Crisis 1 Exam 1
Which statement made by the nurse best demonstrates a core concept of patient- and family-centered care? A. "Would you prefer I call you by your first name?" B. "Would you like to go with the group today to see a movie?" C. "Let me see if I understood your concerns about your medications." D. "Today I'll plan to spend time with you discussing your treatment plan."
C
Which nursing actions demonstrate the ability to engage in active listening during a nurse-client conversation? A. Noting that the client is wringing his or her hands nervously B. Nodding to demonstrate agreement with the client's statement C. Sharing similar personal experiences and feelings with the client D. Introducing new topics when the conversation reverts to silence
A
Which question will the nurse ask the client during a psychosocial assessment to judge existing social patterns? A. "Please describe your typical day." B. "How do you spend your free time?" C. "Do you have a religious affiliation?" D. "Who do you talk to when you have a problem?"
A
A nurse who is comfortable and confident with the interviewing process will effectively use which communication technique? A. Allowing for moments of uninterrupted silence B. Personally fills each void in the conversation C. Avoiding topics that could possibly be embarrassing D. Relying on verbal rather than nonverbal communication
A
A day shift nurse contacts a nurse scheduled for night shift at home and says, "Our unit is full and there are eight patients in the emergency department waiting for a bed." The night shift nurse replies, "Thanks for telling me. I am calling in sick." Which type of problem is evident by the night shift nurse's reply? a. Ethical problem of fidelity b. Legal problem of negligence c. Legal problem of an intentional tort d. Violation of the patients' right to treatment
A
A distraught 8-year-old girl tells the nurse, "I had a horrible nightmare and was so scared. I tried to get in bed with my parents but they said, 'No.' I think I could have gone back to sleep if I had been with them." Which family dynamic is likely the basis of this child's comment? a. Boundaries in the family are rigid. b. The family has poor differentiation of roles. c. The girl is enmeshed in part of a family triangle. d. Generational boundaries in the family are diffuse.
A
A novice nurse has been assigned to the mental health inpatient unit. In order to best facilitate growth in both experience and skills, which assignment should be delegated to the nurse? A. Co-leader of a self-care group B. Medication nurse on night shift C. Reviewing care plans for possible revisions D. Discharge education for clients requiring social services
A
A nurse is caring for an adolescent client who has anorexia nervosa with recent rapid weight loss and a current weight of 90 lb. Which of the following statements indicates the client is experiencing the cognitive distortion of catastrophizing? A. "Life isn't worth living if I gain weight." B. "Don't pretend like you don't know how fat I am." C. "If I could be skinny, I know I'd be popular." D. "When I look in the mirror, I see myself as obese."
A
A nurse is communicating with a client who was admitted for treatment of a substance use disorder. Which of the following communication techniques should the nurse identify as a barrier to therapeutic communication? A. Offering advice B. Reflecting C. Listening attentively D. Giving information
A
A nurse prepares a patient in a rural community for an initial telehealth visit with the health care provider. Select the nurse's priority action. a. Ensure that the patient's rights to privacy are respected. b. Ask the patient, "How much do you know about the Internet?" c. Inform the patient, "This experience will be like appearing on television." d. Advise the patient, "You will be able to hear, but not see, your health care provider."
A
A nursing assistant says to the nurse, "The schizophrenic in room 226 has been rambling all day." When considering the nurse's responsibility to manage the ancillary staff, which response should the nurse provide? a. "It is more respectful to refer to the patient by name than by diagnosis." b. "Thank you for informing me about that. I will document the behavior." c. "It is not unusual for schizophrenics to do that. It's just part of their illness." d. "You have a difficult job. I'm glad you are so accepting of our patients' behaviors."
A
A patient diagnosed with major depressive disorder tells the community mental health nurse, "I usually spend all day watching television. If there's nothing good to watch, I just sleep or think about my problems." What is the nurse's best action? a. Refer the patient for counseling with a recreational therapist. b. Ask the patient, "What kinds of program do you like to watch?" c. Suggest to the patient, "Are there some friends you could call instead?" d. Advise the patient, "Watching television and thinking about problems makes depression worse."
A
A patient has been out of work 3 weeks with a major illness and anticipates another month of recovery. The patient tells the nurse, "I'm trying to keep up with my work email from home. They hired a new person in my department but the person has no experience." Select the nurse's therapeutic response. a. "It sounds like you're saying you are worried about your job security." b. "No one expects you to keep pace with your job while you're recovering." c. "Your employer is required to hold your job for you while you're on sick leave." d. "Don't worry about your job right now. It's more important for you to recover."
A
A patient is diagnosed with an abscess in the cerebellum. Which nursing diagnosis has priority for the plan of care? a. Risk for falls related to loss of balance and equilibrium b. Unilateral neglect related to impairments to perception c. Impaired physical mobility related to spasticity and changes in muscle tone d. Risk for impaired cerebral tissue perfusion related to obstruction secondary to infection
A
A timid client is frequently insulted by another aggressive client. In group session today the client spoke out to the bully about his or her behavior. Which statement by the nurse demonstrates a therapeutic attempt to show approval for the client's actions? A. "How did it feel to be assertive and stand up for yourself?" B. "You did a good job of defending yourself today in group." C. "Did it feel good to defend yourself against that rude behavior?" D. "I hope that you will be able to defend yourself again when you are bullied."
