Mental Health 115 - Exam 2

•A nurse assisting in the care of a client who has a mood disorder. Which of the following client statements by the client indicates readiness for discharge? •A. "Right now, I can't bathe or dress myself, but my family will help me." •B."I can always come stay in the hospital again if I don't want to take care of my own needs." •C. "I will take my medicines as I should and know who to call if I have bad thoughts." •D. "Taking care of myself is important, but it's okay if I don't want to do anything."

C. "I will take my medicines as I should and know who to call if I have bad thoughts."

•A nurse is assisting with the admission of a client to an acute mental health unit following a suicide attempt. The client has a history of depression, substance abuse, and anorexia nervosa. Which of the following actions should the nurse take first? •A. Review the client's toxicology laboratory report. •B. Make a contract with the client for weight gain. •C. Initiate one-to-one nursing observation. •D. Administer the Hamilton depression scale.

C. Initiate one-to-one nursing observation.

An adolescent caught stealing a classmate's laptop says that he needed it to write his paper and that the classmate "has enough money to buy another one anyway." This adolescent is demonstrating which of the following defense mechanisms? A. Denial B. Restitution C. Rationalization D. Conversion

C. Rationalization

A client says to the nurse, "You are the best nurse I've ever met. I want you to remember me." What is an appropriate response by the nurse? A. "Thank you, I think you are special too." B. "I suspect you want something from me. What is it?" C. "You probably say that to all the nurses." D. "Are you thinking of suicide?

D. "Are you thinking of suicide?

What is the rationale for a person taking lithium to have enough water and salt in his or her diet? A. Salt and water as necessary to dilute lithium to avoid toxicity B. Water and salt convert lithium into a useable solute C. Lithium is metabolized in the liver, necessitating increased water and salt D. Lithium and sodium compete for elimination through the kidneys

D. Lithium and sodium compete for elimination through the kidneys

The goal of treatment during the first phase of depression is to: A. Develop a plan for treatment B. Reduce uncooperative behaviors C. Help the client to adjust to antidepressants D. Reduce symptoms and inappropriate behaviors

D. Reduce symptoms and inappropriate behaviors

Nursing interventions for hospitalized clients with PTSD include: A. Encouraging a thorough discussion of the original trauma B. Providing private solitary time for reflection C. Time out during flashbacks to regain self-control D. Use of deep breathing and reality orientation

D. Use of deep breathing and reality orientation

•A nurse is caring for a client who is threatening to commit suicide. Which of the following questions should the nurse ask? •A. "How will you carry out your plan?" •B. "What happened to you in the past to make you so desperate?" •C. "Why do you feel depressed enough to end your life?" •D. "What will you accomplish by taking your life?"

•A. "How will you carry out your plan?"

BD replapse prevention:

difficulty sleeping can cause relapse pyschotherapy can prevent relapse anhedonia is a clinical manifestation of relapse

•A nurse is caring for a client who has an anxiety disorder. Which of the following findings should the nurse recognize as a manifestation of mild anxiety? •A. Incoherent speech •B. Irritability •C. Chest pain •D. Insomnia

•B. Irritability

•A nurse on an inpatient mental health unit is assisting with the admission of a client who reports feeling depressed, sad, moody, and overly anxious. Which of the following assessments should the nurse make first? •A. Coping abilities •B. Support systems •C. Suicide risk •D. Psychiatric history

•C. Suicide risk

•A nurse is caring for a client who has anorexia nervosa. Which of the following actions should the nurse take? •A. Complement the client for weight gain. •B. Allow the client to eat at any time. •C. Provide privacy when friends visit. •D. Weigh the client daily upon waking.

•D. Weigh the client daily upon waking.

priority for bipolar disorder

monitor for escalating behavior

•A nurse is caring for 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 nurse's priority action? •A. Identifying support systems. •B. Assisting the client in identifying coping behaviors. •C. Encouraging self-care. •D. Preventing self-directed violence.

•D. Preventing self-directed violence.

•A nurse in an acute care mental health facility is caring for a client who is experiencing an acute manic episode. Which of the following is the nurse's priority intervention? •A. Discourage the client's inappropriate sexual expression. •B. Control the client's use of loud and vulgar language. •C. Maintain the client's contact with family members. •D. Protect the client and others from impulsive behavior.

