Saunders Mental Health Questions
1092. An emergency department nurse is caring for an adult client who is a victim of family violence. Which priority instruction should be included in the discharge instructions? 1. Information about shelters. 2. Instructions about fighting back. 3. Instructions about calling the police. 4. Instructions about self-defense classes.
1. Information about shelters.
1153. The nurse understands that which issues are psychosocial concern(s) related to aging? Select all that apply. 1. Loss of skills and competencies. 2. Increased quality of relationships. 3. Costs of health care and medications. 4. Adjustment to deterioration in health. 5. Coping with changes in role function.
1. Loss of skills and competencies. 3. Costs of health care and medications. 4. Adjustment to deterioration in health. 5. Coping with changes in role function.
1145. A client who was found on the ground of his back yard by a neighbor is dead on arrival (DOV) to the emergency department. The nurse asks the accompanying family about religious background, understanding that which religion(s) may prohibit autopsy? Select all that apply. 1. Muslim 2. Mormon 3. Buddhist 4. Orthodox Jew 5. Eastern Orthodox
1. Muslim 4. Orthodox Jew 5. Eastern Orthodox
1156. The nurse is providing end-of-life care to a Hindu client. The nurse understands that which behavior is included in this religious group's end-of-life practice? 1. Tying a thread around the neck. 2. Receiving sacraments upon request. 3. Expressing grief through hitting the body. 4. Prohibiting adornment of caskets at the funeral.
1. Tying a thread around the neck.
1093. A client is preparing to attend a Gamblers Anonymous meeting for the first time. The prototype used by this group is the 12-step program developed by Alcoholics Anonymous. Number is order of priority how the steps would be addressed. (Number 1 is the first step, and number 5 is the last step) -Admitting to oneself and to another human being the exact nature of one's wrongs. -Acknowledging that one is entirely ready to have his or her defects of character removed. -Admitting that oneself i
-Acknowledging that one is entirely ready to have his or her defects of character removed. -Admitting that oneself is powerless over gambling and that one's life had become unmanageable. -Admitting to oneself and to another human being the exact nature of one's wrongs. -Making direct amends wherever possible to all people that have been hurt, except when to do so would further harm them or others. -Making an effort to practice the 12-step principles in all affairs, and to carry this message to other compulsive gamblers.
1082. The spouse of a client who abuses alcohol states, " I wish I could just get out of this situation and far away from my spouse." Which response by the nurse is therapeutic? 1. " What aspects of this situation are most difficult for you?" 2. " In order to ensure your safety, it's probably best that you leave." 3. "Maybe you should make this decision when your spouse is stable." 4. "I don't think that's what is best for you or your spouse now. Besides, where would you go?"
1. " What aspects of this situation are most difficult for you?"
1120. The nurse interprets that which comment by the woman whose husband uses physical violence against her is consistent with the presence of self-deprecation commonly found with battered wife syndrome? 1. "Things would be fine if I could just do better." 2. "I stay because I can stay home and I don't have to work." 3. "I told him that this is his last chance; if he hits me again, I'm leaving for good." 4. "I feeling fortunate to be married to a man who really loves me the way that he does"
1. "Things would be fine if I could just do better."
1084. Which description(s) are characteristic(s) of a crisis state for a client. Select all that apply. 1. A client's response to a crisis is individualized. 2. A crisis state will always last from 3 to 5 days. 3. A crisis state does not mean that the individual has a mental illness. 4. Presenting symptoms in a crisis situation are similar for all individuals. 5. A crisis state indicates that the individual is suffering from an emotional illness.
1. A client's response to a crisis is individualized. 3. A crisis state does not mean that the individual has a mental illness.
1087. A client with an eating disorder is planning to attend group meetings with overeaters anonymous. The nurse describes this group to the client, knowing that which finding(s) are characteristic of this form of self-help group? Select all that apply. 1. A common goal is shared by all members. 2. Members are required to remain anonymous. 3. The leader is a professional mental health care provider. 4. Attendance must be prescribed by the health care provider. 5. The program is designed to pr
1. A common goal is shared by all members. 5. The program is designed to provide support to bring about personal change. 6. The group is composed of individuals who are experiencing similar problems.
1148. A client had been admitted to the psychiatric unit for displaying violent behavior and is at risk for potentially harming others. The nurse should take which action(s) when care for this client? Select all that apply. 1. Admit the client to a room near the nurses' station. 2. Face the client while speaking and providing nursing care. 3. Arrange for a security officer to be available in the general area. 4. Close the door to the client's room when giving care to the client. 5. Place the cl
1. Admit the client to a room near the nurses' station. 2. Face the client while speaking and providing nursing care. 3. Arrange for a security officer to be available in the general area.
1168. Which characteristic(s) accurately describes anorexia nervosa? Select all that apply. 1. An intense fear of obesity. 2. Disturbed body image and disturbed self-concept. 3. Onset is often associated with a stressful life event. 4. The client has a phobia against foods that cause weight loss. 5. The client is often preoccupied with foods that cause weight loss.
