Mental health nclex

A 60-year-old client wanders away during halftime at a football game and is found 48 hours later sleeping on a park bench, 100 miles from home. The client is brought to the emergency department by the police. The client can state the name and address but has no recollection of the past 2 days. What is the PRIORITY nursing action? 1. Assess vital signs 2. Contact family members 3. Encourage the client to recall recent events 4. Perform a mental status assessment

1

A client comes to the community mental health clinic seeking treatment for severe anxiety associated with a recent job promotion that requires a 30-minute commute via train. The nurse recognizes that this client MOST LIKELY suffers from which psychological disorder? 1. Agoraphobia 2. Generalized anxiety disorder 3. Social anxiety disorder 4. Zoophobia

1

A client recently admitted to an inpatient unit for treatment of alcoholism says to the nurse, "I only came here to get away from my nagging spouse. Sometimes I think my spouse is the one who should be here. I can stop drinking any time I want." The nurse recognizes that the client is exhibiting which of the following defense mechanisms? 1. Denial and projection 2. Rationalization and depression 3. Regression and displacement 4. Sublimation and reaction formation

1

A client with borderline personality disorder says to the nurse, "You're the only one I trust around here. The others don't know what they are doing and they don't care about anyone except themselves. I only want to talk with you." What is the PRIORITY action for the client's nursing care plan? 1. Assign different staff members to care for the client each day 2. Continue assigning the clients stated preferred nurse to care for the client 3. Frequently reassure the client that all staff members are competent in their jobs 4. Reinforce unit rules and consequences of inappropriate behaviors

1

A client with moderate Alzheimer disease is started on memantine In evaluating the effectiveness of this medication, the registered nurse should assess the client for which of the following? 1. Improved ability to perform activities of daily living 2. Indications that disease progression has stopped 3. Rapid improvement in cognitive functioning 4. Reversal of the disease

1

A client with schizophrenia is hospitalized. After 2 weeks of treatment, the frequency of the client's hallucinations seems to be diminishing. When first hospitalized, the client refused to leave the room. Now the client spends time in the dayroom, sitting in a corner watching television, but does not initiate conversation or social interaction with other clients or staff. What is the MOST APPROPRIATE activity for the client? 1. A board game with a staff member 2. Participation in a group songfest 3. Planning a unit picnic 4. Playing Bingo with other clients

1

A client, who has been hospitalized for 3 days with major depressive disorder, has stayed in the room and not gotten out of bed except for toileting. The nurse enters the room to remind the client that breakfast will be served in the dining room in 20 minutes. The client says, "I'm not hungry and I don't feel like doing anything." What is the BEST response by the nurse? 1. "I will help you get ready; then we can walk to the dining room together." 2. "I'll have breakfast brought to your room." 3. "It's okay. You can join us when you are ready." 4. "You'll feel better when you get up."

1

The client with narcissistic personality disorder often behaves in grandiose and entitled ways, believes that he/she is perfect, and relies on constant reinforcement and admiration from people perceived as ideal. What is the BEST explanation for these clinical characteristics? 1. The client is attempting to maintain self-esteem 2. The client is experiencing delusions of grandeur 3. The client is feeling threatened 4. The client is trying to prevent a panic attack

1

The nurse is caring for a client with bulimia nervosa. Which is the MOST IMPORTANT time for the nurse to monitor the client's behavior? 1. During 1-2 hours after each meal 2. During every meal 3. During the evening meal 4. During the overnight hours

1

The nurse is caring for a client with schizophrenia who has been experiencing visual hallucinations. The client says in a trembling voice, "There's a bad man standing over there in the corner of my room." What is the BEST response by the nurse? 1. "I know you are frightened, but I do not see a man in your room." 2. "I'll make the bad man go away." 3. "Let's go into the dayroom and play checkers." 4. "Your illness is making you hallucinate."

1

The nurse is educating a client in preparation for discharge from the hospital when the client breaks down crying, saying that the health care provider thinks she is crazy because he diagnosed her with a functional disorder. Which statement would be the BEST reply to this client? 1. "Functional disorder is a general diagnosis for a genuine medical issue that medical science does not yet fully understand." 2. "I am very sorry to hear this, but are you sure that's what he meant?" 3. "The health care provider does not know what he's talking about. I'll give you the information my health care provider used." 4. "Why do you think he said that?"

1

The nurse is reviewing a client's preoperative questionnaire and notes that the client has indicated spiritual needs or preferences concerning today's surgery. Which action is MOST APPROPRIATE at this time? 1. Ask the client if a spiritual advisor or clergy member is aware of the surgery 2. Ask the client when a spiritual advisor or clergy member is coming to visit 3. Document the response and notify the health care provider and postoperative nurse 4. Tell the client that the hospital chaplain will be notified for a consult

1

The registered nurse discusses discharge planning with the spouse of an 80-year-old client diagnosed with chronic obstructive lung disease and chronic respiratory failure. The client is bedbound, has a tracheostomy, is on a ventilator, and requires suctioning at least 3 times daily. The spouse says to the nurse, "l've been helping out here, so I'm sure I can manage my spouse's care at home." The nurse's response is based on which understanding? 1. Caregiver strain is a risk for any family member who cares for a loved one at home 2. Client needs to be placed in a skilled nursing facility 3. Clients on ventilators cannot be cared for at home 4. Discharging the client to the home is an unsafe plan

1

Which client statement demonstrates mental health well-being when considering stress and anxiety? 1. "I know that relaxation techniques help me deal with my life's stress and anxiety." 2. "I understand stress and anxiety because my family has a history of depression." 3. "You must understand that stress and anxiety affect everyone's life." 4. "You should identify and then avoid those things that cause you stress and anxiety."