•D. Protect the client and others from impulsive behavior.

•A nurse in an acute care mental health facility is caring for a client who begins to have a panic attack. Which of the following actions should the nurse take first? •A. Ask the client what she was thinking about just before the attack began. •B. Teach the client how to perform relaxation techniques. •C. Administer a PRN antianxiety medication. •D. Stay with the client in a quiet place.

•D. Stay with the client in a quiet place.

•A nurse is caring for a couple who experienced a fetal death at 37 weeks of gestation. Which of the following responses by the nurse is therapeutic? •A. "I think you should call your minister. He can help comfort you." •B. "Did you have any complications during your pregnancy?" •C. "You are both young and can have other children." •D. "It must be very difficult for you both. I will be available if you need anything."

•D. "It must be very difficult for you both. I will be available if you need anything."

•A nurse is caring for a client who reports a state of increasing anxiety and the inability to sleep and concentrate. Which of the following is an appropriate response by the nurse? •A. "Everyone has trouble sleeping at times." •B. "Have you talked to your provider about this yet?" •C. "Why do you think you are so anxious?" •D. "It sounds like you're having a difficult time."

•D. "It sounds like you're having a difficult time."

•A nurse is assisting with an admission assessment for a client who has vegetative signs of depression. Which of the following is an appropriate intervention to recommend including in the plan of care? •A. Discourage rest only at bedtime. •B. Instruct family to avoid visiting during mealtimes. •C. Offer frequent, low-calorie snacks. •D. Developing a structured routine for the client to follow.

•D. Developing a structured routine for the client to follow.

•A nurse is caring for a client who has bipolar disorder and states that his latest computer project is "revolutionizing the industry." Which of the following behaviors is the client exhibiting? •A. Flight of ideas •B. Confabulation •C. Clang associations •D. Grandiosity

•D. Grandiosity

A nurse is collecting data from a client who has GAD. Which of the following findings should the nurse expect? SATA. a. excessive worry for 6 months b. impulsive decision-making c. delayed reflexes d. restlessness e. need for reassurance

a. excessive worry for 6 months d. restlessness e. need for reassurance

•A nurse is assisting with the admission of an adolescent female client who has anorexia nervosa. Which of the following findings should the nurse expect? •A. Diarrhea •B. Tooth erosion •C. Elevated potassium level •D. Muscle weakness

•D. Muscle weakness

•A nurse in an acute care mental health facility is caring for a hospitalized client who has agoraphobia. The nurse observes that the client is making progress when he is able to participate in which of the following activities? •A. Recreational therapy in the day room •B. Daily group therapy sessions •C. A picnic in a local park •D. Lunch in the hospital cafeteria with family

•C. A picnic in a local park

The nurse working with a client during a flashback says, "I know you're scared, but you're in a safe place. Do you see the bed in your room? Do you feel the chair you are sitting on?" The nurse is using what technique? A. Distraction B. Reality orientation C. Relaxation D. Deep breathing

B. Reality orientation

The nurse observes that a client with depression sat at a table with two other clients during lunch. Which is the best feedback the nurse could give the client? A. "Do you feel better after talking with others during lunch?" B. "I'm so happy to see you interacting with others" C. "I see you were sitting with others at lunch today" D. "you must feel so much better than you were a few days ago"

C. "I see you were sitting with others at lunch today"

A nurse is assisting with the plan of care for a client who has BDD. Which of the following actions should the nurse plan to take first? a. determine the clients risk for self harm b. instill hope for positive outcomes c. encourage the client to participate in group therapy d. encourage the client to participate in tx decisions

a. determine the clients risk for self harm

A nurse is working on an acute mental health unit is caring for a client who has PTSD. Which of the following are expected findings? a. difficulty concentrating on tasks b. obsessive need to talk about the traumatic event c. negative self image d. recurring nightmares e. diminished reflexes

a. difficulty concentrating on tasks c. negative self image d. recurring nightmares

a nurse is in a serious prolonged mass casualty incident at an acute care unit. which of the following strategies should the nurse use to help prevent PTSD? a. avoid thinking about it when it is over b. take break during the incident for food and water c. debrief with others following the incident d. hold emotions in check in the days following the incident e. take advantage of the offered counseling

b. take break during the incident for food and water c. debrief with others following the incident e. take advantage of the offered counseling