A
An adult experiencing a recent exacerbation of ulcerative colitis tells the nurse, "I had an accident while I was at the grocery store. It was so embarrassing." Select the nurse's therapeutic response. a. "Most grocery stores have public restrooms available." b. "Tell me more about how you felt when that happened." c. "People usually have compassion about those types of events." d. "Your disease is now in remission so that is not likely to happen again."
A
As Election Day nears, a mental health nurse studies the position statements of various candidates for federal offices. Which candidate's commentary would the nurse interpret as supportive of services for persons diagnosed with mental illness? a. "Full parity insurance coverage for mental illness" b. "Coverage for biologically based mental illnesses" c. "Reimbursement for initial treatment of addictions" d. "Managed care oversight for mental illness services"
A
In order to demonstrate the integration of evidence-based practice (EBP) into the care of a client who has been hospitalized for severe depression and prescribed a selective serotonin reuptake inhibitor (SSRI), the novice nurse will include which action into the plan of care? A. Assess the client for the presence of suicidal ideations with a plausible plan B. Ask the health provider to prescribe the medication to be administered orally C. Acquire the advice of a proficient nurse about implementing suicide precautions D. Apply restraints when the client repeatedly attempts to cut his or her wrists with a plastic knife
A
The nurse recognizes that the greatest barrier to successful mental health treatment and recovery is demonstrated by which client? A. The teenager who fears being rejected by his peers B. The young homeless adult who cannot keep clinic appointments C. The elderly Syrian immigrant who speaks only minimal English D. The middle-aged adult who cannot afford prescription medication
A
The nurse recognizes the influence of a dysfunctional hypothalamus when including which intervention for a specific client? A. Sleep hygiene measures for a 40-year-old diagnosed with acute depression B. Limit setting for a 14-year-old diagnosed with oppositional defiance disorder (ODD) C. Staff to accompany a 30-year-old diagnosed with anorexia nervosa to the bathroom D. Frequent re-orientation to time and place for a 79-year-old diagnosed with dementia
A
The nurse, striving to minimize the bias of a Western view on what is considered acceptable behavior, will consult which mental health associated resource? A. Cultural Formulation Interview (CFI) B. Glossary of Cultural Concepts of Distress C. The client's past and present mental health assessment D. The Diagnostic and Statistical Manual of Mental Disorders
A
When a client expresses an irrational belief, which response by the nurse demonstrates reframing? A. "Your teacher's suggestions about improving your grades, don't mean you're stupid." B. "She wouldn't ask to reschedule the appointment if she didn't want to meet with you." C. "What makes you think your spouse is thinking about leaving you?" D. "Everyone has a bad day. It wasn't your fault."
A
When considering prevalence, the nurse will focus on which disorder(s) when identifying the focus of a community mental health screening? A. Anxiety disorders B. Affective disorders C. Alcohol dependence D. Any substance abuse
A
When discussing the current trend to treat mental health clients in community care environments, the nurse identifies which treatment-related event as the trigger for the shift away from traditional hospitalization? A. Increase in availability of psychopharmacological agents B. Increased availability of community resources for treating the mentally ill C. Decreased voluntary commitments being made to traditional hospital settings D. Decrease in the number of clients being diagnosed as being chronically mentally ill
A
Which scenario best demonstrates empathetic caring? a. A nurse provides comfort to a colleague after an error of medication administration. b. A nurse works a fourth extra shift in 1 week to maintain adequate unit staffing. c. A nurse identifies a violation of confidentiality and makes a report to an agency's privacy officer. d. A nurse conscientiously reads current literature to stay aware of new evidence-based practices.
A
Which statement by the nurse demonstrates a blurring of boundaries with a client diagnosed with depression? A. "The client is just too depressed to shower and dress today." B. "Today we discussed the impact of depression on family members." C. "The client talked about an uncle who was depressed and committed suicide." D. "I'm concerned that the client's depression has been the cause of marital problems."
A
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
A nurse caring for a client who has anorexia nervosa. Which of the following examples demonstrates the nurse's use of interpersonal communication? A. The nurse discusses the client's weight loss during a health team meeting B. The nurse examines their own personal feelings about clients who have anorexia nervosa C. The nurse asks the client about personal body image perception D. The nurse presents an educational session about anorexia nervosa to a large group of adolscents
C
A nurse in an acute mental health facility is assisting with discharge planning for a client who has a severe mental illness and requires supervision. The client's partner works all day but is home by late afternoon. Which of the following strategies should the nurse suggest for follow-up care? A. Receiving daily care from a home health aide B. Having a weekly visit from a nurse case worker C. Attending a partial hospitalization program D. Visiting a community mental health center on a daily basis
C
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 a 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 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 backwards 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, B, C
A nurse is working in a community mental health facility. Which of the following services does this type of program provide? (select all that apply) A. Educational groups B. Medication dispensing programs C. Individual counseling programs D. Detoxification programs E. Family therapy
A, B, C, E
A nurse is obtaining a nursing history from a client who has a new diagnosis of anorexia nervosa. Which of the following questions should the nurse include in the assesment? (Select all that apply) A. "What is your relationship like with your family?" B. "Why do you want to lose weight?" C. "Would you describe your current eating habits?" D. "At what weight do you believe you will look better?" E. "Can you discuss your feelings about your appearance?"
