Mental Health Exam 2

A nurse is caring for a client who states, "My cardiologist told em that I need to reduce stress. What is the best way for me to do that?" Which of the following responses should the nurse make first? A. Physical exercise has been shown to be beneficial in reducing stress." B. "Self-help books are a good way to learn strategies to reduce stress." C. "It might be a good idea for you to try painting to help reduce your stress." D. "Tell me more about the stressors that you are facing in your life."

D. "Tell me more about the stressors that you are facing in your life." -Using the nursing process as a priority framework, assessment of the client comes first. By assessing the stressors that the client is facing, the nurse is able to discuss options that may be most beneficial to the client.

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.) A. Community assessments are used assess the needs of a particular community or population." B. "Community assessments identify conditions and disorders that are prevalent within a community." C. "Community assessments highlight areas of strength within a community or population." D. "Community assessments are the same as cultural assessments." E. "Community assessments are used to consider the services that are being used in the community."

A. "Community assessments are used to assess the needs of a particular ocmmunity or population." B. "Community assessments identify conditions and disorders that are prevalent with a community." C. "Community assessements highlight areas of strength within a community or population." -Community assessments evaluate the needs of a community or population, address prevalent disorders, and identify strengths of the community and population -Community assessments consider the prevalence of specific physical or mental health concerns within the community.

A nurse is facilitating a group session on adaptive defense mechanisms. The nurse should identify which of the following client statements as examples of adaptive defense mechanisms? (Select all that apply.) A. "When I get stressed out, I like to go to the gym." B. "I volunteer at a local substance use help group." C. "When I get home from school, it's hard to hear things for hours after." D. "When people are mean to me, I am mean right back to them." E. "I was so upset after I failed my exam that I broke my laptop."

A. "When I get stressed out, I like to go to the gym." -This is an example of sublimation, which is an adaptive defense mechanism. Sublimation occurs when an individual puts their energy into something constructive to change stressful feelings or emotions. B. "I volunteer at a local substance use help group." -Volunteering at a substance abuse help group is an example of an adaptive defense mechanism. This would be altruism, which is when an individual transforms their feelings and emotions by helping others who are experiencing something similar.

A nurse working at a community outreach center is speaking with a resident who reports, "I'm not sure where my child has gone. They come by daily to bring me meals and help me with my medications. It's been over 2 weeks and I can't reach them." The nurse should identify that the client is experiencing which of the following types of abuse? A. Abandonment B. Explotation C. Physical D. Emotional

A. Abandonment -Abandonment is a type of aggression that involves leaving someone alone that requires assistance, such as an elderly person or child. The caregiver places the person at risk for potential serious harm.

A nurse is caring for a client who is becoming aggressive. Which of the following de-escalation techniques should the nurse use? (Select all that apply.) A. Approach the client with respect B. Respond to the client's concerns C. Block the doorway of the unit D. Address the client in a soft voice E. Stand in front of the client when talking

A. Approach the client with respect B. Respond to the client's concerns D. Address the client in a soft voice

A nurse is caring for a client who has a history of anxiety and hypertension. The nurse should recommend which of the following relaxation techniques for the client? A. Biofeedback B. Prayer C. Reading a book D. Drawing

A. Biofeedback -This relaxation method teaches the client physical and mental exercises to help control their specific automatic physical body functions, such as heart rate, blood pressure, and temperature.

A nurse is caring for a client who is exhibiting manifestations of anxiety. Which of the following manifestation would the nurse expect to see increase during the client's fight or flight response? (Select all that apply.) A. Blood pressure B. Heart rate C. Respiratory rate D. Bowel sounds E. Pupillary response

A. Blood pressure B. Heart rate C. Respiratory rate E. Pupillary response -Blood pressure, heart rate, respiratory rate, and pupillary response are all affected by the body's physiological responses to stress.

A nurse on an inpatient mental health unit is using the Clinical Judgement 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.) A. Determine desired outcomes. B. Determine the best solution based on evidence. C. Determine what resources are needed, including people, equipment, and medications. D. Determine cues that need to be analyzed. E. Prioritize client care.

A. Determine desired outcomes. -When generating solutions, the nurse should determine outcomes of the client's plan of care. Outcomes are the foundation for selecting evidenced-based interventions. B. Determine the best solution based on evidence. -When generating solutions, the nurse should determine the best solution basesd on evidence. These evidenced-based solutions are the foundation for selecting evidence-based interventions. C. Determine what resources are needed, including people, equipment, and medications. -When generating solutions, the nurse should determine what resources are needed to address the desired outcomes.

A nurse is preparing to provide education to a client who is experiencing grief. Which of the following information should the nurse include? A. Feelings of sadness can fluctuate in intensity when a person is grieving. B. Grief is experienced in precise steps or stages. C. Grief is commonly considered a mental health disorder. D. The majority of people experience a debilitating form of grief.

A. Feelings of sadness can fluctuate in intensity when a person is grieving. -Grief can cause intense emotions, such as sadness or anger, and these feelings can fluctuate. This is a normal occurance when grieving.

A charge nurse is preparing an in-service for staff members about non-suicidal self-harm (NSSH). Which of the following information should the nurse include? A. NSSH is often used as a way to release painful emotions. B. NSSH indicates a client has developed a plan for suicide. C. NSSH occurs more often in males than females. D. NSSH is generally not dangerous to a client's physical health.

A. NSSH is often used as a way to release painful emotions. -NSSH is the purposeful damage that a client does to their body without conscious suicidal intent. Injuries are often due to cutting, burning, bitting, or scratching the skin.

A nurse is preparing a presentation for newly hired nurses about the role that nursing self-care has on the social determinants of health. Which of the following information should the nurse include in the presentation? A. Nurses must lead and model well-being among themselves before they can truly partner with others. B. Nurses lack the leadership skils needed to advocate for their clients in all settings. C. Nurses have always been focused on clients with a selfless approach modeling empathy. D. Nurses demonstration of self-sacrifices is a positive quality contributing to positive client outcomes.

A. Nurses must lead and model well-being among themselves before they can truly partner with others. -The nurse must understand how the social determinants of health apply to them and understand and lead themselves in their own physical and mental well-being. This must be done first before nurses can lead others, clients, families, interdisciplinary teams, or communities.

A nurse is planning education for a group of teachers on personality traits. Which of the following traits describes a student who is eager to learn? A. Openness B. Extraversion C. Conscientiousness D. Agreeableness

A. Openness -Openness describes an individual who is eager to learn and experience new things.

A nurse is discussing individual and environmental factors of stress response with a group of newly licensed nurses. The nurse should include which of the following as individual factors? (Select all that apply.) A. Perception B. Temperament C. Lifestyle D. Culture E. Religion

A. Perception B. Temperament C. Lifestyle -All of the above are individual factors that determine how a client may react to stress.

A nurse is preparing education for a community support group about complicated grief and resilience. Which of the following factors should the nurse identify as reducing a client's risk for developing complicated grief? (Select all that apply.) A. Regular religious or spiritual practices B. Previous experience with the loss of a loved one. C. A sense of personal health and well-being. D. A reliable support system E. Being treated for substance abuse

A. Regular religious or spiritual practices -Regular religious or spiritual practices is a protective facto that can reduce a person's risk for developing complicated grief. C. A sense of personal health and well-being -A sense of personal health and well-being is a protective factor that can reduce a person's risk for developing complicated grief. D. A reliable support system -A reliable social support system enhances resilience after a loss and reduces risk for developing complicated grief.

A nurse is screening a client for alcohol and tobacco use. Which of the following types of prevention is the nurse demonstrating? A. Secondary B. Primary C. Tertiary D. Selective

A. Secondary Secondary prevention involes screening for things that could lead to potential health problems.

A nurse is preparing to begin caring for a client and discovers that the client's adult children were recently killed as a result of gun violence. Which of the following actions should the nurse take? A. Spend time reflecting and planning to avoid imposing any personal bias. B. Review all news accounts of the incident to avoid asking the client any questions. C. Discuss any person concerns with a peer. D. Speak with the charge nurse and the nurse manager about plans for client care.

A. Spend time reflecting and planning to avoid imposing any personal bias. -The beginning of client-centered care is self-reflection for one's own beliefs or biases, which helps to guide the nurse to be objective in their care of the client.

A nurse in the emergency department is caring for a client who states they fell down the stairs this morning. Which of the following assessment findings indicates the client might be experiencing physical abuse? (Select all that apply.) A. The client has bruises in various stages of healing on their back. B. The client's eyeglasses are cracked. C. The client is visibly uneasy when their partner enters the area. D. The client has a scar on their upper arm. E. The client has ligature marks around both wrists. F. The client has an open, discolored wound on their shoulder.

A. The client has bruises in various stages of healing on their back. B. The client's eyeglasses are cracked. C. The client is visibly uneasy when their partner enters the area. E. The client has ligature marks around both wrists. -The nurse should recognize that signs of physical abuse include bruises and injuries in various stages of healing on the body. Other signs include welts, open wounds, lacerations, rope marks, black eyes. broken or fractured bones, torn clothing, broken eyeglasses, and individual reports of abuse and mistreatment.

