HESI RN MENTAL HEALTH HESI REVIEW - MULTIPLE CHOICE

A client is admitted to a medical nursing unit with a diagnosis of acute blindness, many tests are performed, and there seems to be no organic reason why this client cannot see. The client became blind after witnessing a hit-and-run car accident, when a family of three was killed. A LPN/LVN suspects that the client may be experiencing: A. Psychosis B. Repression C. Conversion Disorder D. Dissociative Disorder

C. Conversion Disorder

A nurse determines that the wife of an alcoholic client is benefitting from attending an Al-Anon group when the nurse hears the wife say: A) "I no longer feel that I deserve the beatings my husband inflicts on me." B) "My attendance at the meetings has helped me to see that I provoke my husbands violence." C) "I enjoy attending the meetings because they get me out of the house and away from my husband." D) "I can tolerate my husband's destructive behaviors now that I know they are common with alcoholics."

A) "I no longer feel that I deserve the beatings my husband inflicts on me."

Select the nursing interventions for a hospitalized client with mania who is exhibiting manipulative behavior. Select all that apply. A) Communicate expected behaviors to the client B) Ensure that the client knows that he or she is not in charge of the nursing unit C) Assist the client in identifying ways of setting limits on personal behaviors D) Follow through about the consequences of behavior in a non punitive manner E) Enforce rules and inform the client that he or she will not be allowed to attend therapy groups F) Be clear with the client regarding the consequences of exceeding limits that have been set regarding behavior

A) Communicate expected behaviors to the client C) Assist the client in identifying ways of setting limits on personal behaviors D) Follow through about the consequences of behavior in a non punitive manner F) Be clear with the client regarding the consequences of exceeding limits that have been set regarding behavior

An emergency department nurse is caring for an adult client who is a victim of family violence. Which priority instruction would be included in the discharge instructions? A) Information regarding shelters B) Instructions regarding calling the police C) Instructions regarding self-defense classes D) Explaining the importance of leaving the violent situation

A) Information regarding shelters

The nurse employed in a mental health clinic is greeted by a neighbor in a local grocery store. The neighbors ask the nurse, "How is Mary doing? She is my best friend and is seen at your clinic every week." Which is the most appropriate nursing response? A. "I can not discuss any patient situation with you." B. "If you want to know about Mary, you need to ask her yourself." C. "Only because you're worried about a friend, I'll tell you that she is improving." D. "Being her friend, you know she is having a difficult time and deserves her privacy."

A. "I can not discuss any patient situation with you."

A nurse is assessing a client diagnosed with schizophrenia for the presence of hallucinations. Which therapeutic communication technique used by the nurse is an example of making observations? A. "You appear to be talking to someone I do not see." B. "Please describe what you are seeing." C. "Why do you continually look in the corner of this room?" D. "If you hum a tune, the voices may not be so distracting."

A. "You appear to be talking to someone I do not see."

A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The RN also determines that the client is homeless and is exhibiting suspiciousness. The client's plan of care should include what priority problem. A. Acute confusion B. Ineffective community coping C. Disturbed sensory perception D. Self-care deficit

A. Acute confusion

A homeless client who reports feeling sad and depressed tells the mental health nurse that in the past 2 days she has only had 4 hours of sleep. Which action is most important for the RN to implement within the first 24 hours after treatment is initiated? A. Allow the client to rest and sleep. B. Ensure client attend groups addressing coping skills for dealing with depression. C. Begin planning for the clients discharge. D. Encourage verbalization of feelings.

A. Allow the client to rest and sleep.

During admission to the psychiatric unit, a female client is extremely anxious and states that she is worried about the sun coming up the next day. What intervention is most important for the RN to implement during the admission process? A. Assist the client in developing alternative coping skills. B. Remain calm and use a matter of fact approach. C. Ask the client why she is so anxious D. Administer a PRN sedative to help relieve her anxiety.

A. Assist the client in developing alternative coping skills.

A patient admitted voluntarily for the treatment of an anxiety disorder demands to be released from the hospital. Which action should the nurse take initially? A. Contact the patient's health care provider (HCP). B. Call the patient's family to arrange for transportations. C. Attempt to persuade the patient to stay for only a few more days. D. Tell the patient that leaving would likely result in an involuntary commitment.

