RN 3.0 Mental Health 1

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? a. "Did I say something wrong that made you feel tense?" b. "Do you often feel tense when you are talking to a health care provider?" c. "What were we discussing when you began to feel uncomfortable?" d. "It is ok to feel nervous during our counseling sessions."

"What were we discussing that begin to make you feel uncomfortable?" The nurse should use the therapeutic technique of focusing, which promotes discussion about a specific topic. This technique helps identify the cause of the client's feelings and promotes further communication.

A nurse is preparing to administer fluphenazine decanoate 12.5 mg subcutaneous. Available is fluphenazine decanoate 25 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

(12.5mg/25mg) x 1 mL = 0.5 mL

A nurse in an emergency department is caring for an 18-month-old toddler who has a fractured left femur. Which of the following statements by the toddler's parent should cause the nurse to suspect child abuse? a. "My child fell down the stairs." b. "My child was riding a bicycle and fell off." c. "My child slipped out of the high chair." d. "My child climbed up on a chair and it tipped over."

b. "My child was riding a bicycle and fell off." The nurse should suspect possible child abuse in response to this statement because an 18-month-old toddler is not expected to have the developmental ability to ride a bicycle.

A nurse is caring for a client who has alcohol use disorder and is receiving treatment for alcohol withdrawal. The client reports hand tremors 12 hr after admission. Which of the following statements should the nurse make? a. "The tremors are permanent due to nerve damage caused by chronic alcohol use." b. "The tremors will persist for a few days as you are withdrawing from alcohol." c. "Try not to worry about the tremors. Everyone has these during alcohol withdrawal." d. "These tremors are an indication of seizures that are associated with alcohol withdrawal."

b. "The tremors will persist for a few days as you are withdrawing from alcohol." The nurse should inform the client that tremors, as well as other manifestations of alcohol withdrawal, might persist for several days after the last intake of alcohol.

A nurse is caring for a client who has borderline personality disorder. The client has previously identified another nurse as his favorite stating, "He's the best nurse ever." When that nurse calls in sick, which of the following statements indicates that the client is using splitting as a method of coping? a. "He's the worst nurse that's ever taken care of me." b. "You're just lying to me. He's not really sick." c. "He's my favorite nurse and I'm really worried about him." d. "If anyone else tries to take care of me, I'm going to get really upset."

a. "He's the worst nurse that's ever taken care of me." The nurse should identify that the client is using splitting when he relates to others as if they are all good or all bad, rather than as integrated individuals who have both positive and negative attributes. Clients who have borderline personality disorder might use this coping style as a defense mechanism.

A nurse is performing a mental status assessment on an older adult client who has dementia. Which of the following questions should the nurse ask to assess the client's remote memory? a. "What year did you graduate from high school?" b. "What is your favorite childhood memory?" c. "What did you have for supper yesterday?" d. "What is today's date?"

a. "What year did you graduate from high school?" When assessing a client's remote memory, the nurse should ask questions that determine the client's ability to remember things from the distant past. The nurse should ask questions that can be validated to ensure that the information is correct.

A nurse is caring for a client who is brought to the clinic by her adult son who states that his father recently died. The client repeatedly yells at her son stating, "Quit lying about your father!" The nurse should recognize that the client is demonstrating which of the following defense mechanisms? a. Denial b. Identification c. Introjection d. Sublimation

a. Denial The nurse should recognize that the client is demonstrating denial through her belief that her son is lying about her partner's death.

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 stages of grief first? a. Denial b. Bargaining c. Anger d. Depression

a. Denial Evidenced-based practice indicates the nurse should first expect the parents to experience denial. Denial is the first stage of grief and is followed by anger, bargaining, depression, and finally acceptance.

A nurse is conducting a counseling session with a client who has a substance use disorder. The client repeatedly asks personal questions about the nurse. Which of the following actions should the nurse take? a. Explain that this time is designated to focus on the client. b. Answer the personal inquiry questions matter-of-factly. c. Tell the client that interest in someone besides himself is an indication of improvement. d. Request that personal questions be asked after the counseling session is over.

a. Explain that this time is designated to focus on the client. The nurse should understand the difference between a therapeutic nurse-client relationship and a social relationship. The nurse should explain to the client that the counseling session time is designated to focus on the client and resolution of his problems.

A nurse is establishing a therapeutic relationship with a client who has hallucinations. Which of the following actions should the nurse take during the orientation phase? a. Identify the client's perception of the reason for therapy. b. Ask the client to provide a detailed description of the hallucinations. c. Assist the client with the development of problem-solving skills. d. Explore the client's relationship with family members.

a. Identify the clients perception of the reason for therapy. In the initial, orientation phase of the nurse-client relationship, the nurse should establish rapport and confidentiality with the client. The nurse should assess the client's beliefs about the reason for therapy.

