NURS 3311 RN evidence-Based Practice in Mental Health Nursing Assessment

A nurse is teaching the concept of recovery to the family of a client who has a serious mental Illness (SMI). Which of the following statements should the nurse include in the teaching? "Recovery means that the client will be symptom-free." "Recovery means the same as it does for a client who has a medical diagnosis." "Recovery means that the client pursues life goals within the context of their mental illness." "Recovery means that the client is completely independent."

"Recovery means that the client pursues life goals within the context of their mental illness."

A nurse is discussing the effects adverse childhood experiences (ACEs) have on the brain with a client who has a history of ACEs. Which of the following statements should the nurse include? "ACEs does not have an effect on the brain." "ACEs force clients to live in survival mode." "ACEs block memories so that long-term memory is much less effective." "ACEs increase the awareness of clients' surroundings and has a positive effect on memory."

"ACEs force clients to live in survival mode."

A nurse is teaching a group of adolescents about the effects of adverse childhood experiences (ACEs). Which of the following statements should the nurse include? "There can be issues with brain development." "There is concern regarding medication adverse effects" "There is concern about the ability to understand the meaning of ACEs" "There are generally no effects from ACEs"

"There can be issues with brain development."

A nurse is caring for a client who has a serious mental illness (SMI). The client states, "I am so glad to be here because I know I will be healed here and can go on with a normal life!" Which of the following responses should the nurse give? "It sounds like you are motivated to work toward recovery and setting up routines that will work for your life." "You should see full recovery once you start your new medications." "It will take many months of treatment before you are symptom-free." "You should see a marked difference in your symptoms once you begin the group therapy sessions."

"It sounds like you are motivated to work toward recovery and setting up routines that will work for your life."

A nurse is caring for an adolescent who has a history of being physically abused. Which of the following statements should the nurse make regarding the adolescent's risk for abuse in the future? "We have talked with your parent, and you should not experience any more physical abuse from them." "Why don't you create three ways that you think will be helpful in reducing the number of abuse events?" "You must take some steps to keep yourself from being abused, like keeping your mouth shut if someone screams at you." "We are providing you with a resource that helps with self-regulation and decreasing abuse in the future."

"We are providing you with a resource that helps with self-regulation and decreasing abuse in the future."

A nurse is caring for a client who states, "I hate having to shower at night. At home, I shower in the morning to start my day." Which of the following responses should the nurse give to focus on client-centered care? "We have other clients who are on the morning shower list at this time, so you will need to shower in the evening." "We can arrange for you to take your showers in the morning." "Does it really make much difference what time you shower?" "You should shower at night, so you can go to bed clean."

"We can arrange for you to take your showers in the morning."

A nurse in the emergency department (ED) is caring for a client. Which of the following statements by the nurse should initiate a therapeutic relationship with the client? "You know that you should take the medication offered to you in the ED, if you want your symptoms to go away." "Would you be willing to spend some time talking with me about your thoughts on treatment for your concerns today?" "I need to get your blood pressure and pulse first. I will be back to talk with you later, as I have another client who I need to see first." "I understand you were not willing to work with the nurses in the ED today who were trying to help you. Why are you here?"

"Would you be willing to spend some time talking with me about your thoughts on treatment for your concerns today?"

A nurse in a pediatric provider's clinic is caring for four adolescents. Which of the following adolescents should the nurse identify as having a risk of sustaining an adverse childhood experience (ACE)? A 15-year-old adolescent who states their partner broke up with them after 1 month of dating A 12-year-old adolescent who states they are struggling with understanding their math homework A 17-year-old adolescent who states their parent has alcohol use disorder A 16-year-old adolescent who states one of their parents often has to travel for work

A 17-year-old adolescent who states their parent has alcohol use disorder

A nurse in a mental health clinic is reviewing clients' medical records. Which of the following clients should the nurse recognize as having a serious mental illness (SMI)? A client who has schizophrenia A client who has anxiety A client who has a fear of public speaking A client who was arrested for a DUI

A client who has schizophrenia

A nurse is meeting with an interprofessional team to discuss the clients who will be referred to Assertive Community Treatment (ACT) upon discharge. Which of the following clients should the nurse refer? A client who was diagnosed with dementia this week A client who sees a counselor for loneliness A client who is socially awkward and will not speak in front of groups A client who has schizophrenia and takes antipsychotic medication daily and has been hospitalized three times this year

A client who has schizophrenia and takes antipsychotic medication daily and has been hospitalized three times this year

A nurse is asked to evaluate a quantitative study to help prepare for an in-service about client aggression. Which of the following studies should the nurse evaluate? A formal research review of studies on IM medications for client aggression A study surveying the opinions of the nursing staff who are administering fewer IM medications for client aggression A study reporting a reduction in the use of IM medication for client aggression. A study looking at thoughts and feelings from clients who received IM medications for aggression

A study reporting a reduction in the use of IM medication for client aggression.