A. Contact the patient's health care provider (HCP).

A client who has just been sexually assaulted is calm and quiet. The nurse analyzes this behavior as indicating which defense mechanism? A. Denial B. Projection C. Rationalization D. Intellectualization

A. Denial

A patient admitted to a mental health unit for treatment of psychotic behavior spends hours at the locked exit door shouting. "Let me out. There's nothing wrong with me. I don't belong here." What defense mechanism is the patient implementing? A. Denial B. Projection C. Regression D. Rationalization

A. Denial

A client tells the RN that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. What is the priority nursing problem admission to the psychiatric unit? A. Ineffective sexual patterns B. Impaired environmental interpretation C. Disturbed sensory perception D. Compromised Family Coping

A. Ineffective sexual patterns

The RN documents the mental status of a female client who has been hospitalized for several days by court order. The client states" I don't need to be here," and tells the RN that she believes that the T.V. talks to her. The RN should document these assessment statements in which section of the mental status exam? A. Insight and judgement. B. Mood and affect. C. Remote memory. D. Level of concentration.

A. Insight and judgement.

A mental health worker is caring for a client with escalating aggressive behavior. Which action by the MHW warrant immediate intervention by the RN? A. Is attempting to physically restrain the patient. B. Tells the client to go to the quiet area of the unit. C. Is using a loud voice to talk to the client. D. Remains at a distance of 4 feet from the client.

A. Is attempting to physically restrain the patient.

The RN on the evening shift receives report that a client is scheduled for Electroconvulsive Therapy in the morning. Which intervention should the RN implement the evening before the scheduled ECT? A. Keep client NPO after midnight B. Hold all bedtime meds C. Implement elopement precautions D. Give the client an enema at bedtime

A. Keep client NPO after midnight

When reviewing the admission assessment, the nurse notes that a patient was admitted to the mental health unit involuntarily. Based on this type of admission, the nurse should provide which intervention for this patient? A. Monitor closely for harm to self or others. B. Assist in completing an application for admission C. Supply the patient with written information about their mental illness. D. Provide an opportunity for the family to discuss why they felt the admission was needed.

A. Monitor closely for harm to self or others.

A female client requests that her husband be allowed to stay in the room during the admission assessment. While interviewing the client, the nurse nots a discrepancy between the client's verbal and nonverbal communication. What action should the nurse take? A. Pay close attention and document the nonverbal messages B. Ask the client's husband to interpret the discrepancy C. Ignore the nonverbal behavior and focus on the client's verbal messages D. Integrate the verbal and nonverbal messages and interpret them as one

A. Pay close attention and document the nonverbal messages

A LPN/LVN observes that a client is pacing, agitated, and presenting aggressive gestures. The client's speech pattern is rapid and affect is belligerent. Based on these observations, the nurse's immediate priority of care is to: A. Provide safety for the client and other clients on the unit B. Provide the clients on the unit with a sense of comfort and safety C. Assist the staff in caring for the client in a controlled environment D. Offer the client a less stimulated area to calm down and gain control

A. Provide safety for the client and other clients on the unit

A male client with bipolar disorder who began taking lithium carbonate five days ago is complaining of excessive thirst, and the RN finds him attempting to drink water from the bathroom sink faucet. Which intervention should the RN implement? A. Report the client's serum lithium level to the HCP. B. Encourage the client to suck on hard candy to relieve the symptoms. C. No action is needed since polydipsia is a common side effect. D. Tell the client that drinking from the faucet is not allowed.

A. Report the client's serum lithium level to the HCP.

Which therapeutic communication technique is being used in this nurse-client interaction? Client: "My father spanked me often." Nurse: "Your father was a harsh disciplinarian." A. Restatement B. Offering general leads C. Focusing D. Accepting

A. Restatement

The nurse in the mental health unit recognizes which of the following as therapeutic communication techniques? (Select all that apply) A. Restating B. Listening C. Asking the patient "Why?" D. Maintaining neutral responses E. Providing acknowledgment and feedback F. Giving advice and approval or disapproval

A. Restating B. Listening D. Maintaining neutral responses E. Providing acknowledgment and feedback

A female client admitted to the mental health unit starts to shout and scream at the RN. What is the best approach for the RN to take? A. Stay quietly with the patient B. Tell her that she is out of control. C. Distract her by offering her finger foods. D. Ignore the client's acting out behavior.

A. Stay quietly with the patient

After assertiveness training, a formerly passive client appropriately confronts a peer in group therapy. The group leader states, "I'm so proud of you for being assertive. You are so good!" Which communication technique has the leader employed? A. The nontherapeutic technique of giving approval B. The nontherapeutic technique of interpreting C. The therapeutic technique of presenting reality D. The therapeutic technique of making observations

A. The nontherapeutic technique of giving approval

A patient experiencing disturbed thought processes believes that his food is has been poisoned. Which communication technique should the nurse use to encourage the patient to eat? A. Using open-ended questions and silence B. Sharing personal preference regarding food choices C. Documenting reasons why the patient does not want to eat D. Offering opinions about the necessity of adequate nutrition

A. Using open-ended questions and silence

A male client tells the RN that he does not want to take the atypical antipsychotic drug, olanzapine (Zypexa), because of the side effects he experienced when he took the drug for a year. Which experience is most likely related to takingolanzapine? A. Weight gain of 75 lbs. B. Thoughts of wanting to hurt himself. C. Frequent days with diarrhea. D. Alerted liver function test.

