Mh 1

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?

"Are you feeling helpless about changing this behavior?"

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?

"He is the worst nurse that has ever taken care of me"

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?

"What were we discussing that begin to make you feel uncomfortable, Craig?"

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?

"What year did you graduate from high school, Billy Jean?" *Ask a question that can be validated

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 feel better when you dont take your medication?" *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 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?

"You must be very upset about something, Jaquan, if you want to see the provider in the middle of the night"

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?

Countertransference *The nurse unconsciously attributing feelings, positive or negative, about another toward a client

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?

Deinal

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?

Displacement *Redirection of thoughts, feelings, impulses, from an object that causes anxiety to a safer more acceptable one

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?

Explain that the time is designated to be focused on the client

A nurse is assessing a client who has anorexia nervosa. The nurse should expect the client to display which of the following characteristics?

Expressed feelings of decreased self worth

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?

Identify the clients feelings that lead to the self injury *Nursing process - collecting data is first

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?

Identify the clients perception of the reason for therapy

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 on one-on-one observation

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?

The client agrees to notify a staff member of thoughts of self harm

A nurse is assessing a client who is experiencing moderate-level anxiety. Which of the following findings should the nurse expect?

The client has difficult concentrating (also focusing)

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?

"I should keep client info private even after the client, Harold, dies"

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?

"I will give you some space if you calm down. Tell me what is making you feel so tense." *Stay at safe distance and remain calm

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?

"I would like to sit and talk to you" *Offer oneself

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?

"In other words, you seem to be saying you feel unworthy of help"

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?

"My child was riding their bicycle, and fell off"

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?

"The next time this occurs, what might 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?

"There is no point in living any longer"

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?

"These tremors will persist for the next few days as you are withdrawing from alcohol"

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?

"You must feel very frightened, if you think someone wants to hurt you"

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?

"You sound upset, bridget, are you thinking of hurting yourself?" *focus on the clients feelings

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 a pediatric emergency department is caring for four clients. The nurse should suspect possible abuse with which of the following clients?

A 9-month old who nearly drown by having accidentally fallen into the tub and turned the water on.

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?

Ask the client to complete a CAGE questionnaire *Begin was assessment/data collection

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?

Denial *followed by anger, bargaining, depression, acceptance

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?

Document the clients behaviors every 15 minutes while in restraints *There should be TWO fingers that can fit between wrist and clients restraint *There should be someone one-on-one with the client at all times while in restraints

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?

Document the clients refusal in the medical record

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?

Projection

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?

Provide a presentation at area high schools on resisting peer pressure for substance abuse

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?

Regression

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?

Somatic *Believe that their body part in no longer functioning in a realistic or expected manner

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?

Stay with the client and allow the client to cry *Offer self *Silence is a therapeutic technique for those who are grieving

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?

The client gives his favorite possessions to his friends

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?

The client will gain increased self-esteem