A, C, E
A nurse is planning a peer group discussion about the Diagnostic and Statistical Manual of Mental Disorders, 5th edition. 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 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, D, E
A client has been diagnosed with a social phobia. Which statement made by the nurse best supports the milieu of the outpatient day clinic regarding this client's treatment? A. "Everyone here really understands your fears." B. "This is a safe place to learn to interact with people." C. "The rules of the milieu are designed to control behaviors." D. "The milieu seldom changes and so presents a stable environment."
B
A community mental health nurse is preparing to address a national parent-teachers' organization. Which statement concerning the availability of residential treatment centers for emotionally disturbed children in the United States should the nurse include? A. Such centers have increased, but only marginally since 2004 B. The number of centers grew substantially between 2004 and 2008 C. Availability of these centers has declined steadily over the last decade D. Availability of such treatment beds has remained stagnant over the last decade
B
A neighbor telephones the nurse daily, giving lengthy details about multiple somatic complaints and relationship problems. Which limit-setting strategy should the nurse employ? a. Suggest the neighbor call other people in the community. b. Say to the neighbor, "I can talk to you for 15 minutes twice a week." c. Use the telephone's caller identification to screen calls from the neighbor. d. Tell the neighbor, "You should discuss these concerns with your personal physician rather than me."
B
A nurse decides to put a client who has 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
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
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 status
B
A nurse is caring for a group of clients. Which of the following clients should a nurse consider for referral to an assertive community treatment (ACT) group? A. A client in an acute care mental health facility who has a fallen several times while running down the hallway B. A client who lives at home and keeps "forgetting" to come in for a scheduled monthly antipsychotic injection for schizophrenia C. A client in a day treatment program who reports increasing anxiety during group therapy D. A client in a weekly grief support group who reports still missing a deceased partner who has been dead for 3 months
B
A nurse managing the care of a client diagnosed with an eating disorder has begun to experience frustration when the client consistently pushes back against the planned interventions. What action on the part of the nurse is indicated to help strengthen the nurse-client relationship? A. Demonstrating a very matter-of-fact attitude when addressing issues related to interventions B. Acknowledging to the client that working toward these treatment goals must be very frightening C. Regularly sharing with peers the feelings and asking for their suggestions on minimizing the frustration D. Asking that a more experienced nurse be allowed to act as monitor in order to identify any existing countertransference
B
A nurse plans a group meeting for adult patients in a therapeutic milieu. Which topic should the nurse include? a. Coping with grief and loss b. The importance of hand washing c. Strategies for money management d. Staffing shortages expected over the next 3 days
B
A patient asks the psychiatric mental health registered nurse, "I'm having so much anxiety. I think hypnosis would help me. Will you do that for me?" When determining a response, which factor should the nurse consider? a. The patient's current medication regime b. State regulations regarding scope of practice c. The patient's level of participation within the therapeutic milieu d. The plan of care the multidisciplinary team has developed for the patient
B
Considering Maslow's pyramid, which comment indicates an individual is motivated by the highest level of need? a. "Even though I'm 40 years old, I have returned to college so I can get a better job." b. "I help my community by volunteering at a thrift shop that raises money for the poor." c. "I recently applied for public assistance in order to feed my family, but I hope it's not forever." d. "My children tell me I'm a good parent. I feel happy being part of a family that appreciates me."
B
In which scenario is it most urgent for the nurse to act as a patient advocate? a. An adult cries and experiences anxiety after a near-miss automobile accident on the way to work. b. A homeless adult diagnosed with schizophrenia lives in a community expecting a category 5 hurricane. c. A 14-year-old girl's grades decline because she consistently focuses on her appearance and social networking. d. A parent allows the prescription to lapse for 1 day for their 8-year-old child's medication for attention-deficit/hyperactivity disorder.
B
On an inpatient unit, one patient assaults another patient resulting in a small laceration. Considering the patients' right to confidentiality, how will the nurse effectively document this event? a. Ensure unit safety by documenting the hostile and combative characteristics of the assaulting patient. b. Document in each patient's medical record the events and actions taken, using initials of other patients involved. c. Document in both patients' medical records that an occurrence (incident) report was prepared according to agency policy. d. Verbally report the events to other team members and minimize written documentation in order to reduce potential legal consequences.
B
Systematic measurement of body weight, body mass index (BMI), waist circumference, and glucose levels would be most important for a patient beginning a new prescription for which medication? a. Aripiprazole (Abilify) b. Olanzapine (Zyprexa) c. Ziprasidone (Geodon) d. Quetiapine (Seroquel)
B
The decision to intervene as a patient advocate is clearly identified by the American Nurses Association's (ANA) code of ethics in which situation? A. A client's need for assistance while ambulating post-surgery B. A suspicion that a staff member is unfit to provide client care C. Working with a client to identify triggers for aggressive behavior D. Providing emotional support to a client experiencing a loss of a parent
B
The school nurse assesses four adolescents, all of whom outwardly appear healthy. Which adolescent meets one criterion for anorexia nervosa with mild severity? a. 5'2" tall; weight 104 pounds b. 5'7" tall; weight 110 pounds c. 5'5" tall; weight 114 pounds d. 5'8" tall; weight 127 pounds
B
When considering the civil rights of a mentally ill client, which circumstance may affect the autonomy of the client regarding decisions associated with his or her care? A. Being accused of a felony B. Judged to be legally incompetent C. Recent immigrant to the United States D. Being treated for a chronic mental illness
B
When the nurse recognizes a relationship as being symmetrical what intervention would be appropriate? A. Sharing the treatment goals with the parents of an adolescent client B. Asking if discharge instructions should be postponed until the client's life partner arrives C. Discussing concerns about a possibly impaired coworker with the unit's nursing manager D. Calling the primary health provider to discuss the client's pain control management needs
B
Which intervention is appropriate for only an advanced practice mental health nurse? A. Setting milieu management policies for an adolescent unit B. Conducing a couples psychotherapy group focusing on effective parenting C. Assisting a client's family in identifying appropriate housing for their parent D. Presenting information on the special needs of the depressed to a family support group
B
Which nursing assessment question is focused on determining the client's motivation for binge eating? A. "Does binging help you get the attention you need?" B. "Would you say that you are less depressed after binging?" C. "Are you less likely to hear voices while you are binging?" D. "Do you sleep better at least temporarily after binging?