1

The emergency department registered nurse is triaging a client for the risk of suicide. The client had thoughts of self-injury yesterday but is not sure today. Which of the following would be considered a known risk factor for suicide in this client? Select all that apply. 1. Constantly hearing voices saying client is worthless 2. Deliberately took an overdose 1 year ago 3. Has a gun at home 4. Married with 3 children 5. Participation in religious activities 6. Unemployed and unable to find a job

1,2,3,6

The nurse performs an initial assessment on a client with suspected post-traumatic stress disorder Which assessments would support this diagnosis? SELECT ALL THAT APPLY. 1. Difficulty concentrating 2. Feeling detached from others 3. Feeling lethargic and apathetic 4. Flashbacks of the traumatic event 5. Persistent angry, fearful mood

1,2,4,5

Which clinical manifestations would the nurse identify with severe anorexia nervosa? SELECT ALL THAT APPLY. 1. Amenorrhea 2. Fluid and electrolyte imbalances 3. Heat intolerance 4. Presence of lanugo 5. Refusal to exercise 6. Weight loss of 25% below normal weight

1,2,4,6

Which of the following actions would the nurse include in planning care for a client hospitalized for bipolar disorder, acute manic episode? SELECT ALL THAT APPLY. 1. Assign the client to a private room 2. Choose clothing for the client 3. Have the client be in charge of planning an outing for the unit 4. Have the client join other clients in the dining room for meals 5. Have the client participate in physical exercise with a staff member 6. Include the client in group therapy sessions

1,2,5

The nurse is presenting an in-service educational session on child abuse and neglect to a class of certified home health aides In identifying the characteristics of the typical perpetrator of child abuse, the nurse will include which statements? SELECT ALL THAT APPLY. 1. Abusers often have a history of substance abuse 2. Abusers often have a history of growing up in an environment of domestic violence 3. Child abusers always present as being agitated or out of control 4. Men are much more likely to abuse children than are women 5. MOST child abusers have a diagnosis of a mental illness 6. Teenage parents are particularly vulnerable to abusing their children

1,2,6

A client hospitalized for anorexia nervosa has a nursing diagnosis of imbalanced nutrition: less than body requirements. Which nursing actions are appropriate for promoting weight gain in this client? SELECT ALL THAT APPLY. 1. Determine minimum goals for daily caloric intake and weekly weight gain 2. Do not allow client to make food choices 3. Restrict privileges if weight loss occurs 4. Reweigh client on request 5. Set limits on physical activities 6. Sit with client during meals and discuss nutritional value of served foods

1,3,5

The nurse assesses a client who is suspected of using illicit substances. Which assessment findings would indicate heroin withdrawal? SELECT ALL THAT APPLY. 1. Bone and muscle pains 2. Bradycardia 3. Dilated pupils 4. Drowsiness 5. Rhinorrhea

1,3,5

The charge nurse in a long-term memory care facility is making assignments for the Alzheimer unit. Which tasks may be delegated to experienced unlicensed assistive personnel? SELECT ALL THAT APPLY. 1. Assisting clients with bathing and hair care 2. Evaluating safety hazards in clients' rooms 3. Monitoring clients for behavioral changes 4. Placing bed alarms at night for clients at risk for wandering 5. Reporting swallowing difficulties of a client during mealtime

1,4,5

A client with generalized anxiety disorder is referred to outpatient mental health department for cognitive behavioral therapy (CBT). The CBT includes which INTERVENTIONs and strategies? Select all that apply. 1. Desensitization to a specific stimulus or situation 2. Discussing the interpersonal difficulties that have led to the client's psychological problems 3. Helping the client develop insight into the psychological causes of the disorder 4. Relaxation techniques 5. Self-observation and monitoring 6. Teaching new coping skills and techniques to reframe thinking

1,4,5,6

A client with major depressive disorder has been hospitalized for 3 days The night nurse reports that the client has been unable to go to sleep until late at night. The client gets up, paces the hallway, wrings her hands, and appears teary. Which INTERVENTIONs should be included in the client's nursing care plan? SELECT ALL THAT APPLY. 1. Arrange for the client to receive 20 minutes of natural sunlight each day 2. Encourage the client to take naps during the day to make up for lost sleep 3. Have the client engage in strenuous physical exercise just before bedtime 4. Serve the client a glass of warm milk in the evening 5. Spend time with the client in a quiet environment just before bedtime 6. Tell the client to take a warm bath before going to bed