1. An intense fear of obesity. 2. Disturbed body image and disturbed self-concept. 3. Onset is often associated with a stressful life event. 5. The client is often preoccupied with foods that cause weight loss.
1110. A client with a diagnosis of depression has experienced poor nutritional intake for the last 3 weeks. Which nursing intervention(s) are most appropriate to address the client's poor nutritional intake? Select all that apply. 1. Arranging to site with the client during meals. 2. Offering the client several small meals and snacks per day. 3. Weighing the client three times per week before breakfast. 4.Explaing to the client the importance of good nutritional intake. 5. Consulting with the
1. Arranging to sit with the client during meals. 2. Offering the client several small meals and snacks per day. 5. Consulting with the nutritionist to provide a menu that is nutritionally sound.
1124. The nurse understands that which cultural group(s) emphasize the family as the decision maker as opposed to the individual? Select all that apply. 1. Asian Americans. 2. Native Americans. 3. African Americans. 4. Mexican Americans. 5. European Americans.
1. Asian Americans. 2. Native Americans. 3. African Americans. 4. Mexican Americans.
1091. A client with schizophrenia is experiencing distressful thoughts secondary to paranoia. Which intervention(s) should the nurse include in the plan of care? Select all that apply. 1. Avoid laughing when near the client. 2. Whisper when communicating near the client. 3. Increase socialization of the client among his peers. 4. Have the client sign a written release of information form. 5. Provide food items that are in containers that need to be opened. 6. Begin to educate the client about
1. Avoid laughing when near the client. 5. Provide food items that are in containers that need to be opened.
1119. Which behavior presented by the client with mania requires the nurse's immediate intervention? 1. Being "too busy to eat" 2. Outlandish, inappropriate dress. 3. Grandiose delusions of being "a royal" 4. Incessant talking that includes sexual innuendo.
1. Being "too busy to eat"
1108. The nurse understands that which area(s) need to be explored in order to conduct a culturally sensitive assessment related to end-of-life care? Select all that apply. 1. Communication about death. 2. The decision-making process. 3. Financial support for client care. 4. The significance of pain and suffering. 5. The nurse's beliefs on death and dying. 6. Amount and type of accepted intervention.
1. Communication about death. 2. The decision-making process. 4. The significance of pan and suffering. 5. The nurse's beliefs on death and dying. 6. Amount and type of accepted intervention.
1137. A client who had just been sexually assaulted and rape is very quiet and calm. Which defense mechanism is the client's behavior demonstrating? 1. Denial 2. Projection 3. Rationalization 4. Intellectualization
1. Denial
1128. Which information should the nurse include in the plan of care for a client with obsessive-compulsive disorder? Select all that apply. 1. Ensure that basic needs are met. 2. Interrupt the client's use of compulsive behaviors. 3. Identify situations that precipitate compulsive behavior. 4. Set limits on behaviors that may interfere with the client's physical well-being. 5. Implement a schedule for the client that distracts from the compulsive behaviors.
1. Ensure that basic needs are met. 3. Identify situations that precipitate compulsive behavior. 4. Set limits on behaviors that may interfere with the client's physical well-being. 5. Implement a schedule for the client that distracts from the compulsive behaviors.
1163. The postsurgical client with a heavy history of alcohol intake is at risk for delirium tremens (DTs). The nurse would monitor this client carefully for development of which sign(s)/ symptom(s) of DTs? Select all that apply. 1. Fever 2. Insomnia 3. Bradycardia 4. Disorientation 5. Fine hand tremors 6. High blood pressure
1. Fever 2. Insomnia 4. Disorientation 5. Fine hand tremors 6. High blood pressure
1155. The nurse is caring for the older adult client understands that which behavior(s) are associated with aging in terms of mental health? Select all that apply. 1. Helplessness 2. Hopelessness 3. Decreased self-worth 4. Decreased self-esteem 5. Increased sense of self-control
1. Helplessness 2. Hopelessness 3. Decreased self-worth 4. Decreased self-esteem
1116. The nurse is preparing a client for the termination phase of the nurse-client relationship. Which intervention is appropriate for this phase? 1. Identifying future needs. 2. Identifying expected outcomes. 3. Planning realistic short-term goals. 4. Developing a realistic plan of action.
1. Identifying future needs.
1111. The nurse notes that the client's diagnosis is documented as schizophrenia. The nurse plans care, knowing that the client is most likely to experience which manifestation of the disorder? 1. Illusions 2. Repetitive fears 3.Compulsive acts 4.Obsessive thoughts
1. Illusions
1144. A client who sustained severe injuries in a motorcycle crash was diagnosed with intensive care unit (ICU) psychosis. The nurse would conclude that the client's status is improving if which client observation is made? 1. Increase the number of hours slept at one time and is increasingly alert. 2. Appears to be delirious but has stopped trying to pull out the nasogastric tube. 3. Tells his wife, "I feel better, but the doctors want to give me a lethal injection!" 4. Keeps his eyes fixed o
1. Increase the number of hours slept at one time and is increasingly alert.
1100. The nurse is conducting a group therapy session when a client diagnosed with a manic disorder begins monopolizing the group. The nurse should take which action(s)? Select all that apply. 1. Inform the client that this is not appropriate behavior. 2. Suggest that the client stop talking and try listening to the others in the group. 3. Tell the client that he will be required to leave the group because of the behavior. 4. Inform the client to stop monopolizing the group or be prepared to lea
1. Inform the client that this is not appropriate behavior. 2. Suggest that the client stop talking and try listening to the others in the group.
