MENTAL HEALTH PRACTICE QUESTIONS
A charge nurse on a mental health unit is discussing client's rights with a newly licensed nurse. Which of the following statements should the charge nurse make?
"Client who are admitted involuntarily maintain the right to give informed consent for procedures."
A nurse is preparing to administer diazepam 7.5 mg IV bolus to a client for alcohol withdrawal. Available is diazepam injection 5 mg/mL. How many mL should the nurse expect to administer?
1.5 mL
A nurse is assisting a client who has a terminal illness adjust to progressive loss of independence. Which of the following statements made by the client indicates acceptance of her illness?
"I am going to order a wheelchair for when I'm unable to walk."
A nurse is providing teaching to the partner of a client who is in a rehabilitation program for alcohol use disorder. The nurse should identify that which fo the following statements by the client's partner indicates an understanding of the teaching?
"I will not take charge of my partner's work responsibilities."
A nurse is teaching coping strategies to a client who is experiencing depression related to partner violence. Which of the following statements by the client indicates an understanding fo the teaching?
"I will talk about my feelings with a close friend."
A nurse is teaching a newly licensed nurse about nursing care plans for clients who have depressive disorders. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
"I will update the plan of care as a client's manifestations of depression change."
A nurse is caring for a client who gave birth to a stillborn baby. Which of the following statements should the nurse make?
"I'll stay with you just in case you want to talk."
A nurse observes a client on a mental health unit pushing on the locked unit door. Which of the following statements should the nurse make?
"It appears as though you would like to open the door."
A nurse is teaching the guardians of a client about their adolescent child's diagnosis of bulimia nervosa. Which of the following statements made by the guardian indicates an understanding of their child's illness?
"It is important for our child to have regular dental checkups."
A nurse is caring for an older adult client who begins to cry and states, "I knew God would punish me and I deserve this horrible sickness!" Which of the following responses should the nurse make?
"Let's talk about what is upsetting you."
A nurse is preparing to administer chlorpromazine 0.55 mg/kg PO to an adolescent who weighs 110 lb. Available is chlorpromazine syrup 10 mg/ 5 mL. How many mL should the nurse administer? Fill in the blank
14 mL
A nurse in an emergency department is caring for a female adolescent who has a diagnosis of bulimia nervosa and had a faint episode during a ballet performance. Which of the following statements by the parents acknowledges the client's diagnosis?
"She won't let me take the trash from her room. I'm concerned about what she has in there."
A nurse is counseling an adolescent who has anorexia nervosa and reports excessive laxative use and a fear of gaining weight. The client states, "I'm so fat I can't even stand to look at myself." Which of the following therapeutic responses demonstrates the nurse's use of summarizing?
"You're saying that you think you are fat and using laxatives because you are afraid of gaining weight."
A nurse is caring for four clients in an ED. The nurse should identify that which of the following clients can give informed consent?
A 35-year-old client who has major depressive disorder.
A nurse on an acute mental health facility is receiving change-of-shift report for four clients. Which of the following clients should the nurse assess first?
A client who is experiencing delusions of persecution.
A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse plan to see first?
A client who is taking clozapine and reports sore throat and chills.
A nurse is reviewing the medication administration for a client who is experiencing adverse effects of chlorpromazine. The nurse should administer benztropine to relieve which of the following adverse effects?
Acute dystonia
A nurse in an emergency department is caring for four clients. Which of the following clients is the nurse required to report as a potential victim of abuse?
An older adult client who is bedbound and has a stage IV pressure ulcer.
A nurse is teaching a group of newly licensed nurses about the use of mechanical restraints. Which of the following should the nurse include in the teaching?
Apply restraints when other means of managing the clients behavior have failed.
A nurse is facilitating a community meeting for acute care clients. One client is constantly talking and using the majority of the group's time. Which of the following interventions should the nurse implement?
Ask group members to discuss feelings about this client's monopolizing behavior.
A nurse is planning discharge teaching for a client who has severe schizoaffective disorder. The nurse should identify that which of the following treatment options can offer interdisciplinary services for the client at home?