A nurse is discussing the continuum of care with a client. Which of the following information should the nurse include? A. The continuum of care includes different clinical settings, such as clinics and hospitals. B. The continuum of care is the basis for understanding levels and severity of mental illness. C. The continuum of care occurs only during hospitialization. D. The continuum of care increase the client's risk for urgent care visits.

A. The continuum of care includes different clinical settings, such as clinics and hospitals. -The 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 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? A. Work with the client to adjust the goal. B. Encourage the client to better manage their panic attacks. C. Remove the goal from the plan of care. D. Change the interventions to eliminate PRN medication.

A. Work with the client to adjust the goal. -The nurse should collaborate with the client to set a new goal that the client is comfortable with.

A nurse is caring for a client who is demonstrating aggressive behavior towards others and is not responding to verbal interventions. Which of the following medications should the nurse anticipate the provider prescribing? A. Ziprasidone B. Paroxetine C. Escitalopram D. Lithium

A. Ziprasidone -The nurse should anticipate the provider to prescribe ziprasidone intramuscularly for a client who is becoming progressively more aggressive. Ziprasidone is an antipsychotic that is commonly prescribed to clients who become aggressive, agitated, or violent. This medication assists with calming the client, which can prevent them from harming themselves or others. * Paroxetine - antidepressant Escitalopram - antidepressant Lithium - mood stabilizer

A nurse is caring for a client who was recently placed in seclusion due to their aggressive behavior. Which of the following statements made by the nurse indicates an understanding of the role the neurological system plays in relation to aggression? A. "Excessive hypothalamus reaction and inadequate regulation of the prefontal area will increase the likelihood on aggression in the client." B. "Excessive amygdala reaction and inadequate regulation of the prefrontal area will increase the likelihood on agression in the client." C. "Excessive hippocampus reaction and inadequate regulation of the prefrontal area will increase the likelihood on agression in the client." D. "Excessive pituitary gland reaction and inadequate regulation of the prefrontal area will increase the likelihood on agression in the client."

B. "Excessive amygdala reaction and inadequate regulation of the prefrontal area will increase the likelihood on agression in the client." -The nurse should recognize that the brain's prefrontal cortex, limbic system, and amygdala play an important role in survival, basic emotions, and aggression. An injury to any of these areas can be problematic and can contribute to the development of aggressive behavior.

Which of the following has been identified as a priority outcome of ensuring a nurse's physical and mental well-being? A. A decrease in the costs of health care B. A growing and sustainable future nursing workforce C. An improved public image nursing D. A reduction of bias surrounding mental health

B. A growing and sustainable future nursing workforce -The significance of personal well-being of the nurse has been clearly identified as a priority in order to grow and sustain the future work force. Modeled through self-care, the nurse ensures both personal well-being and on a larger scale adds to the well-being and sustainability of the future nursing workforce.

A nurse is teaching a client about potential risks of chronic stress. Which of the following conditions should the nurse include as a potential risk? A. Peripheral vascular disease B. Diabetes C. Seizures D. Meningitis

B. Diabetes -Chronic stress is known to increase the risk of many mental and physical conditions, including type 2 diabetes mellitus.

A nurse is teaching a client who is afraid of heights and is planning to drive across a high bridge. The nurse should identify that which of the following structures stimulates the automatic nervous system? A. Thalamus B. Hypothalamus C. Parietal lobe D. Pituitary gland

B. Hypothalamus -The client will find that driving across a high bridge is stressful. The hypothalamus functions as the command-and-control center, responding to signals fo stress by engaging the autonomic nervous system.

A nurse in an outpatient mental health clinic is preparing to conduct an initial client interview. When conducting the interview, which of the following actions should the nurse identify as the priority? A. Coordinate holistic care with social services. B. Identify the client's perception of their mental health status. C. Include the client's family in the interview. D. Teach the client about their current mental health disorder.

B. Identify the client's perception of their mental health status. -Assessment is the priority action when using the nursing process approach to client care. Identifying the client's perception of their mental health status provides important information about the client's psychosocial history.

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? A. Milieu therapy is a type of therapy focused on assisting clients with identifying triggers of anxiety and fear." B. Milieu therapy is focused on creating a safe environment for healing through trauma-informed therapeutic relationships." C. Milieu therapy is a type of group therapy in which clients explore their thoughts, feelings, and experiences." D. "Milieu therapy is a type of individual therapy focused on connecting negative thoughts and behaviors."

B. 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 relations are an essential aspect of this therapy.

A nurse is providing care to a client who has a history of anger. The nurse should identify that comorbidities of anger include which of the following disorders? (Select all that apply.) A. Binge-eating disorder B. Posttraumatic stress disorder C. Substance abuse disorder D. Conduct disorder E. Attention deficit disorder F. Obsessive-compulsive disorder

B. Posttraumatic stress disorder C. Substance abuse disorder D. Conduct disorder E. Attention deficit disorder -The nurse should recognize that anger, aggression, and volence can be triggered by several comorbidities. Disorders such as schizophrenia, psychosis, anxiety, substance use disorders, bipolar disorders, major depressive disorder, attention deficit disorder, attention deficit hyperactive disorder, PTSD, conduct disorders, and personality disorders. Traumatic brain injuries, brain tumors, or inflammation in the brain can also cause aggressive and violent episodes.

A nurse is discussing risk factors of negative stress responses with a group of clients. The nurse should include which of the following risk factors in the discussion? (Select all that apply) A. Birth order B. Temperament C. Interpersonal violence D. Health behaviors E. Financial stability F. Sex

B. Temperament -A client's temperament can affect how they experience and handle stress. C. Interpersonal violence -Social risk factors such as interpersonal violence, can predispose clients to an increased stress response. D. Health behaviors -A client's health and health behaviors can affect how they experience and handle stress.

A nurse is providing teaching to a newly licensed nurse who is caring for a client experiencing aggression related to posttraumatic stress disorder (PTSD). Which of the following statements made by the newly licensed nurse indicates an understanding of the teaching? A. "The client has an increase in dopamine which results in aggressive behavior." B. The client has an excess of serotonin which results in aggressive behavior." C. "The client has a decrease in histamine which results in aggressive behavior." D. "The client has an increase in y-aminobutyric acid which results in aggressive behavior."

B. The client has an excess of serotonin which results in aggressive behavior." -The neurotrasmitter serotonin plays a significant role in severe mental illness as well as aggressive and violent behaviors. Individuals who have demonstrated aggressive behaviors, and those who have been diagnosed with schizophrenia, autism spectrum disorder (ASD), or attention deficit disorder (ADD) are found to have higher serum levels of serotonin subtype 5-hydroxytryptamine (5-HT).

A home health nurse is conducting an initial assessment on a client. Which of the following findings should indicate to the nurse that the client is potentially experiencing neglect? (Select all that apply.) A. The client's daily medications are in a pill organizer. B. The client indicates their toilet has been non-functional for the last few weeks. C. The client's bed linens smell of urine. D. The client's home has stacked boxes and clutter blocking the walkways. E. The client's hair is dirty and tangled. F. The client has a stage one pressure ulcer on their coccyx.

B. The client indicates their toilet has been non-functional for the last few weeks. C. The client's bed linens smell of urine. D. The client's home has stacked boxes and clutter blocking the walkways. E. The client's hair is dirty and tangled. F. The client has a stage one pressure ulcer on their coccyx. -The nurse should recognize that neglect is a form of abuse. Signs of neglect include untreated health problems, dehydration, malnutrition, poor personal hygiene, unsafe living conditions, unsanitary or unclean living conditions, desertion of an individual, or an individual's report of being abandoned or mistreated.

A nurse is discussing euthanasia with a coworker. Which of the following statements indicates and understanding of the role of nurses and euthanasia? A. "The nurse must put their own beliefs aside and do what is best for the client." B. "It is a nurse's personal decision if they want to participate in administering a lethal medication euthanasia." C. "Euthanasia is illegal in the United States, and the core values of nursing do not support it." D. "Euthanasia is really an act of mercy. That is why it is called mercy killing."

C. "Euthanasia is illegal in the United States, and the core values of nursing do not support it." -Euthanasia is the act where a person administers a letal dose of medication to another person. This is illegal in the United States and is inconsistent with nursing core values as identified in Code of Ethics for Nurses with Interpretive Statements.

A nurse is caring for a client who experiences aggression. Which of the following statements made by the client indicates the client experiences hostile aggression? A. "I let off steam by yelling out loud." B. "I shattered a plate because I stubbed my toe in the kitchen." C. "They made me mad and so I hit them." D. "I clench my fists when I have to wait in traffic."

C. "They made me mad and so I hit them." -The nurse should recognize that hostile aggression is the deliberate act of physically or psychologically harming or destroying others.

A nurse is preparing to care for a client who is newly admitted. Which of the following actions should the nurse take immediately? A. Provide the client with an orientation to the unit rules. B. Discuss the provider's prescriptions with the client. C. Address the client's aggressive behavior towards staff. D. Teach the client the purpose of their psychotherapy sessions.

C. Address the client's aggressive behavior towards staff. Using safety and risk reduction framework to prioritize nursing interventions, the nurse would address the client's aggressive behavior towards staff. Aggressive behavior may escalate to violence, which would threaten the safety of the staff and other clients.

