Behavioral Health Exam 1

A nurse is caring for a client who just received a diagnosis of cancer. The client states, "I just don't know what I'm going to do now." Which of the following responses should the nurse make? "In time, you'll know the right thing to do." "I am sorry. Would you like me to call someone for you?" "Can you explain the concerns you're having right now?" "There are multiple treatment options for you to consider."

"Can you explain the concerns you're having right now?"

A nurse is teaching a client who has anxiety disorder about nonpharmacological ways to promote good sleep habits. Which of the following recommendations should the nurse make? "Schedule 20 minutes of aerobic exercise during the hour before bedtime." "Eliminate all caffeinated beverages from your diet." "Sleep for extra time when you can." "Eat a light snack containing carbohydrates before bedtime."

"Eat a light snack containing carbohydrates before bedtime."

A nurse is discussing family therapy with a client. Which of the following statements by the nurse is therapeutic? "Family therapy helped my family." "I need to sign you up for family therapy." "Family therapy can bring about change." "Why do you think you need family therapy?"

"Family therapy can bring about change."

A client recently diagnosed with terminal cancer states to the nurse, "I wish I were dead. I have no reason to live." Which of the following responses should the nurse make? "Please don't talk about such things." "Your prescribed medication will make you feel better." "You still have a lot to live for." "Have you been thinking of hurting yourself?"

"Have you been thinking of hurting yourself?"

A nurse in a mental health clinic is beginning a counseling session with a client who is having difficulties in a personal relationship. The client states that she does not want to talk at all today. Which of the following responses should the nurse make? "How about I just spend some time with you instead? We don't have to talk." "I think you should take a moment to collect your thoughts. Then, you need to talk." "Why don't you want to talk today? We have talked several times before." "I don't believe that you don't want to talk to me. You know it can be helpful."

"How about I just spend some time with you instead? We don't have to talk."

A nurse is assessing a client who has adjustment disorder. Which of the following statements by the client should the nurse recognize as a manifestation of this disorder? "I am unable to remember my address" "I feel like I am living in a fog." "I sometimes cannot remember large blocks of time." "I could have done something to prevent my cousin's death."

"I could have done something to prevent my cousin's death."

A nurse is caring for a client who has major depressive disorder and recently started taking an antidepressant. The nurse should identify which of the following client statements as the priority? "I hate being so helpless. I can't even manage my own finances anymore." "At group therapy today, I wanted to leave. I didn't feel like being with other people." "I have it all figured out. Everything is going to be okay now." "I don't feel like showering. I'd rather just stay in bed today."

"I have it all figured out. Everything is going to be okay now."

A nurse enters a client's room and observes that the client is agitated and pacing rapidly. The client looks at the nurse and says, "Back off. Leave me alone." Which of the following statements should the nurse make? "I will give you space if you calm down. Tell me what is causing you to feel so tense." "I will close the door to provide privacy, and you can tell me what is bothering you." "I will leave you alone for a few minutes while you try to control yourself." "I demand that you calm down now. Your behavior is unacceptable."

"I will give you space if you calm down. Tell me what is causing you to feel so tense."

A nurse is having a conversation with a newly admitted client when the client suddenly stops talking. Which of the following responses should the nurse provide? "I've noticed you have become quiet. Share with me what you are thinking when you are ready." "Apparently, you no longer wish to talk with me. Have I done something to make you angry?" "You need to talk during this time I have set aside for you. Talking will get you out of here." "It is okay if you don't want to talk anymore right now. We can maybe meet again tomorrow."

"I've noticed you have become quiet. Share with me what you are thinking when you are ready."

A nurse in a substance use disorder program is interacting with a client. Which of the following statements indicates the client is using intellectualization as a means of coping with the anxiety of admission? "I was just using the medication to help me during a rough time in my life. I can stop whenever I want." "This all happened because my spouse is unemployed. That puts an enormous amount of stress on me." "I've read that problems with substance abuse can have a variety of predisposing factors." "I just don't want to talk. Anyway, there is nothing you can do to help."

"I've read that problems with substance abuse can have a variety of predisposing factors."

A nurse is caring for a client who attends family counseling with his partner and their children. The client tells the nurse that he will not attend any more sessions and states, "I don't have time for all that talking." Which of the following responses should the nurse provide? "I think you need to continue family therapy if your partner and children want to receive further counseling." "If you continue to attend family counseling, I'm sure you'll be able to resolve your problems soon." "It must be difficult for you to talk about family problems." "You should continue attending the family counseling sessions until the therapist tells you to stop."