Assertive community treatment
A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take?
Assist the client with deep-breathing exercises
A nurse on a medical-surgical unit is assessing a client who sustained injuries 12 hr ago following a MVC. The client's admission blood alcohol level was 325 mg/dL. Which of the following findings should indicate to the nurse that the client is experiencing alcohol withdrawal?
Blood pressure 154/96 mm Hg
A nurse on a mental health unit observes a client who has acute mania hit another client. Which of the following action should the nurse take first?
Call a team of staff members to help with the situation.
A nurse in a mental health facility caring for a client who has schizophrenia. Which of the following findings places the client at the greatest risk for self-directed injury or injuring others?
Command hallucinations
A nurse is planning discharge teaching to a family member of a client who has a diagnosis of depression. Which of the following information about relapse should the nurse include?
Early identification of changes, such as decreased social involvement, is important.
A nurse is performing a cognitive assessment to distinguish delirium from dementia in a client whose family reports episodes of confusion. Which of the following assessment findings supports the nurse's suspicion of delirium?
Easily distracted.
A nurse is planning prevention strategies for partner violence in the community. Which of the following strategies should the nurse include as a method of secondary prevention?
Establish screening programs to identify at-risk clients.
A nurse in a community center is teaching families of clients who have post-traumatic stress disorder (PTSD) about expected clinical manifestations. Which of the following manifestations should the nurse include?
Experiences feelings of isolation.
A nurse is preparing to participate in an interdisciplinary conference for a client who has bipolar disorder. Which of the following behaviors is the priority for the nurse to report to the treatment team?
Giving away possessions.
A nurse is assessing a client who has major depressive disorder and has been receiving amitriptyline for 1 week. Which of the following outcomes should the nurse expect?
Greater risk of attempting suicide as affect and energy improve.
A nurse in a community health center is working with a group of clients who have traumatic stress disorder. Which of the following interventions should the nurse include to reduce anxiety among group members?
Guided imagery
A nurse is caring for a client who is in an abusive relationship and is assisting in the development of a safety plan. Which of the following actions is the first component of a safety plan?
Identify signs of escalation of violence.
A nurse is updating the POC for a client who has bulimia nervosa and is 5% above their ideal body weight. Which of the following interventions should the nurse include in the plan?
Identify the client's trigger foods.
A nurse is teaching the partner of a client who has bipolar disorder how to identify manifestations of acute mania. Which of the following findings should the client' partner report to the provdier?
Inability to sleep
A nurse is caring for a client who has alcoholic cardiomyopathy. Which fo the following laboratory findings should the nurse expect?
Increased creatine phosphate (CPK)
A nurse is performing an admission assessment on a client and notices that the client appears withdrawn and fearful. To establish a trusting nurse-client relationship, which of the following actions should the nurse take first?
Inform the client that this admission is confidential.
A school nurse is assessing a school-age child who experienced the traumatic loss of a parent 8 months ago. Which of the following findings should the nurse identify as an indication that the child is experiencing post-traumatic stress disorder (PTSD)?
Lack of interest in an upcoming holiday
A nurse is educating the parent of a child who has a new diagnosis of autism spectrum disorder. Which of the following manifestations of this disorder should the nurse include in the teaching?
Language delay.
A nurse is planning care for a client who had GAD. At which of the following levels of anxiety should the nurse plan to teach the client relaxation techniques?
Mild
A nurse is planning care for a client who is to undergo electroconvulsive therapy (ECT). Which of the following actions should the nurse include in the plan?
Monitor the client's cardiac rhythm during the process.
A client who has a recent diagnosis of bipolar disorder is placed in a room with a client who has severe depression. The client who has depression reports to the nurse, "My roommate never sleeps and keeps me up, too." Which of the following actions should the nurse take?
Move the client who has bipolar disorder to a private room.
A nurse is planning care for a client who has made repeated physical threats toward others on the unit. Although the client does not want to leave the unit, the nurse requests the provider to transfer the client to another unit, the nurse request the provider to transfer the client to a unit that is equipped to manage violent behavior. Which of the following ethical principles should the nurse apply in the situation?