1101. The nurse educator is conducting a teaching session regarding bullying. The nurse educator informs the students that power arises for the bully from which source(s)? Select all that apply. 1. Physical strength and maturity. 2. Exposing one's own weaknesses. 3. Higher status within a peer group. 4. Knowing another child's weakness. 5. Recruiting other children as support.
1. Physical strength and maturity. 3. Higher status within a peer group. 4. Knowing another child's weakness. 5. Recruiting other children as support.
1109. The nurse is caring for a chemically dependent client who had the potential to experience violent episodes. The nurse should implement which intervention(s)? Select all that apply. 1. Speaking slowly to the client. 2. Moving slowly when approaching the client. 3. Bargaining with the client to prevent the violent episodes. 4. Projecting an attitude of calmness when caring for the client. 5. Encouraging the client to talk out feelings rather than act on them.
1. Speaking slowly to the client. 2. Moving slowly when approaching the client. 4. Projecting an attitude of calmness when caring for the client. 5. Encouraging the client to talk out feelings rather than act on them.
1160. A client who attempted suicide by overdosing with antidepressant pills has been admitted to the psychiatric unit. The nurse, being most concerned with the client's safety, would initially take which action? 1. Stay with the client at all times. 2. Request that a friend remain with the client at all times. 3. Have the client remove all clothing and then put on a hospital gown. 4. Place the client in a seclusion room where there are no dangerous articles.
1. Stay with the client at all times.
1099. The nurse is planning activities for a client with bipolar disorder who is exhibiting aggressive social behavior. Which activity/ activities are most appropriate for the client? Select all that apply. 1. Taking a walk with a staff member. 2. Working on a finger panting project. 3. Playing a game of chess with a staff member. 4. Writing about his on future plans in a journal. 5. Working on a group art project with his roommate. 6. Participating in a basketball game with other clients.
1. Taking a walk with a staff member. 2. Working on a finger panting project. 4. Writing about his on future plans in a journal.
1150. Which behavior(s) observed by the nurse indicates reason for suspicion that a depressed client may be suicidal? Select all the apply. 1. The client has a poor appetite and difficulty sleeping. 2. The client runs out of the therapy group, swearing at the group leader. 3. The client indicates that she does not want to attend an activities any longer. 4. The client asks where the cleaning agents are kept so that she can clean her room. 5. The client becomes angry while speaking on the telep
1. The client has a poor appetite and difficulty sleeping. 3. The client indicates that she does not want to attend an activities any longer. 4. The client asks where the cleaning agents are kept so that she can clean her room.
1086. The nurse is preparing to care for a client who witnessed her mother being shot by an unknown attacker. The nurse interprets that the client is demonstrating behavior that indicates denial if which finding is noted? 1. The client is calm, cooperative, and reserved. 2. The client is justifying unacceptable self behaviors. 3. The client is verbalizing generalizations about the incident. 4. The client is blaming her brother for the incident for not being with them to protect them.
1. The client is calm, cooperative, and reserved.
1146. The nurse understands that which resource creates more opportunity for bullying to occur unnoticed in children? 1. The internet 2. Small classes 3. Low teacher-to-student ratio 4. Parent involvement in school activities
1. The internet
1157. The nursing student is providing end-of-life care to a client who is a Jehovah's Witness. Which nursing action indicates the need for further research with regard to religious influences on health care? 1. The student contacts the chaplain to provide sacrament to the client. 2. The student provides a calendar to the client that does not mark holidays. 3. The student suggests to other members of the health care team that palliative surgery may be an option for this client. 4. The student
1. The student contacts the chaplain to provide sacrament to the client.
1112. A client who is diagnosed with dementia becomes increasingly disoriented and confused at night. Which intervention(s) should the nurse implement for this client? Select all that apply. 1. Use a nightlight 2. Provide a consistent nighttime routine. 3. Turn on the television to a low volume. 4. Reorient the client every 15 minutes until he falls asleep. 5. Allow the client to have visitors during the night hours.
1. Use a nightlight 2. Provide a consistent nighttime routine.
1081. A client in the mental health unit believes that the food is being poisoned. Which intervention(s) would be helpful when attempting to encourage the client to eat? Select all that apply. 1. Use open-ended questions to encourage client dialogue. 2. Offer opinions about the necessity for adequate nutrition. 3. Focus on the client's self-disclosure about food preferences. 4. Identify the reasons that the client had for not wanting to eat. 5. Offer the client food in closed containers, such a
1. Use open-ended questions to encourage client dialogue. 5. Offer the client food in closed containers, such as in cans that have to be opened.
