MH 1

1. A nurse plans to leave a scheduled shift an hour early without notifying or asking permission from the charge nurse. The clients in the nurse's assignments are stable. Which of the following legal torts applies to this situation? a. Negligence b. Battery c. Libel d. Slander

a. Negligence

1. A nurse is admitting a client to an alcohol abuse program. The client states "I'm here because of my boss. It was part of my job to go to parties and drink with clients". The client's statement is an example is an example of which of the following defense mechanism? a. Rationalization b. Compensation c. Reaction-formation d. Suppression

a. Rationalization

1. A nurse on an inpatient mental health unit is admitting a client who has panic-level anxiety. After showing the client to his room, which of the following nursing actions is most therapeutic at this time? a. Remain with the client for a while a. Suggest that the client rest in bed b. Have the client join a therapy group c. Medicate the client with a sedative

a. Remain with the client for a while

1. The nurse is caring for a client following a physical assault. The client states " I don't remember what happened to me". The nurse should recognize that the client is using which of the following defense mechanism? a. Repression b. Displacement c. Ratiolinalization d. denial

a. Repression

1. A nurse is providing behavior therapy for a client who has obsessive compulsive disorder. The client repeatedly checks that the doors are locked at night. Which of the following instructions should the nurse give the client when using thought stopping technique? a. Snap a rubber band on your wrist when you think about checking the locks b. Ask a family member to check the locks for you at night c. Focus on abdominal breathing whenever you go t check the locks d. Keep a journal of how often you check the lock ach night

a. Snap a rubber band on your wrist when you think about checking the locks

1. A nurse is admitting a client with multiple injuries following a motor vehicle crash. Shortly after admission, the clients partner arrives. The partner is distraught and self blames for the accident. Which of the following responses should the nurse make? a. Tell me more about your feelings about what happened to your partner b. I think you should calm down a little before you see your partner c. Why do you think the crash is your fault? d. Do not worry about that. Your partner will be fine

a. Tell me more about your feelings about what happened to your partner

1. A nurse observes a clients spouses sitting alone in the waiting room crying. When approached, the spouse says, "I am really concerned about my husband". Which of the following is a therapeutic nursing response? a. Tell me what is concerning you b. Your husband is making really good progress c. Crying helps us let things out and we feel better d. Did you husband say something to upset you?

a. Tell me what is concerning you

1. During a group session on an inpatient mental health unit, a patient with Bipolar I, currently in a manic state is very intrusive, often interrupting others, and tangenital. The nurse knows it is important for the group to remain therapeutic. Which statement by the nurse is the best way to address the clients behavior? a. Thank you for participating, but we need to make sure everyone in the group has a chance to talk b. I do not think this is the right group for you, maybe you can try another group later c. You are not ready for group at this time, so leave the room d. You need to stop taking over this group right now

a. Thank you for participating, but we need to make sure everyone in the group has a chance to talk

1. A nurse is providing teaching about confidentiality with a newly licensed nurse. Which of the statements by the newly licensed nurse indicates an understanding of the teaching? a. The court might require me to discuss confidential information b. I am required to provide confidential information to insurance companies c. If questioned during a police investigation, I am required to divulge confidential information d. I am legally allowed to discuss confidential information with the clients former therapist

a. The court might require me to discuss confidential information

1. A nurse is preparing an in-service presentation for a group of newly licensed nurses about the use of restraints. Which of the following should the nurse include as a criterion for applying restraints? a. The nurse has already considered alternatives to restraints b. The client must understand the need for the restraints c. The health care provider must renew a restraint prescription every 8 hr d. The restraints should promote the clients safety and prevent injuries

a. The nurse has already considered alternatives to restraints

1. A nurse in a mental health facility is interacting with a client who is angry and becoming increasingly aggressive. Which of the following actions should the nurse take? a. Use clarification to determine what the client is feeling b. Maintain constant eye contact with the client c. Speak to the client using an authoritative voice d. Move the client to a private area so the conversation will not be disturbed

a. Use clarification to determine what the client is feeling

1. A nurse who works in a psychiatric unit is caring for a client who has bipolar disorder. The client comes to the nurse's station at 0300 demanding that the nurse calls the provider immediately. Which of the following responses by the nurse is appropriate? a. You must be very upset about something b. Go back to your room, and ill try to get in touch with your doctor c. You are being unreasonable, and I will not call your doctor at this hour d. I can't call a doctor in the middle of the night unless it's an emergency

