H&H - Mental Health

A female adult client with generalized anxiety disorder (GAD) becomes anxious when she touches fruit and vegetable foods. Which of the following interventions should the nurse perform to best help this client? 1. Instruct the client to avoid touching these foods 2. Ask the client why she becomes anxious in these situations 3. Assist the client in making a meal plan for her family to work with the fear 4. Use cognitive-behavioral techniques to help the client face her fears

4. Use cognitive-behavioral techniques to help the client face her fears

The nurse is educating a client diagnosed with bipolar disorder about the risks associated with lithium therapy. Which of the following is not a complication of lithium treatment? a. Hypothyroidism b. Cholelithiasis c. Arrhythmia d. Nephrogenic diabetes insipidus

b. Cholelithiasis

A client with suspected heroin abuse comes to the clinic for an assessment. Which of the following questions must be asked as part of the CAGE screening questionnaire? Select all that apply. 1. "Have you ever felt the need to cut down on your heroin use?" 2. "What coping mechanisms have helped you with your addiction?" 3. "Have you ever felt guilty about using heroin?" 4. "When did you first use heroin?" 5. "Have you ever been annoyed at criticism of your heroin use?"

1. "Have you ever felt the need to cut down on your heroin use?" 3. "Have you ever felt guilty about using heroin?" 5. "Have you ever been annoyed at criticism of your heroin use?"

A client with a chronic substance abuse disorder is transitioning out of a nursing case management model. Which of the following client statements demonstrate their ability to move towards disengagement? 1. "I am ready to use the supports provided to me to help me move forward" 2. "I feel that lack of resources in my community will act as a barrier to my sobriety" 3. "I have a strong network of friends who still party but understand I can't drink alcohol anymore" 4. "I feel like I have new skills but still feel anxious when doing things on my own"

1. "I am ready to use the supports provided to me to help me move forward"

A client with schizoaffective disorder is escalating their maladaptive anger while on an inpatient psychiatry unit. Which of the following client statements would indicate to the nurse that the client is at risk of assaulting hospital staff? Select all that apply. 1. "I am so tired of being locked up in this unit if I need to hurt someone to leave I will" 2. "I am not angry it is my right to do what I want" 3. "I feel like I am losing control of my life" 4. "I am being assertive when I say I am fed up with this, not angry" 5. "The other clients feel the same way about the lack of care on the unit"

1. "I am so tired of being locked up in this unit if I need to hurt someone to leave I will" 2. "I am not angry it is my right to do what I want" 4. "I am being assertive when I say I am fed up with this, not angry"

A client experiencing auditory hallucinations says to the nurse, "Do you hear that? There is a voice saying mean things about me." What is the MOST appropriate response for the nurse to make? 1. "I don't hear a voice, but what is it saying to you?" 2. "What do you think will help the voice go away?" 3. "There is no voice. You are having a hallucination." 4. "I promise that the voice will go away soon."

1. "I don't hear a voice, but what is it saying to you?"

A 25 year-old woman is brought to the Emergency Department (ED) after being beaten by her husband. She is assessed and is not in danger from her injuries at this time. Which of the following statements, if made by the client, would signal the nurse that she should be hospitalized? Select all that apply. 1. "I think it would be better if my husband was dead" 2. "I have a best friend who lives in another town" 3. "I think my husband might kill me if I go home" 4. "Sometimes I think that I can't go on anymore" 5. "I know if I go home that I will not have anyone to help me"

1. "I think it would be better if my husband was dead" 3. "I think my husband might kill me if I go home" 4. "Sometimes I think that I can't go on anymore" 5. "I know if I go home that I will not have anyone to help me"

The nurse is helping a client to reframe irrational thoughts while completing an ongoing outpatient treatment program. The client states "I will never have a partner who will accept me for who I am." How should the nurse teach the client to reframe this thought? 1. "If a potential partner doesn't help seem to understand your issues right away, you can slowly help them to learn more about you" 2. "You will need to accept that some people will reject you due to your mental health condition" 3. "You can change your thoughts and patterns for a new partner" 4. "Your problems are too complex for a partner at this time, it is important to work on yourself first"

1. "If a potential partner doesn't help seem to understand your issues right away, you can slowly help them to learn more about you"

The nurse provides education to a support group for individuals with bipolar disorder. Which of the following statements best explains the role of neurotransmitters during acute mania? 1. "Norepinephrine stimulates the sympathetic branch of the autonomic nervous system, it is elevated during mania" 2. "Decreased serotonin is a central factor in mania because of its role in sleep regulation" 3. "Increased levels of acetylcholine may result in sexual and aggressive behavior" 4. "Decreased dopamine is involved in fine muscle movement and may contribute to mania"

1. "Norepinephrine stimulates the sympathetic branch of the autonomic nervous system, it is elevated during mania"

A client with social phobia who is nervous about partaking in exposure therapy asks the nurse to briefly describe the process. Which of the following statements would be inappropriate for the nurse to include in the discussion? 1. "The therapist will use a 'flooding' technique, as it is the most effective." 2. "Exposure therapy uses a process of systematic desensitization." 3. "The goal is to help you gain control of the fear." 4. "You may experience mild to moderate discomfort when engaging in new activities."

1. "The therapist will use a 'flooding' technique, as it is the most effective."

A nurse is working with an asthmatic client who is participating in a smoking cessation program. The client reveals that he 'slipped' a few days ago, but it was only one cigarette. He feels worried and doubtful about reaching his goal and fears for his children. Which of the following responses by the nurse is considered non-therapeutic? 1. "Things get worse before they get better." 2. "What are your fears concerning your children?" 3. "You must be feeling upset." 4. "Tell me some of the events that led to your slip."

1. "Things get worse before they get better."

Which of the following individuals is most susceptible to substance abuse disorders? 1. A 16 year old male with a fractured femur 2. A 36 year old female who just lost her husband 3. A 65 year old male that reports having "excruciating pain" 4. A 29 year old female that was recently diagnosed with hypothyroidism

1. A 16 year old male with a fractured femur

A nurse is assigned to a client with bipolar disorder that is scheduled for electroconvulsive therapy (ECT). Which of the following are potential complications of this treatment? Select all that apply. 1. Confusion 2. Hemorrhage 3. Short-term memory loss 4. Disorientation 5. Long-term memory loss

1. Confusion 3. Short-term memory loss 4. Disorientation

A client diagnosed with generalized anxiety disorder (GAD) is taking diazepam. Which of the following instructions should the nurse give to the client with regards to this medication? Select all that apply. 1. Consult with the health care provider (HCP) prior to stopping the medication 2. Avoid eating cheese and tyramine-rich foods 3. Take the medication on an empty stomach 4. Do not consume alcohol while taking the drug 5. Stop taking the drug if swelling of the lips and face and difficulty breathing is observed

1. Consult with the health care provider (HCP) prior to stopping the medication 4. Do not consume alcohol while taking the drug 5. Stop taking the drug if swelling of the lips and face and difficulty breathing is observed

The nurse is assessing a client admitted to an inpatient psychiatry unit for a manic episode. When conducting a demographic assessment, which factors put the client at an increased risk of aggression or violence? Select all that apply. 1. History of violence 2. Male gender 3. Difficulty expressing or dealing with emotions 4. History of difficulty with anger management 5. Age 14-24 years

1. History of violence 2. Male gender 5. Age 14-24 years

A client diagnosed with alcohol abuse disorder is likely to have which of the following fluid and electrolyte imbalances? 1. Hyponatremia 2. Hypermagnesemia 3. Hyperkalemia 4. Hypercalcemia

1. Hyponatremia

A community health nurse is assessing a client's personal coping skills while working at a Women's Shelter for victims of intimate partner violence. The client recently moved to the community from another country and has limited social supports. Which of the following client statements demonstrate positive coping by the client? Select all that apply. 1. I find that running helps me to think more clearly since entering the shelter 2. In the past, my mother was able to help me through difficult times 3. This time I am going to stay in the shelter until I am ready to move to my own place 4. My culture values family I know I could go back to my community for help 5. I am not sure of what might happen if I go home

1. I find that running helps me to think more clearly since entering the shelter 2. In the past, my mother was able to help me through difficult times 3. This time I am going to stay in the shelter until I am ready to move to my own place 4. My culture values family I know I could go back to my community for help

A client has high levels of anxiety that interfere with their ability to work, disrupts their relationships and changes their ability to interact with others. Which nursing diagnosis stem would be appropriate for this client? 1. Ineffective coping 2. Social isolation 3. Ineffective health maintenance 4. Chronic low self-esteem

1. Ineffective coping

Which of the following activities are appropriate during the orientation stage of a therapeutic relationship? 1. Introduce self by name and professional designation 2. Reflect on the progress you have made together 3. Establish shared goals for care 4. Evaluate the effectiveness of the nursing interventions