Care for a client if BD:

offer concise explanations establish consistent limits use a firm approach with communication

Expected findings - Dysrhytmic disorder:

presence of manifestations for at least 2 years

ASD expected findings

the client expresses a sense of unreality about the traumatic incident

a nurse is discussing the care of a client who has MDD. WHich statement is correct?

the client is at greatest risk for suicide during the first weeks of an MDD episode

Indication of derealization:

the client states that the furniture in the room seems to be small and far away

ECT in bipolar disorder

tx in clients experiencing severe mania

Intervention for dissociative fugue:

work with the client to develop grounding techniques

•A nurse in a community clinic is speaking to a parent who expresses concern for her adolescent son. Which of the following statements by the mother should indicate to the nurse that the adolescent is at risk for suicide? •A. "His basketball coach committed suicide last month." •B. "He has slept 9 hours each night for the past 2 years." •C. "He is very religious and attends services twice a week." •D. "He spends much of his time with his school friends."

•A. "His basketball coach committed suicide last month."

•A nurse observes that a client is sitting alone in her room crying. As the nurse approaches, she states, "I'm feeling really down and don't want to talk to anyone right now." Which of the following responses is appropriate for the nurse? •A. "I'll just sit here with you for a few minutes then." •B. "It might help you feel better if you talk about it." •C. "I understand. I've felt like that before, too." •D. "Why are you feeling so down?"

•A. "I'll just sit here with you for a few minutes then."

•A nurse is caring for a 20-year-old college student who has a 2-year history of bulimia nervosa. She tells the nurse, "I know my eating binges and vomiting are not normal, but I cannot do anything about them." Which of the following is a therapeutic response by the nurse? •A. "It seems like you are feeling helpless about this behavior." •B. "Do you have any idea why you do this?" •C. "I'm proud of you for recognizing that this behavior is not normal." •D. "You should stop because you need to. You are destroying your health."

•A. "It seems like you are feeling helpless about this behavior."

•A nurse is caring for a client who has major depressive disorder. The client states to the nurse, "Everything I do is wrong." Which of the following responses should the nurse make? •A. "You appear upset. Tell me more about that." •B. "I think you should take a walk for some fresh air." •C. "Why do you think that everything you do is wrong?" •D. "How was your group therapy session this morning?"

•A. "You appear upset. Tell me more about that."

•A nurse on an inpatient unit is caring for a client who has major depressive disorder. The nurse observes an improvement in the client's grooming when the client comes to breakfast. Which of the following statements should the nurse make? •A. "You look very nice after your bath." •B. "You should do that more often. You look great!" •C. "Everyone feels better after showering." •D. "Why are you so dressed up? Is it a special occasion?"

•A. "You look very nice after your bath."

•A client who is depressed and has attempted suicide tells the nurse, "I should have died because I am totally worthless." Which of the following responses should the nurse make? •A. "You've been feeling that your life has no meaning." •B. "It's not unusual for people who have depression to feel this way." •C. "Why do you feel you are worthless?" •D. "You have a great deal to live for."

•A. "You've been feeling that your life has no meaning."

•A nurse is collecting data from a group of clients who have anxiety disorders and have prescriptions for various psychotropic medications. The nurse should recognize which of the following clients as having an increased risk for suicide? •A. A client who has an obsessive-compulsive disorder and takes fluoxetine •B. A client who has generalized anxiety disorder and takes diazepam. •C. A client who has social anxiety disorder and takes propranolol. •D. A client who has generalized anxiety disorder and takes diphenhydramine

•A. A client who has an obsessive-compulsive disorder and takes fluoxetine

•A nurse is collecting data from a client who is to begin taking alprazolam. Which of the following findings should the nurse identify is a contraindication to this medication? •A. Alcohol use disorder •​B. Drug withdrawal •​C. Seizure disorder •​D. Suicide attempts