A. Weight gain of 75 lbs.

A nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented that the client is experiencing anxiety as a result of a situational crisis. The nurse determines that this type of crisis is caused by: A) Witnessing a murder B) The death of a loved one C) A fire that destroyed the client's home D) A recent rape episode experienced by the client

B) The death of a loved one

A client's medication sheet contains a prescription for sertraline (Zoloft). To ensure safe administration of the medication, a nurse would administer the dose: A) On an empty stomach B) At the same time each evening C) Evenly spaced around the clock D) As needed when the client complains of depression

B) At the same time each evening

A nurse is preforming a follow-up teaching session with a client discharged 1 month ago. The client is taking fluoxetine (Prozac). What information would be important for the nurse to obtain during this client visit regarding the side effects of the medication? A) Cardiovascular symptoms B) Gastrointestinal dysfunctions C) Problems with mouth dryness D) Problems with excessive sweating

B) Gastrointestinal dysfunctions

A client with schizophrenia explains that she has 20 children and then very seriously points to the RN and explains that she is one of them. What is the most therapeutic response for the RN to provide? A. "Let's go ask another RN is this is true." B. "My name tag shows that I am a RN here." C. "I can't possibly be one if your children." D. "I know that you don't have 20 children."

B. "My name tag shows that I am a RN here."

A client diagnosed with post-traumatic stress disorder is admitted to an inpatient psychiatric unit for evaluation and medication stabilization. Which therapeutic communication technique used by the nurse is an example of a broad opening? A. "What occurred prior to the rape, and when did you go to the emergency department?" B. "What would you like to talk about?" C. "I notice you seem uncomfortable discussing this." D. "How can we help you feel safe during your stay here?"

B. "What would you like to talk about?"

A client is admitted for bipolar disorder and alcohol withdrawal, depressive phase. Based on which assessment finding will the RN withhold the clonidine (Catapres) prescription? A. Pulse rate 68-78 bpm B. BP readings of 90/62 mmHg to 92/58 C. Temperature of 99.5-99.7 F D. Respiration rate of 24 bpm

B. BP readings of 90/62 mmHg to 92/58

The LPN/LVN calls security and has physical restraints applied when a client who was admitted voluntarily becomes both physically and verbally abusive while demanding to be discharged from the hospital. Which represents the possible legal ramifications for the nurse associated with these interventions? (Select all that apply) A. Libel B. Battery C. Assault D. Slander E. False Imprisonment

B. Battery C. Assault E. False Imprisonment

The RN is providing education about strategies for a safety plan for a female client who is a victim of intimate partner violence. Which strategies should be included in the safety plan? (Select all that apply) A. Purchase a gun to use for protection. B. Establish a code with family and friends to signify violence. C. Take a self-defense course that retaliates the abuser with injury. D. Have a bag ready that has extra clothes for self and children. E. Plan an escape route to use if the abuser blocks the main exit.

B. Establish a code with family and friends to signify violence. D. Have a bag ready that has extra clothes for self and children. E. Plan an escape route to use if the abuser blocks the main exit.

A client who has agoraphobia (a fear of crowds) is beginning desensitization with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client's plan of care? A. Encourage substitution of positive thoughts for negative ones B. Establish trust by providing a calm, safe environment C. Progressively expose the client to larger crowds D. Encourage deep breathing when anxiety escalates in a crowd

B. Establish trust by providing a calm, safe environment

A male client comes to the emergency center because he has an erection that will not resolve. The client reports that he is taking trazodone (Desyrel) for insomnia. Which information is most important for the nurse ask the client? A. When was the last time you drank alcoholic beverage? B. Have you taken any medications for erectile dysfunction? C. Are you having any other sexual dysfunctions or problems? D. Do you have a history of angina or high blood pressure?

B. Have you taken any medications for erectile dysfunction?

The RN is leading a group on the inpatient psychiatric unit. Which approach should the RN use during the working phase of group development? A. Establishing a rapport with group members B. Helping clients identify areas of problem in their lives C. Discussing ways to use new coping skills learned D. Clarifying the nurse's role and clients' responsibilities

B. Helping clients identify areas of problem in their lives

Which client statement suggests the RN that the client is using a defense mechanism of projection to deal with anxiety related to admission to a psychiatricunit? A. At least I hit the wall instead of hitting the psychiatric aide. B. I am here because the police thought I was doing something wrong. C. I want to be here because I know it is the best psychiatric facility. D. Don't believe everything my family tells you, I am not crazy.