"It must be difficult for you to talk about family problems."

A nurse is caring for a client who has schizophrenia and states, "My doctor is trying to kill me." Which of the following responses should the nurse make? "Your doctor wants to help you, not kill you." "How long has your doctor been trying to kill you?" "It must be frightening to feel that your doctor is trying to kill you." "Why would you say that your doctor is trying to kill you?"

"It must be frightening to feel that your doctor is trying to kill you."

A nurse is providing support for a client who is grieving the loss of her mother who died from Alzheimer's disease. Which of the following statements should the nurse make? "Hopefully, knowing your mother is in a better place provides you with some comfort." "I know how you're feeling. I recently lost my father." "It must be very difficult for you to deal with your mother's death." "I want you to let me know what I can do to help you cope with your mother's death."

"It must be very difficult for you to deal with your mother's death."

A nurse is talking with a client about his admission to a mental health unit. The client states, "I just don't know if I should be here. What will my family think?" Which of the following responses by the nurse uses the therapeutic communication technique of reflection? "It sounds like you are concerned about your family's reaction." "What your family thinks isn't important; you need to be concerned about getting well." "Many clients are concerned about the reactions of their families." "It sounds like your family doesn't seem to understand you."

"It sounds like you are concerned about your family's reaction."

A nurse is discussing exercise activities with an acute care client who has schizophrenia and is overweight due to psychotropic medications. The client refuses to participate in an aerobic exercise class and instead requests to walk in the facility's gym. Which of the following responses should the nurse make? "It sounds like you have come up with an alternative exercise that works for you." "The aerobics class will be more effective at burning calories than walking." "Can you tell me why you do not want to participate in the planned group activity?" "Do you understand that psychotropic medications cause weight gain?"

"It sounds like you have come up with an alternative exercise that works for you."

A nurse is assessing a client who has major depressive disorder. The client states, "I might as well be dead. I have always been a failure." Which of the following responses should the nurse make? "Let's discuss these feelings further." "You have a great deal to offer in life." "Why do you think you feel this way?" "Feeling like a failure is expected with depression."

"Let's discuss these feelings further."

A nurse in an acute mental health facility is caring for a client who states, "This place is ridiculous. I can't stand spending another day here!" Which of the following responses should the nurse make? "You should focus on the good things so the bad things seem less important." "I'm sure tomorrow will be a better day." "Let's talk about the events of your day." "Don't be so negative when you are young and physically healthy."

"Let's talk about the events of your day."

A nurse is caring for a client who has an anxiety disorder. Which of the following statements by the client should the nurse recognize as demonstrating the defense mechanism of displacement? "I smoked for years, but now I cannot stand to be around cigarette smoke." "I didn't get the promotion at work because my boss hates me." "My partner yelled at me, so I made the cat go outdoors." "I won't worry about losing my job until my child's break from school is over."

"My partner yelled at me, so I made the cat go outdoors."

A nurse is interacting with a client in the dayroom of an acute mental health facility. The client accuses the nurse of being "too bossy" and states the nurse does not have the right to pressure anyone. Which of the following responses should the nurse offer? "Why are you feeling pressured by me?" "Tell me what I said that made you feel uncomfortable." "What makes you say that?" "You shouldn't make negative statements since I'm trying to help you."

"Tell me what I said that made you feel uncomfortable."

A nurse is performing an admission assessment for a client who has schizophrenia. The client suddenly stops talking and begins staring intently at a chair in the corner of the room. Which of the following responses should the nurse make? "Tell me what you are seeing by that chair." "There is nothing over there except a chair." "Whatever you are seeing by that chair is not real." "Please try to focus on our conversation."

"Tell me what you are seeing by that chair."

A nurse is caring for a client who is postoperative following an amputation of the left lower leg. The client states, "I can't believe this has happened to me. I don't deserve this." Which of the following responses should the nurse provide? "I agree with you. You did not deserve this." "What makes you say that you don't deserve this?" "Tell me what you're feeling about what has happened." "The feelings you're having are normal following an amputation."

"Tell me what you're feeling about what has happened."

A nurse is caring for a client who has schizophrenia. The client states, "Aliens came into my room last night and took a sample of my blood." Which of the following responses should the nurse make? "Aliens do not exist." "Has your daughter had her baby?" "Do you mean to say a laboratory technician drew your blood last night?" "That does not sound real."

"That does not sound real."