1. Introduce self by name and professional designation

The nurse must engage an aggressive client. The client is striking out physically at hospital staff and a Code White has been called. The nurse states to the client "you seem very upset" the client validates the nurse by saying "I am just so angry right now." What is the next step the nurse should take? 1. Invite the client to sit down and talk about their feelings 2. Stand in front of the client and block the door 3. Ask the security members to restrain the client 4. Encourage the client to speak to the psychiatrist who is on the unit

1. Invite the client to sit down and talk about their feelings

A client is showing increased signs of agitation and anxiety. The nurse has utilized psycho-social interventions and de-escalation techniques but requires a pharmacological adjunct. Which of the following medications would be appropriate for this client? Select all that apply. 1. Lorazepam 2. Haloperidol 3. Loxapine 4. Risperidone 5. Alprazolam

1. Lorazepam 5. Alprazolam

A client is increasingly agitated. The nurse is completing a risk assessment for the assaultive stage for anger, aggression or violence. Which of the following client behaviors would indicate they are at risk of assaulting another person? Select all that apply. 1. Negative or hostile response to limit-setting by the nurse 2. Hyperactivity 3. Need for support of anger from others 4. Intense or avoidant eye contact 5. Verbal abuse, profanity, argumentativeness or threats

1. Negative or hostile response to limit-setting by the nurse 2. Hyperactivity 4. Intense or avoidant eye contact 5. Verbal abuse, profanity, argumentativeness or threats

The nurse is caring for a client admitted with alcohol withdrawal symptoms. The nurse enters the client's room and notices that the client has suddenly become diaphoretic and exhibiting body tremors. A comprehensive physical assessment was done. Which of the following actions should the nurse take? Select all that apply. 1. Notify the health care provider (HCP) 2. Administer vitamin B1 3. Monitor vital signs continuously 4. Assess the gag reflex with a tongue blade 5. Place soft wrist restraints on the client

1. Notify the health care provider (HCP) 2. Administer vitamin B1 3. Monitor vital signs continuously

A client under observation on an inpatient psychiatry unit tells the nurse he is going to kill his wife when he is discharged. What is the nurse's responsibility in this situation? 1. Notify the health care provider (HCP) immediately 2. Notify the police immediately 3. Inform the nurse manager about the client's statements 4. Explore the client statement further

1. Notify the health care provider (HCP) immediately

A client with schizophrenia is admitted to the inpatient mental health unit with auditory command hallucinations telling her to take her own life. Which of the following interventions should be implemented to increase client safety? Select all that apply. 1. Place client's razor, scissors and nail clippers in a secure storage area 2. Ensure there are no cords in the room 3. Give the client some alone time to reflect 4. Offer to take the client for a walk outside 5. Ensure that the stairwells are secured

1. Place client's razor, scissors and nail clippers in a secure storage area 2. Ensure there are no cords in the room 5. Ensure that the stairwells are secured

Which of the following nonpharmacological interventions are ideal for a client experiencing a manic episode? Select all that apply. 1. Place the client in a quiet, dim room 2. Remove hazardous objects from the environment 3. Offer Electroconvulsive Therapy (ECT) 4. Allow the client to participate in board games with other clients 5. Provide frequent rest periods

1. Place the client in a quiet, dim room 2. Remove hazardous objects from the environment 3. Offer Electroconvulsive Therapy (ECT) 5. Provide frequent rest periods

A nurse is caring for a schizophrenia client who has auditory hallucinations. Which of the following interventions will help build the nurse-patient relationship? Select all that apply: 1. Providing frequent, brief one-on-one contact 2. Using therapeutic touch 3. Promote a calm, quiet environment 4. Provide a puzzle or craft 5.. Ask the client what the voices are saying

1. Providing frequent, brief one-on-one contact 3. Promote a calm, quiet environment 4. Provide a puzzle or craft 5.. Ask the client what the voices are saying

A home health nurse is doing an initial visit to a family who has a child living with autism spectrum disorder (ASD). Upon arrival, the nurse observes that the floors are cluttered with toys, kitchen utensils are not properly stored and cabinet doors do not have safety locks. What should be the initial action taken by the nurse? 1. Put away the toys and kitchen utensils 2. Educate the family about maintaining a home environment for a child with ASD 3. Contact the nursing supervisor to report the issue 4. Assess the circumstances that led to the mess

1. Put away the toys and kitchen utensils

The nurse is assessing a newly admitted client in a mental health setting. Which of the following cultural considerations are appropriate for the nurse to perform when caring for the client? Select all that apply. 1. Respect self-reported ethnicity and cultural practices 2. Family members are best to interpret the client's language and nonverbal communication 3. Recognize the impact of self-reported culture on understanding and acceptance of diagnosis 4. Incorporate self-reported cultural practices into client's plan of care 5. Identify communication barriers and utilize a professional translator as needed

1. Respect self-reported ethnicity and cultural practices

A nurse in an inpatient psychiatry unit is using de-escalation techniques for a new client who is feeling "trapped" in the unit. The client is on a 72-hour hold for a suicide attempt. Which of the following de-escalation techniques would be appropriate for this client? Select all that apply. 1. Respond to the client as early as possible 2. Maintain a large personal space 3. Establish what the client feels they need 4. Tell the client that they can leave when they want to 5. Assess the situation for indicators of stress

1. Respond to the client as early as possible 2. Maintain a large personal space 3. Establish what the client feels they need 5. Assess the situation for indicators of stress

On assessment for a client admitted with acute psychosis, the nurse notes the client has rigid posture, clenching of the fists and jaw and is hyperactive. The client has a history of violence and substance use. Which of the following nursing diagnosis is appropriate for this client? 1. Risk for other-directed violence 2. Risk for self-directed violence 3. Ineffective coping 4. Stress overload

1. Risk for other-directed violence

A client with an antisocial personality disorder and schizophrenia experiences chronic aggression. Which of the following medications would be appropriate for the long-term management of chronic aggression in this client? 1. Selective serotonin reuptake inhibitors (SSRIs) 2. Lithium 3. Anticonvulsants 4. Beta-blockers 5. Benzodiazepines

1. Selective serotonin reuptake inhibitors (SSRIs) 3. Anticonvulsants

A nurse prepares to administer lithium carbonate to a client diagnosed with bipolar disorder. Which of the following laboratory results must be reported to the health care personnel (HCP) immediately? 1. Serum sodium level of 120 mEq/L (120 mmol/L) 2. Serum potassium level of 5 mEq/L (5 mmol/L) 3. Serum calcium level of 9.2 mg/dL (2.3 mmol/L) 4. Serum magnesium level of 1.8 mg/dL (0.74 mmol/L)

1. Serum sodium level of 120 mEq/L (120 mmol/L)

An Emergency Department (ED) nurse is assessing a client with injuries suspicious of intimate partner violence. Which of the following nursing questions helps to uncover the client's perceptions of what has happened? Select all that apply. 1. Tell me more about how you have been in the past few days or weeks. 2. Who do you talk to when you feel overwhelmed? 3. How does your living situation with your partner affect your life? 4. Who can you trust? 5. Describe how you are feeling right now.

1. Tell me more about how you have been in the past few days or weeks. 3. How does your living situation with your partner affect your life? 5. Describe how you are feeling right now.

A nurse is conducting a health history interview with a 16 year-old client who has a family history of schizophrenia. Which of the following assessment data suggest to the nurse that the client is in the prodromal stage of the disease? Select all that apply. 1. The client appears disheveled and unkempt 2. The client explains that he is the re-incarnation of Jesus Christ 3. The client smiles and maintains eye contact with the nurse 4. The nurse has to repeat questions 2-3 times 5. The client is failing several classes in school

1. The client appears disheveled and unkempt 4. The nurse has to repeat questions 2-3 times 5. The client is failing several classes in school

A client is admitted to an inpatient psychiatric unit with a diagnosis of anxiety. Which of the following assessment findings indicates the client is experiencing a severe level of anxiety? 1. The client has a greatly reduced perceptual field and demonstrates scattered attention 2. The client shows disorganized or irrational reasoning 3. The client benefits from the guidance of others 4. The client is unable to focus on the surrounding environment

1. The client has a greatly reduced perceptual field and demonstrates scattered attention

A client with borderline personality disorder is experiencing increased anxiety during college classes. Which of the following behaviors is an example of the defense mechanism of "identification?" 1. The client starts dressing like one of their favourite professors 2. The client pretends they received scholarships over the term 3. The client blames other students in the class for their low grades 4. The client brings baking to the class each morning

1. The client starts dressing like one of their favourite professors

A client is experiencing pain levels of anxiety. The nurse moves the client to a quiet space with minimal stimulation. Which initial nursing action will promote client safety? 1. The nurse remains with the client 2. The nurse uses clear and simple statements when communicating with the client 3. The nurse offers the client high-calorie fluids 4. The nurse assesses the need for medication and seclusion