B. I am here because the police thought I was doing something wrong.

The nurse is preparing a patient for the termination phase of the nurse-patient relationship. The nurse prepares to implement which nursing task that is most appropriate for this phase? A. Planning short-term goals B. Making appropriate referrals C. Developing realistic solutions D. Identifying expected outcomes

B. Making appropriate referrals

A client who is admitted to the mental health unit reports shortness of breath and dizziness. The client tells the nurse, "I feel like I am going to die," which nursing problem should the nurse include in this client's plan of care? A. Mood disturbance B. Moderate anxiety C. Altered thoughts D. Social isolation

B. Moderate anxiety

A nurse maintains an uncrossed arm and leg posture. This nonverbal behavior is reflective of which letter of the SOLER acronym for active listening? A. S B. O C. L D. E E. R

B. O rationale: The acronym SOLER includes: A: (S)itting squarely facing the client B: (O)pen posture when interacting with the client C: (L)eaning forward toward the client D: (E)stablishing eye contact E: (R)elaxing

Male who was found sitting in the middle of a busy street is brought to the emergency department. Confused and has difficulty answering questions. After ruling out a physiological etiology for the client's behavior. When admitting the client to the unit, which action is most important for the nurse to take? A. Ask the client about his recent substance use B. Perform a mental status exam C. Determine the number of previous hospitalizations D. Assess the client from head-to-toe

B. Perform a mental status exam

The RN is providing care for a client diagnosed with borderline personality disorder who has self-inflicted lacerations on the abdomen. Which approach should the RN use when changing this client's dressing? A. Provide detailed thorough explanations when cleansing wound. B. Perform the dressing change in a non-judgmental manner. C. Ask in a non-threatening manner why the client cut own abdomen. D. Request another staff member assist with the dressing change.

B. Perform the dressing change in a non-judgmental manner.

A male client approaches the nurse with an angry expression on his face and raises his voice saying, "My roommate is the most selfish, self-centered, angry person I have ever met. If he loses his temper one more time with me, I am going to punch him out!" The nurse recognizes that the client is using which defense mechanism? A. Denial B. Projection C. Rationalization D. Splitting

B. Projection

A client with depression is not attentive to personal hygiene, uses television watching as a means of escape from...inability to enjoy the things that once gave them pleasure. Which coping strategy should the nurse include in the plan of care? A. Relax and reduce the amount of effort to solve the problem B. Recall methods that were most successful in the past C. reach out to family and friends about feelings of abandonment D. turn to other activities to take one's mind off of the issues

B. Recall methods that were most successful in the past

A RN is teaching a client about initiation of a prescribed abstinence therapy using Disulfiram (Antabuse). What information should the client acknowledge understanding? A. Admit to others that he is a substance abuser. B. Remain alcohol free for 12 hours prior to first dose. C. Attend monthly meetings of alcoholics anonymous. D. Completely sustain from heroin or cocaine use.

B. Remain alcohol free for 12 hours prior to first dose.

A female client on a psychiatric unit is sweating profusely while she vigorously does push-ups and then runs the length of the corridor several times before crashing into furniture in the sitting room. Picking herself up, she begins to toss chairs aside, looking for a red one to sit in. When another client objects to the disturbance, the client shouts, "I am the boss here. I do what I want." Which nursing problem best supports these observations? A. Deficient diversional activity related to excess energy level. B. Risk for other related violence related to disruptive behavior. C. Risk for activity intolerance related to hyperactivity. D. Disturbed personal identity related to grandiosity.

B. Risk for other related violence related to disruptive behavior.

An antidepressant medication is prescribed for a client who reports sleeping only 4 hours in the past 2 days and weight loss of 9 lbs within the last month. Which client goal is most important to achieve within the first three days of treatment? A. Meet scheduled appointment with dietitian B. Sleep at least 6 hours a night C. Understands the purpose of the medication regimen D. Describes the reason for hospitalization

B. Sleep at least 6 hours a night

An adolescent male receives a prescription for an antidepressant drug because he is exhibiting a depressed affect. While the client taking the antidepressant, which comparison of the client's behavior before and after taking the drug is most important for the nurse to obtain? A. His appetite B. The emotional quality of his attitude C. His level of activity D. The interactions he has with others

B. The emotional quality of his attitude

A male client with delirium becomes disoriented and confused in his room at night. The best initial nursing intervention is to: A. Move the client next to the nurse's station B. Use an indirect light source and turn off the television C. Keep the television and a soft light on during the night D. Play soft music during the night and maintain a well-lit room

B. Use an indirect light source and turn off the television

A male college student visits the student health center for his annual physical examination. His vital signs and blood glucose...range. His height is 6 feet and 1 inch (185.4 cm), and he weighs 135 pounds (61.36kg). What additional information is most...obtain? A. 24-hour nutritional history B. body mass index C. basal metabolic rate D. complete blood count