1097. The nurse is providing discharge instructions to a client with a history of experiencing command hallucinations to harm self or others regarding interventions directed toward managing the hallucinations. The nurse determines that the client understands theses instructions when the client makes which statement? 1. "My medications won't make me anxious." 2. "I can call my therapist when I'm hallucinating." 3. "I'll learn a lot by meeting with my support group." 4. "I won't hear voices if I
2. "I can call my therapist when I'm hallucinating."
1166. A nurse is conversing with a client who was admitted to the hospital with a diagnosis of acute anxiety disorder The client says to the nurse, " I have a secret that I want to tell you. You won't tell anyone about it, will you?" What is the appropriate nursing response? 1. "No, I won't tell anyone." 2. "I cannot promise to keep a secret." 3. "I'll only tell if it's really important." 4. "Don't tell me anything that's a secret."
2. "I cannot promise to keep a secret."
1129. The nurse if forming a psychotherapy group, and several clients are interested in attending the session. The nurse plans the group, knowing that the maximum number of group members to include is which number? 1. 3 2. 10 3. 12 4. 15
2. 10
1140. The nurse must choose a roommate for a client who is in a state of starvation due to anorexia nervosa. Which client(s) are appropriate choice(s) for this client's roommate? Select all that apply. 1. A client with pneumonia. 2. A client who had back surgery. 3. A client with a fractured pelvis. 4. A client who had a myocardial infarction. 5. A client who is receiving antibiotics and experiencing severe diarrhea.
2. A client who had back surgery. 3. A client with a fractured pelvis. 4. A client who had a myocardial infarction.
1154. Pharmacological therapy is prescribed for a client with Tourette's syndrome. The nurse expects that which type of medication will be prescribed? 1. Anxiolytic. 2. Antidyskinetic. 3. Benzodiazepine. 4. Monoamine oxidase inhibitor.
2. Antidyskinetic.
1167. A client arrives in the emergency department after complaining of unrelieved chest pain for 2 days. When the nurse approaches the client with a 0.4-mg nitroglycerin sublingual tablet, the client states, " I don't need that. The problem that I have is heartburn." The nurse interprets that the client is exhibiting which type of reaction? 1. Anger 2. Denial 3. Resistance 4. Obsessive-compulsive behavior
2. Denial
1162. The nurse planning care for a client who is at risk for suicide includes which intervention in the plan? 1. Place the client in a private room. 2. Establish a therapeutic relationship. 3. Assign a leadership task to the client. 4. Maintain a distance of 10 inches at all times.
2. Establish a therapeutic relationship.
1096. Which description is accurate with regard to Hispanic (Latino) beliefs on end-of-life- care? 1. Organ and blood donation is always allowed. 2. Extended family members are usually involved with care. 3. Pregnant family members are encouraged to participate in care. 4. There may be only a few family members at the client's bedside.
2. Extended family members are usually involved with care.
1151. The nurse understands that which description(s) are characteristic of a client with anorexia nervosa? Select all that apply. 1. Engages in immoral acts. 2. Has the desire to please others. 3. Observes rigid rules and regulations. 4. Reinforces self-approval continuously. 5. Has the need to be correct or perfect.
2. Has the desire to please others. 3. Observes rigid rules and regulations. 5. Has the need to be correct or perfect.
1078. The nurse should include which information in the nursing plan of care for a client with obsessive-compulsive disorder (OCD)? Select all that apply. 1. The medical diagnosis of the client. 2. Individualized goals and objectives. 3. Attendance at group therapy sessions. 4. Self-care measures to improve hygiene. 5. Interruption of all compulsive behaviors.
2. Individualized goals and objectives. 3. Attendance at group therapy sessions. 4. Self-care measures to improve hygiene.
1090. A client approaches the nurse' station, becomes very loud and offensive, and demands to be seen by the health care provider immediately. Which nursing intervention is appropriate for this situation? 1. Inform the client that the behavior is unacceptable. 2. Offer to assist the client to an examination room until the health care provider is notified. 3. Tell the client to go to her room and stay there because being demanding is not tolerated. 4. Tell the client that the health care provider
2. Offer to assist the client to an examination room until the health care provider is notified.
1170. The nurse is providing end-of-life care to a client whose religious background is protestant. The nurse understands that which intervention is included in this religious group's end-of-life practice? 1. Use of meditation. 2. Offering of prayers. 3. Administration of a sacrament. 4. Anointing of the sick by a priest.
2. Offering of prayers.
1171. A client, recently admitted to the behavioral unit, quickly paces about the dayroom while pounding his fists together. The client's speech pattern is rapid, and his affect appears animated and angry. Based on these observations, which intervention should be the nurse's immediate priority? 1. De-escalation of the client's agitation. 2. Provision of a safe, therapeutic milieu. 3. Assessment of the client's agitation level. 4. Elimination of the source of the client's agitation.
2. Provision of a safe, therapeutic milieu.
1138. A client who witnessed a terrorist attack exhibits the inability to talk. The nurse interprets this characteristic as indicative of which condition? 1. Depression 2. Somatization disorder 3. Posttraumatic stress disorder (PTSD) 4. Obsessive-compulsive disorder (OCD)
2. Somatization disorder
1133. Which description is accurate with regard to Native American beliefs on end-of-life care? 1. Usually prefer to die at home. 2. Some avoid contact with the dying. 3. Decision-making is individualized. 4. Family is not involved in decision making.