1. The nurse remains with the client

A nurse is assigned to a client with a substance-abuse disorder. Which of the following scenarios demonstrates a breach of confidentiality? Select all that apply. 1. The nurse tells the transporter to handle the client carefully because he is experiencing alcohol withdrawal 2. The nurse tells the social worker that the client has not regained the ability to walk 3. The nurse notifies visiting family to ask the client directly for updates on his condition 4. The nurse discusses the client's condition with a coworker on the same unit 5. The nurse notifies the charge nurse that the client has been sent for a test

1. The nurse tells the transporter to handle the client carefully because he is experiencing alcohol withdrawal 4. The nurse discusses the client's condition with a coworker on the same unit

A client with an anxiety disorder is experiencing ritualistic behaviors and phobia to germs. The nurse is concerned these behaviors will impact the client's ability to engage in self-care practices. What is a priority area for an initial assessment in this client? 1. To assess their eating practices and fluid intake 2. To assess how much time the client spends on grooming, bathing and dressing 3. To assess if the client is suppressing the urge to void or defecate 4. To assess if the client is sleeping regularly

1. To assess their eating practices and fluid intake

Which of the following are considered diagnostic criteria for a substance abuse disorder? Select all that apply. 1. Tolerance 2. Anorexia 3. Risky use 4. Social impairment 5. Impulsivity

1. Tolerance 3. Risky use 4. Social impairment

A client with attention deficit-hyperactivity disorder (ADHD) is prescribed the medication atomoxetine. Which of the following side effects should the nurse expect? Select all that apply. 1. Weight loss 2. Insomnia 3. Diarrhea 4. Increase in heart rate 5. Skin rash

1. Weight loss 2. Insomnia 4. Increase in heart rate

A client is seeking assistance at a public health unit. The client states he is suffering from intimate partner violence. The nurse assesses his safety and perception of what is happening. Which of the following questions best address the client's situational supports? Select all that apply. 1. Who do you talk to when you are overwhelmed? 2. Do you belong to a spiritual community? 3. During difficult times in the past, who did you want most to help you? 4. What leads you to seek help now? 5. What would need to be done to resolve this situation?

1. Who do you talk to when you are overwhelmed? 2. Do you belong to a spiritual community? 3. During difficult times in the past, who did you want most to help you?

The student nurse listens to the client and responds with the following: "I hear you saying that you are frustrated with the way your family is coping with this change. " Is this an appropriate therapeutic communication technique and why? Select all that apply. 1. Yes, mirroring or reflecting is a good technique to show concern and attention 2. No, the student nurse's "I" statement puts the focus on the nurse instead of the client 3. Yes, rephrasing allows the student nurse to be sure they understand the client's concerns 4. No, putting the label "frustrated" on the client's experience is belittling 5. No, the client is risking introducing conflict into the family

1. Yes, mirroring or reflecting is a good technique to show concern and attention 3. Yes, rephrasing allows the student nurse to be sure they understand the client's concerns

The nurse in the mental health unit is caring for a client who has been prescribed escitalopram for management of depression. The nurse reviews the client's list of medications to ensure there are no drug interactions with their new prescription. Which of the following medications is safe to take with escitalopram? 1. Phenelzine 2. Amlodipine 3. Duloxetine 4. Naproxen

2. Amlodipine

A client diagnosed with bulimia nervosa has a care plan with an outcome related to the normalization of vital signs. Which of the following would be short-term indicators of this outcome? Select all that apply. 1. Temperature of 104F (40C) 2. Heart rate of 90 beats per minute 3. Respiratory rate of 11 breaths/min 4. Blood pressure of 84/40 mmHg 5. Oxygen saturation on 95% room air

2. Heart rate of 90 beats per minute 5. Oxygen saturation on 95% room air

Which of the following statements regarding the pathophysiology of schizophrenia is/are incorrect? Select all that apply. 1. Individuals with schizophrenia have dysregulated dopaminergic signaling 2. Psychotic symptoms are caused by abnormal activity in the cerebellum 3. The use of cannabis causes schizophrenia 4. Excess acetylcholine is associated with psychotic symptoms 5. Individuals with schizophrenia have decreased brain volume

2. Psychotic symptoms are caused by abnormal activity in the cerebellum 3. The use of cannabis causes schizophrenia 4. Excess acetylcholine is associated with psychotic symptoms

A nurse is assigned to a client with suspected alcohol abuse. Which of the following tasks are appropriate to assign to the unlicensed assistive personnel (UAP)? 1. Utilise the Drug Abuse Screening Test (DAST) to determine the diagnosis 2. Record the urinary input and output 3. Provide health teaching regarding acceptable alcohol intake 4. Refer the client to community support services that address substance-related disorders

2. Record the urinary input and output

An 8 year-old child presents to the Emergency Department (ED) with severe anxiety. The parents state they were in a motor vehicle accident 2 months ago. The child's anxiety started after the accident. Which of the following assessment findings would alert the nurse to refer the child to a mental health clinician? 1. The child has a mild laceration on his knee from playing soccer with his friends 2. The child sucks his thumb while he is upset or anxious 3. The child talks about not being as good at school as his friends 4. The child states that he has trouble sleeping at night

2. The child sucks his thumb while he is upset or anxious

A nurse is conducting a comprehensive assessment of a family's dynamics and psychosocial factors. The family is comprised of a mother, father, 12-year-old daughter and 14 year-old son. Which of the following family characteristics may be an indication of potential family dysfunction and requires further assessment by the nurse? 1. The mother and father have individualized expectations for each of their children 2. The children surrender and do what their parents say when there is a disagreement 3. The family uses negotiation as one way to handle differences 4. The family has flexible and realistic expectations of each of it's members

2. The children surrender and do what their parents say when there is a disagreement

A client with auditory hallucinations is admitted to a psychiatric inpatient unit on a Form 1. Which of the following statements about the Form 1 is CORRECT? 1. Form 1 can be completed by a physician or nurse 2. The client can be held for up to 72 hours 3. Form 1 can be renewed by another physician 4. The client can leave the facility if accompanied by a family member

2. The client can be held for up to 72 hours

A nurse is assigned to a client with bipolar disorder. Which of the following circumstances place this client at a higher risk of worsening his condition? 1. The client works in an office for eight hours a day 2. The client drinks 25 oz of alcohol per day 3. The client eats fast food for lunch on a daily basis 4. The client has 2000 mg of sodium per day

2. The client drinks 25 oz of alcohol per day

Which of the following demonstrates the appropriate use of restraints? Select all that apply. 1. The nurse administers lorazepam to a client experiencing a manic episode in order to put him to sleep 2. The nurse checks the hand restraints of her client every 30 minutes 3. The nurse places soft wrist restraints on a client that has just undergone Electroconvulsive Therapy and is constantly pulling on his nasogastric tube 4. The nurse places a belt restraint on a client with Obsessive Compulsive Disorder, who is constantly wandering the halls of the hospital 5. The nurse administers an elbow restraints on a client that refuses to eat

2. The nurse checks the hand restraints of her client every 30 minutes 3. The nurse places soft wrist restraints on a client that has just undergone Electroconvulsive Therapy and is constantly pulling on his nasogastric tube

A nurse is performing her morning assessment on a 16 year-old client with autism spectrum disorder (ASD) recovering from pneumonia. Which of the following interventions by the nurse are the most appropriate for a client with ASD? Select all that apply. 1. To assess throat, the nurse instructs the client to "Open your mouth and say 'ah'" 2. The nurse dims the light in the room before beginning her assessment 3. To assess chest sounds, the nurse instructs the client to "Lift your shirt so that I can listen to your chest" 4. The nurse walks in to begin her assessment while the physician is speaking to the client 5. The nurse only completes a neurological and respiratory assessment and will do the rest later

2. The nurse dims the light in the room before beginning her assessment 3. To assess chest sounds, the nurse instructs the client to "Lift your shirt so that I can listen to your chest" 5. The nurse only completes a neurological and respiratory assessment and will do the rest later

Which of the following therapeutic communication strategies should be a part of a nurse's mental health practice? Select all that apply. 1. Teasing gently 2. Using silence 3. Listening actively 4. Establishing why 5. Positive thinking 6. Offering advice

2. Using silence 3. Listening actively

A newly admitted client with obsessive-compulsive disorder (OCD) must make his bed 25 times before he can have breakfast. Because of this behavior, he missed having his breakfast yesterday in the dining room. Which of the following interventions should the nurse implement to ensure that the client meets his nutritional needs? 1. Tell the client to make his bed one time only 2. Wake the client one hour earlier to perform his morning ritual 3. Educate the client about the importance of breakfast and meeting his nutritional needs 4. Advise the client to have breakfast before making his bed

2. Wake the client one hour earlier to perform his morning ritual

A community health nurse is teaching a class on eating disorders at the local community centre. Which of the following statements indicates a need for further teaching? 1. "Food should only be available during scheduled meal times." 2. "Weight should be taken daily and physical activity should be limited." 3. "Food should be given as positive reinforcement for good behavior." 4. "Trips to the bathroom should be supervised after meals and snacks."