B. body mass index

A young male who was recently diagnosed with bipolar disorder takes lithium carbonate daily. He is graduating...he tells the school nurse that wants to live away from home for college. What information is most important for...family? A. Despite his illness, the client should be able to live away from home B. his serum lithium levels should be routinely evaluated C. he should plan to participate in group or individual therapy while at college D. he should be aware of the symptoms of his illness

B. his serum lithium levels should be routinely evaluated

A female victim of sexual assault is being seen in the crisis center. The client states that she still feels "as though the rape just happened yesterday," even though it has been a few months since the incident. The appropriate nursing response is which of the following? A) "You need to try and be realistic. The rape did not just occur." B) "It will take some time to get over these feelings about your rape." C) "Tell me more about the incident that causes you to feel like the rape just occurred." D) "What do you think that you can do to alleviate some of your fears about being raped again?"

C) "Tell me more about the incident that causes you to feel like the rape just occurred."

A nurse is conducting an initial assessment on a client in crisis. When assessing the client's perception of the precipitating event that lead to the crisis, the appropriate question to ask is: A) "With whom do you live?" B) "Who is available to help you?" C) "What leads you to seek help now?" D) "What do you usually do to feel better?"

C) "What leads you to seek help now?"

A nurse is preparing to care for a dying client, and several family members are at the client' bedside. Select the therapeutic techniques that the nurse would use when communicating with the family. Select all that apply. A) Discourage reminiscing B) Make decisions for the family C) Encourage expression of feelings, concerns, and fears D) Explain everything that is happening to all family members E) Touch and hold the client's or family member's hands if appropriate F) Be honest and let the client and family know that they will not be abandoned by the nurse

C) Encourage expression of feelings, concerns, and fears E) Touch and hold the client's or family member's hands if appropriate F) Be honest and let the client and family know that they will not be abandoned by the nurse

A moderatley depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to a nurse "I'm finally cured." The nurse interprets this behavior as a cue to modify the treatment plan by: A) Suggesting a reduction of medication B) Allowing increased "in-room" activities C) Increasing the level of suicide precautions D) Allowing the client off-unit privileges as needed

C) Increasing the level of suicide precautions

A nurse is caring for a client with anorexia nervosa. The nurse is monitoring the behavior of the client and understands that a client with anorexia nervosa manages anxiety by: A) Engaging in immoral acts B) Always reinforcing self-approval C) Observing rigid rules and regulations D) Having the need always to make the right decision

C) Observing rigid rules and regulations

Which statement demonstrates the best understanding of the nurse's role regarding ensuring that each client's rights are respected? A. "Autonomy is the fundamental right of each and every client" B. "A client's rights are guaranteed by both state and federal laws" C. "Being respectful and concerned will ensure that I'm attentive to my client's rights" D. "Regardless of the client's condition, all nurses have the duty to respect client rights"

C. "Being respectful and concerned will ensure that I'm attentive to my client's rights"

An instructor is correcting a nursing student's clinical worksheet. Which instructor statement is the best example of effective feedback? A. "Why did you use the client's name on your clinical worksheet?" B. "You were very careless to refer to your client by name on your clinical worksheet." C. "Surely you didn't do this deliberately, but you breached confidentiality by using the client's name." D. "It is disappointing that after being told, you're still using client names on your worksheet."

C. "Surely you didn't do this deliberately, but you breached confidentiality by using the client's name."

Nurse Patrick is interviewing a newly admitted psychiatric client. Which nursing statement is an example of offering a general lead? A. "Do you know why you are here?" B. "Are you feeling depressed or anxious?" C. "Yes, I see. Go on." D. "Can you chronologically order the events that led to your admission?"

C. "Yes, I see. Go on."

A patient diagnosed with terminal cancer says to the nurse "I'm going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this. After all, I'm the one who's dying." Which response by the nurse is therapeutic? A. "Have you shared your feelings with your family?" B. "I think we should talk more about your anger with your family." C. "You're feeling angry that your family continues to hope for you to be cured?" D. "You are probably very depressed, which is understandable with such a diagnosis."

C. "You're feeling angry that your family continues to hope for you to be cured?"

When the community health nurse visits a patient at home, the patient states, "I haven't slept the last couple of nights." Which response by the nurse illustrates a therapeutic communication response to this patient? A. "I see." B. "Really?" C. "You're having difficulty sleeping?" D. "Sometimes, I have trouble sleeping too."