A nurse is caring for a client who reports that the television set in the room is really a 2-way radio and states, "Voices are coming from the TV, and everything we say in this room is being recorded." Which of the following responses should the nurse offer? 'What we say is not being recorded." "Let's ignore the voices and talk about something else." "Why do you think the TV is a 2- way radio?" "That must be very frightening."

"That must be very frightening."

A mental health nurse is reviewing a process recording of a therapy session with a client. Which of the following statements should the nurse identify as an example of the communication technique of reflection? "I notice you are pulling on your hair when we discuss your dismissal." "That statement made by the other client appears to have upset you." "Since writing in your journal is frustrating, we should look at this activity more closely." "Give me an example of a time when you felt no one understood you."

"That statement made by the other client appears to have upset you."

A nurse is providing teaching to the partner of a client who has conversion disorder. Which of the following statements by the partner shows an understanding of the teaching? "My partner is pretending to be ill to get attention." "My partner is purposefully making our child sick." "The stress of losing our child caused my partner to go blind." "My partner is worried that he has cancer, even though his tests are normal."

"The stress of losing our child caused my partner to go blind."

A nurse in an emergency department is caring for a female client who has ecchymosis of the trunk and face. The client reports that her partner hit her, causing these injuries. When offered information about shelters for intimate partner violence, the client declines, stating, "I could never leave my husband because of my kids." Which of the following responses should the nurse make? "Aren't you worried about the safety of your children?" "Can you identify which of your behaviors provoke your partner?" "Then next time this occurs, what could you do to ensure your safety?" "You need to remove yourself and your children from an abusive situation."

"Then next time this occurs, what could you do to ensure your safety?"

A nurse receives a call on a crisis intervention hotline from a client. Which of the following statements should the nurse identify as an overt statement indicating the client's risk for suicide? "Everything will be better soon." "I want to donate my organs to help others." "Soon, no one will have to worry about me." "There's no point in living any longer."

"There's no point in living any longer."

A nurse is caring for an adolescent male client who has anorexia nervosa. The client asks, "Have I done any permanent damage to my body?" Which of the following responses should the nurse provide? "Unconsciously, you're admitting you're worried about your physical appearance." "What concerns do you have about your physical health?" "I'm glad to hear that you're concerned about the physical effects of your illness." "Let's wait to discuss that until after you're feeling better."

"What concerns do you have about your physical health?"

A nurse is caring for a client who is receiving cognitive-behavioral therapy. The client tells the nurse, "Nothing good ever happened during my marriage." When using cognitive reframing, which of the following responses should the nurse offer? "Let's discuss what you consider to be negative about your marriage." "What activities take your mind off of your marriage experience?" "What did you learn from your marriage to help you in the future?" "Only you can understand how your marriage negatively affected your life."

"What did you learn from your marriage to help you in the future?"

A nurse is counseling a client who seems relaxed initially but then becomes restless and begins wringing his hands. The nurse states that the client seems tense, and the client agrees. Which of the following statements should the nurse make? "Did I say something wrong that made you feel tense?" "Do you often feel tense when you are talking to a healthcare provider?" "What were we discussing when you began to feel uncomfortable?" "It's okay to feel nervous during our counseling sessions."

"What were we discussing when you began to feel uncomfortable?"

A nurse at a college health clinic is caring for a client who reports manifestations of bulimia nervosa. The client tells the nurse, "I know my eating binges and vomiting are not normal, but I can't control them." Which of the following responses should the nurse provide? "Why do you think you are experiencing these behaviors of binges and vomiting?" "Are other students in your dorm also experiencing this behavior?" "You are feeling helpless about changing this behavior?" "You know you must stop because you are endangering your health."

"You are feeling helpless about changing this behavior?"

A nurse in a mental health clinic is caring for a client who has bipolar disorder and states, "I no longer take my medication because I like the feeling of being manic." Which of the following responses by the nurse is an example of therapeutic communication? "You might feel good now, but what about when you get depressed?" "Why do you think you like feeling manic?" "You feel better when you don't take your medication?" "What do you think your provider will say about missing your medication?"

"You feel better when you don't take your medication?"

A nurse is caring for a client who has depression. The nurse observes that the client has not come to breakfast and is still in bed. The client states, "I'm not worth your time. Leave me alone and go help someone else." Which of the following responses should the nurse make? "Many people feel this way when they first start treatment." "You seem to be saying that you feel unworthy of help." "I disagree. You are certainly worth my time." "You'll feel better once you get up and have some breakfast."