1,4,5,6

A 12-year-old with moderate intellectual disability and an intelligent quotient of 45 is hospitalized. What will the nurse recommend as the BEST recreational activity for this child? 1. Childs favorite stuffed animal 2. Connect-the-dots puzzle book 3. Putting together a 300-piece jigsaw puzzle 4. Writing in a journal about the hospital stay

2

A client is newly admitted to the mental health unit with a diagnosis of schizophrenia with persecutory delusions. Which nursing INTERVENTIONs should the nurse include in the client's plan of care with regard to the delusional thinking? SELECT ALL THAT APPLY. 1. Explore the meaning behind the client's delusions 2. Focus on reality and verbally reinforce it 3. Focus on the client's feelings secondary to the delusions 4. Gently confront the client about the false beliefs 5. Present logical explanations to discredit the delusions

2

A client is receiving nasogastric tube feedings as nutritional rehabilitation for anorexia nervosa. After a weigh-in, the client learns of gaining 2 lb (0.9 kg) and says to the nurse, "See what your force feeding has done to me? I'm fatter and uglier than ever." What is the BEST action by the nurse? 1. Have the client keep a journal and write about feelings 2. Initiate one-on-one supervision of the client during feedings 3. Remind the client that gaining weight means being able to go home 4. Say that the client is not fat and ugly

2

A client with Alzheimer disease is admitted to the hospital for a urinary tract infection. The daughter says to the nurse, "I really want to take my mother home and continue care there. However, lately, my mother has become agitated and restless at night. I'm awake MOST of the night, feel exhausted, and do not know what to do." What is the BEST response by the nurse? 1. "Do not let your mother take naps in the afternoon." 2. "Our social worker can discuss long-term care options with you." 3. "We can ask the health care provider for medication that will help your mother sleep." 4. "Your mother can be cared for in a nursing home."

2

A client with a 20-year history of schizophrenia is hospitalized. The client appears visibly upset, approaches the nurse, and says in a shaky voice, "I can't find my headband. I can't find my headband. The oil is going to leak out of the crack in my head." What is the BEST response by the nurse? 1. "How long has the oil been leaking from your head?" 2. "Let's go back to your room and look for your headband together." 3. "There is no oil coming out of your head." 4. "You are going to miss breakfast if you do not go into the dining room."

2

A client with obsessive-compulsive disorder (OCD) has been cleaning a bathroom for MOST of the morning. When the roommate demands that the client leave the bathroom so that the roommate can shower, the client becomes angry and says, "You can't make me leave, everything is still dirty." What is the BEST nursing action? 1. Engage other staff members to remove the client from the bathroom 2. Give a reminder that the client has been cleaning the bathroom for 1½ hours and it is time to take a break 3. Tell the client that the bathroom is very clean and that this behavior is unreasonable 4. Tell the roommate to use the shower in another room

2

A client with schizophrenia has been hospitalized for a week and placed on an antipsychotic medication. The client tells the nurse of hearing multiple voices all day long arguing about whether the client is a good or bad person. The client says, "Everyone tells me that the voices are not real, but they are driving me crazy." What is the BEST action by the nurse? 1. Give the client a book to read 2. Provide earphones and a DVD player and have the client sing along with the music 3. Tell the client that the voices will go away when the medication starts to work 4. Tell the client to ignore the voices

2

A client with schizophrenia says to the nurse, "The world turns as the world turns on a ball at the beach. But all the world's a stagecoach and I took the bus home." The nurse recognizes this statement as an example of which of the following? 1. Concrete thinking 2. Loose associations 3. Tangentiality 4. Word salad

2

A client with social anxiety disorder is receiving treatment at the local community mental health center. Which situation MOST LIKELY caused the client to seek therapy? 1. The client and spouse are soon moving into a new neighborhood 2. The client's boss has asked the client to represent the company at an upcoming convention 3. The client's primary health care provider (HCP) of 30 years is retiring and the client will be seeing a new HCP 4. The client's son is getting married in a few months

2

A college student finds a roommate mumbling and huddling in the corner of the room. The student brings the roommate to the emergency department, where the roommate is tentatively diagnosed with schizophrenia. The treatment plan includes hospitalization on the acute psychiatric unit and initiation of anti-psychotropic medication therapy. The client refuses to be admitted. Which of the following statements about hospital admission is true for this client? 1. If the client refuses to cooperate with the treatment plan, the client can be involuntarily committed. 2. If the treatment team determines the client poses danger to self or others, the client can be involuntarily committed. 3. The client can be involuntarily committed for observation and treatment if the roommate can provide consent. 4. The diagnosis of schizophrenia alone justifies the need for involuntary commitment.