2. Some avoid contact with the dying.
1147. The nurse is conducting an assessment on a client with dissociative amnesia. Which description characterizes localized amnesia? 1. The client has a loss of all memories about past life. 2. The client blocks out all memories about a specifies period. 3. The client is able to recall some memories in a recent period. 4. The client recalls some but not all memories about a recent period.
2. The client blocks out all memories about a specifies period.
1123. The nurse completes an assessment of a client who is being admitted to the mental health unit. Which finding requires immediate intervention? 1. The spouse states that she disapproves of the treatment plan. 2. The client states that he wishes he could find a way to harm himself. 3. The presence of new bruises on the client's body and old scars on both wrists. 4. The client states that he can't eat much and hasn't been able to sleep for the past week.
2. The client states that he wishes he could find a way to harm himself.
1080. An older adult client states to the nurse, "Lately I'm getting forgetful about things. Do you think I'm getting Alzheimer's disease?" Which response by the nurse is most therapeutic? 1. "Oh, I'm certain it's not Alzheimer's disease because everyone forgets things sometimes." 2. " No, I don't think we really need to discuss this because I' sure it is just normal aging." 3. " Although it's not unusual to experience some lapses of memory, let's discuss your concerns." 4. " I am so forgetful,
3. " Although it's not unusual to experience some lapses of memory, let's discuss your concerns."
1158. A client who is delusional states, "The guards in that prison across the street are coming over here to handcuff me." Which response by the nurse is therapeutic? 1. "You believe the guards are going to handcuff you?" 2. "The guards will only handcuff those who misbehave." 3. "Do you feel afraid that someone is trying to hurt you?" 4. "The guards can't cross the street. So, don't worry about them."
3. "Do you feel afraid that someone is trying to hurt you?"
1114. A client with a potential for becoming violent is agitated and is making aggressive and belligerent gestures at other clients. Which statement made by the nurse is most therapeutic? 1. "Stop this right!" 2. "Seclusion is necessary right now if you do not stop." 3. "Let's talk about what is causing you to become agitated." 4. "We have plenty of leather restraints that we will use on you."
3. "Let's talk about what is causing you to become agitated."
1169. The nurse is performing a mental status examination on an older adult client and is assessing the client's remote memory. The nurse appropriately asks the client which question to conduct this assessment. 1. "Can you tell me what the date is today?" 2. "How did you arrive to that facility today?" 3. "Where did you go on your last vacation?" 4. "What is the name of the facility you are visiting today?"
3. "Where did you go on your last vacation?"
1076. The nurse providing end-of-life care to a Muslim client understands that which practice is accurate regarding end-of-life care? 1. The client's head should be positioned below the body. 2. Discussions about death are usually welcomed and open. 3. A same-gendered Muslim should handle the body if possible. 4. Stopping medical treatment is allowed if permitted by the family.
3. A same-gendered Muslim should handle the body if possible.
1102. A client is admitted to the mental health unit with a diagnosis of depression, and the nurse is developing a plan of care for the client. Which activity is the most appropriate and safest activity to be included in the plan of care? 1. Nothing until the client asks to participate in the milieu. 2. A menu of daily activities, with the nurse insisting that the client participate in all of them. 3. A structured daily program of activities, with the nurse encouraging the client to participat
3. A structured daily program of activities, with the nurse encouraging the client to participate.
1104. A client with anxiety is preoccupied with his health. The nurse determines that the client is experiencing which condition(s)? Select all that apply. 1. Agoraphobia. 2. Social phobia. 3. Apprehension. 4. Claustrophobia. 5. Hypochondriasis.
3. Apprehension. 5. Hypochondriasis.
1075. A client is admitted to the mental health unit after a suicide attempt by hanging. The nurse's most important aspect of care is to maintain client safety. The is best accomplished by which action? 1. Requesting that a peer remain with the client at all times. 2. Removing the client's clothing and placing the client in a hospital gown. 3. Assigning a staff member to the client who will remain with the client at all times. 4. Admitting the client to a seclusion room where all potentially dan
3. Assigning a staff member to the client who will remain with the client at all times
1117. The mental health nurse understands that the basis associated with acts of compulsion in clients with obsessive-compulsive disorder (OCD) is which process? 1. Clients are unaware that they are performing the rituals. 2. Client's consciously attempt to punish themselves or others. 3. Clients unconsciously control unpleasant thoughts or feelings. 4. Clients respond to "the voices" telling them to perform rituals.
3. Clients unconsciously control unpleasant thoughts or feelings.
1107. The nurse is preparing a plan of care for the client who will be seen in the mental health clinic for the first time. In preparing for the orientation phase of the therapeutic relationship, the nurse plans to address which issue? 1. Facilitating behavioral change. 2. Promoting self-esteem in the client. 3. Discussing termination of the relationship. 4. Promoting problem-solving skills in the client.
