Mental Health
A nurse on a behavioral health unit is discussing the tasks of the Clinical Judgment Action Model (CJAM) with a group of newly licensed nurses. Which of the following information about analyzing cues should the nurse include?The nurse should identify subjective and objective data regarding the client's mental health condition.The nurse should use observations, clinical presentation data, and assessment findings to identify the client's mental health alteration.The nurse should determine client mental health outcomes and appropriate nursing interventions.The nurse should monitor the client's responses to nursing interventions and changes in mental health status.
The nurse should use observations, clinical presentation data, and assessment findings to identify the client's mental health alteration.MY ANSWERAnalysis of cues focuses on the nurse comparing client data and assessment findings to identify the client's health alteration based on the client's needs.
A nurse is caring for a newly admitted client who states they are concerned about their privacy and rights while on the psychiatric unit. The nurse should explain to the client that they have which of the following rights? The right to refuse treatmentThe right for their information to be shared with their family at any timeThe right for their clinical notes to be shared with anyone at the facilityThe right for providers to solely decide their treatment options
The right to refuse treatment The right to self-determination allows a client to refuse treatment, including medications. Medication refusals for mental illness are often due to side effects of the stigma of taking such a medication.
A nurse is caring for a client who speaks a different language than the nurse. The nurse is looking for resources to assist with providing educational instructions about the client's medication. Which of the following resources should the nurse use? US Department of Health and Human ServicesHealthy People 2020Centers for Disease Control and PreventionThe Mayo Clinic website
US Department of Health and Human Services The US Department of Health and Human Services has a set of culturally and linguistically appropriate services standards to assist in working with people who speak a limited amount of English.
A nurse is discussing the role of a licensed practical nurse (LPN) with a group of newly licensed nurses. Which of the following statements by a newly licensed nurse indicates an understanding of the role of an LPN? "An LPN can complete an independent assessment.""An LPN can report their observations to an RN.""An LPN can prioritize care based on the data that was collected.""An LPN can develop and provide client education."
"An LPN can report their observations to an RN."MY ANSWERAn LPN can observe, check, monitor, and collect client data and report findings to the RN.
A nurse is reviewing community assessments with a group of newly licensed nurses. Which of the following statements by a newly licensed nurse indicates an understanding of community assessments? (Select all that apply.) "Community assessments are used to assess the needs of a particular community or population.""Community assessments identify conditions and disorders that are prevalent within a community.""Community assessments highlight areas of strength within a community or population.""Community assessments are the same as cultural assessments.""Community assessments are used to consider the services that are being used in the community."
"Community assessments are used to assess the needs of a particular community or population" is correct. Community assessments evaluate the needs of a community or population, address prevalent disorders, and identify strengths of the community and population."Community assessments identify conditions and disorders that are prevalent within a community" is correct. Community assessments evaluate the needs of a community or population and consider the prevalence of specific physical or mental health concerns within the community."Community assessments highlight areas of strength within a community or population" is correct. Community assessments evaluate the needs of a community or population, address prevalent disorders, and identify strengths of the community and population."Community assessments are the same as cultural assessments" is incorrect. Community assessments evaluate the community for specific needs, highlight strengths, and note prevalent conditions or disorders. Cultural assessments are used to better understand the cultural practices and needs of individual clients."Community assessments are used to consider the services that are being used in the community" is correct. Community assessments evaluate the needs of a community or population, address prevalent disorders, and identify resources as well as strengths of the community and population. Resources include the services that are available within the community.
A nurse is caring for a client who was administered an antianxiety medication 1 hr ago. Which of the following statements by the nurse indicates that the nurse is using the evaluation step of the nursing process? "How does your anxiety affect your ability to work?""Have you had anxiety in the past?""What is the dosage of the antianxiety medication that you take at home?""How is your anxiety level now?"
"How is your anxiety level now?"MY ANSWERThis statement by the nurse indicates the evaluation step of the nursing process because the nurse is evaluating the client's anxiety after being administered an antianxiety medication.
A nurse is performing a mental status examination for a newly admitted client. Which of the following questions should the nurse include in the examination? (Select all that apply.) "How would you describe your mood today?""What is the date today?""What is your pain level on a scale of 0 to 10?""Can you please show me how to use this pen?""Why are you wearing a coat when it is hot today?"