2

A student nurse has been assigned to provide care to a client with suicidal ideation who is receiving treatment in an outpatient setting. The student nurse develops a nursing care plan and reviews it with the registered nurse (RN) before meeting with the client Which of the following nursing actions in the care plan requires an INTERVENTION by the RN? 1. Assist the client in identifying the warning signs of a crisis 2. Encourage the client to sign a contract promising not to commit suicide 3. Have the client make a list of people to contact for help and distraction 4. Help the client develop ways of coping with suicidal thoughts

2

After a daily weigh-in, a client with anorexia nervosa realizes a 2-lb weight gain. The client says to the nurse in a distressed voice, "This is terrible. I'm so fat." What is the BEST response by the nurse? 1. "But you look so thin." 2. "I don't see you that way; you are making progress toward a healthy weight." 3. "If you continue to gain weight at this rate, you will be able to go home soon." 4. "You are not fat; it's all in your imagination."

2

An adolescent client is brought to the emergency department by the parents after being found in the bathroom making cuts on an arm with a razor blade. There are a few minor cuts in various stages of healing on the client's forearms. Which of the following is the MOST APPROPRIATE statement to make to this client's parents? 1. "Everything is going to be all right." 2. "The cuts on your child's arm are superficial; there is no immediate danger." 3. "You did the right thing by bringing your child here to get help." 4. "You must be very upset after seeing this."

2

For several months, a client has been unjustifiably accusing the spouse of having affairs. The client comes home from work several times a day to check up on the spouse. Two days ago, the client came home and found the cable TV technician installing new equipment The client became enraged, accused the spouse of sleeping with the technician, and physically attacked the technician. The police were called, and the client was admitted for psychiatric evaluation. Prior to this admission, the client had been self-sufficient in meeting basic needs and worked and attended church regularly. The nurse recognizes that the admitting history is MOST indicative of which of the following? 1. Delusional disorder, erotomanic type 2. Delusional disorder, jealous type 3. Schizophrenia with delusions of a persecutory nature 4. Schizophrenia with paranoid features

2

The 17-year-old child of a client being treated for alcoholism tells the nurse that the parent's disease and behavior have taken a toll on the whole family the child is especially concerned about a 13-year-old sibling who is having trouble in school. The nurse should provide the child with information about what resource? 1. Adult Children of Alcoholics (ACOA) 2. Alateen 3. Alcoholics Anonymous (AA) 4. National Association for Children of Alcoholics (NACOA)

2

The home health aide reports to the nurse care manager that the client has been trying to give away possessions. When the nurse asks the client about this behavior, the client says, "With my spouse dead, there's no reason for me to go on." What is the BEST PRIORITY response by the nurse? 1. "Do you have any friends in the building?" 2. "Have you had any thoughts of hurting yourself?" 3. "Tell me more about how you're feeling." 4. "You're not thinking of killing yourself, are you?"

2

The nurse assigned to care for the client with a diagnosis of histrionic personality disorder expects to observe which characteristics and behaviors? 1. Pears abandonment, agreeable, needs constant reassurance 2. Likes to be the center of attention, exaggerated emotional expression, little tolerance for frustration 3. Seems uncomfortable around people, lack of close friends, indifferent to praise or criticism 4. Tries to intimidate others; manipulative; lacks empathy

2

The nurse is caring for a client with paranoid personality disorder. When the nurse directs the client to go to the dining room for dinner, the client says, "And eat that poisonous food? You better not make me go anywhere near that room" Which statement BEST explains the client's behavior? 1. The client has a problem with authority figures 2. The client has an intense need to control the environment 3. The client is hearing voices 4. The client is trying to control anger

2

The nurse is caring for a hospitalized elderly client who is admitted with pneumonia. Which assessment finding is MOST consistent with the diagnosis of delirium? 1. Client is alert but disoriented to time 2. Client is inattentive and hallucinating 3. Client reports decreased enjoyment in previously pleasurable activities 4. Family reports a gradual progressive inability to remember recent events

2

The nurse is caring for a new mother whose infant has been diagnosed with Down syndrome. The client says to the nurse, "I'm so worried. My husband is so devastated that he won't even look at the baby." What is the BEST response by the nurse? 1. "Both of you will benefit from supportive counseling." 2. "How are you feeling about your baby?" 3. "I will have the doctor speak to your husband." 4. "Why do you think your husband feels this way?"

2

The nurse is planning care for an 11-year-old admitted for surgical treatment of a fractured femur. The child also has attention-deficit hyperactivity disorder, predominantly inattentive type. What is the PRIORITY nursing action? 1. Encourage the child to keep up with school work 2. Give the child a written schedule of daily activities 3. Limit the number of visitors 4. Provide verbal explanations of what to expect during hospitalization

2

The nurse on the mental health unit received report on 4 clients. Which client should the nurse see FIRST? 1. Client diagnosed with major depressive disorder who has consumed no food from the past 3 meal trays 2. Client diagnosed with post-traumatic stress disorder who reports an anxiety level of 8/10 and is pacing in the room 3. Client newly admitted with bipolar mania who reports sleeping only 4 hours last night 4. Client newly admitted with obsessive-compulsive disorder who has spent the last hour counting socks

2

The nurse on the mental health unit recognizes the use of which defense mechanism when a client leaves a stressful family meeting and immediately begins to verbally abuse a roommate? 1. Compensation 2. Displacement 3. Projection 4. Reaction formation

