorexia nervosa should include an assessment of the client's perception of the issue.

5. a nurse is caring for a client who takes paroxetine to treat posttraumatic stress disorder. the client states that he grinds his teeth during the night, which causes pain in his mouth. the nurse should identify which of the following interventions as possible measures to manage the client's bruxism? (select all that apply.) a. concurrent administration of buspirone B. administration of a different ssri c. use of a mouth guard d. changing to a different class of antianxiety medication e. increasing the dose of paroxetine

a. CORRECT: concurrent administration of a low‑dose of buspirone is an effective measure to manage the adverse effect of paroxetine. c. CORRECT: using a mouth guard during sleep can decrease the risk for oral damage resulting from bruxism. d. CORRECT: changing to a different class of antianxiety medication that does not have the adverse effect of bruxism is an effective measure

1. a charge nurse is discussing mental status examinations with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? (select all that apply.) a. "to assess cognitive ability, i should ask the client to count backward by sevens." 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." e. "to assess the client's abstract thinking, i should ask the client to identify our most recent presidents."

a. CORRECT: counting backward by 7s is an appropriate technique to assess a client's cognitive ability. B. CORRECT: observing a client's facial expression is appropriate when assessing affect. c. CORRECT: Writing a sentence is an indication of language ability.

4. a nurse is planning care for the termination phase of a nurse-client relationship. Which of the following actions should the nurse include in the plan of care? a. discussing ways to use new behaviors B. practicing new problemsolving skills C. developing goals d. establishing boundaries

a. CORRECT: discussing ways for the client to incorporate new healthy behaviors into life is an appropriate task for the termination phase.

3. a nurse is working in a community mental health facility. Which of the following services does this type of program provide? (select all that apply.) a. educational groups B. Medication dispensing programs c. individual counseling programs D. Detoxification programs e. Family therapy

a. CORRECT: educational groups are services provided in a community mental health facility. B. CORRECT: Medication dispensing programs are services provided in a community mental health facility. c. CORRECT: individual counseling programs are services provided in a community mental health facility. e. CORRECT: Family therapy is a service provided in a community mental health facility.

1. a nurse working on an acute mental health unit is caring for a client who has posttraumatic stress disorder (PTSd). Which of the following findings should the nurse expect? (Select all that apply.) a. difficulty concentrating on tasks B. obsessive need to talk about the traumatic event C. negative self‑image d. recurring nightmares e. diminished reflexes

a. CORRECT: manifestations of PTSd include the inability to concentrate on or complete tasks. C. CORRECT: manifestations of PTSd include feeling guilty and having a negative self‑image. d. CORRECT: manifestations of PTSd include recurring nightmares or flashbacks.

3. a nurse is assessing a client who has illness anxiety disorder. Which of the following findings should the nurse expect? (Select all that apply.) a. obsessive thoughts about disease B. History of childhood abuse c. avoidance of health care providers d. depressive disorder e. narcissistic personality

a. CORRECT: obsessive thoughts about disease is an expected finding in a client who has illness anxiety disorder. B. CORRECT: a history of childhood abuse is an expected finding in a client who has illness anxiety disorder. c. CORRECT: avoidance of health care providers is an expected finding in clients who have illness anxiety disorder of the care‑avoidant type. d. CORRECT: a depressive disorder is an expected finding in a client who has illness anxiety disorder.

3. a nurse is communicating with a client who was just admitted for treatment of a substance use disorder. Which of the following communication techniques should the nurse identify as a barrier to therapeutic communication? a. offering advice B. Reflecting c. Listening attentively D. Giving information

a. CORRECT: offering advice to a client is a barrier to therapeutic communication that the nurse should avoid using. advice tends to interfere with the client's ability to make personal decisions and choice

2. a nurse is reviewing the medical record of a client who has conversion disorder. Which of the following findings should the nurse identify as placing the client at risk for conversion disorder? a. death of a child 2 months ago B. Recent weight loss of 30 lb c. Retirement 1 year ago d. History of migraine headaches

a. CORRECT: the death of a child 2 months ago is an acute stressor that places the client at risk for conversion disorder

2. 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. CORRECT: this statement reflects the cognitive distortion of catastrophizing because the client's perception of her appearance or situation is much worse than her current condition.

5. 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 indicate an understanding of the teaching? (Select all that apply.) a. "We need to understand that she is 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." e. "She needs to discuss her feelings about substance use to help her recover.

b. CORRECT: Families should be aware of codependent behavior, such as enabling, that can promote substance use rather than recovery. d. CORRECT: abstinence is the primary treatment goal for a client who has a substance use disorder. e. CORRECT: clients must acknowledge their feelings about substance use as part of a substance use recovery program.

2. a nurse is assessing a client who has alcohol use disorder and is experiencing withdrawal. Which of the following findings should the nurse expect? (Select all that apply.) a. bradycardia b. Fine tremors of both hands c. Hypotension d. vomiting e. restlessness

b. CORRECT: Fine tremors of both hands is an expected finding of alcohol withdrawal. d. CORRECT: vomiting is an expected finding of alcohol withdrawal. e. CORRECT: restlessness is an expected finding of alcohol withdrawal.

4. A nurse is making a home visit to a client who is in the late stage of Alzheimer's disease. the client's partner, who is the primary caregiver, wishes to discuss concerns about the client's nutrition and the stress of providing care. Which of the following actions should the nurse take? A. verify that a current power of attorney document is on file. B. instruct the client's partner 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. CORRECT: Providing information on resources for respite care is an appropriate action to provide the client's partner with a break from caregiving responsibilities.