3. "Food should be given as positive reinforcement for good behavior."

A nurse is caring for a client admitted for borderline personality disorder (BPD) in an outpatient setting. The client states to the nurse "you are cold and unfeeling, why are you such a mean person?" Which of the following nursing statements best demonstrates an understanding of transference? 1. "It is inappropriate for you to tell me I am mean when I am trying to help you" 2. "I will come back to talk to you when you are in a better mood" 3. "Tell me about a person who is cold and mean towards you" 4. "It must be difficult to be in the hospital and not be able to leave"

3. "Tell me about a person who is cold and mean towards you"

The nurse observes that a 10 year-old client with attention deficit-hyperactivity disorder (ADHD) is agitated, pacing up and down the hallway and making aggressive gestures towards other clients. Which statement by the nurse would be the most appropriate? 1. "You need to stop this behavior now." 2. "If you sit down in a chair, I will give you a cookie" 3. "You seem restless. Tell me what is happening." 4. "Let me give you something to calm you down"

3. "You seem restless. Tell me what is happening."

A client has recently been admitted to the mental health unit. During the nurse's initial assessment, the client asks, "Can I trust you to keep a secret for me?". What is the most appropriate response by the nurse in order to cultivate a therapeutic relationship? 1. "Yes. As your nurse, I am required to observe client confidentiality." 2. "That depends on the secret. Are you thinking about harming yourself or others?" 3. "Your care is provided by a team. I am not permitted to keep secrets within this circle of care." 4. "Of course you can trust me. What is the secret?"

3. "Your care is provided by a team. I am not permitted to keep secrets within this circle of care."

A nurse is reviewing the care plans of several clients at a mental health clinic. Which of the following best describes a client with anorexia nervosa? 1. A 16 year-old female who must go for a 5K run every morning before breakfast 2. A 14 year-old female gymnast who trains every day and does not menstruate 3. A 17 year-old female with a heart rate of 54 beats per minute and lanugo on her back 4. A 15 year-old female who hates her body and refuses to eat meat

3. A 17 year-old female with a heart rate of 54 beats per minute and lanugo on her back

Which of the following clients should be seen immediately? 1. A client with suspected cocaine abuse that requests pain medication 2. A client with suspected alcohol abuse that has vomited twice 3. A client lying flat in bed with reports of nausea 4. A client reporting shortness of breath when ambulating

3. A client lying flat in bed with reports of nausea

A nurse is preparing to administer alprazolam to a client with generalized anxiety disorder (GAD). Which of the following food or drink is a contraindication to this medication? 1. Chocolate 2. Cheese 3. Alcohol 4. Shellfish

3. Alcohol

A client invites you to their home for dinner to celebrate their success in treatment and to thank you for your excellent nursing care. Which of the following responses would be consistent with a therapeutic relationship? 1. Accept with the understanding that this is a purely professional celebration of achieving the client's goals 2. Decline and report the harassment to your manager 3. Decline to visit the client's home and propose a more professional alternative to recognise their achievement 4. Accept but refrain from any physical contact until after the client is formally discharged

3. Decline to visit the client's home and propose a more professional alternative to recognise their achievement

Which of the following accurately describes the pathophysiology process of bipolar disorder? Select all that apply. 1. Decreased serotonin, increased norepinephrine, and decreased dopamine 2. Increased norepinephrine, dopamine, and serotonin 3. Decreased dopamine, serotonin, and norepinephrine 4. Increased dopamine, decreased serotonin, and increased norepinephrine 5. Damage to areas of the brain affecting emotions

3. Decreased dopamine, serotonin, and norepinephrine 5. Damage to areas of the brain affecting emotions

A client is admitted with obsessive-compulsive disorder. What should the nurse expect to find when assessing the client? 1. Compulsive behaviors will increase the client's anxiety 2. During stressful periods the client will have fewer ritualistic behaviors 3. Intrusive thoughts such as harming others may be present 4. Repetitive or compulsive behaviors are not linked to the client's thoughts

3. Intrusive thoughts such as harming others may be present

A nurse is caring for a client with schizophrenia. He says "The night has a hamburger and take me out to the ballgame at the computer table". Which abnormal thought process would best describe the client's speech? 1. Neologism 2. Flight of ideas 3. Looseness of association 4. Word salad

3. Looseness of association

A nurse is discussing treatment options with the mother of a child living with autism spectrum disorder (ASD). The nurse should include the following points in the discussion except: 1. Therapy for the child will focus on behavior modification 2. Therapy will start with the least restrictive intervention 3. Medication is the most effective treatment for ASD 4. Family therapy is used to build on strengths and develop relationships

3. Medication is the most effective treatment for ASD

The nurse is caring for a client who has a long history of alcohol abuse who is to be discharged tomorrow. Which of the following is most important for the nurse to consider when assisting to create a discharge plan? 1. Referral to a social worker to assist with housing 2. Food tickets to use at a local food bank 3. Participation in Alcoholic Anonymous (AA) groups 4. Prescription for an antidepressant from the HCP

3. Participation in Alcoholic Anonymous (AA) groups

The nurse is screening clients for their potential risk of developing schizophrenia. The following findings are risk factors of schizophrenia, except for: Select all that apply. 1. Obstetric complication 2. Living in a densely populated area 3. Poor parenting 4. Family history of mental illness 5. Low intelligence

3. Poor parenting 5. Low intelligence

A client with aggressive behavior is admitted to the psychiatry unit. What is an example of a biological factor that may be associated with violent and aggressive behavior? 1. Increased serotonin levels 2. Decreased dopamine levels 3. Prefrontal cortex damage 4. Low levels of testosterone paired with high levels of cortisol

3. Prefrontal cortex damage

The nurse is caring for a client with a substance use disorder. The client's daughter is demonstrating behaviors consistent with codependency. Which of the following would indicate codependency in this relationship? 1. The daughter removes all the alcohol from her mother's home 2. The daughter attends support group meetings with her mother 3. The daughter tells her mother's employer she is sick when her mother is intoxicated 4. The daughter limits her interactions with her mother when she is drinking

3. The daughter tells her mother's employer she is sick when her mother is intoxicated

Which of the following factors place an individual at a higher risk of being diagnosed with bipolar disorder? Select all that apply. 1. The individual's grandmother has bipolar disorder 2. The individual has a high fat diet 3. The individual is going through a divorce 4. The individual consumes 30 ounces of alcohol daily 5. The individual's parents are diagnosed with bipolar disorder

3. The individual is going through a divorce 4. The individual consumes 30 ounces of alcohol daily 5. The individual's parents are diagnosed with bipolar disorder

A client has been admitted to the medical unit following a suicide attempt with an unknown amount of acetaminophen. The client says to the nurse, "I'm such a failure, I can't even kill myself properly. I'm just wasting everyone's time". Which response by the nurse is considered therapeutic? 1. "I see how concerned your family are, you're not a failure at all. You have so much to live for!" 2. "You're not wasting my time - I get paid to be here after all." 3. "Can you tell me where you got the acetaminophen and why you chose that medication in particular?" 4. "Can you tell me more about how you're feeling?"

4. "Can you tell me more about how you're feeling?"

The nurse has educated a client with schizophrenia about the side effects of his antipsychotic medications. Which of the following statements by the client indicate that he has understood the health teaching? 1. "I am no longer allowed to drive my car." 2. "If I experience extrapyramidal symptoms, I should stop taking my medications." 3. "I should increase the dose if I have hallucinations." 4. "I should rise slowly from sitting or lying down."

4. "I should rise slowly from sitting or lying down."

A nurse is conducting an information session on how family members can support loved ones who are living with an anxiety disorder. In the session, the nurse should intervene if an attendee says which of the following? 1. "Anxiety results from ineffective coping and use of defense mechanisms." 2. "I will coach my mother through deep breathing exercises." 3. "I will encourage my husband to verbalize his experiences in the military." 4. "I will offer to drive my son to places since he fears public transportation."

4. "I will offer to drive my son to places since he fears public transportation."

A client diagnosed with a fear of eating in public places or in front of people has just finished eating lunch in the dining room in the nurse's presence. Which of the following statements by the nurse reinforces the client's positive action towards anxiety management? 1. "That wasn't so hard, was it?" 2. "At supper, I hope to see you eating with other clients." 3. "You must have been hungry today." 4. "It is progress for you to eat in the dining room with me."

4. "It is progress for you to eat in the dining room with me."