Nonmaleficence
A nurse is preparing to discharge to home an older adult client who attempted suicide. The client lives at home and has difficulty performing ADLs. Which of the following referrals should the nurse initiate? (Select all that apply).
Occupational therapy Meal delivery services PT Home health services
A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan of care?
Offer the client high-calorie foods frequently.
A nurse is assessing a family's dynamics during a counseling session. The nurse should recognize which of the following as an indication of a boundary issue?
Older children who are responsible for their younger siblings
A nurse is caring for an older adult client who is experiencing delirium. Which of the following interventions should the nurse include in the client's plan of care?
Permit the client to perform daily rituals to decrease anxiety.
A nurse is admitting a client who has major depressive disorder and a new prescription of tranylcypromine. Which of the following over-the-counter medications that the client reports taking should the nurse alert the nurse to a potential adverser reaction??
Phenylephrine
A nurse is caring for a child who has conduct disorder and is behaving in a destructive manner, throwing objects, and kicking others. Which of the following therapeutic nursing interventions is the priority?
Reduce environmental stimuli.
A nurse is creating a plan of care for a client who has been placed in seclusion after threatening to harm others on the unit. Which of the following interventions should the nurse include in the plan?
Renew the prescription for the client every 4 hr.
A nurse on a mental health unit is caring for a group of clients. Which of the following actions by the nurse is an example of the ethical principle of justice?
Spending adequate time with a client who is verbally abusive.
A nurse is assessing a client who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect?
Rhinorrhea
A nurse in a mental health clinic is planning care for four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?
Stay with a client who has anorexia nervosa for 1 hr after mealtimes.
A nurse in a mental health clinic is caring for a client who has post-traumatic stress disorder (PTSD) after returning from military deployment. Which of the following is the priority action for the nurse to take?
Stay with the client when flashbacks occur.
A nurse is talking with a group of parents who have recently experienced the death of a child. Which of the following actions shouterm-67ld the nurse take?
Suggest forming a weekly support group for parents who have experienced the death of a child.
A nurse is caring for a client who is taking methylphenidate. The nurse should monitor the child for which of the following findings as an adverse effect of methylphenidate?
Tachycardia.
A nurse is assessing a client for risk factors for the development of depression. The nurse should identify that which of the following factors places the client at an increased risk for depression?
The client has COPD.
A nurse is discussing a 12-step program with a client who has alcohol use disorder and is in an acute care facility undergoing detoxification. Which of the following information should the nurse include in the teaching?
The client should obtain a sponsor before discharge for an increased chance of recovery.
A nurse is assessing a client who has bulimia nervosa. The nurse should expect which of the following finidngs?
Tooth erosion.
A nurse at a provider's office is interviewing an older adult client. Which of the following actions should the nurse plan to take? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)
Use a screening tool to evaluate the client for depression.
A nurse is reviewing laboratory results for a client who has schizophrenia and is taking clozapine. Which of the following values should the nurse identify as a contraindication for receiving clozapine?