•A. Alcohol use disorder

•A nurse is collecting data from a client who has a depressive disorder. The client states, "I just can't feel any happiness or joy in life." Which of the following terms should the nurse use when documenting this finding?​ •A. Anhedonia •​B. Anergia •​C. Anosognosia •​D. Akathisia

•A. Anhedonia

•A nurse is caring for a client three days after admission to an acute care mental health facility for treatment of major depression. The client leaves her current activity, approaches the nurse and states, "There's no reason to go on living. I just want to end it all." Which of the following nursing interventions is appropriate? •A. Ask the client if she has a plan to commit suicide. •B. Recognize the attempt at manipulation and escort the client back to her activity. •C. Assist the client to her room and allow her to rest before resuming activity. •D. Notify the client's family and request a visitor to stay with the client until thoughts of suicide are gone.

•A. Ask the client if she has a plan to commit suicide.

•A nurse is contributing to the plan of care for a client who has obsessive-compulsive disorder regarding brushing his teeth. The client brushes his tongue several times a day and has developed several ulcerations. Which of the following interventions should the nurse identify as a priority? •A. Assist the client in identifying his anxiety level. •B. Speak to the client in a calm and soothing manner. •C. Assist the client to identify triggers to obsessive behaviors. •D. Provide information on stress reduction methods.

•A. Assist the client in identifying his anxiety level.

•A nurse is caring for a client who has anorexia nervosa. The client refuses a high-calorie nutritional supplement. Which of the following ethical principles is the nurse utilizing when respecting the client's decision?​ •A. Autonomy •​B. Beneficence •C. ​Veracity •D. ​Fidelity

•A. Autonomy

•A nurse is assisting with the admission assessment for a client who is receiving treatment following a situational crisis. Which of the following actions is the nurse's priority? •A. Determining if the client has thoughts of self-harm •B. Asking the client to identify the cause of the crisis •C. Identifying the client's coping skills •D. Identifying if friends or family are available to help

•A. Determining if the client has thoughts of self-harm

•A nurse in a long-term care facility is caring for an older adult client who is anxious and has trouble sleeping at night. Which of the following nursing measures should the nurse implement? •A. Get the client ready for sleep at the same time each night. •B. Move the client to a room next to the open nurses' station. •C. Play the client's favorite music in the room while the client is sleeping. •D. Encourage client to take a 1-hr nap each afternoon.

•A. Get the client ready for sleep at the same time each night.

•A nurse is caring for an older adult client who has a prescription for lorazepam 0.5 mg. Which of the following findings should the nurse report to the provider immediately? •A. Increased anxiety •B. Anorexia •C. Blurred vision •D. Disorientation

•A. Increased anxiety

•A nurse is assisting in the care of a client who has a depressive disorder. Which of the following interventions is the nurse's priority? •A. Monitor for risk of self-harm. •B. Administer prescribed antidepressants. •C. Encourage adequate fluid intake. •D. Assist with activities of daily living.

•A. Monitor for risk of self-harm.

•A nurse is collecting data from a client who has major depressive disorder (MDD). Which of the following findings should the nurse expect?​ •A. Significant change in weight •​B. Hyperexcitability •​C. Exaggerated response of pleasure to stimuli •​D. Attention-seeking behavior

•A. Significant change in weight

•A nurse is caring for a client following the recent, sudden death of his partner. The client says, "I feel paralyzed and can't seem to cope with work or family responsibilities anymore." Which of the following types of crisis is the client demonstrating?​ •A. Situational •​B. Maturational •C. ​Adventitious •D. ​Developmental

•A. Situational

•A nurse is collecting data from a client who has obsessive-compulsive disorder (OCD) and finds that the client demonstrates constant repetitive cleaning. The nurse should realize that the client's repetitive behaviors occur due to which of the following? •A. The client's attempt to decrease anxiety. •B. The client's delusion that cleaning is necessary. •C. The client's unconscious need to manipulate others. •D. The client's wish to decrease the time available for interaction with others.

•A. The client's attempt to decrease anxiety.