"How would you describe your mood today?" is correct. The nurse should include this question in the examination. One of the main components of the mental status examination is assessing the client's mood."What is the date today?" is correct. The nurse should include this question in the examination. Orientation is a component of the mental status examination that includes assessment of the client's ability to recognize person, place, and time."What is your pain level on a scale of 0 to 10?" is incorrect. While the nurse should collect data on this client's pain level, this question should not be included as part of a standard mental status examination."Can you please show me how to use this pen?" is correct. The nurse should include this question in the examination. Having the client demonstrate use of a pen is an example of assessing praxis. This is a component of the mental status examination."Why are you wearing a coat when it is hot today?" is incorrect. This question should not be included as part of the mental status examination. The nurse should avoid asking "why" questions because they can cause the client to become defensive.
A nurse is explaining what "duty to warn" means to a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding? "If a client threatens to harm another person, health care providers have a responsibility to inform that person.""If a client threatens to harm themselves, there is a responsibility to report that client to their family.""If a client threatens to harm themselves, there is a responsibility to tell their medical provider.""If a client threatens to harm another person, there is a responsibility to inform the other person's family."
"If a client threatens to harm another person, health care providers have a responsibility to inform that person. "A health care provider has a "duty to warn" when there is a threat from a client to another person to cause harm to them.
A nurse on a behavioral health unit is caring for a newly admitted client who asks, "What is milieu therapy?" Which of the following responses should the nurse make? "Milieu therapy is a type of therapy focused on assisting clients with identifying triggers of anxiety and fear.""Milieu therapy is focused on creating a safe environment for healing through trauma-informed therapeutic relationships.""Milieu therapy is a type of group therapy in which clients explore their thoughts, feelings, and experiences.""Milieu therapy is a type of individual therapy focused on connecting negative thoughts and behaviors."
"Milieu therapy is focused on creating a safe environment for healing through trauma-informed therapeutic relationships."Milieu therapy is focused on creating an environment that is structured to be safe so clients can learn healthier ways to think, interact, or behave. Trauma-informed therapeutic relationships are an essential aspect of this therapy.
A group of nurses is discussing the effectiveness of nursing interventions among clients who have a mental health diagnosis. Which of the following statements accurately identifies a barrier to effective nursing inteventions? (Select all that apply.) "Some mental health clients are unaware that they have a mental health condition.""Some mental health clients experience cognitive deficits and cannot understand their treatment plan.""Many mental health clients experience the effects of polypharmacy.""Many mental health clients are not trustworthy.""Many mental health clients experience worsening clinical manifestations."
"Some mental health clients are unaware that they have a mental health condition" is correct. This describes anosognosia or the condition in which some clients who have a mental illness deny or are unaware that they have a mental illness. This is a barrier to effective nursing interventions."Some mental health clients experience cognitive deficits and cannot understand their treatment plan" is correct. Mental illness can impact a client's cognition, resulting in a slowing, decline, or inability to comprehend. This is a potential barrier to effective nursing interventions."Many mental health clients experience the effects of polypharmacy" is correct. Mental health clients can experience polypharmacy, resulting in challenges in adherence to medication routines and client perception of a diminished quality of life."Many mental health clients are not trustworthy" is incorrect. There is no evidence to support that mental health clients are any more or less trustworthy than other clients. Therefore, this is not evidence of a barrier to effective nursing interventions."Many mental health clients experience worsening clinical manifestations" is correct. Worsening clinical manifestations, such as manifestations of depression or anxiety, can impact the effectiveness of nursing interventions.
A nurse is discussing the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition Text Revisions (DSM-5 TR) with a newly licensed practical nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the DSM-5? "I would use the DSM-5 TR to diagnose clients who have mental health disorders. "The DSM-5 TR assists in planning nursing interventions for clients who have a mental health disorder." "I would use the DSM-5 TR as a guide instructing what specific criteria or questions should be asked for a suspected mental health diagnosis." "The DSM-5 TR tells how to treat a patient who has a mental health diagnosis."
"The DSM-5 TR assists in planning nursing interventions for clients who have a mental health disorder. "Nurses often use the DSM-5 TR diagnostic information to assist with planning, implementing, and evaluating client care. This information can guide nursing interventions for specific needs.
