Mental Health - Pre-Assessment Quiz

A nurse is caring for a client who is experiencing grief following the unexpected death of his spouse. Which of the following statements by the client indicates he is experiencing maladaptive behavior?

"I have started smoking again."

A nurse is caring for a client who has depression. The client refuses to get out of bed, go to activities, or participate in any of the unit's programs. Which of the following responses should the nurse take?

"I will help you get ready and then you can rest after activities"

A nurse is assessing a client who has a mood disorder to determine his readiness for discharge. Which of the following statements by the client indicates he is ready for discharge?

"I will take my medicines as I should and know to call the number you gave me if I have bad thoughts."

A nurse is admitting a clients who is about to undergo surgery for benign prostatic hypertrophy. The client states, "I don't know what I will do if they find I have cancer." Which of the following statements should the nurse make?

"I'm hearing that you are concerned that it might turn out that you have cancer."

A nurse is caring for a client who was involved in heavy combat and observed war casualties. The nurse should suspect that the client is suffering from posttraumatic stress disorder (PTSD) if the client makes which of the following statements?

"In my dreams, all I can see are the wounded reaching out and trying to grab me."

A charge nurse is providing teaching to a staff nurse about assisting the provider with electroconvulsive therapy (ECT). Which of the following responses by the staff nurse indicates understanding of the teaching?

"Informed consent should be obtained prior to ECT."

A nurse in an acute care facility is assessing a client who had a hip surgery and has Alzheimer's disease. The nurse asks the client how therapy went that morning. Which of the following statements by the client should the nurse document as confabulation?

"It was good. The Queen of England visited me there."

A school nurse is talking with a 13-year-old female at her annual health-screening visit. Which of the following comments made by adolescent should be the nurse's priority to address?

"None of the kids at this school like me, and I don't like them either."

A nurse is caring for a client who has been diagnosed with end-stage liver cancer. Which of the following responses is an indication the client is in the denial phase of the grief process?

"The doctor says I only have a few months to live, but I know he is exaggerating to get me to take my medication."

A nurse is teaching a client who has bipolar disorder and prescription for lithium to recognize the manifestations of toxicity. Which of the following statements by the client indicates an understanding of the teaching?

"Vomiting is an indication of toxicity."

A nurse is caring for an adolescent client who has a new diagnosis of schizophrenia. The client's parents are tearful and express feelings of guilt. Which of the following statements should the nurse make?

"You said that you feel guilty about your daughter's diagnosis. Let's talk about what is causing you to feel this way."

A nurse is providing medication teaching for a client who has a new prescription for phenelzine. Which of the following statements should the nurse include in the teaching?

"You should change positions slowly while taking this medication."

A nurse is caring for a group of older adult clients. Which of the following manifestations indicates one f the clients is experiencing delirium?

A client attempts to climb out of bed and repeatedly states she must get home

A nurse in a psychiatric unit is caring for several clients. Which of the following clients should the nurse recommend for group therapy?

A client who has been taking amitriptyline for 3 months for depression

A nurse on an acute mental health unit is caring for a group of clients. For which of the following clients is seclusion contraindicated?

An adult client following a suicide attempt

A nurse is discussing comorbidities associated with eating disorders with a newly admitted client. Which of the following conditions should the nurse include in the discussion? (SATA)

Anxiety Obsessive-compulsive disorder Depression

A nurse in an emergency department is caring for an adolescent client who reports being sexually assaulted just prior to admission. Which of the following actions should the nurse take?

Ask the client to describe the situation

A nurse is caring for a client who has schizophrenia. The client states, "The government is forcing thoughts into my brain through satellites." The nurse should document that the client is experiencing which of the following types of delusions?

Control

A nurse is performing a psychosocial assessment on an adolescent client. Which of the following should indicate to the nurse a potential risk for suicide? (SATA)

Death of a parent at a young age Recent impending move Low parental expectations Sudden decline in school performance

A nurse is planning discharge for a client who has borderline personality disorder. Which of the following interventions should be included for this client?

Dialectical behavior therapy

A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the following findings should the nurse expect?

Hand tremors

A nurse is assessing a client who has a diagnosis of conversion disorder. Which of the following is an expected finding?

Involuntary loss of a sensory function

A nurse is caring for a client who has bipolar disorder. The nurse is reviewing the client's assessment findings and laboratory results. Select the findings that require immediate follow-up.

Lithium level Pulse Sleep Difficulty focusing Rapid speech

A nurse is assessing a client who is receiving treatment with multiple antipsychotic medications and who suddenly became ill. Findings include blood pressure changes, hyperpyrexia, and diaphoresis. The nurse should recognize that which of the following adverse effects may be occurring?

Neuroleptic malignant syndrome

A nurse is admitting a client who is exhibiting manic behavior. The client reports recent personal stressors including the loss of her mother and a divorce. Which of the following is the priority nursing action?

Preventing self-directed violence

A nurse is caring for a client who is discussing this post-traumatic stress disorder and states, "Everyone thinks you should be able to put it out of your mind. It happened so long ago - just get over it!" The nurse responds, "It must be very frustrating to encounter this kind of attitude." The nurse is using which of the following therapeutic communication techniques?

Reflection

A nurse is counseling a client for the management of anxiety. The client is consistently late for appointments and ignores household chores. The client states, "I'm just too stressed. I need someone to take care of me." The nurse identifies this behavior as an example of which of the following defense mechanisms?

Regression

A nurse is caring for a client who has a new diagnosis of human immunodeficiency virus (HIV). He states, "I don't care what the doctors say, there is no way I can have HIV, and I don't need treatment for something I don't have." The nurse identifies that the client is experiencing which of the following types of crisis?

Situational

A client is admitted with post-traumatic stress disorder following a fire in his home in which family members died. Which of the following should the nurse recognize as an adaptive defense mechanism?

The client begins reading a book when he is experiencing hand tremors in response to loud noise

A nurse ins a mental health facility is interacting with a client who us angry and becomes increasingly aggressive. Which of the following actions should the nurse take?

Use clarification to determine what the client is feeling