A nurse is caring for a client who is grieving and states, "No matter what I do, I just can't stop crying. It feels like I am in the grave." Which of the following actions should the nurse take first? A. Suggest an activity for the client to do when feeling sad. B. Explain to the client that crying is a normal response to loss or death. C. Ask the client what they mean by "in the grave." D. Discuss the client's sleep and rest patterns.

C. Ask the client what they mean by "in the grave." -This is an example of using therapeutic communication, a clarification strategy to assist the client to express their thoughts and feelings. This is the priority action because it will aid the nurse in understanding what the client is thinking and feeling, including consideration of self-harm and safety.

A nurse is caring for a client who is dying. The client's family is at the bedside and have placed pictures and objects on the bed with the client. Which of the following actions should the nurse take? A. Request that a hospital chaplain be called to the room. B. Tell the family to remove the objects as they might hinder care. C. Ask the family about the objects and their meaning. D. Remove all personal objects for ease in providing client care.

C. Ask the family about the objects and their meaning. -Asking about the objects allows the nurse to connect with the client's family and understand cultural or spiritual practices. Encouraging a client's spirituality or religious practices is a significant part of grief-informed and client-centered care.

A nurse is discussing the purpost of mental status assessments with a newly hired nurse. Which of the following information should the nurse include? A. Mental status assessments assess the client's family roles and functioning. B. Mental status assessments assess the client's coping abilities and strategies. C. Mental status assessments assess a client's cognitive and behavioral functioning. D. Mental status assessments assess the client's mental health and physical health.

C. 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 manager observes a nurse crying in the nurses' locker room. Which of the following actions should the manager take first? A. Offer to take the nurse to employee health. B. Reassign the nurse's clients for the remainder of the shift. C. Use therapeutic communication to determine why the nurse is crying. D. Provide the nurse with the phone number for the employee counseling services.

C. Use therapeutic communication to determine why the nurse is crying. -Assessing why the nurse is crying is the first action the nurse manager should take. Assessing is the first step in the nursing process. It appears that the nurse has had a difficult or traumatic experience. This response is therapeutic and looking seeks for clarification. Nursing leadership must collaborate with the nurse to determine underlying factors for why the nurse is experiencing compassion fatigue, burnout, or secondary traumatic stress.

A nurse is providing education about medical aid in dying with a group of newly hired nurses. Which of the following statements by a newly hired nurse indicates an understanding of the education? A. "Another person, a nurse or family member, can administer the medical aid-in-dying prescription to the client." B. "Someone who has more than 12 months to live can be eligible for medical aid-in-dying." C. "All states permit medical aid-in-dying for any adult who is considered mentally capable." D. "An adult person with proven mental capacity self-ingests the prescribed medication to die."

D. "An adult person with proven mental capacity self-ingests the prescribed medication to die." -Medical aid-in-dying is a process by which a mentally capable adult (as defined by the state) with a medical prognosis of living less than 6 months request a prescription from their provider that they self-ingest to die without pain or suffering.

A nurse is discussing non-suicidal self-harm (NSSH) with a newly licensed nurse. Which of the following statements should the nurse make? A. "NSSH is considered attention-seeking behavior." B. "NSSH is most often initiated as an adult." C. "There are no serious physical health effects from NSSH." D. "Clients who engage in NSSH rarely seek medical attention."

D. "Clients who engage in NSSH rarely seek medical attention." -It is uncommon for clients who engage in NSSH to seek medical attention.

A nurse is caring for a client who was administered an antianxiety medication 1 hour ago. Which of the following statements by the nurse indicates that the nurse is using the evaluation step of the nursing process? A. "How does your anxiety affect your ability to work?" B. "Have you had anxiety in the past?" C. "What is the dosage of teh antianxiety medication that you take at home?" D. "How is your anxiety level now?"

D. "How is your anxiety level now?" This 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 caring for an adolescent client whose parent died years ago. The client's other parent states that the client has been coming home drunk, lost their driver's license due to reckless driving, and has been skipping school. Which of the following actions is the nurse's priority? A. Educate the client about the importance of adequate nutrition. B. Assist the client to identify feelings. C. Encourage the client to participate in a support group. D. Assess the client for risk of suicide.

D. Assess the client for risk of suicide. -For a client who is experiencing complicated grief, it is the nurse's priority to assess for safety.

A nurse in a high school is caring for an adolescent who has recently suffered the traumatic loss of a classmate and is crying. Which of the following actions should the nurse take first? A. Determine how the student is doing in class B. Contact the student's guardians C. Discuss the studen with their teachers D. Create a safe, nonjudgemental environment

D. Create a safe, nonjudgemental environment -Creating a safe, nonjudgmental environment is vital for establishing trust and developing a therapeutic relationship as a beginning point of client care.

A nurse is caring for a client who states, "When I am stressed at work, I can't help coming home and arguing with my partner." The nurse should recognize that the client is exhibiting which of the following defense mechanisms? A. Intellectualization B. Projection C. Sublimation D. Displacement

D. Displacement -This client is exhibiting displacement, which is a maladaptive defense mechanism. In displacement, an idividual redirects their stress to someone they feel safe with instead of directing it toward the cause of the stressor.

A nurse is assessing a client who experienced abuse. Which of the following findings should the nurse expect? A. Trusting B. Independence C. Fear D. Confidence

C. Fear -The nurse should expect a client who has experienced abuse to exhibit fear.

A nurse is evaluating a client whose partner is concerned about their episodes of recurrent anger. Which of the following statments should the nurse make when explaining potential reasons for the client's anger? (Select all that apply.) A. "The client gets a rush of adrenaline when expressing anger." B. "The client wants to harm someone they think harmed them." C. "The feeling of anger and aggression helps the client to problem solve." D. "The client things their anger is justified." E. "The client feels powerful when angry." F. "When the client is angry, their self-esteem is boosted."

A. "The client gets a rush of adrenaline when expressing anger." B. "The client wants to harm someone they think harmed them." D. "The client things their anger is justified." E. "The client feels powerful when angry." F. "When the client is angry, their self-esteem is boosted."

A nurse is working on an acute mental health unit is caring for a client who has posttraumatic stress disorder (PTSD). Which of the following findings should the nurse expect? (Select all that apply.) A. Difficulty concentrating on tasks B. Obsessive need to talk about the traumatic event C. Negative self-image D. Recurring nightmares E. Diminished reflexes

A. Difficulty concentrating on tasks C. Negative self-image D. Recurring nightmares -Manifestations of PTSD include the inability to concentrate or complete tasks, feeling guilty and having a negative self-image, and recurring nightmares or flashbacks.

A nurse is preparing an educational seminar on stress for other nursing staff. Which of the following information should the nurse include in the discussion? A. Excessive stressors cause the client to experience distress. B. The body's initial adaptive response to stress is denial. C. Absence of stressors results in homeostasis. D. Negative, rather than positive, stressors produce a biological response.

A. Excessive stressors cause the client to experience distress. -Distress is the result of excessive or damaging stressors (anxiety or anger).

A nurse is caring for a client undergoing a procedure and encourages the client to imagine themselves lying on the beach. Which of the following coping styles is the nurse suggesting? A. Guided imagery B. Deep breathing C. Fantasy D. Adjusting expectation

A. Guided imagery -The nusre is suggesting guided imagery. In guided imagery, the client imagines being in a place that represents calmness and relaxation.

A nurse is caring for a client who is experiencing chronic stress. Which of the following does the nurse anticipate that the client will report? (Select all that apply.) A. Increased anxiety B. Recurring sinus infections C. Feelings of depression D. Sudden bursts of energy E. Daily overeating F. Heart palpitations

A. Increased anxiety B. Recurring sinus infections C. Feelings of depression -With chronic stress, the body becomes overwhelmed resulting from the accumulation of the effects of the stressors over time. Some of the psychological and physiological effects of chronic stress include depression, anxiety, and recurring infections.

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.) A. Prioritize establishing a therapeutic relationship. B. Focus on client-centered, holistic care rather than the client's diagnosis. C. Limit family involvement when executing the plan of care. D. Gather data related to the client's clinical manifestations. E. Accurately document implementation of the plan of care.

A. Prioritize establishing a therapeutic relationship. B. Focus on client-centered, holistic care rather than the client's diagnosis. E. Accurately document implementation of the plan of care. -Developing and maintaing a therapeutic relationship is the foundation for providing mental health care. This is a necessary nursing action when implementing a plan of care. -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. -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 was in a motor-vehicle crash. The client states, "I had to get home before 6pm so I had to drive really fast." Which of the following defense mechanisms is the client exhibiting? A. Rationalization B. Displacement C. Identification D. Altruism

A. Rationalization -This client is exhibiting rationalization. In rationalization, a person uses reason or logic to avoid or explain the stressor and avoid their emotions.

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.) A. Recognizing patterns B. Determining the order of priorities C. Linking cues D. Determining what is concerning E. Determining the need for additional information F. Collaborating with members of the interprofessional team

A. Reconizing patterns C. Linking cues D. Determining what is concerning E Determining the need for additional information

A community health nurse is leading a discussion about rape with a neighborhood task force. Which of the following statements by a neighborhood citizen indicates an understanding of the teaching? A. "Rape is a crime of passion." B. "Acquaintance rape often involves alcohol." C. "Young adults are the typical victims of sexual assault." D. "The majority of rapists are unknown to the victims."