A nurse is caring for a client at a college mental health counseling 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? a. Projection b. Dissociation c. Undoing d. Compensation

a. Projection The nurse should identify that a client is using projection when unconsciously transferring unacceptable feelings, thoughts, or traits in oneself onto another person. This response is maladaptive because it prevents the client from accepting responsibility for personal performance in school.

A nurse is caring for a school-age client who begins wetting the bed after finding out that her parents are getting a divorce. The nurse should identify that the client is exhibiting which of the following defense mechanisms? a. Regression b. Projection c. Repression d. Splitting

a. Regression The nurse should identify that regression represents a dysfunctional attempt to reduce anxiety and conflict by returning to less mature behaviors that help the client better tolerate the anxiety.

A nurse is caring for a client who has schizophrenia. The client states, "My internal organs have turned to stone." The nurse should document this finding as which of the following types of delusions? a. Somatic b. Reference c. Persecutory d. Grandiose

a. Somatic The nurse should identify that the client is experiencing a somatic delusion. Clients experiencing a somatic delusion believe that a body part is no longer functioning in a realistic or expected manner.

A nurse is planning reminiscence therapy for an older adult client. The nurse should identify which of the following goals for the client's therapy? a. The client will gain increased self-esteem. b. The client will maintain orientation to place and time. c. The client will independently perform ADLs. d. The client will achieve optimal sensory stimulation.

a. The client will gain increased self-esteem. The nurse should use reminiscence therapy to assist the client in reflecting on past experiences. This review of the client's life is intended to increase the client's self-esteem and attain ego integrity.

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? a. "Many people feel this way when they first start treatment." b. "In other words, you seem to be saying that you feel unworthy of help." c. "You'll feel better once you get up and have some breakfast." d. "I disagree with your feeling that you are not worth my time."

b. "In other words, you seem to be saying that you feel unworthy of help." The nurse should use the therapeutic technique of paraphrasing to clarify the client's statement and promote further communication.

A nurse is caring for a client who has dementia. The client states to the nurse, "Everyone wants to kill me." Which of the following responses should the nurse make? a. "Tell me how everyone wants to hurt you." b. "You must feel very frightened to think someone wants to hurt you." c. "No one here wants to kill you." d. "Who in particular do you think wants to kill you?"

b. "You must feel very frightened to think someone wants to hurt you." The nurse should acknowledge the client's feelings about the delusion. This acknowledgement helps the client to feel safe and accepted.

A nurse in a pediatric emergency department is caring for four clients. The nurse should suspect possible abuse with which of the following clients? a. A 14-month-old toddler who has recently learned to walk and has many bruises on bony prominences in various stages of healing b. A 9-month-old infant who reportedly nearly drowned after climbing into the tub and turning on the water c. A 6-year-old toddler who has a fracture of the tibia and fibula, which reportedly occurred while riding a bicycle d. A 3-year-old toddler who has burns in a splash pattern over the face and chest, reportedly sustained when a tablecloth was pulled, spilling a teapot

b. A 9-month-old infant who reportedly nearly drowned after climbing into the tub and turning on the water The nurse should identify that, while a 9-month-old might have the ability to climb into the tub, it is unlikely that he could turn the water on. The nurse should suspect possible abuse because the reported cause of the accident seems inconsistent with the developmental abilities of most 9-month-old infants.

The 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 towards the client. The nurse should recognize that she is demonstrating which of the following behaviors? a. Suppression b. Countertransference c. Transference d. Assertiveness

b. Countertransference The nurse demonstrates countertransference by unconsciously attributing feelings, positive or negative, about another towards the client.

A nurse is caring for a client who has a new diagnosis of colon cancer. Shortly after the client receives the diagnosis, the nurse enters the client's room and the client begins yelling, "I have received terrible care here and no one cares about me." The nurse should recognize that the client is demonstrating which of the following defense mechanisms? a. Denial b. Displacement c. Reaction formation d. Projection

b. Displacement The nurse should identify displacement as the redirection of thoughts, feelings, and impulses from an object that causes to anxiety to a safer, more acceptable one. In this scenario, the client is redirecting his anxiety about the diagnosis to the staff that is providing care.

A nurse is assessing a client who has anorexia nervosa. The nurse should expect the client to display which of the following characteristics? a. Refuses to participate in physical exercise activities b. Possesses feelings of decreased self-worth c. Preoccupied with concerns about personal health d. Avoids discussion of food

b. Possesses feelings of decreased self-worth The nurse should expect the client who has anorexia nervosa to have an altered sense of self-image and self-identity. The client often bases feelings of self-worth on body weight; therefore, feelings of self-worth are often decreased because the client views herself as overweight.