A novice nurse is caring for a client who is overwhelmed and unable to cope after learning that their partner wants a divorce. What question from the novice nurse will require the nurse manager to intervene and provide guidance? 1. Have you been thinking about hurting yourself or your partner? 2. What has helped you in the past when you felt overwhelmed? 3. Can you tell me more about what you're feeling right now? 4. Do you think your parent's relationship has affected the way you and your partner relate?

4. Do you think your parent's relationship has affected the way you and your partner relate?

In the dining room, a client with schizophrenia is experiencing visual hallucinations and begins yelling and throwing his food. The other clients are getting hit with bits of food and are becoming angry. What should the nurse do FIRST? 1. Call a code white 2. Ask the client to describe the hallucinations 3. Inject haloperidol IM 4. Escort the client from the dining room with another staff member

4. Escort the client from the dining room with another staff member

When teaching a group of parents of high school adolescents about anorexia nervosa, the nurse should describe the disorder as being characterized by which of the following? 1. Fear of being obese, near-normal body weight and a self-critical body image 2. Obsession with the weight of others, chronic dieting and a low self-esteem 3. Fear of losing weight, calorie counting and an unrealistic body image 4. Fear of losing control over diet, emaciation and a disturbed body image

4. Fear of losing control over diet, emaciation and a disturbed body image

A client diagnosed with bipolar disorder is experiencing a manic episode. Which of these following signs are exhibited during this phase? Select all that apply. 1. Restlessness and decreased motor activity 2. Anhedonia and delusions of grandiosity 3. Lack of sexual interest and social isolation 4. Increased motor activity and delusions of persecution 5. Delusions of grandiosity and sexually promiscuous

4. Increased motor activity and delusions of persecution 5. Delusions of grandiosity and sexually promiscuous

The nurse is admitting a client experiencing acute alcohol poisoning. Which of the following findings does the nurse know is not seen in acute alcohol poisoning? 1. Vomiting 2. Hypoglycemia 3. Acidosis 4. Neurodegeneration

4. Neurodegeneration

Which of the following statements is true regarding Tricyclic Antidepressants (TCAs)? 1. TCAs are considered first-line therapy for the management of depression 2. One of the common side effects of TCAs is weight loss 3. TCAs should not be taken with foods such as cheddar and salami 4. One of the side effects of TCAs include sexual dysfunction

4. One of the side effects of TCAs include sexual dysfunction

The nurse is assessing a client for signs of a major depressive disorder. Which of the following symptoms are related to this condition? 1. Increased social functioning 2. Feeling irritable 3. Depression that lasts less than 2 weeks 4. Significant weight change or change in appetite

4. Significant weight change or change in appetite

A client admitted to the Emergency Department (ED) after a catastrophic house fire remains calm, focusing on rescheduling work meetings and contacting their insurance company. The client states "I need to stay in control, I can't think about the fire right now". Which of the following defense mechanisms is the client using to manage their anxiety about the loss of their home? 1. Compensation 2. Rationalization 3. Identification 4. Suppression

4. Suppression

The nurse is educating a client with major depressive disorder about the use of tricyclic antidepressants (TCAs). Which of the following statements made by the client indicates a good understanding of the teaching provided? 1. It is considered first-line therapy in the management of depression 2. Clomipramine is the least serotonergic TCA 3. TCAs have been associated with weight loss 4. TCAs cause sexual dysfunction

4. TCAs cause sexual dysfunction

A client is admitted involuntarily for an acute episode related to schizophrenia. The client has an advanced directive outlining preferences for care. What are the nurse's responsibilities to the client during this admission? 1. The advance directive is not followed during an involuntary admission 2. The nurse should call the client's family and allow them to direct care 3. The nurse will only follow parts of the client's advance directive that can be implemented 4. The health care team is legally bound to follow the advance directive outlined by the client

4. The health care team is legally bound to follow the advance directive outlined by the client

The nurse is caring for a client that is newly admitted to an inpatient psychiatry unit for assessment. The client requires a translator. What should the nurse consider when using a translator in a mental health setting? Select all that apply. a. To use family members as a primary source for translation b. A professional translator will best provide accurate translation of what the client tells the nurse c. A professional translator should be used to interpret language and cultural norms d. The translator should be older than the client e. The client's nonverbal patterns should also be translated

b. A professional translator will best provide accurate translation of what the client tells the nurse c. A professional translator should be used to interpret language and cultural norms e. The client's nonverbal patterns should also be translated

A nursing student is reinforcing education to a client diagnosed with bipolar disorder about lithium therapy. Which of the following statements by the student requires further intervention by the nurse? a. Lithium should be intermittently held in acute illnesses where fluid and electrolyte depletion are present b. Lithium can more commonly cause hyperthyroidism as compared to hypothyroidism c. Renal function should be monitored at least twice yearly d. Ataxia is a sign of lithium toxicity

b. Lithium can more commonly cause hyperthyroidism as compared to hypothyroidism

The nurse is caring for a client in the mental health unit who has been taking risperidone for management of schizophrenia. The nurse observes that the client is experiencing extrapyramidal symptoms (EPS) secondary to the medication and has informed the Physician about the client's status. Which of the following strategies would be inappropriate to implement in treating the client's extrapyramidal symptoms? a. Reduce the dose of risperidone b. Switch to olanzapine c. Switch to haloperidol d. Stop the antipsychotic and reconsider alternative drug classes

c. Switch to haloperidol

All of the following are appropriate non-pharmacological and pharmacological interventions for anxiety disorder except: a. Caffeine or other stimulant use should be reduced or eliminated b. Cognitive behavioural therapy (CBT) should be specific and tailored to the primary diagnosis c. Stress reduction and anxiety management should be implemented d. Short-acting benzodiazepine should be used on a regular, long-term basis

d. Short-acting benzodiazepine should be used on a regular, long-term basis

A client experiencing alcohol intoxication asks the nurse why he is voiding excessively. Which of the following nursing responses demonstrates an understanding of the pathophysiology of acute alcohol intoxication? 1. "Alcohol inhibits the release of the antidiuretic hormone in your body, this causes increased urination" 2. "Increased fluid intake is common with alcohol absorption thereby increasing the need to void" 3. "Chronic alcoholism can result in hyperthyroidism" 4. "Acute alcohol intoxication may cause B vitamin deficiencies"

1. "Alcohol inhibits the release of the antidiuretic hormone in your body, this causes increased urination"

A client newly diagnosed with moderate anxiety is focused on feelings of "skipped heartbeats" during anxious states. How should the nurse respond to the client? 1. "As the adrenaline levels increase in your body it is common to have feelings of skipped heartbeats or a racing heart" 2. "This may be a sign of a heart attack you need to contact your health care provider (HCP)" 3. "It is important for you not to worry about these skipped beats they will not harm you" 4. "These skipped heartbeats will disappear once your anxiety is managed"

1. "As the adrenaline levels increase in your body it is common to have feelings of skipped heartbeats or a racing heart"

A client diagnosed with alcohol withdrawal is prescribed lorazepam. Which of the following demonstrates a contraindication for administering this medication? 1. A 55-year old female that is taking levodopa 2. A 65-year old male with chronic heart failure 3. A 29-year old male taking melatonin 4. A 39 year-old male with gastroesophageal reflux disease (GERD)

1. A 55-year old female that is taking levodopa

Which of the following clients should be seen first? 1. A client diagnosed with bipolar disorder who gives his expensive wristwatch to the nurse 2. A client diagnosed with pneumonia who has crackles upon auscultation 3. A client diagnosed with obsessive compulsive disorder who repeatedly wanders the hallway 4. A client diagnosed with depression who just underwent electroconvulsive therapy and has an oxygen saturation of 95%

1. A client diagnosed with bipolar disorder who gives his expensive wristwatch to the nurse

A nurse has just received report from the previous shift. Which of the following clients should be seen first? 1. A client experiencing alcohol withdrawal has body tremors and a fever 2. A client diagnosed with pneumonia exhibiting crackles on auscultation 3. A client diagnosed with chronic heart failure that has a fractured femur 4. A client that has fallen asleep after a seizure

1. A client experiencing alcohol withdrawal has body tremors and a fever

A school-health nurse is completing an assessment of a senior high school class. Which of the following students is at an increased risk or injury? Select all that apply. 1. A student who is isolated from her peers but started to go to parties 2. A student who uses e-cigarettes and skips class frequently 3. A student dealing with increasing anxiety due to her parent's recent divorce 4. A student playing volleyball and working towards a college scholarship 5. A student with a strong peer group engaged in school activities

1. A student who is isolated from her peers but started to go to parties 2. A student who uses e-cigarettes and skips class frequently 3. A student dealing with increasing anxiety due to her parent's recent divorce

A client is experiencing moderate anxiety due to an upcoming surgical procedure in 2 hours. How can the nurse best support the client? 1. Ask the client what they have used in the past to help manage their anxiety 2. Reassure the client that nothing will happen to them during the surgery 3. Ask the client what is making them anxious 4. Leave the client alone so they can relax before the surgery