WBC count 2,500/mm3
A client who has a diagnosis of depression is attending group therapy. During the group meeting, the nurse asks each member to identify one goal for the day. When it is the client's turn they do not respond. Which of the following actions should the nurse take before repeating the request to the client? a. Allow the client time to formulate an answer b. Prompt the client to give a response c. Move on to the next client d. Offer the client a suggestion for a goal
a. Allow the client time to formulate an answer
A nurse is planning care for an adolescent who is being admitted to an acute care unit following a suicide attempt. Which of the following interventions should the nurse identify as the priority? a. Arrange one-to-one observation of the client b. Encourage interaction with the client's peers c. Administer medication for depressive disorder d. Encourage the client to attend a support group
a. Arrange one-to-one observation of the client
A nurse is admitting a client who has schizophrenia to an acute care setting. When the nurse questions the client regarding their admission, the client states, "I'm red, in the head, and I'm going to bed!" The nurse should document the client's speech pattern as which of the following? a. Clang association b. Word Salad c. Neogolism d. Echolalia
a. Clang association
A nurse is caring for a client who is experiencing alcohol withdrawal. Which of the following medications should the nurse administer fist? a. Diazepam 5 mg IV bolus b. Clonidine 0.1 mg transdermal patch c. Naltrexone 380 mg IM d. Bupropion 150 mg PO
a. Diazepam 5 mg IV bolus
A nurse is caring for a client who has a history of substance use disorder and was involuntarily admitted to a mental health facility. When the nurse attempt to administer oral lorazepam, the client refuses to take the medication and becomes physically aggressive. Which of the following actions should the nurse take? a. Do not administer the lorazepam b. Request a prescription for IV lorazepam c. Request that another nurse attempt to administer the lorazepam d. Place the lorazepam in the client's food
a. Do not administer the lorazepam
A nurse is assessing a client who has borderline personality disorder. Which of the following findings should the nurse expect? a. Emotional lability b. Self-sacrificing c. Suspicious of others d. Grandiosity
a. Emotional lability
A nurse is admitting a client who has anorexia nervosa and is at 60% of ideal body weight. Which of the following interventions should the nurse include in the plan of care? a. Encourage the client to drink 125 mL of fluid each hour while awake b. Allow the client to eat independently in their room. c. Weigh the client twice weekly d. Measure the client's vital signs once each day
a. Encourage the client to drink 125 mL of fluid each hour while awake
A nurse is documenting admission assessment findings for a client who has major depressive disorder. The nurse should identify which of the following findings as clinical manifestations? (Select all that apply.) a. Feelings of hopelessness b. Pressured speech c. Grandiosity d. Anhedonia e. Flat facial expression
a. Feelings of hopelessness d. Anhedonia e. Flat facial expression
A nurse in the emergency department is caring for a client who has alcohol toxicity and is unresponsive. which of the following interventions should the nurse take? a. Gather supplies for endotracheal intubation b. Administer a beta blocker intravenously c. Position the client in a low-Fowler's position d. Place a cooling blanket over the client
a. Gather supplies for endotracheal intubation
A nurse is planning discharge for a client who has bipolar disorder and has a prescription for lithium. Which of the following client statements indicates understanding of the teaching about the medication? a. I should eat a regular diet with normal amounts of salt and fluids. b. I should discontinue the lithium when I begin to feel better c. I need to be careful to avoid becoming addicted to the lithium d. I can skip a dose of medication if my stomach is upset
a. I should eat a regular diet with normal amounts of salt and fluids.
A nurse in a community health center is counseling a family of two parents and two children. Which of the following statements by a family member indicates manipulative behavior? a. If you do my homework for me, I won't bother to for the rest of the day. b. My mom is always upset c. It's not the children's fault. It's mine d. It's your fault that we're having family problems daily
a. If you do my homework for me, I won't bother to for the rest of the day.