A nurse is planning care for a client who has thoughts of suicide. Which of the following goals should the nurse include in the client's plan of care? a. The client will identify positive aspects of others. b. The client agrees to notify a staff member of thoughts of self-harm. c. The client will engage in an independent diversional activity. d. The client will not verbalize thoughts or feelings related to suicide.

b. The client agrees to notify a staff member of thoughts of self harm. The nurse should instruct the client to notify staff if he has suicidal thoughts so that the client's needs are immediately addressed and actions are taken to prevent self-injury or suicide.

A nurse is assessing a client who is experiencing moderate-level anxiety. Which of the following findings should the nurse expect? a. The client has a heightened perceptual field. b. The client has difficulty concentrating. c. The client reports shortness of breath. d. The client reports a sense of impending doom.

b. The client has difficulty concentrating. The nurse should expect the client who has moderate-level anxiety to have difficulty concentrating and focusing. This lack of concentration increases as the anxiety level escalates.

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? a. "I hate being so helpless. I can't even manage my own finances anymore." b. "At group therapy today I wanted to leave. I didn't feeling like being with other people." c. "I have it all figured out. Everything is going to be okay now." d. "I don't feel like showering. I'd rather just stay in bed today."

c. "I have it all figured out. Everything is going to be okay now." The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. Therefore, the nurse should identify that this client statement is the priority because it indicates a possible plan for suicide. This reaction is possible after starting an antidepressant, when the client gains the energy to act upon suicidal thoughts.

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

c. "I will give you some space if you calm down. Tell me what is making you feel so tense." The nurse should stay at a safe distance and remain calm while stressing the importance of maintaining control. The nurse should use verbal de-escalation techniques while determining the client's needs and respecting the client's personal space.

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 the 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? a. "Aren't you worried about the safety of your children?" b. "Can you identify your behaviors that provoke your partner?" c. "The next time this occurs, what might you do to ensure your safety?" d. "You need to remove yourself and your children from the abusive situation."

c. "The next time this occurs, what might you do to ensure your safety?" The nurse should use the therapeutic communication technique of encouraging formulation of a plan of action. With this technique, the nurse encourages the client to explore alternative actions to ensure her safety if abuse occurs in the future. The nurse should assist the client to develop a safety plan, which includes information about shelters, so that she has the information if she chooses to leave in the future.

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? a. "Everything will be better soon." b. "Soon no one will have to worry about me." c. "There's no point in living any longer." d. "I want to donate my organs to help others."

c. "There's no point in living any longer." The nurse should identify this client comment as an overt statement about the client's risk for suicide. The nurse should assess the client's suicidal ideation further and implement interventions to promote her safety.

A nurse at a college campus 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 cannot control it." Which of the following responses should the nurse make? a. "Why do you think you are experiencing these behaviors of binges and vomiting?" b. "Are other students in your dorm also experiencing this behavior?" c. "You are feeling helpless about changing this behavior?" d. "You know you must stop because you are endangering your health."

c. "You are feeling helpless about changing this behavior?" The nurse should use the therapeutic communication technique of restating when responding to the feelings the client has expressed. Restating focuses on the main idea of the client's statement and helps the client understand and explore personal behaviors.

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? a. "You might feel good now, but what about when you get depressed?" b. "Why do you think you like feeling manic?" c. "You feel better when you don't take your medication?" d. "What do you think your provider will say about you going off your medication?"

c. "You feel better when you dont take your medication?" The nurse should use the therapeutic communication tool of validating or clarifying the client's feelings. The client has stated a preference for not taking the medication. This open-ended paraphrasing acknowledges the client's statement and allows for further exploration of the subject.

A nurse is caring for a client who has depression and started taking paroxetine one 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? a. "Why do you feel your family would be better off without you?" b. "Many people feel this way when they are depressed." c. "You sound upset. Are you thinking of hurting yourself?" d. "Your medication hasn't started working yet. Then you'll be feeling differently."

c. "You sound upset. Are you thinking of hurting yourself?" This response exemplifies the therapeutic communication technique of showing empathy. Telling the client, "You sound upset," focuses on the client's feelings, which is a demonstration of therapeutic communication. In addition, the nurse addresses the possibility of suicidal ideation by asking the client directly whether or not she has an intent to harm herself.

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? a. Assign the client to a private room. b. Request that the dietary department provide the client with finger foods. c. Place the client on one-to-one observation. d. Keep the door to the client's room closed.

c. Place the client on one-to-one observation. The nurse has both a legal and professional responsibility to provide a safe environment for the client who is at risk for suicide. The client who is at high risk for suicidal behavior requires constant one-to-one observation to ensure safety.