•A nurse on an acute care mental health unit is caring for a client who has generalized anxiety disorder. The client received an upsetting telephone call and is now rapidly pacing the corridors of the unit. Which of the following actions should the nurse take? •A. Walk with the client at a gradually slowing pace. •B. Allow the client to pace alone until physically tired. •C. Ask a small group of other clients to walk with the client. •D. Calmly instruct the client to stop pacing and sit in the dayroom.

•A. Walk with the client at a gradually slowing pace.

•A nurse is caring for a client who just delivered a stillborn infant at 36 weeks gestation. Which of the following responses should the nurse make? •A. "I understand your grief. I lost a baby also." •B. "You may hold your baby as long as you want." •C. "I have called for the chaplain to come and stay with you." •D. "This is for the best. Your baby was very ill."

•B. "You may hold your baby as long as you want."

•A nurse on the mental health unit is caring for a client who has bipolar disorder and comes to the nurse's station at 0300 demanding to see the provider. Which of the following responses should the nurse make? •A. "Go back to your room, and I'll try to get in touch with your provider in the morning." •B. "You seem to be very upset about something. Tell me about it." •C. "Why don't you wait to speak to your provider in the morning?" •D. "Everything will be okay until morning. You can speak with your provider then."

•B. "You seem to be very upset about something. Tell me about it."

•A nurse is assisting with a conflict-resolution group for adolescent clients in a community clinic facility. Which of the following clients should the nurse identify as being the highest risk for a suicide attempt? •A. A client who stated she is feeling anxious about going to a new school in the fall •B. A client who attempted suicide the previous year •C. A client whose family enjoys target shooting with guns •D. A client with deep religious views whose father recently died in an automobile crash

•B. A client who attempted suicide the previous year

•A nurse is caring for a hospitalized client who has bipolar disorder and is disturbing other clients with incessant talking. Which of the following actions should the nurse take? •A. Allow the client to interact freely with others on the unit. •B. Assist the client to practice social interaction with peers during a community meeting. •C. Escort the client to her room when she is observed trying to interact with other clients. •D. Inform the client that restraints may be necessary if she cannot control her behavior.

•B. Assist the client to practice social interaction with peers during a community meeting.

•A nurse is caring for a client who has obsessive-compulsive disorder (OCD). Which of the following actions should the nurse take first? •A. Discuss alternative coping strategies with the client. •B. Identify expectations for the client's personal participation in care. •C. Instruct the client on relaxation techniques. •D. Provide a structured daily activity schedule for the client.

•B. Identify expectations for the client's personal participation in care.

•A nurse is collecting data from a client following a recent suicide attempt. Which of the following findings in the client's history places him at the greatest risk for another suicide attempt? •A. Access to health care •B. Impulsivity •C. Close family ties •D. Effective problem-solving skills

•B. Impulsivity

•A nurse is collecting data from a female client who has anorexia nervosa. Which of the following findings should the nurse expect? •A. Decreased cholesterol levels •B. Low bone density •C. Heavy monthly periods •D. Elevated serum potassium level

•B. Low bone density

•A nurse is contributing to the plan of care for a client who is newly admitted with severe depression. Which of the following actions should be added to the plan of care? •A. Encourage the client to sleep during the day to make up for insomnia. •B. Offer the client frequent small snacks during waking hours. •C. Monitor the client for bouts of diarrhea. •D. Schedule a brisk physical activity before bedtime to facilitate sleep.

•B. Offer the client frequent small snacks during waking hours.

•A nurse is reviewing the admission laboratory values for a client who has a history of bulimia nervosa. Which of the following findings is the nurse's priority? •A. Serum chloride 96 mEq/L •B. Potassium 2.8 mEq/L •C. Hgb 11g/dL •D. Serum amylase 240 units/L

•B. Potassium 2.8 mEq/L

•A nurse is caring for a client who washes her hands repeatedly and almost constantly. The nurse should recognize the client's actions as which of the following? •A. Attempting to gain attention from others •B. Relieving the client's anxiety •C. Trying to avoid daily responsibilities •D. Acting out manic behavior

•B. Relieving the client's anxiety

•A nurse is collecting data from a client who has generalized anxiety disorders. Which of the following findings should the nurse expect in this client? •A. Sleeps 11 to 12 hr./night •B. Seeks reassurance from others •C. Makes impulsive decisions •D. Exhibits constant hair pulling or skin picking

•B. Seeks reassurance from others

•A nurse is contributing to the plan of care for an adolescent who is admitted for anorexia nervosa and is at 50% of her ideal body weight. Which of the following interventions should the nurse include in the plan? •A. Encourage weekly weight gain of 6 lb. for the first 2 weeks. •B. Set a specific duration for mealtimes. •C. Avoid giving the client liquid supplements. •D. Allow the client privacy during meals in order to promote trust.