C. "You're having difficulty sleeping?"

A LPN/LVN employed in a mental health unit of a hospital is the leader of a group psychotherapy session. The nurse's role in the termination stage of group development is to: A. Encourage problem solving B. Encourage accomplishment of the group's work C. Acknowledge the contributions of each group member D. Encourage members to become acquainted with one another

C. Acknowledge the contributions of each group member

The RN on the day shift receive report about a client with depression who was in bed most of the weekend. The RN walks into the client's room in the morning and finds the client in bed. What intervention is best for the RN to implement? A. Monitor the client's appetite and pattern of sleep. B. Assess the client's feelings about the hospital stay. C. Assist the client to get out of bed and involved in an activity. D. Explain that staff will check on the client every 30 minutes.

C. Assist the client to get out of bed and involved in an activity.

An adolescent male client is hospitalized after he threatened a teacher at school. He admits feeling angry because his mother tricked him and brought him to the hospital. The client states that when his mother visits, he plans to get his belongings from her, but he is not going to talk to her. Which activity is most important for the nurse to complete before the mother arrives? A. Assess the client's self-esteem needs. B. Determine the client's expectations fortreatment. C. Discuss methods for clearly communicating. D. Identify ways to develop support systems.

C. Discuss methods for clearly communicating.

An older ale client with schizophrenia is found smearing feces on the bathroom walls of the chronic mental health unit where he resides. What action should the RN implement? A. Explain that the feces belong in the toilet. B. Show the client how to clean the walls. C. Escort the client out of the bathroom. D. Assist the client to clean the walls

C. Escort the client out of the bathroom.

A manic client announces to everyone in the day room that a stripper is coming to perform this evening. When a nurse firmly state that this is inappropriate and will not happen, the client becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of the situation, the LPN/LVN determines that the appropriate action would be to: A. Orient the client to time, person, and place B. Tell the client that behavior is inappropriate. C. Escort the manic client to her room with assistance D. Tell the client that smoking privileges are revoked for 24 hours

C. Escort the manic client to her room with assistance

Which therapeutic communication technique is being used in this nurse-client interaction? Client: "When I am anxious, the only thing that calms me down is alcohol." Nurse: "Other than drinking, what alternatives have you explored to decrease anxiety?" A. Reflecting B. Making observations C. Formulating a plan of action D. Giving recognition

C. Formulating a plan of action

Which nursing actions are likely to help promote the self-esteem of a male client with moderate depression? (Select all that apply) A. Ask the client what his long-term goals are B. Discuss the challenges of his medical condition C. Include the client in determining treatment protocol D. Encourage the client to engage in recreational therapy E. Provide opportunities for the client to discuss his concerns

C. Include the client in determining treatment protocol D. Encourage the client to engage in recreational therapy

When developing a plan of care for a client admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt, which nursing problem has the highest priority? A. Impaired comfort. B. Risk for injury. C. Ineffective breathing pattern. D. Ineffective coping.

C. Ineffective breathing pattern.

The RN is performing intake interviews at a psychiatric clinic. A female client with a known history of drug abuse reports that she had a heart attack four years ago. Useof which substance places the client at highest risk for myocardial infarction? A. Benzodiazepine B. Alcohol C. Methamphetamine D. Marijuana

C. Methamphetamine

A client with bulimia and depression who is taking phenelzine (Nardil) 90 mg daily is admitted to an acute care hospital for uncontrolled hypertension. What dietary choices should the RN instruct the client to avoid? A. Pan-seared catfish B. Deep fried shrimp C. Pepperoni pizza D. Beef trips with gravy

C. Pepperoni pizza

A RN is preparing the physical environment to interview a new client for admission to the mental health unit. Which environmental setting facilitates the best outcome of the interview? A. Dim the lights in the room to help the patient feel calm. B. Sit within two feet of the client to enhance level of safety and security. C. Reduce the noise level in the room by turning off the television and radio. D. Position table between the client and the RN for extra personal space.

C. Reduce the noise level in the room by turning off the television and radio.

A client with depression remains in bed most of the day, declines activities and refuses meals. Which nursing problem has the greatest priority for this client? A. Loss of interest in diversional activity B. Social isolation C. Refusal to address nutritional needs D. Low self-esteem

C. Refusal to address nutritional needs

A client on the mental health unit is becoming more agitated, shouting at the staff, and pacing in the hallway. When a PRN medication is offered, the client refuses the medication and defiantly sits on the floor in the middle of the unit hallway. What nursing intervention should the nurse implement first? A. Transport the client to the seclusion room B. Quietly approach the client with additional staff members C. Take other client in the area to the client lounge D. Administer medication to chemically restrain client

C. Take other client in the area to the client lounge

An older man with a hx of falls at home tells the clinic nurse that his son, who was incarcerated last year for assault and battery, has become abusive since his release from prison. Which intervention is most important for the nurse to implement? A. Tell the client to call Adult Protective Services if his son's abuse continues. B. Refer the client to a program for victims of domestic violence C. Verify the client's report by determining if there is physical evidence of abuse D. Assist the client in developing an emergency safety plan