B. "Acquaintance rape often involves alcohol." -Alocohol and other substances are often associated with date or acquaintance rape.

A nurse is assessing a client who attempted to die by suicide. The client is currently undergoing cognitive behavioral therapy. Which of the following statements by the client indicates that the therapy has been effective? A. "I have removed all of the mirrors from my house." B. "I guess I am fortuanate to have survived my suicide attempt." C. "It is hard to go out when you know that everyone is laughing at you." D. "At least now when people stare at me, I have enough courage to tell them off."

B. "I guess I am fortuanate to have survived my suicide attempt." -Cognitive behavioral therapy works to help the client adjust to or unlearn negative thoughts and change them to more positive thoughts, attitudes, or emotions. This statement by the client indicates that the therapy has been effective because the client has changed their negative thoughts to a positive thought.

A nurse is caring for a client who is experiencing moderate anxiety. Which of the following actions should the nurse take when trying to give necessary information to the client? (Select all that apply.) A. Reassure the client that everything will be ok. B. Discuss prior use of coping mechanisms with the client. C. Ignore the client's anxiety so that she will not be embarrassed. D. Demonstrate a calm manner while using simple and clear directions. E. Gather information from the client using closed-ended questions.

B. Discuss prior use of coping mechanisms with the client. -Disucssing the prior use of coping mechanisms assists the client in identifying ways of effectively coping with the current stressor. D. Demonstrate a calm manner while using simple and clear directions. -Providing a calm presence assists the client in feeling secure and promotes relaxation. Clients experiencing moderate levels of anxiety often benefit from the direction of others.

A nurse is reviewing the medical records of multiple clients at a community mental health facility. Which of the following events is an example of client experiencing a maturational crisis? A. Rape B. Marriage C. Severe physical illness D. Job loss

B. Marriage - Marriage is an example of a maturational crisis, which is a naturally occuring event during the life span.

A nurse is participating in a wellness check for an 8-year-old child who was recently in a moter-vehicle crash where both guardians were killed. Which of the following findings should the nurse identify as an indication that the child is experiencing traumatic grief? A. The child is seen pulling out the hair on their head. B. The child reports frequent stomachaches. C. The child becomes very upset with any slight deviation in their routine. D. The child is talking excessively and out of turn.

B. The child reports frequent stomachaches. -Children who are experiencing traumatic grief can experience nightmares, a decreased ability to concentrate, and somatic responses, such as stomachaches.

A nures in a mental health clinic is observing a client in the day room. The nurse should identify which of the following actions by the client as a maladaptive defense mechanism? A. The client is sitting down and is painting a picture. B. The client tells another client that all of the therapists are mean. C. The client crumbles up their paper and throws it across the room. D. The client is talking about starting a fundraiser for other people who lost everything in a fire.

B. The client tells another client that all of the therapists are mean. -This client is exhibiting splitting, which is a maladaptive defense mechanism. The maladaptive defense mechanism of splitting is when a person is unable to accept that an idividual can have both good and poor aspects but believes someone is all "bad" or all "good."

A nurse is providing teaching about stress with a client. The nurse should identify that which of the following client statemtns indicates an understanding of the teaching? A. "My stressor will all go away when I retire." B. "My stress could be related to my culture." C. "My attitude about my stressor can influence my coping." D. "I can decrease my stress by getting a new job."

C. "My attitude about my stressor can influence my coping." -A client's perception of themselves and their capability of managing stressors determines how they express their psychological and emotional response to stress.

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? A. "The DSM-5 is a resource that outlines nursing interventions for clients who have been diagnosed with a mental health disorder." B. "The DSM-5 is a resource that provided health care professionals with information on the best course of treatment for mental health disorders." C. "The DSM-5 is a resource that provides information about the clinical manifestations of specific mental health disorders." D. "The DSM-5 is a resource that outlines discharge planning and continuity of care across client populations."

C. "The DSM-5 is a resource that provides information about the clinical manifestations of specific mental health disorders." -The 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 caring for a client who is speaking loudly and threatening to harm staff and other clients. Which of the following medications should the nurse anticipate the provider prescribing for this client? A. Fluoxetine B. Sertraline C. Chlorpromazine D. Duloxetine

C. Chlorpromazine -The nurse should anticipate the provider prescribing chlorpromazine intramuscularly for a client who is becoming aggressive. Chlorpromazine is an antipsychotic that is commonly prescribed for clients who become aggressive, agitated, or violent. This medication assists with calming the client, which can prevent them from harming themselves or others. *Fluoxetine, sertraline, and duloxetine are all antidepressants.

A nurse is assessing a client who experienced sexual assault. Which of the following findings indicate the client is experiencing an emotional reaction of rape-trauma syndrome? (Select all that apply.) A. Genitourinary soreness B. Difficulties with low self-esteem C. Sleep disturbances D. Emotional outbursts E. Difficulty making decisions

D. Emotional outbursts -Emotional outbursts indicate an expressed inital reaction of rape-trauma syndrome. E. Difficulty making decisions -Difficulty making decisions indicates a controlled initial reaction of rape-trauma syndrome.

A nurse is planning care for a client who has a mental health disorder. Which of the following actions should the nurse include as a psychobiological intervention? A. Assist the client with systematic desensitization therapy. B. Teach the client appropriate coping mechanisms. C. Assess the client for comorbid health conditions. D. Monitor the client for adverse effects of medications.

D. Monitor the client for adverse effects of medications.

A nurse is providing care to a client who was recently involved in a motor-vehicle crash. The nurse should identify that the client is in the moderate state of anxiety based on which of the following behaviors? A. Answering questions with the response, "I am glad to be alive." B. Becoming unconscious after seeing a video of the accident. C. Jumping off the bed and running out the door. D. Practicing deep breathing with the nurse.

D. Practicing deep breathing with the nurse. -The ability to learn and practice coping skills is a sign of mild and moderate levels of anxiety.

A charge nurse is providing an in-service to a group of staff nurses about the role of a forensic nurse. Which of the following information should the nurse include? A. Counsel the client about the incident. B. Request the police gather evidence of the incident. C. Encourage the client to seek legal charges against the perpetrator. D. Provide legal testimony as requested by the client.

D. Provide legal testimony as requested by the client. -The charge nurse should include that the role of a forensic nurse is to provide legal testimony on behave of a client who experienced sexual assault.

A nurse is caring for a client who is actively dying. The client's partner is crying and holding the client's hand. Which of the following responses should the nurse make? A. "Let me call the provider and see if they will order you something to help you." B. "I know this is difficult. Would you like me to sit with you?" C. "I see your partner is not responding. I am sure they are not suffereing or in pain." D. "Death is a very spiritual time. I will leave you alone."

B. "I know this is difficult. Would you like me to sit with you?" -The client's partner is experiencing anticipatory grief. Providing a therapeutic presence will create a safe environment for grieving.

A nurse is caring for a client who is screaming at staff members and other clients. Which of the following is a therapeutic response by the nurse to the client? A. "Stop screaming, and walk with me outside." B. "Why are you so angry and screaming at everyone?" C. "You will not get your way by screaming." D. "What was going through your mind when you started screaming?"

A. "Stop screaming, and walk with me outside." -This is an appropriate therapeutic response. Setting limits and the use of physical activity (walking) to deescalate anger is an appropriate intervention.

A nurse is teaching a client about stress-reduction techniques. Which of the following client statements indicates understanding of the teaching? A. "Cognitive reframing will help me change my irrational thoughts to something positive." B. "Progressive muscle relaxation uses a mechanical device to help me gain control over my pulse rate." C. "Biofeedback causes my body to release endorphins so that I feel less stress and anxiety." D. "Mindfullness allows me to prioritize the stressors that I have in my life so that I have less anxiety."

A. "Cognitive reframing will help me change my irrational thoughts to something positive." -Cognitive reframing helps the client look at irrational cognitions (thoughts) in a more realistic light and to restructure those thought in a more positive way.

A nurse is discussing normal grief with a client who recently lost a child. Which of the following statements made by the client indicates understanding? (Select all that apply.) A. "I may experience feelings of resentment." B. "I will probably withdraw from others." C. "I can expect to experience changes in sleep." D. "It is possible that I will experience suicidal thoughts." E. "It is expected that I will have a loss of self-esteem."

A. "I may experience feelings of resentment." B. "I will probably withdraw from others." C. "I can expect to experience changes in sleep." -Resentment, withdrawal, and somatic manifestations (changes in sleep patterns) can all be associated with normal grief.

A nurse is caring for a client who lost a guardian to cancer last month. The client states, "I'd still have my guardian if the doctor would have mad a diagnosis sooner." Which of the following responses should the nurse make? A. "You sound angry. Anger is a normal feeling associated with loss." B. "I think you would feel better if you talked about your feelings with a support group." C. "I understand just how you feel. It felt the same when my guardian died." D. "Do other members of your family feel this way?"

A. "You sound angry. Anger is a normal feeling associated with loss." -This is a therapeutic response for the nurse to make. This response acknowleges the client's emotions and provides education on the normal grief response.