A nurse is reviewing the purpose of the DSM-5 with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? "The DSM-5 is a resource that outlines nursing interventions for clients who have been diagnosed with a mental health disorder.""The DSM-5 is a resource that provides health care professionals with information on the best course of treatment for mental health disorders.""The DSM-5 is a resource that provides information about the clinical manifestations of specific mental health disorders.""The DSM-5 is a resource that outlines discharge planning and continuity of care across client populations."
"The DSM-5 is a resource that provides information about the clinical manifestations of specific mental health disorders."MY ANSWERThe DSM-5 provides information regarding clinical manifestations related to mental health disorders. It is the most trusted source on diagnosing mental health disorders and is developed by the American Psychiatric Association.
A nurse is explaining the purpose of the Family Assessment Device (FAD) to the parents of a child. Which of the following statements by a parent indicates an understanding of the FAD? "The FAD is used to help assess family functioning, specifically the impact of trauma and crisis on family functioning.""The FAD is used to help assess family functioning, specifically in the areas of housing and financial security.""The FAD is used to help assess family functioning, specifically to determine the need to notify Child Protective Services of any family problems.""The FAD is used to help assess family functioning, specifically to determine how the roles of the family work in the family dynamics."
"The FAD is used to help assess family functioning, specifically to determine how the roles of the family work in the family dynamics."MY ANSWERThe FAD is used to look at several areas within the family unit and how they impact the child. These include problem solving and communication, along with behavior control and family roles.
A nurse is reviewing the concept of bias with a newly licensed nurse. Which of the following scenarios should the nurse use to demonstrate biased treatment? A client is not permitted to attend the group therapy activity due to wanting to harm another peer in the group. A client is not permitted to attend the group therapy activity due to having a family therapy session during the same time. A client is not permitted to attend the group therapy activity due to having thoughts of harming themselves with "anything they can find." A client is not permitted to attend the group therapy activity because they practice the Buddhist faith.
A client is not permitted to attend the group therapy activity because they practice the Buddhist faith. Bias is when treatment of a client is verified in the form of stereotyping, prejudice, or discrimination. Therefore, this scenario demonstrates biased treatment.
A nurse is providing teaching to a group of newly licensed nurses about stigma. Which of the following client scenarios should the nurse include as an example of self-stigma? A client refuses to go to their provider for manifestations of anxiety until they meet with their cultural leader, a shaman.A client stops taking their medication for anxiety because they do not like how it makes them feel.A client refuses to pick up their prescription for an antidepressant because they do not want the pharmacist to know that they are on an antidepressant.A client refuses a follow-up appointment for their anxiety because they are waiting until they can arrange transportation.
A client refuses to pick up their prescription for an antidepressant because they do not want the pharmacist to know that they are on an antidepressant. Self-stigma is when an individual has a negative view or internalized shame regarding their mental illness, often due to the public stigma of mental illness.
A nurse is reviewing the medical records of a group of clients. The nurse should identify that which of the following factors places a client at risk for mental illness? A family member with a diagnosis of diabetesA medical diagnosis of diabetesA history of using community support servicesA history of abuse
A history of abuse A history of abuse places a client at risk for mental illness.
A nurse is discussing ethical principles with another nurse. Which of the following should the nurse include as an example of the principle of nonmaleficence? A nurse evaluates the client's desire for autonomy while considering the personal safety of other clients on the unit.A nurse encourages the client to determine which therapeutic activity they would like to participate in.A nurse plans to spend equal amounts of time with each client assigned to their care.A nurse makes a referral to speech therapy for a client who is experiencing dysphagia.
A nurse evaluates the client's desire for autonomy while considering the personal safety of other clients on the unit. The principle of nonmaleficence involves doing no harm. By weighing the risks and benefits of the client's desire for autonomy while considering the safety of the other clients on the unit, the nurse is practicing nonmaleficence.