"You seem to be saying that you feel unworthy of help."

A nurse is caring for a client who has depression and started taking paroxetine 1 week ago. The client states to the nurse, "My family would be better off without me." Which of the following responses should the nurse make? "Many people feel this way when they are depressed." "Why do you feel your family would be better off without you?" "You sound upset. Are you thinking of hurting yourself?" "Your medication hasn't started working yet. Soon, you'll be feeling differently."

"You sound upset. Are you thinking of hurting yourself?"

A nurse is admitting a client with a hip fracture to the medical-surgical unit. The client states, "I've never been in the hospital before, and I feel like I have a lot of anxiety." Which of the following responses should the nurse offer? "You're feeling anxious about being in the hospital for the first time." "Anxiety while in the hospital is a feeling many people experience." "Why do you think you feel anxious about being in the hospital." "What activities do you enjoy when you're not in the hospital?"

"You're feeling anxious about being in the hospital for the first time."

A nurse cares for clients in a community mental health facility. For which of the following clients should the nurse provide a tertiary care intervention? A client who has generalized anxiety disorder and reports increased anxiety and insomnia A client who is expressing hopelessness during a crisis A client who is recovering from a crisis and asks for help in completing the recovery process A client who is having difficulty coping with stress and wants to learn relaxation techniques

A client who is recovering from a crisis and asks for help in completing the recovery process

A nurse in an acute mental health facility is leading a nursing staff discussion about the legal aspects of involuntary admissions. Which of the following pieces of information should the nurse include? A client who is involuntary admitted must take prescribed medications. An involuntary admission of a client is limited to 2 weeks. A client who is involuntarily admitted can leave the facility against medical advice. An involuntary admission is justified if the client is a danger to others.

An involuntary admission is justified if the client is a danger to others.

A nurse is caring for a client who has schizophrenia. The nurse notices that the client is pacing up and down the hall rapidly and muttering in an angry manner. Which of the following actions should the nurse perform first? Place the client in seclusion Administer PRN haloperidol IM to the client Apply mechanical restraints to the client Approach the client in a non threatening manner

Approach the client in a non threatening manner

A nurse is performing a brief mental status examination for a client. To assess a client's ability to concentrate, the nurse should do which of the following? Say 3 words and ask the client to repeat them Point to 2 objects and ask the client to name them Ask the client to write a sentence Ask the client to name the months of the year in reverse

Ask the client to name the months of the year in reverse

A nurse is admitting a client who states he is hearing voices telling him what to do. Which of the following actions should the nurse take? Instruct the client to sit in a quiet place when he hears voices Provide therapeutic touch when the client seems anxious Tell the client that the voices do not exist Ask the client to repeat what the voices are saying

Ask the client to repeat what the voices are saying

A nurse is caring for an adult client who has alcohol use disorder. Today, the client states she is refusing further treatment and is leaving the mental health facility. Which of the following actions should the nurse take? Request a prescription for restraints from the provider Ask security to lock the unit's exit doors Notify the client's family members of the client's intent to leave. Ask the client to sign an against medical advice (AMA) form.

Ask the client to sign an against medical advice (AMA) form.

A nurse on an inpatient mental health unit is attending an interdisciplinary treatment team meeting for a client who has bipolar disorder with rapid cycling. The client is being prepared for discharge following his fourth admission last year. Which of the following referrals should the nurse make for the client first? Assertive community treatment Support group Private counseling Vocational rehabilitation services

Assertive community treatment

A nurse is caring for a client who spent the past several minutes mumbling about being "doomed to die" and is now pacing in an increasingly agitated and angry manner. Which of the following actions should the nurse take first? Place the client in seclusion Request a prescription for physical restraints Administer PRN medication for agitation Attempt to reduce environmental stimuli

Attempt to reduce environmental stimuli

A nurse in an employee assistance program is counseling a client who states, "I just feel completely lost at work these days." The nurse replies, "You must feel like you are not getting things done." Which of the following therapeutic communication techniques is the nurse using? Presenting reality Encouraging comparison Offering general leads Attempting to translate words into feelings

Attempting to translate words into feelings

A nurse is assessing a newly admitted client who has generalized anxiety disorder and states, "I drink alcohol to forget the pain." The client is exhibiting a maladaptive response to which of the following defense mechanisms? Compensation Conversion Projection Suppression