A nurse is caring for an adult client who has injuries resulting from spousal violence. The client does not wish to report the violence to law enforcement authorities. Which of the following nursing actions is the highest priority? A. Advise the client about the location of safe houses and shelters. B. Encourage the client to particpate in a support group for survivors of abuse. C. Implement case management to cooridinate community and social services. D. Educate the client about the use of stress management techniques.

A. Advise the client about the location of safe houses and shelters. -The greatest risk to this client is injury from further abuse; therefore, the priority action is to assist the client with development of a safety plan that inclues the identification of safe places to live.

A nurse is working with a client who has recently lost a guardian. The nurse recognizes that which of the following factors influence a client's grief and coping ability? (Select all that apply.) A. Interpersonal relationships B. Culture C. Birth order D. Religious beliefs E. Prior experience with loss

A. Interpersonal relationships B. Culture D. Religious beliefs E. Prior experience with loss

A nurse is assessing a client in an inpatient mental health unit. Which of the following findings should the nurse expect if the client is in the preassaultive stage of violence? (Select all that apply.) A. Lethargy B. Defensive responses to questions C. Disorientation D. Facial grimicing E. Agitation

B. Defensive responses to questions D. Facial grimicing E. Agitation

A nurse decides to put a client who has a psychotic disorder in seclusion overnight because the unit is very short-staffed, and the client frequently fights with other clients. The nurse's actions are an example of which of the following torts? A. Invasion of privacy B. False imprisonment C. Assault D. Battery

B. False imprisonment -A civil wrong that violates a client's civil rights is a tort. In this case, it is false imprisonment, which is the confining of a client to a specific area (a seclusion room) if the reason for such confinement is for the convenience of the staff.

A nurse is providing preoperative teaching for a client who was informed of the need for emergency surgery. The client has a respiratory rate 30/min, and says, "This is difficult to comprehend. I feel shaky and nervous." The nurse should identify that the client is experiencing which of the following levels of anxiety? A. MIld B. Moderate C. Severe D. Panic

B. Moderate -Moderate anxiety decreases problem-solving and may hamper the client's ability to understand information. Vital signs may increase somewhat, and the client is visibly anxious.

A nurse working in an emergency department is assessing a preschool-age child who reports abdominal pain. Which of the following findings should alert the nurse to possible abuse? (Select all that apply.) A. Abrasions on knees B. Round burn marks on forearms C. Mismatched clothing D. Abdominal rebound tenderness E. Areas of ecchymosis on torso

B. Round burn marks on forearms -Round burn marks anywhere on the child's body can indicate cigarette burns and should alert the nurse to possible abuse. E. Areas of ecchymosis on torso -Areas of ecchymosis (discoloration from bleeding under the skin) on the torso, back, or buttocks should alert the nurse to possible abuse

A nurse is involved in a serious and prolonged mass casualty incident in the emergency department. Which of the following strategies should the nurse use to help prevent developing a trauma-related disorder? (Select all that apply.) A. Avoid thinking about the incident when it is over. B. Take breaks during the incident for food and water. C. Debrief with others following the incident. D. Avoid displays of emotion in the days following the incident. E. Take advantage of offered counseling.

B. Take breaks during the incident for food and water. C. Debrief with others following the incident. E. Take advantage of offered counseling.

A nurse is talking with a client who reports experiencing increased stress because a new partner is "pressuring me and my kids to go live with him. I love him, but I'm not ready to do that." Which of the following recommendations should the nurse make to promote a change in the client's situation? A. Learn to practice mindfulness B. Use assertiveness techniques C. Exercise regularly D. Rely on the support of a close friend

B. Use assertiveness techniques -Assertive communication allows the client to assert their feelings and then make a change in the situation.

A nurse is caring for a client who was recently sexually assaulted. The client states, "I never should have been out on the street alone at night." Which of the following responses should the nurse make? A. "Your actions had nothing to do with what happened." B. "You should focus on recovery rather than blaming yourself for what happened." C. "You believe this wouldn't have happened if you hadn't been out alone?" D. "Why do you feel that you should not have been alone on the street at night?"

C. "You believe this wouldn't have happened if you hadn't been out alone?" -This response uses the therapeutic communication technique of restating, which promotes reflection and verbalization of feelings.

A nurse in an emergency mental health facility is caring for a group of clients. The nurse should identify that which of the following clients requires a temporary emergency admission? A. A client who has schizophrenia with delusions of grandeur B. A client who has manifestations of depression and attempted suicide a year ago C. A client who has borderline personality disorder and assaulted a homeless man with a metal rod D. A client who has bipolar disorder and paces quickly around the room while talking to themselves.

C. A client who has borderline personality disorder and assaulted a homeless man with a metal rod -A client who is a current danger to self or others is a candidate for a temporary emergency admission.

A nurse is caring for a client in an inpatient mental health facility who gets up from a chair and throws it across the day room. Which of the following is the priority nursing action? A. Encourage the client to express feelings out loud. B. Maintain eye contact with the client. C. Move the client away from others. D. Tell the client that the behavior is not acceptable.

C. Move the client away from others. -The behavior indicates that the client is at greatest risk for harming others. The priority action for the nurse is to move the client away from others.

A nurse is caring for a client following the loss of a partner due to a terminal illness. Identify the sequence of Engel's five stages of grief that the nurse should expect the client to experience. (Select the stages of grief in order of occurence. All steps must be used.) A. Developing awareness B. Restitution C. Shock and disbelief D. Recovery E. Resolution of the loss

C. Shock and disbelief A. Developing awareness B. Restitution E. Resolution of the loss D. Recovery

A client tells a nurse, "Don't tell anyone, but I hid a sharp knife under my mattress in order to protect myself from my roommate, who is always threatening me." Which of the following actions should the nurse take? A. Keep the client's communication confidential, but talk to the client daily, using therapeutic communication to convince them to admit to hiding the knife. B. Keep the client's communication confidential, but watch the client and their roommate closely. C. Tell the client that this must be reported to the health care team because it concerns the health and safety of the client and others. D. Report the incident to the health care team, but do not inform the client of the intention to do so.

C. Tell the client that this must be reported to the health care team because it concerns the health and safety of the client and others. -The information presented by the client is a serious safety issue that the nurse must report to the health care team. Using the ethical principle of veracity, the student tells the client truthfully what must be done regarding the issue.

A charge nurse is leading a peer group discussion about family and community violence. Which of the following statements by a member of the group indicates an understanding of teaching? A. "Children older than 5 are at greater risk for abuse." B. "Substance use disorder does not increase risk for violence." C. "Entering an intimate relationship increases risk for violence." D. "Pregnancy increases the risk for violence from a spouse or partner."

D. "Pregnancy increases the risk for violence from a spouse or partner."

A nurse is caring for a client who states, "I'm so stressed at work because of my coworker. I am expected to finish others' work because of their laziness!" When discussing effective communication, which of the following statements by the client to the coworker inidcates client understanding? A. "You really should complete your own work. I don't think it's right to expect me to complete your responsibilities." B. "Why do you expect me to finish your work? You must realize that I have my own responsibilities." C. " It is not fair to expect me to complete your work. If you continue, the I will report your behavior to our supervisor." D. "When I have to pick up extra work, I feel very overwhelmed. I need to focus on my own responsibilities."

D. "When I have to pick up extra work, I feel very overwhelmed. I need to focus on my own responsibilities." -This response demonstrates assertive communication, which allows the client to state his feelings about the behavior and then promote a change.

A nurse is conducting group therapy with a group of clients. Which of the following statements made by a client is an example of aggressive communication? A. "I wish you would not make me so angry." B. "I feel angry when you leave me." C. "It makes me angry when you interrupt me." D. "You'd better listen to me."

D. "You'd better listen to me." -This statement implies a threat and a lack of respect for another individual.

A nurse is collecting an admission history for a client who has acute stress disorder (ASD). Which of the following client behaviors should the nurse expect? A. The client remembers many details about the traumatic incident. B. The client expresses heightened elation about what is happening. C. The client remembers first noticing manifestations of the disorder 6 weeks after the traumatic incident occured. D. The client expresses a sense of unreality about the traumatic incident.

D. The client expresses a sense of unreality about the traumatic incident. -The client who has ASD often expresses dissociative manifestations regarding the event, which includes a sense of unreality.

A nurse is discussing the role of a licensend 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? A. "An LPN can complete an independent assessment." B. "An LPN can report their observations to an RN." C. "An LPN can prioritize care based on the data that was collected." D. "An LPN can develop and provide client education."

B. "An LPN can report their observations to an RN." An LPN can observe, check, monitor, and collect data and report findings to the RN.

A nurse is caring for a client who is at risk for isolation. Which of the following is the best outcome for this client? A. The client will remain in the community area at all times. B. The client will attend 3 groups per day by the end of the week. C. The client will attend family sessions. D. The client will eat meals with the other clients.

B. The client will attend 3 groups per day by the end of the week. -This outcome meets all of the elements of the SMART framework. This outcome is specific, measurable, attainable, realistic, and timely.