B
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, C, D
A nurse is performing an admission assessment of a client who has bulimia nervosa with purging behavior. Which of the following is an expected finding? (Select all that apply) A. Amenorrhea B. Hypokalemia C. Yellowing of the skin D. Slightly elevated body weight E. Presence of lanugo on the face
B, D
The nurse is determining discharge living arrangements for a mental health client. Which behavior demonstrated by the client would qualify him or her for financial reimbursement for placement into a psychiatric home care environment? A. Engages in numerous compulsive rituals B. Expresses paranoia regarding police persons C. Experiences panic attacks when among strangers D. Experiences both auditory and visual hallucinations
C
A client clearly states, "I'm not taking that pill and you can't make me." Which statement best addresses the nursing obligation to a client who is demonstrating non-adherent behaviors? A. "You're right: I can't make you take the medication." B. "Something is wrong; you seem very tense and agitated today." C. "The medication will help you relax; if it doesn't, we'll talk about other options." D. "You won't get better if you insist upon being noncompliant with your plan of care."
C
A client diagnosed with major depression is reluctant to agree to the medication therapy stating, "I don't see how medication that affects my brain is going to make me less depressed." Which statement by the nurse best addresses the client's concern? A. "While the brain is a very complex organ, it does respond very well to this medication." B. "Are you afraid of taking the medication because of what your friends and family maythink?" C. "Your brain controls your emotions; this medication will help the brain do that moreeffectively." D. "The staff has your best interests in mind and knows that this medication is very effective in treating depression."
C
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
A community mental health nurse is planning care to address the issue of depression among older adult clients in the community. Which of the following interventions should the nurse implement as a method of tertiary prevention? A. Educating clients on health promotion techniques to reduce the risk of depression B. Performing screenings for depression at community health programs C. Establishing rehabilitation programs to decrease the effects of depression D. Providing support groups for clients at risk for depression
C
A group of nurses privately discuss patients under their care. Which nurse's comment indicates the need for clinical supervision regarding countertransference? a. "My patient is always asking my permission to do something, just like a child." b. "When our unit is understaffed, it seems like we have more incidents of disruptive behavior." c. "My patient tries to tell me what to do all the time. I got a divorce because my spouse used to do that." d. "Our patients have had so many traumatic life experiences. I find myself feeling sympathetic sometimes."
C
A hospitalized client has a history of resorting to aggressive verbal abuse when angry. Which nursing action demonstrates a behavioral modification technique? A. 10 minutes of recreation therapy is lost for each verbal outburst B. Client is educated on the benefits of deep breathing to control anger C. A nutritious snack is earned each time an abusive outburst is avoided D. Client is scheduled to attend a daily group session on anger management
C
A mentally ill gunman opens fire in a crowded movie theater, killing six people and injuring others. Which comment about this event by a member of the community most clearly shows the stigma of mental illness? a. "Gun control laws are inadequate in our country." b. "It's frightening to feel that it is not safe to go to a movie theater." c. "All these people with mental illness are violent and should be locked up." d. "These events happen because American families no longer go to church together."
C
A nurse assesses a new patient whose chief concern is "daily crying spells." Which comment from the patient would prompt the nurse to suspect a medical reason is causing the problem rather than depression? a. "I usually drink two or three cups of coffee in the morning." b. "I often have headaches, especially when the pollen count is high." c. "Years ago I had thyroid problems but they cleared up and I stopped the medicine." d. "I recently had three moles removed because my doctor thought they were suspicious."
C
A nurse assesses four adolescents diagnosed with various eating disorders. Which comment would the nurse expect from the adolescent diagnosed with anorexia nervosa? a. "I look good because whenever I overeat, I purge myself." b. "I love sweets. I make myself throw up so I can eat more." c. "I've lost 60 pounds but I'm still a size 2. I want to be a size 0." d. "I've hidden my eating disorder from everyone, even my parents."
C
A nurse is caring for a client who has bulimia nervosa and has stopped purging behavior. The client tells the nurse about fears of gaining weight. Which of the following responses should the nurse make? A. "Many clients are concerned about their weight. However, the dietitian will ensure that you don't get too many calories in your diet." B. "Instead of worrying about your weight, try to focus on other problems at this time." C. "I understand you have concerns about your weight, but first, let's talk about your recent accomplishments," D. "You are not overweight, and the staff will ensure that you do not gain weight while you are in the hospital. We know that is important to you."