•B. Set a specific duration for mealtimes.

•A nurse is contributing to the plan of care for a newly-admitted client who has severe depressive disorder. Which of the following interventions should the nurse include in the plan? •A. Give the client choices of activities. •B. Spend time with the client. •C. Play a game of chess with the client. •D. Encourage the client to make decisions.

•B. Spend time with the client.

•A nurse is assisting in the care of a client who has bipolar disorder. The client states, "I feel like Superman. I can do anything. I can fly home today and then become a U.S. Senator." Which of the following findings should the nurse document the client is exhibiting?​ •A. Flight of ideas •B. ​Grandiosity •C. ​Reality testing •D. ​Derealization

•B. ​Grandiosity

•A nurse is reinforcing teaching with a client who has a new prescription for fluoxetine. Which of the following instructions should the nurse include? •A. "Avoid foods that contain tyramine." •B. "Plan t to discontinue this medication as soon as your depression is relieved." •C. "Expect that your mood might take one to three weeks to begin improving." •D. "Stop taking this medication if weight loss or gain occurs."

•C. "Expect that your mood might take one to three weeks to begin improving."

•A nurse is caring for a client who has depression and states that she is too tired to get out of bed or dress. Which of the following statements by the nurse is appropriate? •A. "You really need to follow the rules of the unit and get out of bed." •B. "If you do not get out of bed, you will not receive your meal." •C. "I will help you sit up and get your slippers on." •D. "You should rest in bed until you feel able to take part in unit activities."

•C. "I will help you sit up and get your slippers on."

•A nurse who works in a community clinic facility is discussing suicide interventions with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of a tertiary intervention? •A. "Nurses should perform screenings to identify clients at risk for suicide." •B. "Nurses should recognize the lethality of a suicide plan." •C. "Nurses should arrange counseling for the family following the suicide of a client." •D. "Nurses should provide a safe environment to prevent the client from committing suicide."

•C. "Nurses should arrange counseling for the family following the suicide of a client."

•A nurse is caring for an older adult client who has a fractured hip. The client says, "I guess I've lived long enough and my time is up." Which of the following responses should the nurse make? •A. "You are in really good shape for your age." •B. "This is just a minor setback. You will be back on your feet in no time." •C. "You feel as though your life is ending?" •D. "The doctors are going to take good care of you. There is nothing to worry about."

•C. "You feel as though your life is ending?"

•A nurse is caring for a client who has depression. When the nurse encourages the client to join an activity the client states, "What's the use?" Which of the following is an appropriate nursing intervention? •A. Sit down with the client and ask her why she doesn't want to participate. •B. Tell the client that it is time for the activity, and accompany her to the activity. •C. Convince the client how helpful it will be to engage in the activity. •D. Tell the client that she has a self-defeating attitude and it will only make her feel worse.

•C. Convince the client how helpful it will be to engage in the activity.

•A nurse is caring for a client who has obsessive compulsive disorder (OCD) and is constantly picking up after others and cleaning in the day room. The nurse should recognize the client's actions as which of the following? •A. Manipulating and controlling others' behavior. •B. Focusing attention on useful tasks. •C. Decreasing anxiety to a tolerable level. •D. Limiting the amount of time available for interaction with others.

•C. Decreasing anxiety to a tolerable level.

•A nurse in an acute care mental health facility is caring for a client who commits suicide. Which of the following is the priority intervention for staff following this incident? •A. Attending a counseling session for staff members who provided care for the client. •B. Encouraging other clients on the unit to talk about their feelings regarding the suicide. •C. Identifying cues in the client's behavior that might have warned staff that he was contemplating suicide. •D. Recommending resources for the client's family to help them deal with their grief.