2

The registered nurse is leading a support group for partners of military veterans suffering from postiraumatic stress disorder (PTSD) A participant asks the nurse how to identify the typical symptoms of PTSD. The nurse responds that MOST individuals with PTSD report which symptoms? 1. Auditory hallucinations, feelings of paranoia, isolation from others 2. Increased anxiety, reliving the event, feeling detached from others 3. Rapidly changing emotions, delusions, lethargy 4. Recurring nightmares, uncontrollable anger, daytime sleepiness

2

The school nurse is called to the classroom to assist with a 7-year-old with attention-deficit hyperactivity disorder who is throwing books and hitting the other children. What is the BEST INITIAL action for the nurse to take? 1. Administer a PRN dose of methylphenidate 2. Ask the child to blow up a balloon 3. Give the child a "time out" in a quiet place 4. Reinforce the consequences of disruptive behaviors

2

The nurse Is preparing discharge instructions for a client with a history of alcohol abuse on the third day after an emergency appendectomy. The nurse suspects delirium tremens based on which assessment data? Select all that apply. 1. Bradypnea 2. Diaphoresis 3. Hallucinations 4. Lethargy 5. Tachycardia

2,3,5

The nurse is developing a plan of care for a 16-year-old client with bulimia nervosa. Which INTERVENTIONs would be included in the plan of care? SELECT ALL THAT APPLY. 1. Allow client to remain on current laxatives 2. Assess client for electrolyte imbalances 3. Be alert to hidden or discarded food wrappers 4. Do not allow client to keep a food diary during hospitalization 5. Monitor client for 1-2 hours after each meal in a central area

2,3,5

A child with a high level of school absenteeism has been determined to have school phobia. The school nurse should counsel the child's parent/caregiver to take which action? 1. Allow the child to stay home when the child seems particularly anxious 2. Encourage the parent/caregiver to sit in the classroom with the child 3. Insist on school attendance immediately, starting with a few hours a day 4. Return the child to school when the cause of the school phobia has been identified

3

A client has been admitted to the acute inpatient psychiatric unit with a diagnosis of major depressive disorder (unipolar depression). The nurse understands that this diagnosis was made because the client has been exhibiting at least 1 of which of the 2 KEY clinical findings daily for at least 2 weeks? 1. Daily sleep disturbance or significant weight loss 2. Decreased ability to think or low energy 3. Depressed mood or loss of interest or pleasure 4. Thoughts of worthlessness or recurrent thoughts of death

3

A client is brought to the emergency department after the spouse finds the client locked in the car inside their garage with the motor running. The spouse says to the nurse, "If I hadn't come home early from work, my spouse would be dead I can't believe this is happening." What is the BEST response by the nurse? 1. "Do you have any relatives or close friends who can help you through this?" 2. "Has your spouse seemed depressed lately?" 3. "This has been very overwhelming for you. What are you feeling right now?" 4. "Well, you did find your spouse. You need to focus on helping your spouse get better"

3

A client who is diagnosed with breast cancer asks the nurse, "Am I going to die?" Which statement by the nurse promotes a therapeutic relationship? 1. "Cancer is no longer a death sentence you may live for many years." 2. "l will ask the chaplain to talk to you sometime today." 3. "People with cancer experience fear of dying; tell me about your concerns." 4. "Tell me about your life and hopes for the future."

3

A client with a diagnosis of antisocial personality disorder was given a 2-hour pass to leave the hospital. The client returned to the unit 15 minutes past curfew and did not sign in. The next day, this behavior is brought up in a group meeting. The client says, "It's all the nurse's fault. The nurse was right there and did not remind me to sign in." What is the BEST response by the nurse? 1. "I'm sorry. I should have reminded you to sign in" 2. "It is not my fault that you forgot to sign in." 3. "It is your responsibility to sign in when you return from a pass." 4. "You were late coming back from your pass. Is that why you did not sign in?"

3

A client with a diagnosis of schizophrenia with catatonia has recently been admitted to the psychiatric unit. Which of the following is the PRIORITY nursing diagnosis? 1. Impaired social interaction 2. Impaired verbal communication 3. Risk for deficient fluid volume 4. Risk for impaired skin integrity

3

A client with a history of obsessive-compulsive personality disorder (OCPD) is seeking treatment for a gastrointestinal disorder and is scheduled for a colonoscopy at 10:00 AM. Due to a computer glitch, the procedure is postponed to 3:00 PM. Which response would be characteristic of an individual with OCPD? 1. "How dare they change my appointment? I insist that the procedure be done at 10:00 AM." 2. "That's fine. I can come in whenever it is convenient for everyone." 3. "This is unacceptable. I had my whole day planned out." 4. "Why are they doing this to me?"

3

A client with severe major depressive disorder is lying in bed and has not moved for 3 hours. The client will respond slowly to "yes" and "no" questions otherwise, the client does not respond when spoken to. The clinical manifestations exhibited by the client are known as: 1. Psychogenic dystonia 2. Psychogenic gait 3. Psychomotor retardation 4. Somatization

3

A female client who was the victim of acquaintance rape 2 months ago is receiving therapy for posttraumatic stress disorder (PTSD). She says to the nurse, "It's all my fault. I should have known not to accept a drink from someone I just met in a bar." What is the BEST response by the nurse? 1. "It may take time to overcome those thoughts and feelings." 2. "Those kinds of thoughts are self-destructive. You should stop thinking about it." 3. "You could not have anticipated the rape. You did not deserve or ask for it." 4. "You have to stop blaming yourself so you can move on with your life."