A nurse is caring for a client. Whic of the following actions by the nurse demonstrates the evaluating outcomes step of the Clinical Judgement Action Model (CJAM)? A. Revising the plan of care B. Handling psychiatric emergencies C. Providing evidence for hypothesis D. Determining if additional information is needed

A. Revising the plan of care The plan of care should be revised based on the evaluation of oucomes and to what degree the outcomes have been met.

A client who is experiencing prolonged grief disorder (PGD) is at risk for which of the following? (Select all that apply.) A. Suicide B. Hallucinations C. Binge eating D. Social dysfunction E. Delirium

A. Suicide -Clients who have PGD, or complicated grief, are at an increased risk for suicide and might display a general disinterest in living and deficits in work and social functioning. D. Social dysfunction -Clients who have PGD are at an increased risk for suicide, increased use of alcohol and tobacco, present a general disinterest in living, and display deficits in work and social functioning.

A nurse is caring for a client who is in mechanical restraints. Which of the following statements should the nurse include in the documentation? (Select all that apply.) A. "Client ate most of their breakfast." B. "Client was offered 8 oz of water every hr." C. "Client shouted obscenities at assistive personnel." D. "Client received chlorpromazine 15 mg by mouth at 1000." E. "Client acted out after lunch."

B. "Client was offered 8 oz of water every hr." C. "Client shouted obscenities at assistive personnel." D. "Client received chlorpromazine 15 mg by mouth at 1000." -Objective data should be documented

A nurse is caring for a client who reports headache, nausea, and difficulty sleeping. The client states, "My dog died a few weeks ago, and I miss them so much." Which of the following statements by the nurse demonstrates a grief-informed approach? A. "What time of the day do the headaches begin?" B. "The loss of your dog must be difficult. Can you share what happened?" C. "What activities are you doing before you go to bed?" D. "Have you recently changed what you are eating?"

B. "The loss of your dog must be difficult. Can you share what happened?" -A grief-informed approach begins with focusing on what occured. This is done while acknowledging the loss and creating a compassionate, safe environment.

A nurse is leading a group of clients in an outpatient setting. The nurse should recognize which of the following client statements as an example of a maladaptive defense mechanism? A. "When I get overly stressed at work, I need to just get out of there and go for a walk at lunch." B. "When my partner yells at the dog I run and hide, but I don't know why I do that." C. "When I am overly stressed I will just sit and watch a movie to help me relax." D. "Losing my child to cancer is so painful that I decided to raise money for cancer research so nobody else has to go through this."

B. "When my partner yells at the dog I run and hide, but I don't know why I do that." -This is an example of repression, which is a maladaptive defense mechanism. In repression, a client can admit that they have certain feelings or reactions about a stressor, but they will avoid thinking or talking about what led up to those feelings.

A nurse is reviewing manifestations of non-suicidal self-harm (NSSH). Which of the following findings should the nurse identify as a warning sign that a client might be engaging in self-harm behavior? A. A client is talking to a friend about a recent job loss. B. A client is wearing long-sleeve shirts in hot weather C. A client reports meditating when feeling upset D. A client who takes an aerobics class to decrease stress

B. A client is wearing long-sleeve shirts in hot weather -Clients who engage in NSSH often try to conceal their self-harm behavior from others due to shame or embarassment. Wearing long-sleeve shrits or pants in hot weather might indicate that the client is covering up evidence of self-harm.

A nurse is caring for a client who smokes and has lung cancer. The client reports, "I'm coughing because I have that cold that everyone has been getting." The nurse should identify that the client is using which of the following defense mechanisms? A. Reaction formation B. Denial C. Displacement D. Sublimation

B. Denial -This is an example of denial, which is pretending the truth is not reality to manage the anxiety of acknowledging what is real.

A charge nurse is reviewing Kubler-Ross: Five Stages of Grief with a group of newly licensed nurses. Which of the following stages should the charge nurse include in the teaching? (Select all that apply.) A. Disequilibrium B. Denial C. Bargaining D. Anger E. Depression

B. Denial C. Bargaining D. Anger E. Depression

A nurse is discussing acute vs. prolonged stress with a client. Which of the following effects should the nurse identify as an acute stress response? (Select all that apply.) A. Chronic pain B. Depressed immune system C. Increased blood pressure D. Panic attacks E. Unhappiness

B. Depressed immune system C. Increased blood pressure E. Unhappiness

A nurse is preparing a community education seminar about family violence. When discussing types of violence, the nurse should include which of the following? A. Refusing to pay bills for a dependent, even when funds are available, is neglect. B. Intentionally causing someone to fall is an example of physical violence. C. Striking a sexual partner is an example of sexual violence. D. Failure to provide a stimulating environment for normal development is emotional abuse.

B. Intentionally causing someone to fall is an example of physical violence. -Physical violence occurs when physical pain or harm is directed toward another individual.

A nurse is caring for a client who is experiencing a crisis. Which of the following medications might the provider prescribe? (Select all that apply.) A. Lithium carbonate B. Paroxetine C. Risperidone D. Haloperidol E. Lorazepam

B. Paroxetine -SSRI antidepressants may be prescribed to decrease the anxiety and depression of a client who is experiencing a crisis. E. Lorazepam -Benzodiazepines may be prescribed to decrease the anxiety of a client who is experiencing a crisis.

A nurse is caring for a client who has been physically abusive to others and was admitted to an inpatient mental health unit. Which of the following client behaviors should the nurse identify as early signs of potential aggression? (Select all that apply.) A. Socializing with selected individuals B. Refusing to eat C. Speaking in a soft voice D. Pacing the floor E. Destroying items F. Attempting to leave before discharge

B. Refusing to eat D. Pacing the floor E. Destroying items F. Attempting to leave before discharge

A nurse is caring for a client who is speaking in a loud voice with clenched fists. Which of the following actions should the nurse take? A. Insist that the client stop yelling. B. Request that the other staff members remain close by. C. Move as close to the client as possible. D. Walk away from the client.

B. Request that the other staff members remain close by. -Request that the other staff remain close by to assist if necessary.

A nurse is preparing to assess an infant. Which of the following is an expected finding of shaken baby syndrome? (Select all that apply.) A. Sunken fontanels B. Respiratory distress C. Retinal hemorrhage D. Altered level of consciousness E. Increase in head circumference

B. Respiratory distress C. Retinal hemorrhage D. Altered level of consciousness E. Increase in head circumference

A nurse hears a newly licensed nurse discussing a client's hallucinations in the hallway with another nurse. Which of the following actions should the nurse take first? A. Notify the nurse manager. B. Tell the nurse to stop discussing the behavior. C. Provide an in-service program about confidentiality. D. Complete an incident report.

B. Tell the nurse to stop discussing the behavior. -The greatest risk to this client is an invasion of privacy through the sharing of confidential information in a public place. The first action to take is to tell the newly licensed nurse to stop discussing the client's hallucinations in a public location.

A nurse is caring for a client who was diagnosed with amyotrphic lateral sclerosis (ALS), has been hospitalized for aspiration pneumonia, and has failed a swallow evaluation. The provider determined the need for a feeding tube to be insterted. However, the client is refusing to have the tube inserted. The nurse is experiencing moral distress. Which of the following actions should the nurse take first? A. Identify the area of concern B. Address the current situation C. Request an ethics committee D. Determine the nurse's responsibility

A. Identify the area of concern -When using the nursing process, the first step is to assess. This requries the nurse to identify the issue and the ethical concern involved. This allows the nurse to develop moral courage as a client advocate.

A unit manager is evaluating the nurses' understading of occupational stress. Which of the following statements are examples of the effects of occupational stress? (Select all that apply.) A. "Everyone is sick sometimes, but lately, with all the client deaths, the number of people calling in sick is increasing." B. "We had three more nurses hurt themselves during work last month." C. "Sometimes, I have to work on other units where everyone feels negative. It is rough just bing on a different unit." D. "We have had so many of our longtime clients die these last few weeks. It is overwhelming." E. "Many of the nurses on the unit volunteer for the unit self-governance committee."

A. "Everyone is sick sometimes, but lately, with all the client deaths, the number of people calling in sick is increasing." -Frequent or increased absenteeism can be a result of increased or chronic occupational stress. B. "We had three more nurses hurt themselves during work last month." -Work-related injuries can be a result of increased or chronic occupational stress. C. "Sometimes, I have to work on other units where everyone feels negative. It is rough just bing on a different unit." -Low morale can be a result of increased or chronic occupational stress. D. "We have had so many of our longtime clients die these last few weeks. It is overwhelming." -Nurses who work in units or situations where they experience frequent loss or exposure to death are often unable to process their own grief. This is an example of occupational grief.

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.) A. "How would you describe your mood today?" B. "What is the date today?" C. "What is your pain level on a scale of 0 to 10?" D. "Can you please show me how to use this pen?" E. "Why are you wearing a coat when it is hot today?"

A. "How would you descibe your mood today?" B. "What is the date today?" D. "Can you please show me how to use this pen?" -One of the main components of the mental status examination is assessing the client's mood. -Orientation is a component of the mental status examination that includes assessment of the client's ability to recognize person, place, and time. -Having the client demonstrate use of a pen is an example of assessing praxis. This is a component of the mental status examination.