1. Ask the client what they have used in the past to help manage their anxiety

A client is diagnosed with alcohol dependence. Which of the following are appropriate non-pharmacological treatments for this condition? Select all that apply. 1. Cognitive Behavioral Therapy 2. Repositioning the client 3. Referral to Alcoholic Anonymous (AA) 4. Relaxation training 5. Administer oxygen via nasal prongs

1. Cognitive Behavioral Therapy 3. Referral to Alcoholic Anonymous (AA) 4. Relaxation training

A 5 year-old child is diagnosed with autism spectrum disorder (ASD). The mother asks the nurse to explain available treatment and therapy options for the child and the family. The mother denies that the child has self-harming behavior. Which of the following treatments should the nurse include? Select all that apply. 1. Cognitive behavior therapy (CBT) 2. Electroconvulsive therapy 3. Family therapy 4. Support group 5. Antipsychotics

1. Cognitive behavior therapy (CBT) 3. Family therapy 4. Support group 5. Antipsychotics

A client at your outpatient clinic is also an employee at your spouse's restaurant. Coping with workplace stress is a significant challenge for this client. When your spouse asks if the employee is receiving treatment, the response should be based on which of the following? 1. Confirming the individual' status as a client of the clinic is a breach of confidentiality 2. Disclosure within the marital unit is privileged, but the nurse will be liable if the spouse shares the client information with anyone else 3. Patient confidentiality requires that the nurse not disclose the client's diagnosis or prognosis, and instead only provide generalities to their spouse 4. As an employer, the spouse has a vicarious interest in the health of their employee

1. Confirming the individual' status as a client of the clinic is a breach of confidentiality

A nurse is assigned to a client diagnosed with borderline personality disorder. He consistently breaks unit rules and displays manipulative actions. It is most appropriate for the nurse to do which of the following? 1. Confront the client's actions and set limits on activities 2. Ignore the client's actions and allow him to express his feelings 3. Set realistic goals with the client to reduce his anxiety 4. Refer the client to the health care provider (HCP) to prescribe a higher dose of pain medication

1. Confront the client's actions and set limits on activities

The nurse is assessing a client admitted to an inpatient psychiatry unit for severe anxiety. When conducting a demographic assessment, which factors put the client at an increased risk for maladaptive expressions of anger? Select all that apply. 1. Diagnosis of dementia or brain injury 2. Puberty and adolescence 3. History of ineffective coping 4. History of violence 5. Diagnosis of borderline, histrionic or antisocial personality disorder

1. Diagnosis of dementia or brain injury 2. Puberty and adolescence 3. History of ineffective coping 5. Diagnosis of borderline, histrionic or antisocial personality disorder

Which of the following are early signs of lithium toxicity? 1. Diarrhea and vomiting 2. Polyuria and dysphagia 3. Anorexia and oliguria 4. Hypotension and tachycardia

1. Diarrhea and vomiting

The nurse caring for a client experiencing a manic episode and prepares a sterile field for wound care. The client becomes restless and knocks over the table that contains the equipment for the dressing change. Which of the following actions should the nurse take? Select all that apply. 1. Dispose the equipment and obtain a new sterile tray 2. Quickly perform the dressing using the same equipment 3. Report the incident to a colleague 4. Push the call bell for assistance 5. Report the incident to the client's health care provider (HCP)

1. Dispose the equipment and obtain a new sterile tray 4. Push the call bell for assistance

Which Selective Serotonin Reuptake Inhibitor (SSRI) has the highest risk of QTc prolongation at therapeutic doses? 1. Escitalopram 2. Sertraline 3. Fluoxetine 4. Paroxetine

1. Escitalopram

A client with anxiety has an increased heart rate, respirations, and blood pressure. They are experiencing moderate discomfort and narrowing of perceptual fields. Which nursing intervention is most appropriate for this client? 1. Explore behaviors that have worked to relieve anxiety in the past 2. Minimize the environmental stimuli and move the client to a quieter setting 3. Use a low pitched voice and speak slowly 4. Set physical limits in order to ensure client safety

1. Explore behaviors that have worked to relieve anxiety in the past

The nurse in the mental health unit is educating a client about haloperidol. Which of the following statements about this medication is false? 1. Haloperidol has a high risk of inducing a seizure 2. It has a high risk of causing extrapyramidal symptoms 3. Haloperidol may prolong the QT interval 4. Haloperidol is a safe option during pregnancy

1. Haloperidol has a high risk of inducing a seizure

A nurse is caring for an 8 year-old client diagnosed with autism spectrum disorder (ASD). Which of the following behaviors is the client most likely to exhibit? Select all that apply. 1. Has difficulty developing friendships 2. Expresses self-deprecation 3. Preoccupied with flicking light switches 4. Thrives on being the focus of attention 5. Indifferent to affection and personal contact.

1. Has difficulty developing friendships 3. Preoccupied with flicking light switches 5. Indifferent to affection and personal contact.

Which of the following client actions would alert the nurse that they are in the pre-assaultive stage of anger, aggression, or violence? Select all that apply. 1. The client is asking the other inpatients if they are unhappy with care 2. The client is hitting, punching and striking object in their room 3. The client is increasingly withdrawn and not talking to the nurse 4. The client is defying the nurse by not taking their medications 5. The client has possession of a pair of scissors in their room

1. The client is asking the other inpatients if they are unhappy with care 3. The client is increasingly withdrawn and not talking to the nurse 4. The client is defying the nurse by not taking their medications

Which of the following situations indicates the potential for a nontherapeutic relationship? Select all that apply. 1. The client loans the nurse money and is promptly repaid 2. The nurse and client enjoy joking about the other nurses 3. The nurse reminds the client of her granddaughter 4. The nurse finds her/himself thinking about the client when away from work 5. The client and nurse have gotten to know each other and enjoy the time they spend together 6. The client's family brings a treat for the nurses on the unit to share

1. The client loans the nurse money and is promptly repaid 2. The nurse and client enjoy joking about the other nurses 4. The nurse finds her/himself thinking about the client when away from work

Which of the following situations might self-disclosure or personal sharing on the part of the nurse be an appropriate part of the therapeutic relationship? 1. When it helps the client to gain insight into their situation and reach their goals 2. When it helps deepen the friendship between nurse and client 3. Only when permitted by organisational and regulatory policies and procedures 4. When the nurse has guidance based on personal experience

1. When it helps the client to gain insight into their situation and reach their goals

A nurse in a psychiatric inpatient unit has scheduled a time to speak to a client admitted three hours ago with suicidal ideation. The client does not want to speak with the nurse. Which nursing statement demonstrates consistency and promotes a therapeutic relationship with the client? 1. "I will come back and talk when you are ready" 2. "It's all right. I would like to spend time with you. We don't have to talk" 3. "Tell me what you are thinking right now" 4. "I am not comfortable sitting here without talking I will come back later"

2. "It's all right. I would like to spend time with you. We don't have to talk"

The nurse is teaching a client with bulimia nervosa about fluoxetine. Which of the following statements by the client indicates a need for further teaching? 1. "I take fluoxetine to treat the symptoms of my anxiety and depression." 2. "Taking fluoxetine concurrently with phenelzine will reduce my urge to purge." 3. "It will take several weeks before I see any improvement." 4. "Taking this medication will reduce the frequency of my binge-eating."

2. "Taking fluoxetine concurrently with phenelzine will reduce my urge to purge."

A 28 year-old male client is admitted to the Emergency Department (ED) after a sexual assault. The client states "I feel so helpless and embarrassed right now." Which of the following nursing statements best supports the client at this time? 1. "This is not your fault, it is the fault of the person who attacked you" 2. "You sound like you are feeling helpless, I am here to help you today" 3. "You have options and a choice in how we will proceed today" 4. "It is not common for men to experience sexual assault, I am here to help you through this examination"

2. "You sound like you are feeling helpless, I am here to help you today"

Which of the following situations must be reported to the client's health care provider (HCP)? Select all that apply. 1. A client with a substance abuse-related disorder falls asleep shortly after having a seizure 2. A client with alcohol withdrawal experiences an increased temperature (38C) 3. A client with drug dependence experiences a fall 4. The nurse administers two extra doses of lorazepam 5. The nurse administers thiamine IV 15 minutes before administering glucose

2. A client with alcohol withdrawal experiences an increased temperature (38C) 3. A client with drug dependence experiences a fall 4. The nurse administers two extra doses of lorazepam

A young adult female client comes to the clinic due to gastrointestinal (GI) issues. The client's mother reveals her unhealthy eating habits such as consuming large amounts of carbohydrates and junk food at a time. The mother also reveals that the client is always in the bathroom. Which of the following referrals is the most appropriate? 1. A dietician 2. A mental health clinic 3. A weight loss program 4. An overeating support group of adolescents