3. Discussing termination of the relationship.
1152. A client who is admitted to the nursing unit following a fall from a second story porch has a history of heroin addiction. The nurse should monitor the client carefully for which sign(s) of heroin withdrawal? Select all that apply. 1. Constipation 2. Staggering gait 3. Frequent yawning 4. Runny nose (rhinorrhea) 5. Goose bumps (piloerection) 6. Inability to sleep (insomnia)
3. Frequent yawning 4. Runny nose (rhinorrhea) 5. Goose bumps (piloerection) 6. Inability to sleep (insomnia)
1164. The nurse understands that the client with which religious background will be prohibited from becoming an organ donor? 1. Hindu 2. Jewish 3. Muslim 4. Buddhist
3. Muslim
1143. The nurse is monitoring a group therapy session whose members are expressing intimate personal opinions and feelings around personal tasks. The nurse recognizes that these activities are characteristic of which stage of group development? 1. Forming 2. Storming 3. Norming 4. Performing
3. Norming
1079. A client asks the nurse to explain what milieu therapy is. The nurse responds, knowing that the primary focus of milieu therapy can be best described by which statement? 1. Changing behavior through crisis intervention. 2. A cognitive approach to changing client behavior. 3. Providing a safe, therapeutic environment for clients. 4. A behavioral approach to changing behavior appropriately.
3. Providing a safe, therapeutic environment for clients.
1118. The nurse is reviewing the record of a client who was admitted to the mental health unit and notes that the client was admitted by voluntary status. The nurse interprets this status as indicating which client information? 1. The admission was mandated by official court order. 2. The admission was made without the client's consent. 3. The client had the right to demand and obtain release from the hospital. 4. The client has been committed by a group of mental health professionals.
3. The client had the right to demand and obtain release from the hospital.
1098. During the termination phase of the nurse-client relationship, the nurse observes that the client continually makes statements that reflect minimization of the relationship. What is the appropriate interpretation(s) of the client's behavior? Select all that apply. 1. The client is not ready for discharge. 2. The client requires further treatment. 3. The client is displaying normal behavior at this time. 4. The client's minimization is a typical behavior during termination. 5. The client
3. The client is displaying normal behavior at this time. 4. The client's minimization is a typical behavior during termination.
1094. The nurse is caring for a Jewish client who was in a serious car accident and is currently on life support. With regard to the client's religious beliefs, the nurse understands which information? 1. The client most likely will not undergo any further life-saving measures. 2. The client will most likely be cremated after death, and an autopsy will be performed. 3. The client should not be left alone at any time, and the presence of a rabbi is desirable. 4. The client's life most likely wil
3. The client should not be left alone at any time, and the presence of a rabbi is desirable.
1113. A client is experiencing difficulty with the grieving process. Which outcome is appropriate for this client? 1. The client reports three additional coping strategies. 2. The client verbalizes the connections between significant losses and low self-esteem. 3. The client verbalizes the stages of grief and plans to attend a community grief group. 4. The client verbalizes a decreased desire for self-harm and discuss alternatives to suicide.
3. The client verbalizes the stages of grief and plans to attend a community grief group.
1125. The nurse providing end-of-life care to a client who is of Islamic background should contact which family member in order to determine whether the family should be given any information about the client's health condition? 1. The client's sister. 2. The client's mother. 3. The client's male cousin. 4. The client's female cousin.
3. The client's male cousin.
1159. The nurse is developing a plan of care for a client who is scheduled to have electroconvulsive therapy (ECT). Which factor is a priority for this client? 1. The client's fear. 2. The family's anxiety. 3. The risk for aspiration. 4. The possibility of incontinence during the procedure.
3. The risk for aspiration.
1172. The nurse is caring for a client who has been diagnosed with dissociative identity disorder (multiple personality). Which assessment finding(s) should the nurse expect to note in this client? Select all that apply. 1. Alter personalities do not take control of the host personality. 2. The client has the ability to recall important information at all times. 3. There is a host personality and other personalities referred to as "alters". 4. Two or more fully developed, distinct, and unique p
3. There is a host personality and other personalities referred to as "alters". 4. Two or more fully developed, distinct, and unique personalities exist within the client. 5. The "alters" may be aware of the host, but the host usually is not aware of the "alters".
1077. On admission assessment, the nurse is obtaining subjective data about a client's sexual and reproductive status. The client states, "I don't want to discuss this; it's private and personal." Which response by the nurse is most therapeutic? 1. "I'd hate being asked these sorts of questions too, but it's a necessary part of providing you with the best care." 2. "This is difficult for you to speak about, but I need this information from you in order to perform a complete assessment." 3. "I a
4. " I know that some of these questions are difficult for you, but, as a professional nurse, I am obligated to respect your confidentiality."
1130. A client who is experiencing auditory hallucinations is fearful that the voices will direct him to kill himself. Which nursing statement would be therapeutic at this time? 1. "I can hear the voices too." 2. "The voices are not real, and they cannot hurt you." 3. "I know that you think you can hear voices, but you really can't." 4. "I don't hear any voices. Tell me how it makes you feel to hear these voices."