3

After a client with Alzheimer disease is found wandering in the middle of the street at 3:00 AM and returned by police, the community health nurse teaches family members about measures to keep the client safe at home. What is the MOST IMPORTANT strategy for the nurse to include in the instruction? 1. Ensure that the client is never left alone 2. Notify neighbors of the client's tendency to wander 3. Place a chain lock on the door above or below the client's eye level 4. Place a safe return bracelet on the clients non-dominant hand

3

An 87-year-old client has been admitted to the hospital with signs and symptoms of a urinary tract infection along with agitation; confusion, and disorientation to time and place. What is the MOST IMPORTANT nursing action? 1. Encouraging frequent fluid intake 2. Keeping the bed elevated with the side rails raised 3. Providing one-on-one supervision 4. Turning lights off in client's room to reduce stimulation

3

An elderly client at the end of life is visited by family members. One begins to cry and asks the nurse, "Will you please stay for a few minutes?" The nurse has other clients to care for as well. Which statement by the nurse is the MOST helpful? 1. "I am busy right now but can stay for a few minutes." 2. "I can call the clergy to come sit with you." 3. "I can stay and sit with you if you would like." 4. "I don't think I should interrupt your family time."

3

The client had surgery for possible cancer The positive biopsy result is back in the medical record: but the client has not been told that the biopsy showed malignancy. The client asks the nurse, "Am I going to die?" What is the BEST way for the nurse to INITIALLY handle the situation? 1. "Everyone will die one day, but good treatment is available for MOST cancers today." 2. "I can understand your anxiety about the situation. Let me call your health care provider (HCP)." 3. "Share with me your thoughts and feelings about the situation." 4. "The biopsy result came back as malignant, but that doesn't mean the cancer is not treatable."

3

The mental health nurse engaged in dialogue with a client would recognize transference when the client makes which statement? 1. "I can pretend to have feelings; how would you know the difference?" 2. "My roommate doesn't seem to like me very much." 3. "Sharing my thoughts with you will be difficult; you remind me of my sister." 4. "The people who work here do not seem genuine."

3

The nurse is caring for a client who entered the psychiatric emergency department in a state of acute psychosis after ingesting illicit substances. The parents ask the nurse if the client will develop schizophrenia. What is the MOST APPROPRIATE response by the nurse? 1. "I know it must be terrible to see your son like this, but he will be fine." 2. "MOST people have permanent side effects after an episode like this." 3. "Your son will have to remain here for observation until we know more." 4. "Your son would be fine right now if he had not taken these drugs."

3

The nurse is managing the care of a client diagnosed with chronic anxiety. Which behavior demonstrates to the nurse that the client possesses resilience? 1. Avoids anxiety-producing situations 2. Is able to identify anxiety-inducing triggers 3. Practices stress reduction techniques daily 4. Relies on anxiolytic medication to manage symptoms

3

The nurse is providing care to a client experiencing posttraumatic stress disorder (PTSD) following a terrorist attack at the client's place of worship. What is the PRIORITY nursing action? 1. Acknowledge the client's feelings of anger 2. Assess the client's support system 3. Encourage the client to talk about the trauma 4. Offer the client a PRN sleep medication

3

The nurse on the mental health unit receives report about a client diagnosed with schizophrenia who is experiencing a delusion of reference. Which client statement supports this symptom? 1. "I need for you to get rid of these bugs that are crawling under my skin." 2. "Hear that? She told me to kill my father." 3. "That song is a message sent to me in secret code." 4. "Those Martians are trying to poison me with the tap water."

3

The nurse plans care for a client diagnosed with anorexia nervosa who is being admitted after failure of outpatient treatment. Which client outcome will the nurse PRIORITIZE ? 1. Acknowledges poor interpersonal skills 2. Identifies new coping mechanisms 3. Increases caloric intake to gain weight 4. Verbalizes sources of conflict and anger

3

The nurse speaks with a client diagnosed with schizophrenia who begins to look away toward the door and grimace. Which statement by the nurse is MOST therapeutic at this time? 1. "It would be helpful if you could look at me while we talk." 2. "We can finish our conversation later; thank you for speaking with me." 3. "What do you see at the door?" 4. "When you don't look at me, I feel like you don't trust me"

3

The registered nurse is counseling the parent of a child recently diagnosed with attention-deficit hyperactivity disorder (ADHD), combined type. Which statement by the parent requires an INTERVENTION? 1. "I should offer a choice between 2 things for my child's clothes or meals." 2. "I will need to advocate for an individualized educational plan for my child." 3. "My child will outgrow this disorder around age 20." 4. "When talking with my child, I should not be multi-tasking."