C
A nurse is planning care for several clients who are attending community-based mental health programs. Which of the following clients should the nurse visit first? A. A client who received a burn on the arm while using a hot iron at home B. A client who requests a change of antipsychotic medication due to some new adverse effects C. A client who reports hearing a voice saying that life is not worth living anymore D. A client who tells the nurse about experiencing manifestations of severe anxiety before and during a job interview
C
A nurse participating in a community health fair interviews an adult who has had no interaction with a health care professional for more than 10 years. The adult says, "I like to keep to myself. Crowds make me nervous." Which action should the nurse employ? a. Refer the adult for a full health assessment. b. Explore the adult's family and social relationships. c. Ask the adult, "How do you feel about the quality of your life?" d. Explain to the adult, "We can help you feel better about yourself."
C
A patient begins a new prescription for risperidone (Risperdal). Which intervention should the nurse include in the plan of care? a. Monitor intake and output daily. b. Educate patient about foods that contain tyramines. c. Assess sitting, standing, and lying blood pressure daily. d. Administer with food to reduce gastrointestinal irritation.
C
A patient has been disruptive to the therapeutic milieu for two days. A certified nursing assistant says to the nurse, "We need to seclude this patient because this behavior is upsetting everyone on the unit." Considering patients' rights, the nurse should respond, a. "Seclusion is not part of this patient's plan of care." b. "Let's think of some new ways to help this patient be less disruptive." c. "Thank you for that suggestion. I will discuss it with the health care provider." d. "Disruptive behavior is expected with mental illness. We must respond therapeutically."
C
A patient tells the community mental health nurse, "I told my health care provider I was having trouble sleeping and he prescribed trazodone 50 mg every night. I read on the internet that drug is an antidepressant, but I'm not depressed. What should I do?" Which response by the nurse is correct? a. "I will help you contact your health care provider for clarification regarding this new prescription." b. "Insomnia and depression usually go hand-in-hand. If your depression is relieved, your sleep will improve." c. "In low doses, trazodone helps relieve insomnia. Higher doses are needed for antidepressant effects to occur." d. "Information on the internet is often misleading and incorrect. It's more important to trust the judgment of your health care provider."
C
An adult plans to attend an upcoming tenth high school reunion. This person says to the nurse, "I am embarrassed to go. I will not look as good as my classmates. I haven't been successful in my career." Which comment by the nurse addresses this cognitive distortion? a. "You look fine to me. Do think you will have fun at your reunion?" b. "Everyone ages. Other classmates have had more problems than you." c. "Do you think you are the only person who has aged and faced difficulties in life?" d. "I think you are doing well in the face of the numerous problems you have endured."
C
An experienced nurse in a major medical center requests a transfer from a general medical unit to an acute care psychiatric unit. Which organizational feature would best support this nurse's successful transition? a. Assignment to medication administration for the first 6 months b. Working with a seasoned mental health technician for the first month c. Co-assignment with a knowledgeable psychiatric nurse for an extended orientation d. Staff development activities focused on developing therapeutic communication skills
C
Considering the administration of medications, the nurse applying evidence-based nursing practice will engage in which nursing activity? A. Educating the client regarding the side effects of a newly prescribed antidepressant B. Confirming the client's identity prior to administering a prescribed PRN medication C. Determining the client's preference about when a medication prescribed once daily is administered D. Assessing the client for allergies prior to the administration of a newly prescribed mood stabilizing medication
C
In which nurse-patient interaction would it be appropriate for the nurse to consider using touch? a. Comforting a tearful patient of Japanese heritage b. Counseling a child who was physically abused by a parent c. Welcoming a person of Hispanic heritage to a new group session d. Interacting with a Native American who has a hearing impairment
C
Shortly after hospitalization, an adolescent diagnosed with anorexia nervosa says to the nurse, "Being fat is the worst thing in the world. I hope it never happens to me." Which response by the nurse is appropriate? a. "You need to gain weight to become healthier." b. "Your world would not change if you gained a few pounds." c. "Tell me how your world would be different if you were fat." d. "Your attractiveness is not defined by a number on the scales."
C
The nurse admits a patient experiencing hallucinations and delusional thinking to an inpatient mental health unit. The plan of care will require which service occurs first? a. Social history b. Psychiatric history c. Medical assessment d. Psychological evaluation
C
The nurse interacts with a veteran of World War II. The veteran says, "Veterans of modern wars whine and complain all the time. Back when I was in service, you kept your feelings to yourself." Select the nurse's best response. a. "American society in the 1940s expected World War II soldiers to be strong." b. "World War II was fought in a traditional way but the enemy is more difficult to identify in today's wars." c. "We now have a better understanding of how trauma affects people and the importance of research-based, compassionate care." d. "Intermittent explosive devices (IEDs), which were not in use during World War II, produce traumatic brain injuries that must be treated."
C
The nurse plans care for a newly hospitalized patient experiencing panic level anxiety after an automobile accident. The patient has no physical injuries. When selecting goals from the Nursing Outcomes Classification (NOC), the nurse will a. Select outcomes related to patient learning. b. Focus first on the long-term goals for the patient. c. Individualize outcomes based on the patient's needs. d. Confer with the patient about which outcomes the patient wants to achieve.