A nurse is planning care for a client who has schizophrenia and reports auditory hallucination. Which of the following interventions should the nurse include in the plan? a. Promote the use of music to compete with the client's auditory hallucinations b. Inform the client that the auditory hallucinations are not real c. Avoid asking the client if they are experiencing auditory hallucinations d. Instruct the client on the use of voice recognition regarding the auditory hallucinations
a. Promote the use of music to compete with the client's auditory hallucinations
A nurse is discussing the home care of a client who has advanced Alzheimer's disease with he client's partner, who is planning to go out of town for several days. Which of the following resources should the nurse recommended to the caregiver? a. Respite Care b. Partial Hospitalization c. Adult Day Care Program d. Geropsychiatric unit
a. Respite care
A nurse is caring for a client who has schizophrenia and began taking a conventional antipsychotic medication yesterday. Which of the following findings indicates the nurse should administer benzotropine 2 mg IM a. Shuffling Gait b. Hypotension c. Decreased WBC Count d. Blurred vision
a. Shuffling gait
A nurse in a n outpatient mental health setting is collecting a health history from a client who is taking paroxetine for depression. the client reports to the nurse that he also takes herbal supplements. The nurse should advise the client that which of the following supplements interacts adversely with paroxetine? a. St. John's Wort b. Saw palmetto c. Echinacea d. Ginkgo
a. St. John's Wort
During a client's initial interview in a mental health inpatient setting, a nurse identifies that the client is maintaining eye contact and leaning forward. Which of the following assumptions should the nurse make based on the client's nonverbal behaviors? a. The client is interested in what the nurse is saying b. The client is attempting to manipulate the nurse c. The client is physically attracted to the nurse d. The client needs to feel accepted by the nurse
a. The client is interested in what the nurse is saying
While observing group therapy, a nurse recognizes that a client is behaving in a way suggestive of dependent personality disorder. Which of the following behaviors is consistent with this condition? a. The client needs excessive external input to make everyday decisions b. The client demonstrates a dedication to their job that excludes time for leisure activities c. The client adheres to a rigid set of rules d. The client has difficulty starting new relationships unless they feel accepted
a. The client needs excessive external input to make everyday decisions
A nurse is caring for a client who is experiencing a situational crisis. Which of the following findings should the nurse expect? a. The client recently lost a grandparent in a motor vehicle crash b. The client's town was hit by a tornado c. The client's youngest child is leaving for college d. The client is ambivalent about their upcoming retirement
a. The client recently lost a grandparent in a motor vehicle crash
A nurse is reviewing the medical record of a client who has anorexia nervosa. Which of the following findings should the nurse identify as an indication the client requires hospitalization? a. Total body fat 8.7% b. Potassium 3.6 mEq/L c. Temperature 36.1 (96.9) d. Heart rate 54/min
a. Total body fat 8.7%
A nurse is reviewing routine laboratory values for several clients who re taking lithium carbonate. Which of the following clients should the nurse assess further for findings indicating lithium toxicity? a. A client who has a fasting blood glucose level of 80 mg/dL b. A client who has a sodium level of 128 mEq/L c. A client who has a BUN of 18 mg/dL e. A client who has a potassium level of 3.6 mEq/L
b. A client who has a sodium level of 128 mEq/L
A nurse is caring for a group of clients. Which of the following findings should the nurse report? a. A client who is taking clozapine and has a WBC count of 7,500 mm3 b. A client who is taking lamotrigine and has developed a rash c. A client who is taking valproate and has a platelet count of 150,000/mm3 d. A client who is taking lithium and has a lithium level of 1.2 mEq/L
b. A client who is taking lamotrigine and has developed a rash
A nurse in a mental health facility is planning discharge for a client who has a history of alcohol use disorder. Which of the following post discharge activities should the nurse plan to include? a. Taking the oral medication buprenorphine to prevent alcohol use b. Attending a relapse prevention group several times each week c. Beginning a methadone treatment program at a local center d. Living with their parent, who has promised to keep them away from alcohol
b. Attending a relapse prevention group several times each week
A nurse is planning care for a client who is experiencing acute mania. Which of the following interventions should the nurse include in the plan to promote sleep? a. Have the client participate in a morning aerobics group b. Encourage frequent rest periods throughout the day c. Provide a distraction such as television at night d. Offer the client hot chocolate at bedtime
b. Encourage frequent rest periods throughout the day
A nurse is assessing a client who recently used cocaine. Which of the following findings should the nurse expect? a. Polyphagia b. Hypertension c. Decreased temperature d. Depressed mood
b. Hypertension
A nurse in a mental health clinic is planning car for a client who has a new prescription for olanzapine. Which of the following interventions should the nurse identify as the priority? a. Advice the client to take frequent sips of water b. Instruct the client to avoid driving during initial therapy c. Consult a dietitian for a calorie-controlled diet plan d. Recommend that the client exercise regularly
b. Instruct the client to avoid driving during initial therapy
A nurse is planning care for a client who has depression and has made frequent suicide attempts. Which of the following statements indicates the client has a decreased risk for suicide? a. I'm relieved now that my financial affairs are in order b. It is easier to talk about my feelings now c. Suddenly I have enough energy to do anything I want d. Thank you for always taking such good care of me
b. It is easier to talk about my feelings now.