Compensation

A school nurse is caring for an adolescent client with a history of a depressive episode 1 year ago. He appears withdrawn from social activities, and his school performance is declining. Which of the following actions should the nurse take first? Ask teachers to monitor the client for other signs of depression Encourage the client to express his feelings in a journal Conduct a suicide-risk assessment Initiate a structured daily schedule of activities

Conduct a suicide-risk assessment

A nurse is caring for a client who reminds her of a negative person in her past. These memories cause the nurse to unconsciously displace negative feelings onto the client. The nurse should recognize that she is demonstrating which of the following behaviors? Countertransference Transference Suppression Assertiveness

Countertransference

A nurse is providing teaching to a client who has obsessive-compulsive disorder and performs hand hygiene to decrease anxiety. Which of the following actions by the nurse implements modeling as a behavioral intervention strategy? Setting a time limit between episodes of hand hygiene Demonstrating performance of hand hygiene at scheduled times Telling the client to shout "stop" each time an urge to perform hand hygiene arises Instructing the client to practice muscle relaxation when experiencing the urge to perform hand hygiene.

Demonstrating performance of hand hygiene at scheduled times

A nurse is providing support for the parents of a child who has a new diagnosis of a terminal brain tumor. The nurse should expect the parents to experience which of the following states of grief first? Denial Bargaining Anger Depression

Denial

A nurse is caring for a client with bipolar disorder who is experiencing mania. Which of the following actions is the nurse's priority? Offer the client finger foods every 2 hours Determine if the client is a danger to herself Monitor the client's vital signs every 2 hours Move the client to a quiet area

Determine if the client is a danger to herself

A nurse in an emergency department is teaching newly licensed nurses about planning interventions for clients who experience sexual assaults. Which of the following actions should be included in the teaching? Determine if the client is experiencing thoughts of self-harm Postpone collection of forensic evidence if a sexual assault nurse examiner is not available Encourage the client to shower before undergoing a physical examination Assess the client for the presence of a maturational crisis

Determine if the client is experiencing thoughts of self-harm

A school nurse is providing care to a student who is angry and states, "My parents don't know I'm gay, so I can't visit my girlfriend in the hospital while she receives cancer treatment." Which of the following forms of grief is the client experiencing? Chronic grief Uncomplicated grief Disenfranchised grief Delayed grief

Disenfranchised grief

A nurse is administering an oral sedative to a client who is receiving care following an involuntary admission. The client states, "I'm not taking any more medication." Which of the following actions should the nurse perform? Administer the medication by another route. Refer the client's refusal to the facility's ethics committee. Inform the client that, due to her involuntary admission, she cannot refuse a sedative. Document the client's refusal of the medication in the medical record.

Document the client's refusal of the medication in the medical record.

A nurse in an outpatient mental health clinic is interviewing a client who has schizophrenia and appears to be experiencing auditory hallucinations. Which of the following actions should the nurse take first? Distract the client from the hallucination. Teach the client strategies to decrease the hallucinations. Identify whether the client is on antipsychotic medications. Explore what the voices are saying to the client.

Explore what the voices are saying to the client.

A nurse is caring for a client with borderline personality disorder (BPD) who exhibits a pattern of behavior of playing one staff member against another. Which of the following actions should the nurse take? Have the same staff member work with the client on a long-term basis Sit down and listen to the client's feelings about other staff members Explore with the client his use of clinging and distancing behaviors Arrange for the client to share complaints regarding staff members with the nursing supervisor

Explore with the client his use of clinging and distancing behaviors

A nurse in an acute care mental health facility observes a client who has bipolar disorder begin to shout and use offensive language toward a visitor. Which of the following actions should the nurse take? Direct other clients to move toward the client as a show of force Tell the client that the conversation will be ended if the shouting continues Give the client 2 options for ending the situation Move quickly to stand directly in front of the client before speaking

Give the client 2 options for ending the situation

A nurse is assessing a client who was recently admitted following a suicide attempt. Which of the following behaviors is the priority for the nurse to report to the adolescent's treatment team? Excessive crying Calling family members Giving away possessions Spending time alone

Giving away possessions

A nurse is reviewing the plan of care for a client who has bipolar disorder. Which of the following is an effect of using cognitive behavioral therapy (CBT) for a client who has bipolar disorder? Prevents the need for mood-stabilizing medications Helps the client deal with distorted thought processes Aids communication among family members Replace the need for lifestyle interventions

Helps the client deal with distorted thought processes

A nurse is conducting a screening class for depression. Which of the following should be the nurse's goal for secondary prevention? Deter condition-related complications Identify the severity of the condition Identify the condition early Prevent the onset of the condition

Identify the condition early

A nurse is caring for a client who was admitted to the mental health unit for substance use disorder. The client states, "I am a nurse on the medical-surgical floor, and I don't want my coworkers to know I have been diverting drugs." Which of the following actions should the nurse take? Explain to the client that there is a legal obligation to inform coworkers of her actions. Inform the client that the information will be shared with the treatment team. Advise the client that her supervisor will be transferring her to another unit following treatment. Tell the client her coworkers' opinions should not matter.