C. Verify the client's report by determining if there is physical evidence of abuse

A male hospital employee is pushed out of the way by a female employee because of an oncoming gurney. The pushed employee becomes very angry and swings at the female employee. Both employees are referred for counseling with the staff psychiatric nurse. Which factor in the pushed employee's history is most related to the reaction that occurred? A. Is worried about losing his job to a woman B. Tortured animals as a child C. Was physically abused by his mother D. Hates to be touched by anyone

C. Was physically abused by his mother

After meeting with a healthcare provider, a client who is diagnosed with bipolar disorder is screaming and stomping. Which action should the nurse take? A. instruct the client to reduce the volume of his voice B. administer a PRN sedative by injection C. accompany the client to a quiet area of the unit D. encourage the client to attend a support group

C. accompany the client to a quiet area of the unit

When preparing to administer to domestic violence screening tool to a female client, which statement should the RN provide? A. "If your partner is abusing you, I need to ask these questions." B. "State law mandates that I ask if you are a victim of domestic violence" C. "The HCP provider needs to know if you are experiencing any domestic abuse" D. "All clients are screened for domestic abuse because it is common in our society"

D. "All clients are screened for domestic abuse because it is common in our society"

A young adult female visits the mental health clinic complaining of diarrhea, headache, and muscle aches. She is afebrile, denies chills, and all laboratory findings are within normal limits. During the physical assessment, the client tells the RN that her sister thinks she is neurotic and calls her a hypochondriac. Which response is best for the RN to provide? A. "Unless your sister has a medical education, ignore her comments." B. "I can hear that your sister's comments are overwhelming you." C. "Do you think it's possible that you might be a hypochondriac?" D. "Besides your sister's comments, what in life is troubling you?"

D. "Besides your sister's comments, what in life is troubling you?"

A client is admitted to the mental health unit and reports taking extra antianxiety medication because, "I'm so stressed out. I just want to go to sleep." The RN should plan one-on-one observation of the client based on which statement? A. "What should I do? Nothing seems to help." B. "I have been so tired lately and needed to sleep." C. "I really think that I don't need to be here." D. "I don't want to walk. Nothing matters anymore."

D. "I don't want to walk. Nothing matters anymore."

During an annual physical by the occupational nurse working in a corporate clinic, a male employee tells the nurse that his high-stress job is causing trouble in his personal life. He further explains that he often gets so angry while driving to and from work that he has considered "getting even" with other drivers, how should the nurse respond? A. "Anger is contagious and could result in major confrontation" B. "Try not to let your anger cause you to act impulsively" C. "Expressing your anger to a stranger could result in an unsafe situation" D. "It sounds as if there are many situations that make you feel angry"

D. "It sounds as if there are many situations that make you feel angry"

A patient with a diagnosis of major depression who has attempted suicide says to the nurse, "I should have died! I've always been a failure. Nothing ever goes right for me." Which response demonstrates therapeutic communication? A. "You have everything to live for." B. "Why do you see yourself as a failure?" C. "Feeling like this is all part of being depressed." D. "You've been feeling like a failure for a while?"

D. "You've been feeling like a failure for a while?"

On review of the patient's record, the nurse notes the admission was voluntary. Based on this information, the nurse anticipates which patient's behavior? A. Fearfulness regarding treatment measures. B. Anger and aggressiveness directed toward others. C. An understanding of the pathology and symptoms of the diagnosis. D. A willingness to participate in the planning of the care and treatment plan.

D. A willingness to participate in the planning of the care and treatment plan.

A male client is admitted to the psychiatric unit for recurrent negative symptoms of chronic schizophrenia and medication adjustment of risperidone (Risperdal). When the client walks to the nurse's station in a literally contracted position, he states that something has made his body contort into a monster. What action should the nurse take? A. Medicate the client with the prescribed antipsychotic thiordazine (mellaril) B. Offer the client a prescribed physical therapy hot pack for muscle spasms C. Direct client to occupational therapy to distract him for somatic complaints D. Administer the prescribed anticholinergic benztropine (Cogentin) for dystonia

D. Administer the prescribed anticholinergic benztropine (Cogentin) for dystonia

The occupational health nurse is working with a female employee who was just notified that her child was involved in a motor vehicle accident and taken to the hospital. The employee states, "I can't believe this. What should I do?" Which response is best for the RN to provide in this crisis? A. "Tell me what you think should happen." B. "How serious was the collision?" C. "What do you think you should do?" D. Call for transportation to the hospital

D. Call for transportation to the hospital

A male client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. What intervention is best for the RN to implement? A. Isolate the client from other clients B. Administer PRN sedative C. Avoid recognizing the behavior D. Escort the client to his room