3

The spouse brings a client to the emergency department due to erratic behavior and expressions of despair. The emergency department is extremely busy with many clients. When the triage nurse asks if the client feels suicidal now, the client shrugs the shoulders. What INITIAL action should the triage nurse take? 1. Ask the client to make a verbal contract to not harm self 2. Document that the client is not currently suicidal 3. Place the client in an inside hallway with one-on-one observation 4. Return the client to the waiting room with the spouse

3

Which client BEST demonstrates recovery associated with a mental illness? 1. One who demonstrates self-direction and responsibility regarding physical and psychosocial needs 2. One who is receiving holistic care that addresses both physical and psychosocial needs 3. One who lives, works, and is involved with family and friends to the HIGHEST level of ability 4. One who, while diagnosed with a mental illness, is able to demonstrate hope for the future

3

Which statement by a client with a diagnosis of dependent personality disorder would the nurse recognize as progress toward a positive therapeutic outcome? 1. "I really appreciate all the time you have spent trying to help me." 2. "I think I really messed up at work today." 3. "My mother could not drive me here today, so I took the bus." 4. "When my parents go away on vacation, I'm planning to stay with my cousin."

3

The clinic nurse speaks with the spouse of a client being treated for alcohol use disorder. Which statements by the spouse indicate codependence? SELECT ALL THAT APPLY. 1. "I am focusing on my new hobby and my friends in the book club." 2. "I left and didn't awaken my spouse, who went back to sleep after turning off the alarm clock." 3. "I try to get up early and keep the children from being too loud in the mornings." 4. "If I didn't get so stressed about my job, my spouse wouldn't drink so much." 5. "When my spouse was sick, I called and rescheduled clients so my spouse could rest."

3,4,5

The nurse reviews the social history of an adolescent client and understands that which behaviors support a diagnosis of conduct disorder? SELECT ALL THAT APPLY. 1. Blames voices when confronted about misbehavior 2. Fluctuates moods between depression and elation 3. Inserts thumbtacks into the feet of a neighbor's dog 4. Taps a pen on the desk to deliberately annoy peers 5. Vandalizes a painting in a local art museum

3,5

A client on a medical unit recently received a diagnosis of end-stage renal disease and was told of the need to go on dialysis. This morning the client was found in the bathroom trying to commit suicide by hanging using hospital gown ties. The client was stabilized and transferred to the psychiatric unit. Which of the following is the HIGHEST PRIORITY nursing action for this client? 1. Assess the client's risk for another suicide attempt 2. Encourage the client to express current feelings about the medical diagnosis 3. Place the client in a private room near the nurses' station 4. Provide continuous one-to-one observation with the client

4

A client on the locked unit of an inpatient psychiatric hospital says to a nurse on the evening shift, "During the day they let me out to go to the gift shop. You're my favorite nurse I know you'll be a good sport and give me a pass." What is the BEST response by the nurse? 1. "I guess the day shift staff needs to be reminded of the rules." 2. "The gift shop is not even open right now." 3. "Why do you want to go to the gift shop?" 4. "You do not have privileges for leaving the unit. I cannot give you a pass"

4

A client recently diagnosed with schizophrenia is brought to the mental health clinic by the identical twin sibling for the first follow-up visit after hospitalization. The client's sibling says to the nurse, "I read that schizophrenia runs in families. I guess I'm doomed." Which is the BEST response by the nurse? 1. "At the moment, I would worry more about how your sibling is doing." 2. "The odds are about 50-50 that you will come down with the disease as well." 3. "Would you like to talk to a health care provider about this?" 4. "You are at risk for the disease. However, there are other factors that contribute to the development of schizophrenia."

4

A client recently diagnosed with schizophrenia is hospitalized. The client appears distraught and says to the nurse, "The voices are bad today. They are so angry with me." Which of the following is the BEST response by the nurse? 1 "Do you need something to help you calm down?" 2. "Don't pay any attention to the voices. Let's go into the dayroom." 3. "The voices are not real. Tell them to go away." 4. "What are the voices saying to you?"

4

A client states, "I just don't know what to do about this situation with my parents," and the nurse replies, "I'm sure you will do the right thing." Which summary is true regarding the nurse's response? 1. The nurse has encouraged exploration of the client's situation 2. The nurse has shown interest in the client's concerns 3. The response conveys empathy toward the client and promotes self-confidence 4. The response devalues the client's feelings and gives false reassurance

4

A client who was placed in restraints appears in the hallway an hour later and states, "I'm Houdini... I can get out of anything. There could be trouble now." Which of the following is the BEST response to this client? 1. "How are you feeling now?" 2. "How did you manage to get out of the restraints?" 3. Say nothing but signal to other staff that assistance is needed. 4. "What kind of trouble are you thinking about?"