•C. Identifying cues in the client's behavior that might have warned staff that he was contemplating suicide.

•A nurse is caring for a client who has depression. After two days of treatment, the nurse notices that the client is suddenly more active and there are no longer signs of a depressive state. Which of the following interventions should the nurse recommend for the plan of care? •A. Encourage family to take the client out of the facility for short periods of time. •B. Reward the client for her change in behavior. •C. Monitor the client's whereabouts at all times. •D. Ask the client why her behavior has changed.

•C. Monitor the client's whereabouts at all times.

•A nurse is caring for a client who has major depressive disorder. Which of the following actions should the nurse take when developing a relationship with the client? •A. Share personal information to help the client feel comfortable. •B. Develop an emotional commitment to the client. •C. Set boundaries with the client regarding personal space. •D. Tell the client if she reminds the nurse of a personal friend or relative.

•C. Set boundaries with the client regarding personal space.

•A nurse is caring for a client who is experiencing a manic episode. Other clients begin to complain about her disruptive behavior on the unit. Which of the following nursing interventions is appropriate? •A. Warn the client that further disruptions will result in seclusion. •B. Ignore the client's behavior, realizing that it is consistent with her illness. •C. Set limits on the client's behavior and be consistent in approach. •D. Ask the client to recommend consequences for disruptive behavior.

•C. Set limits on the client's behavior and be consistent in approach.

•A nurse is caring for a client who is has an anxiety disorder and who has begun to hyperventilate, wring her hands, and is pacing the floor continually. Which of the following actions should the nurse take first? •A. Ask the client what precipitated this anxiety. •B. Offer the client a prescribed antianxiety medication. •C. Tell the client you will remain with her. •D. Take the client to a quiet room.

•C. Tell the client you will remain with her.

•A nurse is caring for a client who witnessed her brother's homicide and has posttraumatic stress disorder (PTSD). Which of the following findings should the nurse expect? •A. The client talks constantly about the traumatic experience. •B. The client is constantly drowsy and sleeps 11-12 hr daily. •C. The client is easily startled by loud voices. •D. The client reports satisfying personal relationships with family and close friends.

•C. The client is easily startled by loud voices.

•A nurse is collecting data from a client who has bipolar disorder with mania. Which of the following findings is the nurse's priority? •A. The client is hostile and sarcastic towards the staff. •B. The client gives personal items and money away to other clients. •C. The client paces in the hallway during the day and most of the night. •D. The client demonstrates flight of ideas.

•C. The client paces in the hallway during the day and most of the night.

•A nurse is caring for a postpartum client and her newborn. The client asks the nurse to feed the newborn. Which of the following responses should the nurse make? •A. "I'll feed him today. Maybe tomorrow you can try it." •B. "It's not difficult at all. You'll be fine." •C. "You should feed the baby yourself because you'll be going home tomorrow." •D. "Feeding an infant can feel a little intimidating at first, but I'll stay with you to help."

•D. "Feeding an infant can feel a little intimidating at first, but I'll stay with you to help."

•A nurse in an acute care mental health facility is caring for a client who has depression and has performed no ADLs since admission 3 days ago. The nurse observes that the client is now wearing clean clothes and has combed her hair. Which of the following is an appropriate response by the nurse? •A. "Oh, I'm so pleased that you finally put on clean clothes." •B. "Why did your wear clean clothes and comb your hair today?" •C. "That's good. You have on clean clothes and have combed your hair." •D. "I see that you have on clean clothes and have combed your hair."

•D. "I see that you have on clean clothes and have combed your hair."

•A nurse is caring for a newly admitted female client who has depression and refuses to get out of bed, dress, or participate in group therapy. Which of the following is an appropriate nursing response? •A. "If you don't participate in your care, you will not get better." •B. "You can remain in bed until you feel well enough to join the milieu." •C. "The unit rules state that clients may not remain in bed." •D. "I will assist you in getting out of bed and getting dressed."

•D. "I will assist you in getting out of bed and getting dressed."