A nurse is establishing a therapeutic relationship with a client who has antisocial personality disorder. which of the following strategies should the nurse use when communicating with this client? a. Behave in a friendly manner toward the client b. Set realistic limits on the clients behavior c. Show respect for the client's need for isolation d. Act as a role model for assertiveness
b. Set realistic limits on the clients behavior
A nurse is caring for a client who is undergoing electroconvulsive therapy (ECT) and will receive succinylcholine. The client asks the nurse about this medication. Which of the following responses should the nurse make? a. succinylcholine will enhance the therapeutic effects of this treatment b. Succinylcholine is given to reduce muscle movements during therapy c. Succinylcholine will decrease the anxiety level that you might experience with this treatment d. Succinylcholine is used as a general anesthetic to make sure you are sleeping during the procedure
b. Succinylcholine is given to reduce muscle movement during therapy."
A nurse is reviewing the electronic medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings is the priority for the nurse to notify the provider? a. The client's chard indicates a 1.36-kg (3-lb) weight gain in one month b. The client reports an inability to breathe easily c. The clients laboratory results indicate a fasting blood glucose level of 130 mg/dL d. The client reports having recently started smoking cigarettes
b. The client reports an inability to breathe easily
A nurse is caring for a client who has schizophrenia and is experiencing psychosis. The nurse should identify that which of the following findings indicates a potential psychiatric emergency? a. The client is exhibiting echolalia b. The client reports command hallucinations c. The client reports loss of motivation d. The client is exhibiting blunted affect
b. The client reports command hallucinations
A nurse is teaching a client who has a depressive disorder about fluoxetine. which of the following information should the nurse include in the teaching? a. You might notice an increase in saliva while taking this medication b. You might experience difficulties with sexual functioning while taking this medication. c. You should expect an improvement in symptoms of depression in 3 to 4 days d. You may notice a temporary ringing in the ears when starting this medication
b. You might experience difficulties with sexual functioning while taking this medication.
A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report? a. A client refuses ECT after signing the consent form b. A client who was voluntarily admitted left the unit against medical advice c. A client was administered one-half of the prescribed dose of medication d. A client was placed in restraints after attempts to de-escalate aggressive behaviors failed
c. A client was administered one-half of the prescribed dose of medication
a nurse is caring for a group of clients. Which of the following findings is the nurse required to report? a. A client who has bipolar disorder and tested positive for genital herpes simplex virus reports having multiple sexual partners b. A client who has depression reports having a lack of interest in assisting their partner in the care of their children c. A client who has borderline personality disorder threatened to harm their roommate d. An adolescent client who has anorexia nervosa has a BMI of 17
c. A client who has borderline personality disorder threatened to harm their roommate
A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse document as a negative symptom of this disorder? a. Delusions b. Neologisms c. Anhedonia d. Echopraxia
c. Anhedonia
A client who has paranoid schizophrenia is attending a treatment planning conference with a family member. During the discussion of the medication adherence portion of the plan, a nurse notices that the family member seems distracted. which of the following actions should the nurse take? a. Call the family member to the side to inquire if they have questions or concerns about the treatment plan b. Advise the family member that this treatment plan has been developed specifically for the client to follow c. Ask the family member if they have any thoughts or questions about the treatment plan d. Document that the family member does not support this medication treatment plan
c. Ask the family member is they have any thoughts or questions about the treatment plan
During morning rounds, a nurse finds a client who has schizophrenia trembling and tearful in their bed. The client reports that a bomb was placed in their room by a family member during visiting hours. which of the following actions should the nurse take? a. Ask the client to identify the bomb in the room b. Initiate disaster protocols per facility policies and procedures c. Assess the client for evidence of a perceptual disturbance d. Convince the client that there is no bomb in their room