2. A mental health clinic

A nurse admits a client with bulimia nervosa (binging and purging behaviors) to a medical unit. Which of the following interventions are appropriate for this client? Select all that apply. 1. Administer bupropion 200mg PO twice daily per Healthcare Provider's order 2. Administer fluoxetine 60mg PO daily her Healthcare Provider's order 3. Daily electrocardiogram (ECG) 4. Serum electrolyte levels daily 5. Encourage the client to keep daily weight log

2. Administer fluoxetine 60mg PO daily her Healthcare Provider's order 3. Daily electrocardiogram (ECG) 4. Serum electrolyte levels daily

A client diagnosed with bipolar disorder is currently experiencing depression. The client prefers to use Electroconvulsive Therapy (ECT) as part of her treatment plan. Which of the following statements are correct regarding this treatment? 1. ECT involves delivering an electrical current to the frontal portion of the head to induce seizures in the brain 2. ECT poses as a risk to clients who have had a recent myocardial infarction or stroke 3. ECT can be performed without obtaining consent 4. ECT may cause hemorrhage

2. ECT poses as a risk to clients who have had a recent myocardial infarction or stroke

A 23 year-old woman is admitted to the Emergency Department (ED) with severe hypokalaemia. Which of the following are signs or symptoms related to bulimia nervosa? Select all that apply. 1. Decreased serum amylase levels 2. Evidence of tooth erosion and dental caries 3. Normal to slightly low body weight 4. Peripheral edema 5. Hypernatremia

2. Evidence of tooth erosion and dental caries 3. Normal to slightly low body weight 4. Peripheral edema

Which of the following antidepressants is least likely to produce withdrawal symptoms upon abrupt discontinuation? 1. Bupropion 2. Fluoxetine 3. Citalopram 4. Duloxetine

2. Fluoxetine

A nurse is caring for an 8 year-old client with attention deficit-hyperactivity disorder (ADHD). Which of the following symptoms is the client most likely to exhibit? 1. An affinity for sugar and sweets 2. Forgetfulness and losing things frequently 3. Rigid adherence to daily routines 4. Antisocial behavior and a lack of empathy

2. Forgetfulness and losing things frequently

The nurse discovers that an adolescent female client with anorexia nervosa is taking diet pills rather than adhering to the prescribed diet. Which of the following actions should the nurse do first? 1. Discuss how weight loss and emaciation can negatively affect her health 2. Listen to the client's fears about losing control of her diet during treatment 3. Explain how diet pills can jeopardize health 4. Take the diet pills from her and place her on constant observation

2. Listen to the client's fears about losing control of her diet during treatment

A client with an intellectual disability is experiencing chronic aggression. Which of the following medications would help the client manage chronic aggression? Select all that apply. 1. Selective serotonin reuptake inhibitors (SSRIs) 2. Lithium 3. Anticonvulsants 4. Gabapentin 5. Atypical antipsychotics

2. Lithium 5. Atypical antipsychotics

A female client with paranoid schizophrenia has been hospitalized during an acute psychotic episode. She refuses to eat and has lost 10 pounds since she was admitted. What is the most appropriate nursing intervention? 1. Supervise the client's meals 2. Offer canned or packaged food 3. Taste the food to demonstrate that it has not been poisoned 4. Request an order for nasogastric feeding

2. Offer canned or packaged food

The nurse is planning discharge instructions for a client diagnosed with generalized anxiety disorder (GAD) who recently finished cognitive-behavioural therapy (CBT). Which of the following goals is the most appropriate to include in the care plan? 1. Patient will suppress feelings of anxiety 2. Patient will identify anxiety-producing situations 3. Patient will eliminate all anxiety from daily situations 4. Patient will remain in contact with a crisis counselor

2. Patient will identify anxiety-producing situations

The nurse is reviewing the medication orders for a client with schizophrenia. Which of the following drugs can increase levels of clozapine in the body? 1. Cigarette smoking 2. Prednisone 3. Carbamazepine 4. Phenytoin

2. Prednisone

Which stage of the therapeutic relationship is it appropriate for the nurse to make referrals to other disciplines and professionals? 1. Orientation 2. Resolution/Conclusion 3. Working 4. Primary

2. Resolution/Conclusion

A client is admitted to the Emergency Department (ED) with impulsive behaviors, feelings of worthlessness, hopelessness, and helplessness. Which of the following nursing diagnosis is appropriate for this client? 1. Risk for other-directed violence 2. Risk for self-directed violence 3. Ineffective coping 4. Stress overload

2. Risk for self-directed violence

Which of the following assessment findings support the diagnosis of alcohol abuse? 1. Hyperthyroidism and hyponatremia 2. Tenting of the skin 3. Decreased vision and impulsivity 4. Extreme thirst and weight gain

2. Tenting of the skin

The nurse is evaluating a client with a nursing diagnosis for "risk for self-directed harm." Which of the following outcomes demonstrate that this diagnosis is resolved? 1. The client identifies when they are angry, alternatives to aggression and avoids violating other's personal space 2. The client expresses their feelings, verbalizes denial of suicidal ideas and plans for the future 3. The client identifies ineffective and effective coping, uses their support systems and engages in personal actions to manage stressors differently 4. The client expresses feelings constructively, reports feelings of calmness and has optimal decision making skills

2. The client expresses their feelings, verbalizes denial of suicidal ideas and plans for the future

A nurse is caring for a client diagnosed with bulimia nervosa who is starting treatment. What is the most appropriate treatment goal for this client? 1. The client will eat appropriate portions of food 2. The client will manage life stressors without binge eating or purging 3. The client will maintain a weight within the normal range 4. The client will reduce the number of binge eating episodes per week

2. The client will manage life stressors without binge eating or purging

Your client, age 45, is diagnosed with stage 4 multiple myeloma and has been placed in palliative care this morning. Upon entering your client's room, you see that she is crying and says to you, "I'm not ready to die". What is your response? 1. "I understand how you feel, it is scary to be placed in palliative care" 2. "Don't worry, everything will be alright" 3. "Can you tell me more about your feelings related to death?" 4. "Why do you think that you are going to die?"

3. "Can you tell me more about your feelings related to death?"

The nurse meets with the parents of a child diagnosed with autism spectrum disorder (ASD). What is the most appropriate advice from the nurse? 1. "Ignore his head banging. He is just trying to get attention." 2. "If he throws a tantrum, place him in a quiet room for twenty minutes." 3. "Ensure that the activities they participate in have expected outcomes." 4. "Try to incorporate new activities into their schedule to avoid repetition and boredom."

3. "Ensure that the activities they participate in have expected outcomes."

A nurse is assessing a client admitted with suspected alcohol abuse. It is most appropriate to ask the client which of the following questions during the psycho-social component of the interview? 1. "When was the last time you drank alcohol?" 2. "Why did you begin abusing alcohol?" 3. "How do you cope during stressful situations?" 4. "Do your parents abuse alcohol?"

3. "How do you cope during stressful situations?"

A client with severe anxiety is admitted to an inpatient psychiatry unit. The nursing diagnosis on the care plan states the client is experiencing ineffective health maintenance due to severe anxiety. Which of the following client statements support this diagnosis? 1. "I just feel so hopeless I don't have any control over my life" 2. "I eat all of the time to try to distract myself from my anxiety" 3. "I just can't stop making sure the stove is turned off my routine takes over everything in my life" 4. "I keep having recurring memories about an accident I had as a child"

3. "I just can't stop making sure the stove is turned off my routine takes over everything in my life"

The parents of a client newly diagnosed with anorexia nervosa ask the nurse about the treatments used for eating disorders. Which of the following statements by the nurse is the most appropriate? 1. "Treatment will mainly consist of antidepressants and psychotherapy." 2. "Family support groups are available for parents caring for children with eating disorders." 3. "Psychotherapy and nutritional management are the main forms of treatment." 4. "Treatment will consist of supervised meals and group therapy."

3. "Psychotherapy and nutritional management are the main forms of treatment."