A nurse is providing care to a client who has a history of violent behavior. The nurse should identify which of the following client statements as a risk factor for potential (future) violent behavior? (Select all that apply.) A. "I don't really have a lot to be proud of." B. "When I get mad, I make myself count to 10 and take deep breaths." C. "I drink a half gallon of vodka every day." D. "I occasionally use cocaine." E. "I have been arrested two times for a domestic disturbance." F. "Sometimes I yell at people who cut me off when I'm driving."

A. "I don't really have a lot to be proud of." C. "I drink a half gallon of vodka every day." D. "I occasionally use cocaine." E. "I have been arrested two times for a domestic disturbance." F. "Sometimes I yell at people who cut me off when I'm driving."

A nurse is discussing the care of a client following a sexual assault with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of teaching? A. "I will administer prophylactic treatment for sexually transmitted infections, like chlamydia." B. "I am not required to obtain informed consent before the sexual assault nurse examiner collects forensic evidence." C. "I can expect manifestations of rape-trauma syndrome to be similar to bipolar disorder." D. "I should use narrative documentation when documenting subjective data."

A. "I will administer prophylactic treatment for sexually transmitted infections, like chlamydia." -Administer prophylactic treatment for infections (chlamydia) according to the CDC.

A nurse is teaching a client about the purpose of participating in a therapy group about coping strategies. WHich of the following client statements indicates an understanding of the teaching? A. "Learning positive coping strategies can help me adapt to life after the death of my partner." B. "I will learn the purpose of the medications I am prescribed." C. "During the therapy, we will learn how to improve our interpersonal and behavioral skills." D. "This is a social group for people like me. We will plan recreational activities together."

A. "Learning positive coping strategies can help me adapt to life after the death of my partner." -Programs that focus on support and active coping strategies, such as venting, positive reframing, humor, and emotional support, assist clients to adapt and navigate the grieving process.

A nurse is caring for a client who is experiencing extreme anger. Which of the following client statements should the nurse identify as being consistent with adverse childhood experiences (ACEs)? (Select all that apply.) A. "My parents separated when I was 9 years old." B. "My sibling and I would stay alone for days at a time while my parent was gone." C. "My older sibling died of a heroin toxicity when I was 12 years old." D. "My parent remarried and just celebrated their fifth wedding anniversary." E. "My parent used to hit my sibling and I with a belt when we were younger." F. "When I was younger, I experienced drive-by shootings in my neighborhood."

A. "My parents separated when I was 9 years old." B. "My sibling and I would stay alone for days at a time while my parent was gone." C. "My older sibling died of a heroin toxicity when I was 12 years old." E. "My parent used to hit my sibling and I with a belt when we were younger." F. "When I was younger, I experienced drive-by shootings in my neighborhood." -The nurse shouldrecognize that ACEs are events that a child experiences before age 18 that might have been traumatic and could potentially affect them emotinally. These include experiencing neglect or abuse, experiencing some sort of violence, having a parent or sibling that is incarcerated, having parents that are seperated, having someone in the household with a mental illness or experiencing substance disorder.

A nurse is teaching about physiological responses to stress with a group of clients. The nurse should include which of the following short-term physiological changes in the teaching? (Select all that apply) A. Increase in muscular tension, blood pressure, and triglycerides B. Increase in heart rate and respiratory rate C. Corticosteroid relase increases stamina and impedes digestion D. Cortisol release increase glucogenesis and reduces fluid loss E. Increased immune system function F. Increased risk of depression, autoimmune disorders, and heart disease

A. Increase in muscular tension, blood pressure, and triglycerides B. Increase in heart rate and respiratory rate C. Corticosteroid relase increases stamina and impedes digestion D. Cortisol release increase glucogenesis and reduces fluid loss -All of the above are short-term physiological responses to stress.

A group of nurses is discussing the effectiveness of nursing interventions among colients who have a mental health diagnosis. Which of the following statements accurately identifies a barrier to effective nursing interventions? (Select all that apply.) A. "Some mental health clients are unaware that they have a mental health condition." B. "Some mental health clients experience cognitive deficits and cannot understand their treatment plan." C. "Many mental health clients experience the effects of polypharmacy." D. "Many mental health clients are not trustworthy." E. "Many mental health clients experience worsening clinical manifestations."

A. "Some mental health clients are unaware that they have a mental health condition." -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. B. "Some mental health clients experience cognitive deficits and cannot understand their treatment plan." -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. C. "Many mental health clients experience the effects of polypharmacy." -Mental health clients can experience polypharmacy, resulting in challenges in adherence to medication routines and client perception of a diminished quality of life. E. "Many mental health clients experience worsening clinical manifestations." -Worsening clinical manifestions, such as manifestations of depression or anxiety, can impact the effectiveness of nursing interventions.

A nurse is teaching a newly licensed nurse who is caring for a client who has previously demonstrated aggressive and violent behavior. Which of the following statements should the nurse make? (Select all that apply.) A. "The client's aggression might be linked to their history of schizophrenia." B. "A client who has heart failure tends to be aggressive." C. "A client who has a traumatic brain injury may demonstrate violent behavior." D. "A client who has bipolar I disorder could be at higher risk for danger to others." E. "A client who has been sexually abused might experience aggressive episodes." F. "A child who has autism might experience episodes of aggression."

A. "The client's aggression might be linked to their history of schizophrenia." C. "A client who has a traumatic brain injury may demonstrate violent behavior." D. "A client who has bipolar I disorder could be at higher risk for danger to others." E. "A client who has been sexually abused might experience aggressive episodes." F. "A child who has autism might experience episodes of aggression." -The nurse should recognize that the neurotransmitter serotonin is linked to me tal illnesses, as well as aggressive and violent behavior. Those who have aggressive behavior and a diagnosis of schizophrenia, ASD (autism spectrum disorder), or attention deficit disorder tend to have higher serum serotonin levels. Violent behavior can also be linked to substance use disorders, traumatic brain injuries, PTSD, bipolar I disorder, impulse control disorders, and ADHD.

A nurse is caring for a client who was recently diagnosed with prolonged grief disorder (PGD). Which of the following client statements should the nurse address? A. "There is nothing to do; I just can't go on living without my child." B. "These feelings of sadness and anger can be very intense for me." C. "During the support group, I will be encourage to talk about my child." D. "A professional therapist is specially trained to help with my grief."

A. "There is nothing to do; I just can't go on living without my child." -This is a safety concern and should be addressed immediately. Any mention of suicidal thoughts or not wanting to live requires immediate nursing intervention.

A nurse is caring for a client who has end-stage pancreatic cancer. The client has decided to forgo any additional treatment and be allowed to die. Which of the following responses should the nurse make to honor the client's request? A. "This action is supported by your right to self-determination." B. "This action is beyond my scope of practice." C. "This action goes against the ANA Code of Ethics." D. "This is an unusual request and not common practice."

A. "This action is supported by your right to self-determination." -End-of-life care is within the nursing scope of practice and the role of the nurse is to advocate for the client, provide supportive care by alleviating suffering, and support the client's right of decision.

A charge nurse is discussing mental status examinations with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? (Select all that apply) A. "To assess cognitive ability, I should ask the client to count backward by sevens." B. "To assess affect, I should observe the client's facial expression." C. "To assess language ability, I should instruct the client to write a sentence." D. "To assess remote memory, I should have the client repeat a list of objects." E. "To assess the client's abstract thinking, I should ask the client to identify our most recent presidents."

A. "To assess cognitive ability, I should ask the client to count backward by sevens." B. "To assess affect, I should observe the client's facial expression." C. "To assess language ability, I should instruct the client to write a sentence."

A nurse is caring for a client who is exhibiting hypervigilance and restlessness. The client states, "I need to figure a way out of this mess." The nurse should recognize that the client is most likely in which of the following stages of anxiety? A. Mild B. Moderate C. Severe D. Panic

A. Mild -The client is experiencing a mild level of anxiety. A mild level of anxiety can manifest in hypervigilance and restlessness. At this stage, the client may be open to problem solving and is likely at a peak level of concentration.

A nurse is planning a peer group discussion about the Diagnositic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). Which of the following information is appropriate to include in the discussion? (Select all that apply.) A. The DSM-5 includes client education handouts for mental health disorders. B. The DSM-5 establishes diagnostic criteria for individual mental health disorders. C. The DSM-5 indicates recommended pharmacological treatment for individual mental health disorders. D. The DSM-5 assists nurses in planning care for client's who have mental health disorders. E. The DSM-5 indicates expected assessment findings of mental health disorders.

B. The DSM-5 establishes diagnostic criteria for individual mental health disorders. D. The DSM-5 assists nurses in planning care for client's who have mental health disorders. E. The DSM-5 indicates expected assessment findings of mental health disorders.

A nurse is caring for a client who has sustained life-threatening injuries. The health care team is discussing withdrawl of life-sustaining treatment. The decision to withdraw treatment is made by which of the following? A. Independently by the medical staff, based on evidence and best practices B. The health care team and the family C. Individual care providers, based on universal ethics protocols D. Rarely done as it violates medical ethics and current standards of practice

B. The health care team and the family -The decision to withdraw life-sustaining care is the responsibility of the health care provider and is best done with the health care team and the client's family. The nurse provides a significant role in management of care.