4. "I don't hear any voices. Tell me how it makes you feel to hear these voices."
1121. A client who is diagnosed with chronic depression is being considered for electroconvulsive therapy (ECT). The client appears calm, but the family is anxious and states, "My son's brain will be destroyed. How can you be doing this to people?" 1. "It sounds as though you need to speak to your son's psychiatrist." 2. "You should be supportive of your son's decision to have this treatment." 3. "Would it help if I arranged for you to see the ECT room and speak to the staff?" 4. "It appears tha
4. "It appears that you have fears about the procedure. Let's sit down and discuss them."
1095. Two weeks after beginning antidepressant medication, a client says to the nurse, "Now that I am taking an antidepressant, no one will need to worry about me trying to commit suicide. Everyone can sleep easy at night." Which response indicates that the nurse understands the effect of antidepressant therapy? 1. "The fact of the matter is that you can easily relapse into depression." 2. "Yes, that is correct because you are responding so positively to the medication." 3. "Well, if you make a
4. "It is really important for you to take your medication and follow-up with your health care provider as scheduled."
1115. A hospitalized client who has been experiencing delusions begins to shout, "You're all here to kill me. Let me out of here!" Which response is most therapeutic? 1. "What makes you think we plan to kill you?" 2. "I'll leave and come back later when you calm down." 3. "I am not going to hurt you; I am here to help you!" 4. "It must be frightening to think other may want to hurt you."
4. "It must be frightening to think other may want to hurt you."
1088. A client who has been diagnosed with depression is preparing for discharge. The nurse determines that the client has an understanding of the disorder if the client makes which statement? 1. "I don't need anyone; I have myself to rely on!" 2. "I'll never let my boss, my job, or my family get to me like this ever again!" 3. "I've always been able to make decisions for myself. I'll do anything not to ever feel this horrible way ever again!" 4. "It's important for me to eat well, exercise, and
4. "It's important for me to eat well, exercise, and to take my medication. If I begin to feel bad again, I'll see my doctor."
1142. A client tells the nurse, "After I have my breast removed, I know that my husband will not find me as pretty as I was before we got married." Which response to the client is appropriate? 1. "You never know, you husband will still love you, so just forget it." 2. "I understand that you are sad, but after your surgery, you will look normal." 3. "You should focus on taking care of yourself. Your husband still needs you." 4. "You're concerned about how your husband will think of you after surg
4. "You're concerned about how your husband will think of you after surgery."
1161. Which action is the best approach for the nurse to use in crisis counseling? 1. Reassuring. 2. Passive listening. 3. Exploring early life experiences. 4. Active focusing on the current situation.
4. Active focusing on the current situation.
1139. Which culture emphasizes the "right to know" perspective with regard to diagnosis and prognosis so the client can make informed health care decisions? 1. Asian 2. Middle Eastern 3. Native American 4. American/ European
4. American/ European
1165. The nurse determines that which client is most characteristic of a victim of elder abuse? 1. A 75-year-old man with type 2 diabetes mellitus. 2. An 80-year-old man with newly diagnosed glaucoma. 3. A 70-year-old woman with early diagnosed skin melanoma. 4. An 85-year-old woman who lives alone and has an amputated leg.
4. An 85-year-old woman who lives alone and has an amputated leg.
1149. A client demonstrates acute anxiety when hospitalized after experiencing a seizure. The appropriate intervention to decrease the client's anxiety is which action? 1. Ignore the signs and symptoms of anxiety so that they will soon disappear. 2. Make sure the client knows all the correct medical terms to understand what is happening. 3. Administer a sedative, and explain treatment measures after the medication has taken effect. 4. Approach the client in a calm and caring manner, and assis
4. Approach the client in a calm and caring manner, and assist the client with the use of coping mechanisms.
1085. A client with a leg amputation is upset about his appearance. The nurse intends to address which most closely associated psychosocial problem? 1. inability to be mobile. 2. Isolating self from others. 3. Inability to tolerate activity. 4. Concern about body persona.
4. Concern about body persona.
1122. The nurse is preparing a discharge plan for a client who attempted suicide. What should be the focus of this client's plan of care? 1. Follow-up appointments. 2. Providing the hospital telephone number. 3. Encouraging the family to always be with the client. 4. Contracts and immediately available crisis resources.
4. Contracts and immediately available crisis resources.
1105. The nurse care plan indicated that a client is at risk for self-harm. A priority outcome of care is that the client performs which action? 1. Displays less anxiety and agitation. 2. Establishes a relationship with staff and peer. 3. Develops adequate coping and problem-solving skills. 4. Denies suicidal ideation and identifies options to deal with stressors.