C
The nurse presents a class about mental health and mental illness to a group of fourth graders. One student asks, "Why do people get mentally ill?" Select the nurse's best response. a. "There are many reasons why mental illness occurs." b. "The cause of mental illness is complicated and very hard to understand." c. "Sometimes a person's brain does not work correctly because something bad happens or they inherit a brain problem." d. "Most mental illnesses result from genetically transmitted abnormalities in cerebral structure; however, some are a consequence of traumatic life experiences."
C
The nurse who holds very strong beliefs about the right to life issue is asked by a client to provide information about the procedures associated with an abortion. When considering the principle of veracity, what action should the nurse take when responding to the client's educational needs? A. Refer the request to the primary health care provider B. Explain to the client that the nurse's view on abortion is biased C. Present the information in a matter-of-fact, non-emotional manner D. Delay the discuss until another nurse is available to provide the information
C
What is the fundamental rule when considering the need for securing informed consent from a client for a treatment? A. The primary provider determines the need for informed consent B. Involuntary commitment negates the need for informed consent C. If the procedure intrudes into the body or poses a health risk consent is needed D. If the client is incompetent, informed consent is provided by an appointed surrogate
C
What is the primary factor considered when determining the need for an involuntary mental health commitment? A. The cognitive status of the client B. The behaviors being demonstrated C. The danger posed by the behaviors D. The criminal nature of the behavior
C
Which anticonvulsant mood stabilizer often prescribed for bipolar disorder carries a Black Box warning that includes pancreatitis? A. Ramelteon B. Lamotrigine C. Valproic acid D. Carbamazepine
C
Which assessment data confirms that the client diagnosed with anorexia nervosa has achieved a fundamental treatment outcome? A. Acknowledges that symptoms of depression exist B. Client has eaten 60% of three meals per day for 3 consecutive weeks C. Client has maintained weight at 87% of ideal body weight for 2 months D. Demonstrates an understanding of what constitutes healthy eating habits
C
Which client statement supports the nurse's assessment that the client has demonstrated resiliency? A. "Losing a parent is a natural part of life." B."I know I'm not the first person to lose a loved one." C. "I've learned from experiencing other losses that I'll be okay." D. "Losing my mother is the hardest thing I've ever experienced."
C
Which intervention implemented by a community mental health nurse demonstrates the unique skills required of that position? A. Prescribing medications B. Advocating for a community clinic C. Making a referral to a neighborhood food bank D. Providing spiritual counseling for client and their family
C
Which intervention should the nurse implement to reinforce value education for an adolescent client with a history of being both physically and emotionally abused? A. Helping the client identify those who have or are still being abusive B. Reinforcing for the client the steps to take when one is being abused in any form C. Modeling to demonstrate the difference between assertive and aggressive behavior D. Presenting the client with information regarding the various forms of abusive behavior
C
Which nursing assessment question is focused on securing information about what Freud called the client's conscious mind? A. "Are you satisfied with the life you lead?" B. "Do you feel loved and valued by your family?" C. "What are your beliefs about interracial marriage?" D. "Can you identify something that you feel you do well?"
C
Which nursing intervention will best address the intense need to control demonstrated by a client receiving treatment of bulimia nervosa? A. Monitoring the client for the presence of suicidal thoughts and behaviors B. Helping the client reframe irrational thinking that leads to dysfunctional eating C. Clearly stating expectations and admitting that they differ from those of the client D. Having the client keep a journal that identifies triggers that cause dysfunctional eating
C
Which patient is likely to achieve maximum benefit from cognitive behavioral therapy (CBT)? a. Older adult diagnosed with stage 3 Alzheimer's disease b. Adult diagnosed with schizophrenia and experiencing delusions c. Adult experiencing feelings of failure after losing the fourth job in 2 years d. School-age child diagnosed with attention-deficit/hyperactivity disorder (ADHD)
C
Which question will the nurse ask in order to assess a client's ability to think clearly? A. "Are you employed full time?" B. "Do you feel guilty about your recent divorce?" C. "How do you plan to afford getting your own apartment?" D. "What do you think is your most valuable personal characteristic?"
C
Which scenario meets the criteria for "normal" behavior? a. An 8-year-old child's only verbalization is "No no no." b. A 16-year-old girl usually sleeps for 3 or 4 hours per night. c. A 43-year-old man cries privately for 1 month after the death of his wife. d. A 64-year-old woman has difficulty remembering the names of her grandchildren.
C
Which statement by the nurse addresses the fundamental issue associated with an ethical dilemma? A. "Have you ever resolved an ethical dilemma before?" B. "What are your beliefs regarding treatment for chronic illnesses?" C. "Let's discuss the pros and cons of the three available treatment plans." D. "The problem poses an ethical question that complicates the decision process."
C
Which statement by the nurse best confirms the relationship being maintained with the client is a therapeutic one? A. "I'll plan to meet with you again tomorrow at our regular time." B. "Do you agree with me that we need to focus on your anger issues?" C. "Can you give me some examples of how your coping skills have improved?" D. "I'm sure you will get significant benefit from attending the group I suggested."
C
Which statement made by the nurse concerning a client experiencing musculoskeletal pain demonstrates attention to the evaluation portion of the nursing process? A. "The client's daughter confirmed that he had knee replacement surgery three years ago." B. "The client's inability to ambulate effectively without assistance is a priority problem." C. "After 2 weeks of physical therapy, the client can safely walk the length of the hallway." D. "The client has expressed a strong fear of falling when asked to walk without assistance."