D. Escort the client to his room

A nurse is working with a client who has sought counseling after trying to rescue a neighbor involved in a house fire. Despite the client's efforts, the neighbor died. Which action does the nurse engage in with the client during the working phase of the nurse-client relationship? A. Exploring the client's ability to function B. Exploring the client's potential for self-harm C. Inquiring about the client's perception of appraisal of the neighbor's death D. Inquiring about and examine the client's feelings that may block adaptive coping

D. Inquiring about and examine the client's feelings that may block adaptive coping

Following involvement in a MVC, a middle aged adult client is admitted to the hospital with multiple facial fractures. The client's blood alcohol level is high on admission. Which PRN prescription should be administered if the client begins toexhibit signs and symptoms of delirium tremens (DTs)? A. Prochlorperazine (Compazine) 5 mg IM. B. Hydromorphone (Dialuadid) 2 mg IM. C. Chlorpromazine (Thorazine) 50 mg IM. D. Lorazepam (Ativan) 2 mg IM.

D. Lorazepam (Ativan) 2 mg IM.

Which therapeutic communication technique is being used in this nurse-client interaction? Client: "When I get angry, I get into a fistfight with my wife, or I take it out of the kids." Nurse: "I notice that you are smiling as you talk about this physical violence." A. Encouraging comparison B. Exploring C. Formulating a plan of action D. Making observations

D. Making observations

The RN is admitting a male client who takes lithium carbonate (Eskalith) twice a day. Which information should the RN report to the HCP immediately? A. Short term memory loss. B. Five pound weight gain C. Decreased affect. D. Nausea and vomiting.

D. Nausea and vomiting.

Unresolved feelings related to loss most likely may be recognized during which phase of the therapeutic nurse-client relationship? A. Working B. Trusting C. Orientation D. Termination

D. Termination

A patient's unresolved feelings related to loss would be most likely observed during which phase of the therapeutic nurse-patient relationship? A. Trusting B. Working C. Orientation D. Termination

D. Termination rationale: In the termination phase, the relationship comes to a close. Ending treatment sometimes may be traumatic for patients who have come to value the relationship and the help. Because loss is an issue, any unresolved feelings related to loss may resurface during this phase.

A nurse states to a client, "Things will look better tomorrow after a good night's sleep." This is an example of which communication technique? A. The therapeutic technique of "giving advice" B. The therapeutic technique of "defending" C. The nontherapeutic technique of "presenting reality" D. The nontherapeutic technique of "giving false reassurance"

D. The nontherapeutic technique of "giving false reassurance"

What is the most important goal for a client with major depression who has been receiving an antidepressant medication for two weeks? A. ventilate feelings of sadness B. eats three meals a day C. participates in group meetings D. does not attempt to commit suicide

D. does not attempt to commit suicide

A female client with obsessive compulsive disorder complains that she is feels "driven" to check the locks on her front door at.. Which response is best for the nurse toprovide? A. have you had a bad experience related to unlocked doors? B. What are your thoughts when you are checking the locks? C. feelings of being drive to do something are related to anxiety D. repeating the same behavior helps you to diminish your anxiety

D. repeating the same behavior helps you to diminish your anxiety

The RN is preparing medications for a client with bipolar disorder and notices that the client discontinued antipsychotic medication for several days. Which medication should also be discontinued? a. Lithium. (Lithotabs) b. Benzotropine (Cogentin). c. Alprazolam (Xanax). d. Magnesium (Milk of Magnesia).

b. Benzotropine (Cogentin).

A client with borderline personality disorder tells the nurse, "You are the best nurse on the unit! The other nurses don't care about me the way you do." Which response is best for the nurse to provide this client? a.) "I am not the best nurse. All the nurses are good." b.) "The other nurses and I are here to help you get better" c.) "You don't think the other nurses care about you?" d.) "I do care about you as a person but nothing more."

b.) "The other nurses and I are here to help you get better"

While sitting in the day room of the mental health unit, a male adolescent avoids eye contact, looks at the floor, and talks softly when interacting verbally with the RN. The two trade places, and the RN demonstrates the client's behaviors. What is the main goal of this therapeutic technique? a. Initiate a non-threatening conversation with the client. b. Dialogue about the ineffectiveness of his interactions c. Allow the client to identify the way he interacts. d. Discuss the client's feelings when he responds.

c. Allow the client to identify the way he interacts.

A young female client is admitted to the emergency room because she was raped that evening by her date. How should the nurse record the client's chief complaint in the medical record? a.) Client reported that she had sexual relations against her will. b.) Client claims that she was forced to participate in sexual intercourse. c.) Client has been sexually assaulted. d.) Client states, "my date raped me tonight."

d.) Client states, "my date raped me tonight."