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? A. The nurse should identify subjective and objective data regarding the client's mental health condition. B. The nurse should use observations, clinical presentation data, and assessment findings to identify the client's mental health alteration. C. The nurse should determine client mental health outcomes and appropriate nursing interventions. D. The nurse should monitor the client's responses to nursing interventions and changes in mental health status.

B. The nurse should use observations, clinical presentation data, and assessment findings to identify the client's mental health alteration. -Anaylisis 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 client in a clinic. The client states, "I am overwhelmed by stress." Which of the following should the nurse identify as the highest priority question to ask the client? A. "Do you have any relative who have problems with stress?" B. "How much physical activity do you typically get in a day?" C. "What kinds of things do you find helpful for coping with your stress?" D. "How much sleep do you get each night?"

C. "What kinds of things do you find helpful for coping with your stress?" -The highest priority during an initial assessment would be to determine what the client is doing to cope with stress at present, preferably via an open-ended inquiry.

A nurse is providing care to a client whose partner recently died. The client asks, "Do you think meditation helps with stress?" Which of the following responses should the nurse make? A. "Here are some meditation techniques that I use to help with stress." B. "There is no clinical evidence that meditation helps, but it wouldn't hurt." C. "You may find meditation gives comfort and lowers your stress." D. "Using meditation along with anther effective coping strategy may help you."

C. "You may find meditation gives comfort and lowers your stress." -This response addresses the client's concerns and affirms the client's choice to try meditation as a form of stress managment.

A nurse enters the day room, observes the clients, and performs a situational assessment. Which of the followig situations should the nurse identify as the priority to address? A. A client who is standing in from of a wall and staring blankly at it. B. A client who does not want to go back to their room. C. A client who is arguing with another client who is backed into a corner. D. A client requesting to talk with a staff member in private.

C. A client who is arguing with another client who is backed into a corner. This 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.

A nurse is leading a group of clients who are using the Holmes-Rahe Life Stress Inventory Scale to sell-assess stressors in their life. Which of the following findings indicates the highest degree of stress? A. A client who has reported being assigned more responsibility at work B. A client with children who will be relocating to a new city for work. C. A client who is returing to college following the loss of their job D. A client who is recently separated from their spouse

C. A client who is returing to college following the loss of their job -A client who is returning to college after losing a job is dealing with two significant stressors simultaneously.

A nurse is caring for a client who states, "I am so stressed over my upcoming reunion because I am not as successful as most of my classmates." The nurse should consult a therapist for the client to start which of the following therapies? A. Aversion therapy B. Biofeedback C. Cognitive reframing D. Desensitization therapy

C. Cognitive reframing -This client would benefit from cognitive reframing, which is a technique used to change the way a person things about something.

A nurse is conducting a follow-up visit with a client whose child was recently killed in a school shooting. The client states, "I don't know how to act or what to say. My child was the shooter." The nurse should determine that the client's statement is consistent with which of the following? A. Death anxiety B. Anticipatory grief C. Disenfranchised grief D. Prolonged grief disorder

C. Disenfranchised grief -Disenfranchised grief occurs when the expression of grief is not socially, culturally, or publicly recognized.

A nurse is caring for a client who reports that their partner threatens them when they disagree about finances. The nurse should identify that the client is experiencing which of the following types of abuse? A. Economic B. Physical C. Emotional D. Sexual

C. Emotional -The nurse should identify that the client is experiencing emotional abuse. Emotional abuse can be verbal threats, saying hurtful words, intimidating or repeatedly ignoring someone. Emotional abuse can also be called psychological abuse.

A nurse is caring for a client who has derealization disorder. Which of the following findings should the nurse identify as an indication of derealization? A. The client describes a feeling of floating above the ground. B. The client has suspicions of being targeted in order to be killed and robbed. C. The client states that the furniture in the room seems small and far away. D. The client cannot recall anything that happened during the past 2 weeks.

C. The client states that the furniture in the room seems small and far away. -Stating that one's surroundings are far away or unreal in some way is an example of derealization.

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? A. "The FAD is used to help assess family fucntioning, specifically the impact of trauma and crisis on the family functioning." B. "The FAD is used to help assess family fuctioning, specifically in the areas of housing and financial security." C. The FAD is used to help assess family functioning, specifically to determine the need to notify Child Protective Services of any family problems." D. "The FAD is used to help assess family functioning, specifically to determine how the roles of the family work in the family dynamics."

D. "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 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 educating a group of clients on the concept of hardiness. Which of the following statements should the nurse include in the teaching? A. "The foundation of hardiness is the ability to fixate on a stressor in an effort to suppress negative thinking." B. "Hardiness is a personality trait that refers to how a person reacts to the world around them." C. "Hardiness is a genetic predisposition that is non-modifiable." D. "The foundation of hardiness is a positive self-perception and attitudes of hopefulness."

D. "The foundation of hardiness is a positive self-perception and attitudes of hopefulness." -A positive self-perception about one's abilities, skills, and capacity to manage stress, along with an attitude of hopefulness is the foundation of hariness and provides a protective factor when managing stress.

A nurse is caring for a client who has been newly diagnosed with a terminal illness and is experiencing significant stress. The client states, "Do you think prayer would help?" Which of the following statements should the nurse make? A. "It could be that prayer is your only hope." B. "We do not have evidence that prayer helps, but it wouldn't hurt." C. "I can help you feel calmer by teaching you meditation exercises." D. "You may find prayer gives comfort and lowers your stress."

D. "You may find prayer gives comfort and lowers your stress." -Many clients find that spiritual measures, including prayer are helpful in mediating stress. Studies have shown that spiritual practices can enhance the client's sense of well-being. When a client suggests a viable means of reducing stress, it should be supported by the nurse.

A nurse manager is discussing sexual assault nurse examiners (SANEs) and the interventions they use when caring for clients who have been sexually assaulted. Which of the following interventions should the nurse include? A. A SANE informs the client of the requirements to file a police report. B. A SANE instructs the client to follow-up with their provider in 2 months. C. A SANE requests the police collect the physical evidence from the client's body following the assault. D. A SANE offers clients some options about their care.

D. A SANE offers clients some options about their care. -The nurse should include in the in-service that a SANE offers the client choices to assist them in making informed decisions about the care they receive.

A nurse manager is assessing their unit for factors that contribute to the development of compassion fatigue. Which of the following factors should the nurse manager identify as increasing the risk for compassion fatigue? A. Nurses formed a shared governance group to meet with nursing leadership. B. Nurse are provided with scheduled breaks every shift. C. Nurse managers offer one-on-one meetings with staff. D. A large number of nurses are working extra shift hours.

D. A large number of nurses are working extra shift hours. -Extra shift hours is a factor that places nurses at risk for compassion fatigue. Additionally, nurses are at risk for compassion fatigue due to repeated exposure to client suffering, deaths, and traumatic experiences.

A nurse is caring for a client who recently lost their partner in a motor vehicle crash. Which of the following actions should the nurse take to provide supportive grief-informed care? A. Provide the client with a list of local grief support groups. B. Place the client's personal items within reach. C. Have the client complete their menu request. D. Ask the client how they met their partner.

D. Ask the client how they met their partner. -This is an example of reminiscing. Reminiscing allows the client to talk about the person who died and is a way to show compassion and normalize their grief. Grief-informed care normalizes the grieving process and includes therapeutic communication and opportunities to remember the person who died.

A nurse is caring for a client who has emphysema and recently reduced their level of activity because they fear developing dyspnea. When teaching the client to use guided imagery, which of the following should the nurse encourage the client to visualize? A. Walking on a beach without using supplemental oxygen. B. Sleeping comfortablly and soundly, without respiratory distress C. Placing their hand to feel the rise and fall of their chest D. Dangling feet in a pool and taking regular deep breaths

D. Dangling feet in a pool and taking regular deep breaths -The client has a dysfunctional perspective of dyspnea. Guided imagery can help replace the dysfunctional image with a positive coping image. Encouraging the client to imagine a regular breathing pattern will help improve oxygen-carbon dioxide exhange and facilitate relaxation.

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)? A. Taking action B. Prioritizing hypothesis C. Analyzing cues D. Recognizing cues

D. Recognizing cues -The 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 presenting an in-service on the cycle of violence to nursing staff. The nurse should include that the perpetrator becomes affectionate at which of the following phases? A. Acute battering B. Build-up C. Displacement D. Respite

D. Respite - The nurse should include that respite is phase 3 of the cycle of violence. During this phase, the violence or abuse is no longer considered an acute stressor. It has been forgotten about by the perpetrator and the violence has stopped. This is also known as the "honeymoon" phase.

A nurse in an acute mental health facility is planning care for a client who has dissociative fugue. Which of the following interventions should the nurse add to the plan of care? A. Teach the client to recognize how stress brings on a personality change in the client B. Repeatedly present the client with information about past events C. Make decisions for the client regarding routine daily activities D. Work with the client on grounding techniques

D. Work with the client on grounding techniques -Grounding techniques (stomping the feet, clapping the hands, or touching physical objects) are useful for clients who have a dissociative disorder and are experiencing manifestations of derealization.