C
While weighing patients on an eating disorders unit, the nurse overhears a psychiatric technician say, "I wish I had an eating disorder; maybe I'd lose a little weight." What is the nurse's best action? a. Report the clinical observation to the nursing supervisor. b. Ask the psychiatric technician, "What did you mean by that comment?" c. Privately discuss the importance of sensitivity with the psychiatric technician. d. Immediately interrupt the interaction between the patient and psychiatric technician.
C
A 55-year-old lives 100 miles from her parents and mother-in-law. In the past year, her father had back surgery, her mother broke her hip, and her mother-in-law had a cardiac event. Which nursing diagnosis is most applicable to the 55-year-old? a. Risk for complicated grieving related to impending deaths of parents b. Risk for injury related to frequent long drives to care for aging parents c. Risk for chronic low self-esteem related to overwhelming responsibilities d. Risk for caregiver role strain related to responsibilities for care of aging parents
D
A charge nurse is conducting a class on therapeutic communication with a group of newly licensed nurses. Which of the following aspects of communication should the nurse identify as a component of verbal communication? A. Personal space B. Posture C. Eye contact D. Intonation
D
A client has demonstrated behaviors suggestive of schizophrenia. As a part of the diagnostic process, the nurse is preparing the client for a magnetic resonance imaging study (MRI). Which statement by the nurse best addresses the client's concern about why the test is being done? A. "It's a painless way to see inside the brain and view its structures." B. "It's a series of cross-sectional pictures of the structure of your brain." C. "This method reduces the brain's exposure to x-rays and radioactive isotopes." D. "The study will show how well the blood is flowing to the ventricles of your brain."
D
A client prescribed a second-generation antipsychotic (SGA) asks why the medication is referred to with that term. What is the nurse's best response? A. "It's used to identify the newer form of antipsychotic medications." B. "SGAs are capable of treating a larger variety of mental illnesses." C. "SGAs produce fewer side effects than the first generation formulation does." D. "They contain a higher ratio of serotonin to dopamine than first generation forms do."
D
A colleague tells the nurse, "I have not been able to sleep for the past three days. I feel like a robot." What is the nurse's best action? a. Direct the colleague to leave the facility immediately. b. Observe the colleague closely for evidence of impaired practice. c. Offer to administer medications to patients assigned to the colleague. d. Confer with the supervisor about the nurse's ability to safely deliver care.
D
A nurse counsels a widow whose husband died 5 years ago. The widow says, "If I'd done more, he would still be alive." Select the nurse's therapeutic response. a. "I understand how you feel after such a terrible loss." b. "That was a long time ago. Now it's time to move on with your life." c. "You did a very good job of caring for him, especially since he was sick so long." d. "Your husband was 82 years old with severe chronic obstructive pulmonary disease."
D
A nurse in an acute mental health facility is communication with a client. The client states, "I can't sleep. I stay up all night," The nurse responds, "You are having difficulty sleeping?" Which of the following therapeutic communication techniques is the nurse demonstrating? A. Offering general leads B. Summarizing C. Focusing D. Restating
D
A nurse is planning care for a client who anorexia nervosa with binge-eating and purging behavior. Which of the following actions should the nurse include in the client's plan of care? A. Allow the client to select preferred meal times B. Establish consequences for purging behavior C. Provide the client with a high-fat diet at the start of treatment D. Implement one-to-one observation during meal times
D
A nurse is talking with the caregiver of a child who has demonstrated recent changes in behavior and mood. When the caregiver of the child asks the nurse for reassurance about their child's condition, which of the following responses should the nurse make? A. "I think your child is getting better. What have you noticed?" B. "I'm sure everything will be okay. It just takes time to heal." C. "I'm not sure what's wrong. Have you asked the doctor about your concerns?" D. "I understand you're concerned. Let's discuss what concerns you specifically."
D
A nurse working in an acute care unit for adolescents diagnosed with mental illness says, "Our patients have so much energy. We need some physical activities for them." In recognition of needs for safety and exercise, which activity could the treatment team approve? a. Badminton tournament b. Competitive soccer matches c. Intramural basketball games d. Line dancing to popular music
D
A nurse's sibling happily says, "I want to introduce you to my fiancé. We're getting married in six months." The nurse has encountered the fiancé in a clinical setting and is aware of the fiancé's diagnosis of schizophrenia. What is the nurse's best response? a. In private, tell the sibling about the fiancé's diagnosis. b. Encourage the sibling to postpone the wedding for at least a year. c. Ask the fiancé, "Have you told my sibling about your mental illness?" d. Say to the sibling and fiancé, "I hope you will be very happy together."
D
A patient has been oppositional, demanding, and resistant to working on goals. A mental health nurse tells the nursing supervisor, "We finally had a serious talk. I let that patient know it's time to get right with God and stop this behavior." Recognizing the nurse's actions were not acceptable, select the supervisor's responding action. a. Review the facility policies regarding patient's rights with the nurse. b. Ask the nurse about documentation related to this patient interaction. c. Schedule the nurse for a staff development activity on cultural sensitivity. d. Work with the nurse to prepare and analyze a process recording of the interaction.