c. Assess the client for evidence of a perceptual disturbance
A nurse is communicating with a client in an inpatient mental health facility. Which of the following actions by the nurse demonstrates the use of active listening? a. Offering self b. Use of silence c. Attention to body language d. Reflection of feelings
c. Attention to body language
A nurse in a provider's office is collecting a health history from the guardian of a school-age child who has been taking atomoxetine. Which of the following adverse effects reported by the guardian is the priority for the nurse to report to the provider? a. Reduced appetite b. Fatigue c. Dark urine d. Sweating
c. Dark urine
A nurse in an emergency department is admitting a client who reports experiencing a headache and heart palpitations after having a glass of wine 1 hr ago. The client has a history of depression and a blood pressure of 210/105 mm Hg and a temperature of 39.9 C (103.8 F). Which of the following actions should the nurse take first? a. Administer phentolamine 5 mg IV to the client b. Apply a hypothermic blanket to the client c. Determine the clients prescribed medication regimen d. Initiate IV access for the client
c. Determine the clients prescribed medication regimen
A nurse in a mental health clinic is caring for a client who has bipolar disorder and reports that they stopped taking lithium 2 weeks ago. he nurse should recognize which of the following as an expected adverse effect that might have caused the client to stop taking the medication? a. Sore throat b. Photophobia c. Hand tremors d. Constipation
c. Hand tremors
A nurse is obtaining a mental health history from an older adult client. Which of the following actions should the nurse plan to take? a. Raise the pitch of the voice when speaking to the client b. Begin the interview by explaining the plan of care c. Interview the client in a private setting d. Ask the client to complete a detailed questionnaire
c. Interview the client in a private setting
A nurse is planning care for a newly admitted client who has bipolar disorder and is experiencing mania. which of the following is the priority action by the nurse? a. Schedule the client for group therapy sessions b. Maintain consistent rules c. Provide frequent high-calorie snacks d. Avoid the use of value judgments
c. Provide frequent high-calorie snacks
A nurse is caring for a client who has antisocial personality disorder and is receiving behavioral therapy through operant conditioning. Which of the following client behaviors indicates effectiveness of the therapy? a. Controls anger outbursts to avoid being placed in seclusion b. No longer exhibits a fear of social or public situations c. Refrains from manipulating others to earn dining room privileges d. Imitates the therapist's use of a relaxation technique
c. Refrains from manipulating others to earn dining room privileges
A community health nurse is planning an education program about depressive disorders. Which of the following factors should the nurse include as increasing the risk for depression? a. Male Gender b. Hyperthyroidism c. Substance Use Disorder d. Being married
c. Substance use disorder
A nurse is caring for a client who has borderline personality disorder. Which of the following goals is the priority when planning care for this client? a. The client will take prescribed medications as scheduled b. The client will express feelings of frustration c. The client will refrain from self-mutilation d. The client will participate in group therapy
c. The client will refrain from self-mutilation
A nurse is assessing a school-age child who has conduct disorder. Which of the following characteristics should the nurse expect the child to demonstrate? a. Feelings of remorse b. Extended periods of depression c. Deficits in intellectual functioning d. Aggression toward animals
d. Aggression toward animals
A nurse on a mental health unit is admitting a client who is anxious and tells the nurse, "I hear voices telling me what to do." Which of the following actions should the nurse take? a. Tell the client that the voices do not really exist b. Touch the client to help reduce feelings of anxiety c. Instruct the client to go to a quiet room when the voices start talking d. Ask the client what the voices are saying
d. Ask the client what the voices are saying
A nurse is providing teaching to a client who is to begin undergoing light therapy at home. Which of the following information should the nurse include in the teaching? a. Ensure a family member can be present during treatment b. Increase fluid intake for 24 hours before the treatment starts c. Change position slowly when the treatment is complete d. Avoid looking directly at the light during treatment.
d. Avoid looking directly at the light during treatment.