Inform the client that the information will be shared with the treatment team.

A home health nurse is providing teaching for the family of a client who has moderate Alzheimer's disease. The family plans to care for the client in the home. Which of the following recommendations should the nurse include in the teaching? Place nonskid throw rugs over smooth floors Install locks at the top of exterior doors Provide clothing that has zippers instead of buttons Encourage the client to take frequent naps during the day.

Install locks at the top of exterior doors

A nurse is caring for a client who has panic disorder and is experiencing anxiety at the panic level. Which of the following actions should the nurse take first? Identify the cause of the anxiety. Instruct the client to take slow, deep breaths. Teach the client how to use positive self-talk. Explain the physical manifestations of anxiety to the client.

Instruct the client to take slow, deep breaths.

A nurse is interviewing an older adult client about possible abuse by her caregiver. Which of the following techniques should the nurse use? Use a confrontational approach Avoid directly asking the client if she has been abused Maintain a nonjudgmental tone Avoid being in the room alone with the client

Maintain a nonjudgmental tone

A nurse is planning care for a newly admitted client who has bipolar disorder and is experiencing acute mania. Which of the following client goals should the nurse identify as the priority? Practicing problem-solving skills Understanding the medication regimen Identifying indications of relapse Maintaining adequate hydration

Maintaining adequate hydration

A nurse is helping a client who has an anxiety disorder select a nonpharmacological stress-reduction therapy for home use. Which of the following therapies engages the insular cortex of the brain to allow the client to focus on a single thought that is important to the client in the present moment? Guided imagery Progressive relaxation Cognitive reframing Mindfulness

Mindfulness

A nurse in the emergency department is assessing a client who has generalized anxiety disorder. Which of the following actions should the nurse take first? Instruct the client to use guided imagery Move the client to a quiet area Assist the client in identifying his coping skills Allow the client time to express his feelings

Move the client to a quiet area

A nurse is caring for a client in a mental health facility and overhears the client discussing plans to harm her father-in-law physically when she is discharged. Which of the following interventions should the nurse take? Ask the nurse to sign a contract agreeing not to harm others Notify the provider of the client's threat Keep the client's discussion confidential Place the client in individual observation

Notify the provider of the client's threat

A nurse is creating a plan of care for a group of clients. Which of the following interventions is the priority for the nurse to include? Offering high-calorie beverages to a client who is in the manic phase of bipolar disorder Practicing relaxation techniques with a client who has an anxiety disorder Assisting a client who has a depressive disorder with decision-making regarding group activities Providing teaching to a client who has schizophrenia about a new prescription for clozapine

Offering high-calorie beverages to a client who is in the manic phase of bipolar disorder

A nurse is communicating with a client at an inpatient mental health facility. Which of the following actions by the nurse demonstrates the proper use of active listening? Offering self Using silence Paying attention to body language Reflecting feelings

Paying attention to body language

A nurse is developing a plan of care for a client who has anorexia nervosa. Which of the following nursing actions is contraindicated for this client? Explaining that tube feeding will be necessary if the client refuses oral intake Weighing the client each day prior to any oral intake Permitting the client to spend some quiet time alone after each meal Refraining from commenting about the client's eating during mealtimes

Permitting the client to spend some quiet time alone after each meal

A nurse is performing an admission assessment for a client who has schizophrenia. The nurse notices that the client's appearance is unkempt, and he appears to be actively hallucinating. Which of the following should be the nurse's priority assessment? Perception of reality Ability to follow directions Mental status Physical needs

Physical needs

A nurse is caring for a client who attempted suicide and refuses to sign a no-suicide contract. Which of the following actions should the nurse take when implementing suicide precautions? Place the client in 1-on-1 observation Assign the client to a private room Keep the door closed to the client's room Ask the dietary department to provide the client with finger foods

Place the client in 1-on-1 observation

A nurse is caring for a client at a college mental health counselling center. The client received a failing grade in a course and spends the entire counseling session blaming the teacher. The nurse should recognize this behavior as an example of which of the following defense mechanisms? Projection Dissociation Undoing Compensation