A nurse is caring for a client and asks the client for their name, date of birth, and what day and time it is. Which of the following steps of the nursing process is the nurse performing? Assessment Evaluation Implementation/intervention Planning

Assessment

A nurse is interviewing a newly admitted client who has major depressive disorder to determine if they might be having thoughts of suicide. Which of the following steps of the nursing process is the nurse performing? Planning Evaluation Assessment Implementation

Assessment

A nurse on an Inpatient mental health unit is is providing care to clients. Which of the following actions by the nurse is within the scope of practice for an RN on this unit? Psychotherapy Coordination of care Consultation Biological therapies

Coordination of care

A nurse is planning care for a client. Which of the following characteristics are essential for the nurse to effectively implement therapeutic use of self? (Select all that apply.) Emotional balance Assertiveness in facing life's challenges Goal-directed Compassionate care for clients Advanced skills in medication administration

Emotional balance Assertiveness in facing life's challenges Goal-directed Compassionate care for clients

A nurse is talking with a client who has been diagnosed with a phobia. The nurse states, "Tell me more about your fear of elevators." Which of the following therapeutic communication techniques is the nurse demonstrating? Exploring Clarification Restating Paraphrasing

Exploring

A nurse is caring for a client who has a serious mental illness (SMI) and is recovering from substance use disorder. The client has been taught that abstinence and looking at recovery as an ongoing process is the most effective way to vlew recovery. The nurse should identify this model as which of the following? Harm Reduction model Social Ecological (SE) model Rehabilitation model Trauma-informed care model

Harm Reduction model

A nurse is developing a client-centered plan of care for a client. Which of the following actions should the nurse include in the plan? Contact the client's family to build the client's schedule for the day Have the client select their nurse for each shift. Have the client select a therapy session time from the available slots. Consult with the charge nurse on which nursing interventions to include in the plan of care.

Have the client select a therapy session time from the available slots.

A nurse is caring for a client who has been sexually assaulted. Which of the following actions should the nurse take first to develop a therapeutic relationship with the client? Orient the client to the unit schedule Maintain a safe milieu. Review the client's past mental health history. Assist the client in choosing goals for their facility stay.

Maintain a safe milieu.

A nurse on a mental health unit is teaching a newly licensed nurse about the social ecological (SE) model when caring for clients who have a serious mental illness and need housing. Which of the following are factors of the SE model that the nurse should include? (Select all that apply.) Religion Organizational Individual Physical Policy Community Interpersonal

Organizational Individual Policy Community Interpersonal

A nurse is reviewing the medical record of a client on a chemical dependency unit and notes the provider refers to the recovery and the rehabilitation models. The nurse should identify that which of the following goals are similar in both models? Promotion of frequent hospitalizations to adjust medications Promotion of dependence on family members Promotion of reliance on medication Promotion of independence

Promotion of independence

A nurse on a mental health unit administered an antipsychotic medication to a combative client. The nurse goes to assess the client 30 min later and finds the client sleeping in their room. Which of the following Standards of Practice is the nurse demonstrating? Standard 1 Assessment Standard 3 Outcomes Identification Standard 4 Planning Standard 6 Evaluation

Standard 6 Evaluation

A nurse is assessing a client who has schizophrenia with an exacerbation of auditory hallucinations. The client is from a culture that stigmatizes mental health concerns. Which of the following responses should the nurse expect when they ask about the nature and frequency of the hallucinations? The client will be silent and give no eye contact. The client will smile and give a detailed explanation of the hallucinations. The client will give an angry look and yell that they do not have hallucinations. The client will give eye contact and cry out saying they hear voices now.

The client will be silent and give no eye contact.

A nurse is finding housing for a client who has a serious mental iliness (SMI) and is being discharged. Which of the following factors should the nurse consider? Available recreational activities Length of time since the diagnosis of the SMI Scheduled counseling appointments The degree of freedom the client will have to make decisions

The degree of freedom the client will have to make decisions

A nurse is caring for a client who has a mental illness. The client also vapes and has a history of tachycardia and high blood pressure. The nurse should teach health promotion on which of the following topics? (Select all that apply.) Tobacco/vaping Cardiovascular diet Medication adherence Adverse childhood experiences (ACES) Regular exercise

Tobacco/vaping Cardiovascular diet Medication adherence Regular exercise