3. a nurse is caring for a client who is to begin taking fluoxetine 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. CORRECT: When discontinuing fluoxetine, the client should taper the medication slowly according to a prescribed tapered dosing schedule to reduce the risk of withdrawal syndrome

5. a nurse is counseling a client who has factitious disorder imposed on another. Which of the following client statements should the nurse expect? a. "i had to pretend i was injured in order to get disability benefits." B. "i know that my abdominal pain is caused by a malignant tumor." c. "i needed to make my son sick so that someone else would take care of him for a while." d. "i became deaf when i heard that my husband was having an affair with my best friend."

c. CORRECT: a client who has factitious disorder imposed on another often consciously injures another person or causes them to be sick due to a personal need for attention or relief of responsibility.

1. 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 adverse 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 manifestations of severe anxiety before and during a job interview

c. CORRECT: a client who hears a voice telling him he is not worthy is at greatest risk for self‑harm, and the nurse should visit this client first.

1. a nurse in an emergency mental health facility is caring for a group of clients. the nurse should identify that which of the following clients requires a temporary emergency admission? a. a client who has schizophrenia with delusions of grandeur B. a client who has manifestations of depression and attempted suicide a year ago c. a client who has borderline personality disorder and assaulted a homeless man with a metal rod d. a client who has bipolar disorder and paces quickly around the room while talking to himself

c. CORRECT: a client who is a current danger to self or others is a candidate for a temporary emergency admission.

4. a nurse in an acute mental health facility is assisting with discharge planning for a client who has a severe mental illness and requires supervision much of the time. the client's wife works all day but is home by late afternoon. Which of the following strategies 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. CORRECT: a partial hospitalization program can provide treatment during the day while allowing the client to spend nights at home, as long as a responsible family member is present

2. a community mental health nurse is planning care to address the issue of depression among older adult clients in the community. Which of the following interventions should the nurse plan as a method of tertiary prevention? a. educating clients on health promotion techniques to reduce the risk of depression B. Performing screenings for depression at community health programs c. establishing rehabilitation programs to decrease the effects of depression D. Providing support groups for clients at risk for depression

c. CORRECT: rehabilitation programs are an example of tertiary prevention. tertiary prevention deals with prevention of further problems in clients already diagnosed with mental illness.

1. 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 an increased risk for substance use following retirement. d. older adults develop substance use to mask manifestations of dementia.

c. CORRECT: retirement and other life change stressors increase the risk for substance use in older adults, especially if there is a prior history of substance use.

a nurse is assisting with systematic desensitization for a client who has an extreme fear of elevators. Which of the following actions should the nurse implement with 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. CORRECT: systematic desensitization is the planned, progressive exposure to anxiety‑provoking stimuli. during this exposure, relaxation techniques suppress the anxiety response.

3. a nurse is planning care for a client who is experiencing benzodiazepine withdrawal. Which of the following interventions should the nurse identify as the priority? 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. CORRECT: the greatest risk to the client is injury. implementing seizure precautions is the priority intervention.

3. a client tells a 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 the health care team because it concerns the health and safety of the client and others. d. Report the incident to the health care team, but do not inform the client of the intention to do so.

c. CORRECT: the information presented by the client is a serious safety issue that the nurse must report to the health care team. using the ethical principle of veracity, the student tells the client truthfully what must be done regarding the issue

4. 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 b. bupropion c. disulfiram d. carbamazepine

c. CORRECT: the nurse should expect to administer disulfiram to help the client maintain abstinence from alcohol.

4. a nurse caring for a client who has anorexia nervosa. Which of the following examples demonstrates the nurse's use of interpersonal communication? a. the nurse discusses the client's weight loss during a health care team meeting. B. the nurse examines her own personal feelings about clients who have anorexia nervosa. c. the nurse asks the client about her body image perception. D. the nurse presents an educational session about anorexia nervosa to a large group of adolescents.

c. CORRECT: the nurse's one‑on‑one communication with the client is an example of interpersonal communication

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. CORRECT: Free association is the spontaneous, uncensored verbalization of whatever comes to a client's mind.

5. a nurse in an acute mental health facility is planning care for a client who has dissociative fugue. Which of the following interventions should the nurse add to the plan of care? a. Teach the client to recognize how stress brings on a personality change in the client. B. repeatedly present the client with information about past events. C. make decisions for the client regarding routine daily activities. d. Work with the client on grounding techniques.

d. CORRECT: Grounding techniques, such as stomping the feet, clapping the hands, or touching physical objects, are useful for clients who have a dissociative disorder and are experiencing manifestations of derealization.

3. a nurse is collecting an admission history for a client who has acute stress disorder (aSd). Which of the following information should the nurse expect to collect? a. The client remembers many details about the traumatic incident. B. The client expresses heightened elation about what is happening. C. The client states he first noticed manifestations of the disorder 6 weeks after the traumatic incident occurred. d. The client expresses a sense of unreality about the traumatic incident

d. CORRECT: The client who has aSd often expresses dissociative manifestations regarding the event, which includes a sense of unreality.

1. a nurse working in a mental health clinic is providing teaching to a client who has a new prescription for diazepam for generalized anxiety disorder. Which of the following information should the nurse provide? a. three to six 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 dependence than other antianxiety medications. d. report confusion as a potential indication of toxicity

d. CORRECT: confusion is a potential indication of diazepam toxicity that the client should report to the provider.

4. a nurse is developing a plan of care for a client who has conversion disorder. Which of the following actions should the nurse include? a. encourage the client to spend time alone in his room. B. monitor the client for self‑harm once per day. c. allow the client unlimited time to discuss physical manifestations. d. discuss alternative coping strategies with the client.

d. CORRECT: the nurse should discuss alternative coping strategies with the clien