Projection

A nurse in a mental health unit is planning care for a client who is receiving treatment for self-inflicted injuries. Which of the following interventions is the priority when planning care for this client? Promoting and maintaining client safety Teaching the client alternative coping strategies Discussing reasons for the client's behavior Helping the client recognize feelings

Promoting and maintaining client safety

A nurse in an acute mental health facility is caring for a client who is experiencing an acute manic episode. Which of the following actions is the nurse's priority? Maintain the client's contact with her family. Discourage the client's use of vulgar language. Protect the client from impulsive behavior. Redirect the client's excessive energy to creative tasks.

Protect the client from impulsive behavior.

A community mental health nurse is planning strategies to address substance use by adolescents. Which of the following interventions should the nurse include as a method of primary prevention? Educate high-school teachers about detecting the manifestations of substance use Encourage random testing for substance use for adolescents participating in extracurricular activities Provide a presentation at local high schools on resisting peer pressure for substance use Offer substance use treatment options for adolescents from low income households

Provide a presentation at local high schools on resisting peer pressure for substance use

A nurse is caring for a client who is showing evidence of addiction to a pain medication prescribed for rheumatoid arthritis. When questioned about the usage of the medication, the client states, "It is not an illegal drug." Which of the following defense mechanisms is the client using? Displacement Rationalization Projection Sublimation

Rationalization

A nurse is speaking with parents who are at a clinic for a 2-week follow-up visit after the birth of their second child. They report that their 5-year-old daughter has started to wet the bed at night after being toilet trained for 2 years. The nurse should tell the parents that this is expected behavior and illustrates which of the following defense mechanisms? Compensation Repression Regression Suppression

Regression

A nurse in the emergency department is treating a child with bruises. The nurse suspects child abuse, but the provider disagrees and discharges the client. Which of the following actions should the nurse take first? Request a social service consultation Contact the child's guardian to discuss the suspicion Report the provider's actions to the state medical board Report the suspected abuse to law enforcement

Report the suspected abuse to law enforcement

A client states, "I haven't seen my child for 2 weeks." The nurse responds, "Your child has not visited you for 2 weeks?" Which of the following communication techniques is the nurse using? Making an observation Voicing doubt Restating Accepting

Restating

A nurse is planning care for a client who has suicidal ideation and is being transferred to the mental health unit. Which of the following interventions should the nurse include in the client's plan of care? Search the client and his belongings upon arrival. Keep the door to the client's room closed. Instruct assistive personnel to check on the client every 15 min. Assign the client to a private room near the nurses' station.

Search the client and his belongings upon arrival.

A nurse is caring for a client who is experiencing panic-level anxiety. Which of the following actions should the nurse take? Speak to the client in a high-pitched voice Speak to the client firmly and authoritatively Remove potentially harmful objects before leaving the client alone in the room Offer the client low-calorie or no-calorie fluids

Speak to the client firmly and authoritatively

A nurse is caring for a client who has severe anxiety disorder and is in a state of panic in the dayroom. Which of the following actions should the nurse take? Leave the client alone to regain control Encourage the client to express her feelings Place the client in restraints Speak to the client in a calm voice

Speak to the client in a calm voice

A nurse is caring for a client who has major depressive disorder and is severely withdrawn. Which of the following techniques should the nurse use to facilitate communication with the client? Continue to talk if the client does not provide an immediate verbal response Use platitudes when talking with the client Ask the client direct questions Speak to the client using simple and concrete terminology

Speak to the client using simple and concrete terminology

A nurse on a mental health unit is caring for a client who has antisocial personality disorder and is becoming increasingly loud and belligerent. Which of the following approaches should the nurse use to manage this client's behavior? Confront the client for breaking the rules Escort the client to the nurses' station Stand near the client to offer comfort and support Speak to the client with clear, calm, caring statements

Speak to the client with clear, calm, caring statements

A nurse is caring for a client whose adolescent child just died in a motor vehicle crash. The client is crying inconsolably. Which of the following actions should the nurse take? Suggest that the client call the facility's chaplain Provide a quiet place for the client to be alone Stay with the client and allow the client to cry Express sympathy for the client's loss

Stay with the client and allow the client to cry

A nurse in an emergency department is caring for a client who states, "I tripped over the dog again." The nurse notes the client has multiple lacerations and ecchymoses and sees in the client's medical record that she visited 2 months ago for similar injuries. Which of the following actions should the nurse take? Ask the client what she believes she did to deserve being physically abused. Avoid documenting subjective verbatim statements from the client regarding injuries. Talk about making a safety plan Explain the cycle of violence to the client