•A nurse is discussing suicide intervention with nursing staff. Which of the following actions should the nurse identify as an example of secondary intervention? •A. Providing support for family and friends following a suicide •B. Identifying individuals who are at higher risk for attempting suicide •C. Recognizing the warning signs of suicide •D. Performing life-saving measures following a suicide attempt

•D. Performing life-saving measures following a suicide attempt

•A nurse is caring for a newly-admitted client who has obsessive-compulsive disorder. Which of the following actions should the nurse take? •A. Set strict limits on the client's behaviors. •B. Inform the client that the ritualistic behaviors serve no purpose. •C. Isolate the client for a period of 48 hr. •D. Plan the client's schedule to allow time for rituals.

•D. Plan the client's schedule to allow time for rituals.

•A nurse is making a home visit for a 16-year-old adolescent who attempted suicide. Which of the following behaviors should alert the nurse that the adolescent still has suicidal intent? •A. Telling his parents that he doesn't want to talk about the attempt •B. Stating that he wants to be with his peers more than with his parents •C. Preferring to eat his meals while watching TV •D. Planning to give his CD collection to his girlfriend

•D. Planning to give his CD collection to his girlfriend

•A nurse is caring for a client who is 2 weeks postpartum. The client tells the nurse, "I feel really down and sad lately. I have no energy and I feel like I'm going to cry." Which of the following actions should the nurse take first? •A. Reinforce teaching about ways to increase rest and sleep. •B. Arrange for counseling to help the client cope with the stress of being a parent. •C. Request a prescription for an antidepressant medication. •D. Use a postpartum depression-screening tool with the client.

•D. Use a postpartum depression-screening tool with the client.

•A nurse is caring for a client who is in the acute manic phase of bipolar disorder. Which of the following activities is appropriate for the nurse to suggest to the client? •A. Attending a client's birthday party in the café •B. Watching a movie with a group of clients in the day room •C. Participating in a basketball game in the gym •D. Walking with the nurse on the grounds of the facility

•D. Walking with the nurse on the grounds of the facility

•A nurse is assisting in the development of a staff educational inservice about depression. Which of the following factors should the nurse identify as a primary risk factor for depression?​ •A. Being married •B. ​Pregnancy •​C. Male gender •D. ​Chronic illness

•D. ​Chronic illness

•A nurse is collecting data from a client who has posttraumatic stress disorder (PTSD) following a sexual assault. Which of the following is an expected finding?​ •A. Sleeping 12 hr or more each day •B. ​Increasing sense of attachment to others •C. ​Constant need to talk about the event •D. ​Increasing feelings of anger

•D. ​Increasing feelings of anger

•A nurse is caring for a client who escapes anxiety-causing thoughts by ignoring their existence. The nurse should recognize this behavior as which of the following defense mechanisms?​ •A. Repression •​B. Splitting •C. ​Sublimation •D. ​Undoing

•D. ​Undoing

•A nurse is collecting data from an adolescent client who has anorexia nervosa. Which of the following findings should the nurse expect?​ •A. Tachycardia •​B. Constipation •​C. Metrorrhagia •​D. Hyperkalemia

•​B. Constipation

•A nurse is collecting data from a group of clients who have depressive disorders. Which of the following findings should the nurse expect? •A. A focus on past successes •B. Hallucinations •​C. A lack of energy •D. Increased libido

•​C. A lack of energy

•A nurse is assisting with planning of care for a client following a suicide attempt. Which of the following interventions is an appropriate suicide precaution?​ •A. Remove utensils from the client's meal trays. •​B. Assign the client to a private room. •​C. Inspect the client's personal belongings. •​D. Tuck bedcovers over client's hands and arms.

•​C. Inspect the client's personal belongings.

•A nurse is assisting in the care of a client who exhibits manifestations of a major depressive episode. The provider wants to rule out medical conditions that also cause these manifestations. Which of the following medical conditions should the nurse anticipate the provider testing for?​ •A. Pancreatitis •​B. Cholecystitis •​C. Tuberculosis •​D. Hypothyroidism

•​D. Hypothyroidism

•A nurse is caring for a client who has a new diagnosis of human immunodeficiency virus (HIV). The client 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 should identify that the client is experiencing which of the following forms of crisis?​ •A. Adventitious •​B. Internal •​C. Maturational •​D. Situational

•​D. Situational