D
A patient is hospitalized with a diagnosis of anorexia nervosa. The nurse reviews the patient's laboratory results below. Sodium 143 mEq/L Potassium 3.1 mEq/L Chloride 102 mEq/L Magnesium 2.2 mEq/L Calcium 8.4 mg/dL Phosphate 3.0 mg/dL The nurse should take which action next? a. Measure the patient's body temperature. b. Inspect the patient's skin and sclera for jaundice. c. Assess the patient's mucous membranes for erosion. d. Auscultate the patient's heart rate, rhythm, and sounds.
D
A patient reports to a primary care provider about sleeplessness, constant fatigue, and sadness. In our current health care climate, what is the most likely treatment approach that will be offered to the patient? a. Group therapy b. Individual psychotherapy c. Complementary therapy d. Psychopharmacological treatment
D
An adult experienced a spinal cord injury resulting in quadriplegia 3 years ago and now lives permanently in a skilled care facility. Which comment by this person best demonstrates resiliency? a. "I often pray for a miracle that will heal my paralysis so I will be whole again." b. "I don't know what I did to deserve this fate or whether I am tough enough to endure it." c. "My accident was a twist of fate. I suppose there are worse things than being paralyzed." d. "Being paralyzed has taken things from me but it hasn't kept me from being mentally involved in life."
D
In a staff meeting at an inpatient mental health facility for persons, the administrator announces that psychiatric technicians will now be supervised by the milieu director rather than by nurses. What is the nurse's best action? a. Confer with colleagues about their opinions regarding the proposed change. b. Volunteer to participate on a committee charged with defining job responsibilities of unlicensed assistive personnel. c. Ask the administrator to delay implementation of this change until the decision can be reviewed by an interdisciplinary team. d. Advise the administrator of regulations in the state nurse practice act regarding supervision of unlicensed assistive personnel
D
The nurse is conducting an admission interview with a client newly admitted voluntarily to the mental health unit for acute depression. Which statement made by the nurse best addresses the initial goal of a therapeutic nurse-patient relationship? A. "I am very pleased that you decided to seek treatment for your depression." B. "The staff is very experienced in treating clients with depression like yours." C. "Please feel free to discuss your problems with me or any of the other nursing staff." D. "My aim is to provide you with a safe, consistent environment to deal with your issues."
D
The nurse prepares outcomes to the plan of care for an adult diagnosed with mental illness. Which strategy recognizes the current focus of treatment services for this population? a. The patient's diagnoses are confirmed using advanced neuroimaging techniques. b. The nurse confers with the treatment team to verify the patient's most significant disability. c. The nurse prioritizes the patient's problems in accordance with Maslow's hierarchy of needs. d. The patient and family participate actively in establishing priorities and selecting interventions.
D
The treatment goal is for the hospitalized mental health client to be discharged to a residential treatment environment. The nurse includes which experience into the client's plan of care as a priority intervention? A. Art therapy to reduce the effects of the client's illness B. Recreational therapy to improve the client's social well-being C. Physical therapy to address any existing musculoskeletal disabilities D. Occupational therapy to assist in assuming skills needed to regain independence
D
What classic characteristic is noted in clients diagnosed with bulimia nervosa? A. Male B. Obesity C. Involved in sports D. Onset in late adolescence
D
Which assessment data would the nurse expect to document after the administration of a mental status examination on a client with no history of mental illness? A. Denies any difficulties of a financial nature B. Generally eats three meals a day with snacks C. Sleeps 7 hours a night and 1 hour each afternoon D. Speaks and presents information in an organized fashion
D
Which comment by the nurse would be appropriate to begin a new nurse-patient relationship? a. "Which of your problems is most serious?" b. "I want you to tell me about your problems." c. "I'm an experienced nurse. You can trust me." d. "What would you like to tell me about yourself?"
D
Which institution specific clinical practice resource will the nurse use to integrate evidence-based practice (EBP) into the care of a client hospitalized for the purpose of the evaluation of his or her current therapy plan? A. Researching current medication options using Internet resources B. Reviewing decision points for therapy planning provided by clinical practice guidelines C. Using a clinical algorithm in the form of a decision tree to review treatment approaches D. Implementing a clinical pathway to provide expected outcomes using a measurable format
D
Which patient would the nurse expect to have the most difficulty with problem solving and decision making? a. An 18-year-old diagnosed with bulimia nervosa at age 14; has taken oral doses of fluoxetine (Prozac) daily for 3 years b. A 46-year-old diagnosed with schizophrenia at age 24; has taken oral doses of clozapine (Clozaril) daily for 18 years c. A 62-year-old diagnosed with bipolar disorder at age 28; has taken oral divalproex sodium (Depakote) daily for 16 years d. A 52-year-old diagnosed with schizophrenia at age 21; has taken monthly injections of haloperidol (haldol decanoate) for 12 years
D
Which statement by the nurse best demonstrates a dilemma associated with the utilization of evidence-based practice (EBP) in the mental health clinical setting? A. "The client can't afford the cost of the medication he's being prescribed." B. "The client doesn't see the benefit of changing to this new form of therapy." C. "I really hated that the in-service on that new therapy modality was filled up." D. "It's hard to review the literature about this new treatment when we are so short staffed."
D
Which statement demonstrates the nurse's implementation of a therapeutic projective question? A. "Do you believe that miracles are possible?" B. "Has your life ever been touched by a miracle?" C. "If you were granted two wishes what would they be?" D. "If you could wish this problem away, what would your life be like?"
D