A nurse is delegating client care tasks to a licensed practical nurse (LPN) and an assistive personnel. Which of the following tasks should the nurse assign to the LPN? a. Obtain the weight of a client who has bipolar disorder and is experiencing mania b. Assess the nutritional intake of a client who has anorexia nervosa and has refused to eat for the past 2 days c. Monitor the cardiovascular status of a client who is experiencing serotonin syndrome d. Change the dressing of a client who has borderline personality disorder and superficial self-inflicted wounds
d. Change the dressing of a client who has borderline personality disorder and superficial self-inflicted wounds
A nurse is caring for a client who has a recent diagnosis of mild Alzheimer's disease. The client's partner asks the nurse about expected manifestations. The nurse should teach the partner to expect which of the following manifestations to occur first? a. Inability to recognize family members b. Chooses clothing that is inappropriate for weather c. Exhibits a change in personality d. Frequently misplaces objects
d. Frequently misplaces objects
A nurse is admitting a client who has alcohol use disorder. Which of the following statements by the client indicates that the client is using denial as a defense mechanism? a. I put in extra hours at work so I won't think about drinking b. I know that wine is good for my heart, so that's why I drink some each evening. c. I make up for my drinking by taking my partner on nice vacations d. I am able to go to work every day, so I don't have a problem
d. I am able to go to work every day, so I don't have a problem.
A nurse in a clinic is assessing a client whose partner died 4 months ago. Which of the following statements indicates that the client is at risk or complicated grief? a. I wish I had been nicer and more generous with my wife before she died b. I told my wife to go to the doctor, but she wouldn't listen to me c. I think about my wife all the time when I go on outings with my family d. I feel so empty without my wife that it's hard to get up every morning.
d. I feel so empty without my wife that it's hard to get up every morning.
A charge nurse is preparing an educational session for a group of newly licensed nurses to review client rights under the law. Which of the following statements should the nurse make? a. Information regarding clients should remain confidential until after death b. Failure to report suspected maltreatment or neglect of a disabled adult is a felony in all states c. As long as client identity is disguised, their health information can be shared between professionals on the internet. d. In the event a client threatens to harm others, medications can be administered without consent
d. In the event a client threatens to harm others, medications can be administered without consent
A home health nurse is assessing an older adult client whose sibling is the primary caregiver. Which of the following findings should the nurse identify as a possible indicator of neglect? a. Increased confusion b. Sleep disturbances c. Cluttered environment d. Inappropriate dress
d. Inappropriate dress
A nurse is caring for a client whose child has a terminal illness. The client requests information about how to deal with the upcoming loss. Which of the following statements should the nurse make? a. It will be better for you to keep busy to avoid thinking about your child's death b. You will complete the grieving process about a year after your child's death c. The grief process will start once your child actually dies d. It is not uncommon to feel angry toward yourself or others.
d. It is not uncommon to feel angry toward yourself or others.
a nurse is admitting a female client who has anorexia nervosa. Which of the following manifestations should the nurse expect during the admission assessment? a. Diarrhea b. Heavy menstrual bleeding c. Tachycardia d. Orthostatic hypotension
d. Orthostatic hypotension
A nurse is planning care for a 7-year-old child who has ADHD. Which of the following interventions should the nurse identify as the priority? a. Decrease distractions during meal times b. Provide positive feedback when the child completes a task c. Clearly identify consequences for unacceptable behavior d. Remove unnecessary equipment from the child's surroundings
d. Remove unnecessary equipment from the child's surroundings
A nurse is caring for a client in a mental health facility. The nurse overhears another staff member make derogatory comments to the client. Which of the following actions should the nurse take? a. Confront the staff member b. Encourage the client to report the incident c. Document the incident in the client's health record d. Report the occurrence to the charge nurse
d. Report the occurrence to the charge nurse
A nurse is caring for an older adult client who has dementia and has wandered into the day room looking for their deceased partner. Which of the following actions should the nurse take? a. Move the client to a room near the nurse's station b. Limit visitors until the client is oriented to the environment c. Tell the client that their partner is deceased d. Talk with the client about activities they enjoyed with their partner
d. Talk with the client about activities they enjoyed with their partner