A nurse is preparing to care for a newly admitted client. Place the following nursing actions in the order the nurse should perform them. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Addressing the client's aggressive behavior towards the staff is the first priority nursing action. Aggressive behavior represents an immediate risk for other-directed harm and requires the nurse to establish firm and safe boundaries within the therapeutic milieu of the unit.Evaluating the client's history of suicidal behaviors is the second priority nursing action. History of suicidal behaviors should be evaluated upon admission and at regular intervals to ensure client safety.Providing orientation to the unit's rules is the third priority nursing action. This allows the client to understand unit rules, sets boundaries, and provides a clear explanation of safety, roles, therapeutic milieu, and an overview of the unit environment.Discussing the provider's current prescriptions is the fourth priority nursing action. This action connects the provider, plan of care, and the role of other team members to the client's recovery. This is best done after the nurse has ensured staff and client safety and outlined expectations and boundaries.Discussing the client's therapy schedule is the fifth priority nursing action. Once the nurse has ensured staff and client safety, outlined expectations and boundaries, and discussed specific provider prescriptions, more specific information such as therapy schedules would be appropriate to discuss
A nurse is caring for a client who is newly admitted to the acute psychiatric unit for alcohol use disorder. The client reports growing up in an Amish community. Which of the following actions should the nurse take? Inform the client that the nurse follows Judaism. Provide the client with a Bible. Assess for personal bias related to alcohol use disorder before interacting with the client. Ask the client where they grew up practicing Amish traditions.
Assess for personal bias related to alcohol use disorder before interacting with the client. To ensure the nurse does not have any bias in their treatment of the client, the nurse should first understand what their own culture and biases are to not hinder client care.
A nurse on an inpatient mental health unit is using the Clinical Judgment Action Model (CJAM) to guide their care of a client. Which of the following tasks should the nurse complete to generate solutions? (Select all that apply.) Determine desired outcomes.Determine the best solution based on evidence.Determine what resources are needed, including people, equipment, and medications.Determine cues that need to be analyzed.Prioritize client care.
Determine desired outcomes is correct. When generating solutions, the nurse should determine outcomes of the client's plan of care. Outcomes are the foundation for selecting evidence-based interventions.Determine the best solution based on evidence is correct. When generating solutions, the nurse should determine the best solution based on evidence. These evidence-based solutions are the foundation for selecting evidence-based interventions.Determine what resources are needed, including people, equipment, and medications is correct. When generating solutions, the nurse should determine what resources are needed to address the desired outcomes.Determine cues that need to be analyzed is incorrect. Determining cues that need to be analyzed occurs in the analysis step of the CJAM.Prioritize client care is incorrect. Prioritizing client care occurs during the analysis step of the CJAM.
A nurse is planning a presentation regarding mental illness for a local health fair. Which of the following should the nurse include as a characteristic of mental illness? Resilience following a loss of a jobDifficulty maintaining social relationshipsVolunteering at a crisis centerEnding a friendship with an individual who demands participation in dangerous activities
Difficulty maintaining social relationships Mental illnesses are associated with distress and/or problems functioning in social, work, or family activities.
A charge nurse is presenting on the topic of mental health diagnoses during a unit meeting. The charge nurse should identify that the DSM-5 TR classification is used in conjunction or paired with what other classification system? Nursing Intervention ClassificationsMaslow's hierarchy of needsInternational Classification of DiseaseErikson's Stages of Psychosocial Development
International Classification of Disease The DSM-5 classification is often used in conjunction or paired with the World Health Organization's International Classification of Disease (ICD).
A nurse is screening a client for alcohol and tobacco use. Which of the following types of prevention is the nurse demonstrating? SecondaryPrimaryTertiarySelective
Secondary Secondary prevention involves screening for things that could lead to potential health problems.
A nurse is discussing the purpose of mental status assessments with a newly hired nurse. Which of the following information should the nurse include? Mental status assessments assess the client's family roles and functioning.Mental status assessments assess the client's coping abilities and strategies.Mental status assessments assess a client's cognitive and behavioral functioning.Mental status assessments assess the client's mental health and physical history.
Mental status assessments assess a client's cognitive and behavioral functioning.The mental status assessment is an evidence-based structured assessment of a client's cognitive and behavioral functioning used to monitor and evaluate clinical manifestations.
A nurse is preparing a poster presentation on the priorities of Healthy People 2030. Which of the following priority goals should the nurse include? The practice of trephination for the treatment of mental illness Prevention practices related to cyber-bullying Increasing institutionalization of clients who have severe mental health disorders Limit screening of mental illness to those individuals who display manifestations
Prevention practices related to cyber-bullying Cyber-bullying is a stressor that can result in mental health disorders. By implementing practices targeted at prevention of cyber-bullying, the priority goal of prevention of mental health disorders is met.