Talk about making a safety plan

A nurse is speaking with a client whose partner was killed unexpectedly. The client states, "I just don't know what to do now." Which of the following actions should the nurse take? Give the client advice about what to do during the next few days Reassure the client that he will feel better soon Distract the client by discussing events not related to the crisis Talk to the client about available community resources

Talk to the client about available community resources

A nurse is caring for a client who has Alzheimer's disease and becomes agitated while refusing morning hygiene care. Which of the following actions should the nurse take? Call the provider to request a prescription for an antipsychotic medication Talk to the client from 2 arm lengths away Firmly state to the client that morning care will be performed Obtain assistance to restrain the client for safety

Talk to the client from 2 arm lengths away

A nurse is teaching a parent who has admitted to verbally abusing his children about stress management techniques. Which of the following strategies is the nurse providing? Tertiary prevention Primary prevention Individual psychotherapy Family psychotherapy

Tertiary prevention

A nurse is completing an admission for an adolescent client who has depression. The nurse should identify which of the following findings as the priority? The client is confrontational with his parents. The client is getting Ds in his classes because he frequently skips school. The client states he smokes half a pack of cigarettes per day. The client gave his favorite possessions to friends.

The client gave his favorite possessions to friends.

A nurse in an emergency department is assessing a client who has bipolar disorder and is in a manic state. Which of the following findings is the highest priority? The client reports sleeping 2 to 3 hours a night. The client speaks to the nurse in a demanding tone. The client reports not attending group therapy. The client reports not taking medication for the past 2 weeks.

The client reports sleeping 2 to 3 hours a night.

A nurse is caring for a client who has post-traumatic stress disorder (PTSD). Which of the following actions by the client indicates the current treatment plan is effective? The client reports techniques she uses to promote sleep The client shows limited emotion when witnessing a traumatic event The client asks the nurse's opinion about the clothes she is wearing The client avoids situations that might trigger memories of past trauma

The client reports techniques she uses to promote sleep

A nurse is communicating with a newly admitted client. Which of the following rationales identifies the nurse's purpose for using therapeutic communication with the client? Therapeutic communication identifies and analyzes the client's problems. Therapeutic communication builds a relationship that will allow the expression of mutual concerns. Therapeutic communication provides a basis for the client's relationship with the provider. Therapeutic communication ensures the client will remain cooperative with his care in the facility.

Therapeutic communication builds a relationship that will allow the expression of mutual concerns.

A nurse in a mental health facility is meeting with a client diagnosed with major depression. During the conversation, the client stops speaking, and the nurse sits silently next to the client for several minutes. The nurse should identify that the therapeutic communication technique of silence is used for which of the following purposes? To show approval of the client's desire to not talk To give the client time to evaluate the nurse To encourage the client to express feelings or concerns To prevent the nurse from making a nontherapeutic response

To encourage the client to express feelings or concerns

A nurse is caring for a client who is having an acute panic attack. Which of the following actions should the nurse take? Speak to the client in a raised voice Walk the client to the dayroom Use repetition when speaking with the client Secure the client in his room alone

Use repetition when speaking with the client

A nurse is caring for a client who has post-traumatic stress disorder (PTSD) and who is undergoing Eye Movement Desensitization and Reprocessing (EMDR) therapy. The nurse should identify that EMDR includes which of the following strategies? Exposes the client to circumstances that trigger the PTSD Assists the client with behavioral modification Encourages the client to visualize a relaxing scene when traumatic memories occur Uses stimuli to change how the client processes the trauma

Uses stimuli to change how the client processes the trauma

A nurse is caring for a client who has chronic alcohol use disorder and claims that her family is exaggerating the problem. The nurse should identify this behavior as which of the following defense mechanisms? denial introjection regression rationalization

denial

A nurse is caring for a client who has a new diagnosis of colon cancer. Shortly after the client received the diagnosis, the nurse enters the client's room. The client begins yelling: "I've received terrible care here, and no one bothers to help me." The nurse should recognize that the client is demonstrating which of the following defense mechanisms? denial displacement reaction formation projection

displacement

A nurse is caring for a client who has an anxiety disorder. The client states that she forgot her partner's birthday after they had an argument. The nurse recognizes this action as which of the following defense mechanisms? repression splitting conversion projection

repression