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

c. Stay with the client and allow the client to cry. The nurse demonstrates respect for the client and his feelings by staying with him. The use of silence is a therapeutic communication technique and allowing the client to cry is therapeutic during times of grieving.

A nurse in a mental health facility is reviewing confidentiality requirements with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the information? a. "I am legally required to notify a client's employer about a substance use disorder." b. "If a client is involuntarily committed, I can discuss information with the client's next of kin." c. "I can discuss a client's treatment with others as long as they are employees of the facility." d. "I should keep information private even after a client dies."

d. "I should keep information private even after a client dies." The nurse should be aware that a client's right to privacy continues even after death.

A nurse is admitting a client following care in the emergency department for an intentional overdose of opioids. The client states, "I feel so alone. No one can help me." Which of the following responses by the nurse is therapeutic? a. "Let's finish your admission and then talk about your feelings." b. "How come you feel that no one can help you when you are receiving help now?" c. "Why do you feel that no one can help you?" d. "I would like to sit and talk with you."

d. "I would like to sit and talk to you" The nurse should use the therapeutic communication technique of offering one's self to demonstrate caring and interest in the client and the client's feelings.

A nurse at an acute mental health facility is caring for a client who has acute mania due to bipolar disorder. At 0300, the client runs to the nurse's station and demands to see the provider immediately. Which of the following responses should the nurse make? a. "Your request is unreasonable. We cannot call your provider at 3:00 in the morning." b. "If you can calm down for 5 minutes then I will call your provider for you." c. "Calm down, go back to your room, and come back in 15 minutes and we'll talk about how you're feeling." d. "You must be very upset about something to want to see your provider in the middle of the night."

d. "You must be very upset about something to want to see your provider in the middle of the night." The nurse should respond to the client's concern with empathy, which shows concern for the client's feelings and offers an opportunity for the client to clarify the situation.

A nurse in a mental health clinic is caring for a client who states, "I think I might have a problem with alcohol." Which of the following actions should the nurse take first? a. Provide the client with information about a 12-step recovery program. b. Encourage the client to accept responsibility for his alcohol use. c. Teach the client alternate coping mechanisms to use in place of alcohol. d. Ask the client to complete a CAGE Questionnaire.

d. Ask the client to complete a CAGE Questionnaire. The nurse should apply the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify the provider of a change in the client's status, she must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision. Therefore, the first action the nurse should take is to assess the client's alcohol use. Use of a CAGE Questionnaire is helpful to determine the impact of alcohol use on the client's life.

A nurse is preparing to apply wrist restraints on a client who is threatening to harm others and has not responded to less invasive interventions. Which of the following actions should the nurse plan to take? a. Obtain a PRN prescription for restraints from the client's provider. b. Visually observe the client every 10 min until restraints are removed. c. Ensure that three fingers can fit between the restraint and the client's wrist. d. Document the client's behavior every 15 min while restraints are in place.

d. Document the client's behavior every 15 min while restraints are in place. The nurse should plan to document the client's behavior every 15 min while restraints are in place. This frequent documentation meets the legal requirement for use of restraints; helps provide for prompt identification of complications related to restraint use; and helps ensure that restraints are removed as soon as possible, depending on the client's behavior.

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 take? a. Administer the medication by another route. b. Refer the client's refusal to the facility's ethics committee. c. Inform the client that, due to her involuntary admission, she cannot refuse a sedative. d. Document the client's refusal of the medication in the medical record.

d. Document the client's refusal of the medication in the medical record. The nurse should respect the client's right to refuse medication, even if the client is receiving treatment due to an involuntary admission. The nurse should document this refusal in the medical record and assess the reasons for the client's refusal.

A nurse is caring for a client who has borderline personality disorder. The nurse enters the client's room and finds the client cutting into his flesh with a paper clip. After providing first aid, which of the following actions should the nurse take first? a. Encourage the client to discuss feelings about his self-injurious behavior during group therapy. b. Fill out an incident report for risk management about the client's self-injurious behavior. c. Document the client's self-injurious behavior in his medical record. d. Identify the client's feelings that led to the self-injurious behavior.

d. Identify the client's feelings that led to the self-injurious behavior. The nurse should apply the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify the provider of a change in the client's status, she must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision. Therefore, the first action the nurse should take is to assist the client to identify events or feelings that led to his self-injurious behavior.

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

d. Provide a presentation at area high schools on resisting peer pressure for substance use. Planning interventions that prevent the onset of substance use is an example of primary prevention. By providing information to adolescents on methods to resist peer pressure for substance use, the nurse can help prevent the substance use from occurring.

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

d. The client gave his favorite possessions to friends. The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. Therefore, the nurse should identify this finding as the priority. Giving away valued and prized possessions is an indication of suicidal ideation, which is the greatest risk for clients who have depression.