A group of nurses is discussing implementation of a plan of care for a client who has a mental illness. Which of the following nursing actions should be included when implementing a plan of care? (Select all that apply.) Prioritize establishing a therapeutic relationship.Focus on client-centered, holistic care rather than the client's diagnosis.Limit family involvement when executing the plan of care.Gather data related to the client's clinical manifestations.Accurately document implementation of the plan of care.
Prioritize establishing a therapeutic relationship is correct. Developing and maintaining a therapeutic relationship is the foundation for providing mental health care. This is a necessary nursing action when implementing a plan of care.Focus on client-centered, holistic care rather than the client's diagnosis is correct. Focusing on holistic, client-centered care is a necessary nursing action when implementing a plan of care and allows the nurse to consider the person rather than their diagnosis.Limit family involvement when executing the plan of care is incorrect. Including the client and their family when executing a plan of care is an evidence-based strategy for improving client participation. Families should be included in the plan of care when possible.Gather data related to the client's clinical manifestations is incorrect. Gathering data is completed prior to implementation of a client's plan of care.Accurately document implementation of the plan of care is correct. Documentation is an essential aspect of implementation of the plan of care. Documentation validates nursing actions and provides visibility of nursing care.
A nurse is caring for a client who is at an increased risk for isolation. Which of the following interventions should the nurse identify as significant for the client's recovery? Incorporate de-escalation techniques when caring for the client.Provide nursing presence by spending time with the client daily.Encourage small, frequent, high-calorie meals.Orient the client to reality
Provide nursing presence by spending time with the client daily.MY ANSWERProviding nursing presence by spending time with a client who is at risk for isolation is a significant nursing intervention that is based on developing and maintaining a therapeutic relationship.
A nurse is caring for a client and notes that the client has become increasingly restless over the last hour. This is an example of which of the following steps of the Clinical Judgment Action Model (CJAM)? Taking actionPrioritizing hypothesesAnalyzing cuesRecognizing cues
Recognizing cuesMY ANSWERThe nurse should identify that this is an example of recognizing cues. Recognition of cues considers any changes in a client's condition, such as an increase in anxiety.
A nurse is using the Clinical Judgment Action Model (CJAM) to guide a client's care. Which of the following tasks is designed to facilitate the analysis of cues? (Select all that apply.)Recognizing patternsDetermining the order of prioritiesLinking cuesDetermining what is concerningDetermining the need for additional informationCollaborating with members of the interprofessional team
Recognizing patterns is correct. Recognizing patterns is a task that is designed to facilitate the analysis of cues.Determining the order of priorities is incorrect. Determining the order of priorities is a task for prioritizing the client's problems, which occurs following the analysis of cues. It is not a task that is designed to facilitate the analysis of cues.Linking cues is correct. Linking cues is a task that is designed to facilitate the analysis of cues.Determining what is concerning is correct. Determining what is concerning is a task that is designed to facilitate the analysis of cues.Determining the need for additional information is correct. Determining the need for additional information is a task that is designed to facilitate the analysis of cues.Collaborating with members of the interprofessional team is incorrect. Collaborating with members of the interprofessional team occurs during the generating solutions portion of the CJAM. It is not a task that is designed to facilitate the analysis of cues.
A nurse is caring for a client. Which of the following actions by the nurse demonstrates the evaluating outcomes step of the Clinical Judgment Action Model (CJAM)? Revising the plan of careHandling psychiatric emergenciesProviding evidence for hypothesisDetermining if additional information is needed
Revising the plan of careThe plan of care should be revised based on the evaluation of outcomes and to what degree the outcomes have been met.
A nurse is working in a neighborhood where the population is culturally diverse. Which of the following actions should the nurse take to ensure the delivery of culturally competent care? Reflect on their own culture. Read a book about the countries of the residents' ancestry. Talk to the residents of the neighborhood about their culture. Provide care that meets the residents' needs.
Talk to the residents of the neighborhood about their culture. Cultural competence involves gaining knowledge about another individual's culture. Speaking to the residents of the neighborhood can assist the nurse in gaining this knowledge.
A nurse is caring for a client who reports that they are having a hard time completing their ADLs due to feeling anxious. The client also reports feeling tired, difficulty sleeping, and having a poor appetite. The nurse should anticipate they would fall in which end of the mental health continuum? The client would fall closer towards the mental illness end or struggling.The client would fall closer towards the mental health end or thriving.The client would not clearly fall on the mental health continuum as they do not have a mental illness diagnosis.The client should be evaluated by the provider before their observance on the mental health continuum is noted, as currently they would fall in the middle.