4. Denies suicidal ideation and identifies options to deal with stressors.
1106. A mother is reprimanding her child for writing on the playroom wall with a crayon. Later that afternoon, the child blames her younger sister for making a mess in their playroom. This is an example of which type of behavior? 1. Denial 2. Repression 3. Suppression 4. Displacement
4. Displacement
1073. A client in a long-term care facility who had multiple sclerosis is embarrassed about the need to use a wheelchair and the muscle spasms that are readily visible in her legs. Which approach is therapeutic in assisting the client to cope? 1. Keep the client in her room as much as possible . 2. Assist the client with all activities of daily living (ADLs). 3. Tell the client that many of the people in the facility have these same sorts of problems. 4. Encourage and praise perseverance in per
4. Encourage and praise perseverance in performing ADLs, and assist the client to dress and groom daily
1089. The nurse is working with an anxious client who has sought counseling after an unsuccessful attempt to rescue a neighbor who was trapped in a house fire. Which goal should be addressed during the working phase of the nurse-client relationship? 1. Confirming the client's ability to function normally. 2. Exploring the client's potential for self-harm behaviors. 3. Inquiring about the client's perception or appraisal of the neighbor's death. 3. Inquiring about the client's perception or appra
4. Identifying any feelings about the client's actions that may affect his normal adaptive coping.
1083. A crisis center nurse receives a telephone call from a client who states that he wants to kill himself and that he had a bottle of sleeping pills in from of him. What is the appropriate nursing action? 1. Keep the client talking, and allow him to ventilate his feelings. 2. Use therapeutic communication techniques, especially the reflection of feelings. 3. Insist that the client give you his name and address so that you can get the police there immediately. 4. Keep the client talking, and
4. Keep the client talking, and signal another staff member to trace the call so that appropriate help can be sent.
1132. The nurse should schedule which activity for a newly admitted manic client? 1. Working alone on a finger painting picture project. 2. Joining a combination lunch and spiritual discussion. 3. Attending the unit's daily progressive relaxation group. 4. Participating in a scheduled staff/ client basketball match.
4. Participating in a scheduled staff/ client basketball match.
1127. The nurse understand that which statement describes a person who is mentally healthy? 1. Self-concept is distorted. 2. Life direction is disturbed. 3. Thoughts are not reality-based. 4. Perceptions of strengths are realistic.
4. Perceptions of strengths are realistic.
1141. The nurse understands that which statement describes a person who is mentally ill? 1. Life productivity is undisturbed. 2. Meeting one's own needs is not problematic. 3. Ability to find meaning in life is unimpaired. 4. Preoccupation with thoughts and self is present.
4. Preoccupation with thoughts and self is present.
1074. The nurse uses which approach when caring for a client with a diagnosis of acute undifferentiated schizophrenia? 1. Repeatedly points out inconsistencies in the client's communication . 2. Allows the client to set his or her own treatment goals for the plan of care. 3. Lets the client act out initially and uses the quiet room and restraints as needed. 4. Provides assistance with grooming and nutrition until the client's thinking is cleared.
4. Provides assistance with grooming and nutrition until the client's thinking is cleared
1135. A client who is diagnosed with psychosis is pacing up and down the hall and using aggressive gestures and rapid speech. The nurse determines that which intervention is the immediate priority of care? 1. Providing a safe environment by isolating the client. 2. Offering the client is less stimulated area in which to regain control. 3. Assisting the client to a controlled environment, such as a quiet seclusion room. 4. Providing a safe, therapeutic environment for the client and all other cli
4. Providing a safe, therapeutic environment for the client and all other clients on the unit.
1126. The nurse is conducting a group therapy session when a client threatens to act out physically and states that he will punch another member of the group. The nurse should take which initial action? 1. Tell the client that he must leave immediately. 2. Call security to come to the session immediately. 3. Tell the client that if he hits another client he will be restrained and placed in seclusion. 4. Tell the client that he can talk about his anger but cannot act on it during the group sess
4. Tell the client that he can talk about his anger but cannot act on it during the group session.
1136. A client is admitted voluntarily to the mental health unit. Based on this type of admission, the nurse anticipates which client behavior? 1. The client will e hostile toward the unit's staff. 2. The client will be resistant to treatment interventions. 3. The client will be apprehensive about terminating his treatment plan. 4. The client will be actively involved in the formulation of his treatment plan.
4. The client will be actively involved in the formulation of his treatment plan.
1103. A client with a phobia will be treated for the condition using a behavior modification technique known as systematic desensitization. The nurse described the components of this form of therapy to the client and instructs the client that which is descriptive of the program? 1. The client will take medication daily to control the condition. 2. The client will talk to self to control actions more effectively. 3. The client will meet with others with the same problem in a support group. 4.
4. The client will be introduced to short periods of exposure to the phobic object.
1134. The nurse is caring for a client who is being treated for arachnophobia (a fear of spiders). The therapy includes slowly exposing the client to the object of fear (a spider) for short periods in a very controlled environment. The nurse understands that this form of behaviors modification can be described as which type of therapy? 1. Milieu therapy. 2. Aversion therapy. 3. Self-control therapy. 4. systematic desensitization.
4. systematic desensitization.
1131. A client is displaying aggressive behavior that is escalating. The nurse should plan which intervention(s) for the client at this time? Select all that apply. 1. Confining the client. 2. Ignoring the client's behaviors. 3. Allowing the client to take control. 4.Keeping a safe distance from the client. 5. Moving the client to a quieter area.
4.Keeping a safe distance from the client. 5. Moving the client to a quieter area.