A nurse in a mental health unit attends interdisciplinary rounds for a client. Which of the following statements made by an interdisciplinary team member would indicate they may be engaging in counter-transference with the client? 1. "The client needs to increase his daily activity and decrease his smoking" 2. "I recommend the client be checked for hiding his medications" 3. "The client is always sabotaging his chances and taking advantage of everyone" 4. "The client asked me about my marriage yesterday"

3. "The client is always sabotaging his chances and taking advantage of everyone"

The nurse hears another nurse say to a client with schizophrenia "The voices you claim to be hearing are not real. No one else can hear them. If you're looking for attention, this is not the way to get it." What should the nurse do first? 1. Ask the client to confirm what the nurse heard 2. Report the nurse's behavior to the charge nurse 3. Confront the other nurse privately 4. Ask the client to leave the room

3. Confront the other nurse privately

The nurse is caring for a client diagnosed with major depressive disorder who has been prescribed trazodone. Which of the following side effects stated by the client indicates the need for further teaching? 1. Drowsiness 2. Blurry vision 3. Hypertension 4. Urinary hesitancy

3. Hypertension

A client admitted to inpatient psychiatry for a suicide attempt is demonstrating difficulty with simple tasks, poor problem solving, and poor cognitive functioning. Which of the following nursing diagnosis is most appropriate for this client? 1. Risk for other-directed violence 2. Risk for self-directed violence 3. Ineffective coping 4. Stress overload

3. Ineffective coping

The nurse is teaching a client in a transitional outpatient treatment program about responses to stress. Which of the following strategies would indicate a positive response to stress? 1. Avoiding situations that cause stress 2. Believing that things will resolve themselves after a period of time 3. Redefining a situation to use to see the positive and negative sides 4. Focusing on traits within oneself that lead to stressful situations

3. Redefining a situation to use to see the positive and negative sides

A nurse is caring for a client newly diagnosed with bipolar disorder. The nurse plans to evaluate the client's feeling about the new diagnosis. Which of the following is the correct way to document the client's response? 1. The client feels as though the diagnosis provides him with an understanding of the condition 2. The client seems depressed and does not want to discuss the diagnosis at this time 3. The client states, "This is a lot of information to absorb, I don't know what to think." 4. Presently, the client appears to be having a manic episode

3. The client states, "This is a lot of information to absorb, I don't know what to think."

The nurse is caring for a client with bipolar disorder. In which of the following cases should an incident report be filed? 1. The nurse administers a scheduled analgesic 2. The nurse administers lorazepam and metoprolol at the same time 3. The nurse administers one more dose of lithium than ordered 4. The client's blood pressure drops from 130/80 to 100/60 after administration of bumetanide

3. The nurse administers one more dose of lithium than ordered

The nurse is caring for a client who is experiencing mania. Which of the following nursing interventions would be appropriate for this client? 1. The nurse increases the client's social interactions 2. The nurse allows the client to focus on more than one topic during a conversation 3. The nurse encourages rest periods and frequent snacks for the client 4. The nurse assists the client to release their energy through exercise

3. The nurse encourages rest periods and frequent snacks for the client

The nurse providing discharge teaching to a client after a suicide attempt. The client says "My life would be better if my mother were dead. Maybe that will happen now." What is the responsibility of the nurse in this situation? 1. To call the client's mother and make her aware of the comment 2. To ask the client why he feels this way about his mother 3. To notify the healthcare provider (HCP) immediately to assess the situation 4. To ask the client if he has plans to harm his mother

3. To notify the healthcare provider (HCP) immediately to assess the situation

The nurse who is caring for a client with acquired immunodeficiency syndrome (AIDS) overhears the client verbalizing suicidal ideation. Which of the following questions should the nurse ask to best determine the seriousness of the client's suicidal thoughts? 1. "How long have you been thinking about harming yourself?" 2. "Have you made a will for all of your things?" 3. "Does your family know about this?" 4. "How are you planning on harming yourself?"

4. "How are you planning on harming yourself?"

At a local clinic, a mother tells the nurse she notices her daughter spends long periods of time in the bathroom after meals. She is concerned her child has an eating disorder and asks the nurse how to approach her daughter about it. Which of the following statements would be best for initiating the conversation? 1. "You are worrying me by always going to the bathroom after eating." 2. "You look great these days. How are you feeling?" 3. "I think you have an eating disorder and I want you to see someone about it." 4. "I am worried about you. Tell me more about what is bothering you?"

4. "I am worried about you. Tell me more about what is bothering you?"

A client with schizophrenia tells the nurse that she wishes she was dead. Which of the following actions should the nurse complete first? 1. Offer the client lorazepam PRN 2. Have the client sign a no-suicide contract 3. Document suicide risk assessment 4. Ask the client if she has a plan

4. Ask the client if she has a plan

A client with severe anxiety asks the nurse for education regarding mindfulness. What is the nurse's first step in the teaching-learning process with this client? 1. Provide links to online mindfulness exercises 2. Demonstrate mindfulness techniques to the client 3. Reinforce the client's health literacy by providing evidence-informed information on mindfulness 4. Demonstrate active listening and explore the client's interest in mindfulness in more detail

4. Demonstrate active listening and explore the client's interest in mindfulness in more detail

A nurse prepares to administer lithium carbonate to a client diagnosed with bipolar disorder. Upon assessment of laboratory values, she discovers that the client has a serum sodium level of 110 mmol/L (110 mEq/L). Which of the following signs and symptoms does the nurse expect the client to exhibit? 1. Muscle twitching 2. Extreme thirst 3. Increased urinary specific gravity 4. Diminished deep tendon reflexes

4. Diminished deep tendon reflexes

The nurse is educating a client about the side effects of duloxetine. Which of the following side effects mentioned is incorrect? 1. Xerostomia 2. Weight loss 3. Anxiety 4. Hypoglycemia

4. Hypoglycemia

A nurse is working with a newly admitted client with bulimia nervosa. Which of the following interventions would be the first priority for the nurse? 1. Build a therapeutic relationship 2. Schedule cognitive-behavioral therapy (CBT) sessions 3. Administer 60 mg of fluoxetine 4. Perform a thorough physical assessment

4. Perform a thorough physical assessment

A nurse is caring for a client that has been diagnosed with bipolar disorder. Which of the following tasks are appropriate to delegate to an unlicensed assistive personnel (UAP)? 1. Assess for suicide risk during the depressive phase 2. Explain procedures using simple and concrete words 3. Determine the effectiveness of the client's medication 4. Provide the client with finger foods

4. Provide the client with finger foods

The night nurse is caring for a client with post-traumatic stress disorder (PTSD) and finds him crying on the floor, repeatedly saying, "I didn't mean to kill all those people." After examining the client and assisting him safely back to bed, which of the following actions should the nurse do first? 1. Notify the nurse manager 2. File and incident report on the fall 3. Raise all the bed rails up to prevent the client from falling from his bed again 4. Put the bed alarm back on

4. Put the bed alarm back on

The nurse is caring for a client who was just diagnosed with obsessive-compulsive disorder (OCD). What is the most appropriate first-line pharmacological treatment for the client's OCD? 1. Duloxetine 2. Amitriptyline 3. Venlafaxine 4. Sertraline

4. Sertraline

A public health nurse is asked to teach a class about attention deficit-hyperactivity disorder (ADHD). The nurse recognizes that potential risk factors to ADHD include all of the following except: 1. Family experiences financial struggles 2. The child was birthed prematurely 3. The child's grandfather was diagnosed with ADHD 4. The child is easily distracted and is unable to follow instructions at school

4. The child is easily distracted and is unable to follow instructions at school

A client with resistant schizophrenia has been taking Clozapine 25 mg/day for 10 weeks. Which of the following findings is MOST concerning for this client? 1. The client has not had a bowel movement in 3 days 2. The client feels dizzy upon standing 3. The client's blood glucose is 9.6 mmol/L (143 mg/dL) 4. The client has a fever and sore throat

4. The client has a fever and sore throat

The nurse is caring for a client experiencing delirium tremens. The healthcare provider (HCP) orders 2 mg of lorazepam (Ativan) in 500 mL of normal saline to be infused IV over 3 hours. The drop factor of the IV tubing available on the unit is 15 gtts/mL. Calculate the IV flow rate in drops per minute. Record your answer using a whole number.

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Match the definition with the description of each ego defense mechanism: Compensation Suppression Intellectualization Projection Identification Repression

Compensation - Extra effort to achieve to reduce sense of inadequacy Suppression - Deliberately forgetting source of anxiety Intellectualization - Using reason to avoid emotion Projection - Transferring uncomfortable feelings to someone else Identification - Trying to emulate an admired person Repression - Unconsciously forgetting upsetting information or emotions

The nurse is conducting the mental status examination (MSE) for a client with suspected Alzheimer's disease. Which of the following assessments are completed for the "appearance" component of this examination? Select all that apply. a. Grooming and dress b. Excessive or reduced body movements c. Level of eye contact d. Level of hygiene e. Height, weight and nutritional status

a. Grooming and dress d. Level of hygiene e. Height, weight and nutritional status

A 15 year-old client accesses the community health nurse at a school clinic. On assessment, the client is withdrawn, anxious and appears non-trusting of the nurse. Which of the following questions would promote an accurate assessment in an adolescent client? Select all that apply. a. What is your home environment like? b. Do you participate in any activities? c. Do you drink alcohol or use e-cigarettes? d. Have you ever thought of dying or harming yourself? e. Do you have any issues with personal hygiene?

a. What is your home environment like? b. Do you participate in any activities? c. Do you drink alcohol or use e-cigarettes? d. Have you ever thought of dying or harming yourself?