The client would fall closer towards the mental illness end or struggling. The mental health continuum is a range of responses a person displays in response to life events. The ends vary between positive and negative responses, often viewed as mental health versus mental illness.
A nurse is reviewing the chart of a client who has paranoid schizophrenia. The nurse should identify that the Diagnostic and Statistical Manual of Mental Disorders, 5th edition Text Revision (DSM-5 TR) distinguishes the different types of schizophrenia based on which of the following criteria? Current medication history When the manifestations started Family history of mental illness The client's full history
The client's full history The DSM-5 TR criteria can be broken down based on the client's manifestations obtained during the complete health history.
A nurse is discussing the continuum of care with a client. Which of the following information should the nurse include? The continuum of care includes different clinical settings, such as clinics and hospitals.The continuum of care is the basis for understanding levels and severity of mental illness.The continuum of care occurs only during hospitalization.The continuum of care increases the client's risk for urgent care visits.
The continuum of care includes different clinical settings, such as clinics and hospitals.MY ANSWERThe continuum of care includes various clinical settings that contribute to the recovery of the client, including offices or clinics, partial hospitalization programs, respite care programs, crisis centers, and inpatient hospitals.
A nurse is presenting information on mental health services over the last 50 years to a group of newly licensed nurses. In 1946, the National Mental Health Act was signed into law which resulted in which of the following? The establishment of the mental health court to determine soundness or fitness to stand trialThe development of mental health centers throughout community settingsThe creation of the National Institute for Mental HealthThe coverage of mental health services for children and youth
The creation of the National Institute for Mental Health The National Mental Health Act created the National Institute of Mental Health. The need for psychiatric services has increased over the years, specifically following World War II. The National Mental Health Act was signed in 1946 by President Harry Truman. This called for a National Institute of Mental Health, and the first meeting of the council took place that same year. The National Institute of Mental Health is a federal agency that researches mental illness and was a pioneer in assisting in the transformation of treatment and understanding of mental illnesses.
A newly licensed nurse is reviewing the American Nurses Association's core professional values of nursing. Which of the following actions by the nurse demonstrates the value of empowerment? The nurse becomes a trainer for new equipment for other nurses on the unit.The nurse schedules care around the client's religious practices of daily prayer.The nurse supports the autonomy of a client who refuses chemotherapy, even though their family wants it.The nurse provides resources to the client who wants to create a living will before they have surgery.
The nurse provides resources to the client who wants to create a living will before they have surgery. The value of empowerment involves the use of decision making to solve problems for the client. Assisting a client in accessing the resources needed to create a living will is a demonstration of this value.
A nurse is discussing different factors of the determinants of mental health during a staff meeting. Which of the following factors should the nurse include in the discussion? (Select all that apply.) Receiving paid maternity leave Unsafe drinking water Exposure to an adverse childhood event A playground in the neighborhood National policy addressing cyber-bullying
Unsafe drinking water is correct. Unsafe drinking would be considered a household factor. Without access to necessary resources such as food and water, the client is at increased risk for the development of mental health disorders. Exposure to an adverse childhood event is correct. An exposure to an adverse event is in the category of life-course. A playground in the neighborhood is correct. A playground in the neighborhood is a protective factor that would fall under the category of community. National policy addressing cyber-bullying is correct. National policies that protect against instances of cyber-bullying would be a protective factor under the category of country level factors.
A nurse is caring for a client who has a care plan goal of having fewer than five panic attacks per week. The client is struggling to meet this goal. Which of the following actions should the nurse take? Work with the client to adjust the goal.Encourage the client to better manage their panic attacks.Remove the goal from the plan of care.Change the interventions to eliminate PRN medication.
Work with the client to adjust the goal.MY ANSWERThe nurse should collaborate with the client to set a new goal that the client is comfortable with.
A nurse enters the day room, observes the clients, and performs a situational assessment. Which of the following situations should the nurse identify as the priority to address?A client who is standing in front of a wall and staring blankly at itA client who does not want to go back to their roomA client who is arguing with another client who is backed into a cornerA client requesting to talk with a staff member in private
priority.A client who is arguing with another client who is backed into a cornerMY ANSWERThis is the priority because there is a threat of bodily harm to another client. A situational assessment is a survey of the environment for client and staff safety.