4

A client who was suddenly overwhelmed with an intense fear that something terrible was going to happen is brought to the emergency department by the spouse after they were out at dinner. The client is now shaking and has shortness of breath and heart palpitations. What is the PRIORITY nursing action? 1. Encourage the client to perform deep breathing exercises 2. Explore possible reasons for the episode 3. Place the client in a private room and tell the client to relax 4. Stay with the client

4

A newly admitted client with schizophrenia has been exhibiting severe social withdrawal, odd mannerisms, and regressive behavior. The client is sitting alone in the room when the nurse enters, says "good morning," and proceeds to sit down next to the client. Without responding, the client stands up and starts to leave. Which of the following actions is BEST for the nurse to take? 1. Ask where the client is going 2. Immediately follow the client out the door 3. In a loud voice, direct the client to come back to the room 4. Remain silent and allow the client to leave

4

A nurse on the telemetry unit receives a client admitted from the emergency department with acute alcohol intoxication, confusion, and a diabetic toe ulcer. Which INTERVENTION would be the PRIORITY ? 1. Assess for signs of alcohol withdrawal 2. Assess the need for alcohol rehabilitation referral 3. Let the client sleep off the alcohol intoxication 4. Monitor blood glucose levels during the night

4

A nurse performs the initial assessments for 4 assigned clients. The nurse identifies which client as being at GREATEST RISK for the development of delirium? 1 32-year-old client with gastroenteritis 2. 55-year-old client with coronary artery disease, 4 days post coronary bypass surgery 3 60-year-old client with type Il diabetes. 2 months post bilateral above-knee amputations 4. 80-year-old client with chronic obstructive pulmonary disease, chronic respiratory failure, and urosepsis

4

A young adult with obesity comes to the free clinic for a 2-week post-antibiotic follow-up visit for a superficial abdominal skin abscess. The client has a history of major depressive disorder and was hospitalized twice in the past 6 months for attempted suicide. The client now reports feeling "emotionally upset, alone, and at the end of my rope" due to difficulty finding a job and inability to qualify for medical insurance. The client is currently prescribed fluoxetine but has not been able to follow up with the prescribing health care provider (HOP). What is the PRIORITY nursing diagnosis (ND) at this time? 1. Hopelessness 2. Ineffective coping 3. Risk for infection 4. Risk for suicide

4

A young client is diagnosed with major depressive disorder. Three weeks prior, the client's fiancé broke off their engagement, claiming the client was "too fat and ugly." During a one-on-one interaction with the nurse, the client says, "My fiancé is really wonderful and is not to blame for calling off the engagement. I look awful and I'm not much good for anything." What is the BEST response by the nurse? 1. "How could your fiancé be wonderful after saying those things to you?' 2. "I think you are better off without your fiancé." 3. "Maybe the breakup was for the BEST." 4. "Tell me how you felt when your fiancé broke up with you."

4

The daughter of an 80-year-old client recently diagnosed with Alzheimer disease says to the nurse, "I can anticipate getting this disease myself at some point." What is the BEST response by the nurse? 1. "Have you suffered any recent head trauma?" 2. "If you modify your lifestyle, you can reduce your risk of familial Alzheimer disease." 3. "It is good that you recognize this now so you can plan for your future care." 4. "Not necessarily. The strongest known risk factor for Alzheimer disease is age."

4

The nurse prepares to assess a newly admitted client diagnosed with chronic alcohol abuse whose laboratory report shows a magnesium level of 1.0 mEq/L (0.5 mmol/L). Which assessment finding does the nurse anticipate? 1. Constipation and polyuria 2. Increased thirst and dry mucous membranes 3. Leg weakness and soft, flabby muscles 4. Tremors and brisk deep-tendon reflexes

4

The parent of an adolescent calls the mental health crisis hotline and says, "I just watched a TV program about bulimia and I think my child may have this disease." What is the MOST LIKELY reason that the parent came to this conclusion? 1. The adolescent has been wearing bulky, oversized clothing. 2. The adolescent has lost 20 lb (9 kg) in 2 months. 3. The adolescent stopped going to the gym. 4. The parent has found numerous candy, cake, and cookie wrappers under the adolescent's bed

4

The partner of a client with borderline personality disorder calls the clinic and reports coming home from work to find the client with self-inflicted superficial cuts to the arm. The partner tells the nurse, "My partner does something like this every time I have to go away on business. My partner is not serious about doing something really harmful, just trying to stop me from going away." What is the BEST response by the nurse? 1. "Are you still going to take your business trip?" 2. "It sounds like you are having a difficult time coping with your partner's behavior." 3. "Your partner is MOST LIKELY doing it for attention, so it's BEST to just ignore it." 4. "Your partner needs to be seen in the clinic today."

4

The student nurse is performing an assessment of a 10-year-old diagnosed with attention-deficit hyperactivity disorder (ADHD). In addition to the 3 core symptoms of ADHD (hyperactivity, impulsiveness, and inattention), which of the following would the student nurse expect to find during the assessment? 1. Confusion and a learning disability 2. Delayed physical and emotional development 3. Disorientation and cognitive impairment 4. Low self-esteem and impaired social skills

4

Which statement made by the nurse during a therapy session demonstrates a need for FURTHER INSTRUCTION regarding effective therapeutic communication techniques? 1. "I don't understand what you mean. Can you give me an example?" 2. "It is doubtful the president is out to get you." 3. "Tell me more about the day your child died." 4. "Why did you get so angry when she ignored you?"

4