a. You must be very upset about something

1. A nurse is caring for a client who is extremely suspicious of the nursing staff and other clients. Which of the following nursing approaches is appropriate when establishing a therapeutic relationship with this client? a. Disclose some personal information to the client to demonstrate approachability b. Approach the client frequently throughout the day for brief interactions c. Adopt a neutral attitude when providing care d. Wait for the client to initiate interaction

c. Adopt a neutral attitude when providing care

1. A nurse is planning care for a client scheduled to receive electroconvulsive therapy (ECT). Which of the following medications should the nurse anticipate administrating prior to the procedure? a. Epinephrine b. Diphenhydramine c. Atropine d. Fluoxetine

c. Atropine

1. A client is being educated about electroconvulsive therapy (ECT) as a treatment option. The client asks for a discussion about it with the physician and his family members prior to making a decision. What ethical principle in the nurse considering when supporting the clients request? a. Beneficence b. Veracity c. Autonomy d. justice

c. Autonomy

1. A nurse is instructing a client with a new prescription for alprazolam to treat insomnia. Which of the following instructions should the nurse include? a. Monitor for urinary retention b. Take this medication with a fat meal c. Avoid activities that require alertness such as driving d. Take this medication every night before sleep

c. Avoid activities that require alertness such as driving

1. A nurse is providing dietary instructions for a client with a new prescription for a monoamine oxidase inhibitor (MAOI). When the client develops a sample lunch menu, which of the following items requires intervention by the nurse? a. Celery sticks b. Glass of whole milk c. Bologna sandwich d. Sliced apples

c. Bologna sandwich

1. A nurse is caring for a client who was involuntarily committed and is scheduled to receive electroconvulsive therapy (ECT). The client refuses the treatment and will not discuss why with the health care team. Which of the following actions should the nurse take? a. Ask the client family to encourage the client to receive ECT b. Inform the client that ECT does not require a consent c. Document the clients refusal of the treatment in the medical record d. Tell the client he cannot refuse the treatment because he was involuntarily committed

c. Document the clients refusal of the treatment in the medical record

1. A nurse is caring for a client who has cocaine use disorder. Which of the following manifestations should the nurse expect the client to have during withdrawal? a. Hand tremors b. Rapid speech c. Fatigue d. Seizures

c. Fatigue

1. A nurse is caring for a new client that exhibits manifestations of a major depressive disorder. The health care provider states a need to rule out medical conditions which could also be linked to the findings. The nurse should expect diagnostic testing for which of the following medical conditions? a. Tuberculosis b. Cholecystitis c. Hypothyroidism d. Pancreatitis

c. Hypothyroidism

1. A nurse is caring for a young adult client following the sudden death of his wife. The client feels paralyzed in his ability to cope with work and family responsibilities. Which of the following types of crisis is the client experiencing? a. Developmental b. Adventitious' c. situational d. Maturational

c. situational

Which statement about mental illness is accurate? A) Mental illness changes with time in history and the group defining it. B) Mental illness to reach the level of love and belonging in Maslow's hierarchy of needs C) Mental illness is demonstrating irrational , illogical behavior D) It is a matter of individual unconformity to social norms.

A) Mental illness changes with time in history and the group defining it.

What is the primary reason the client should be included in his /her treatment planning, if possible A) To be involved in the objectives/goal planning for care B) To hear what each team member says about the prognosis C) To read the medical record. D) It provides an opportunity to discuss staff roles

A) To be involved in the objectives/goal planning for care

What statement by the nurse indicates more education is required regarding negligence in client care? A) Only hospital administration and the physician are held responsible for determining the quality of care for the client and can be found negligent, B) Negligence is when a nurse fails to act in a manner that a reasonably prudent nurse would circumstances. C) A nurse who falls to assess for suicide potential in a client who has threatened suicide in the past can be found negligent D) Certain conditions must be met to determine negligence and hold the nurse responsible

A) Only hospital administration and the physician are held responsible for determining the quality of care for the client and can be found negligent,

What communication technique is persistent questioning of a client? A) Probing B) Focusing C) Presenting reality D) Offering self

A) Probing

What is the initial essential condition of getting acquainted based on the nurse's acceptance, warmth, and nonjudgmental attitude? A) Rapport B) Trust C) Respect D) Genuineness

A) Rapport

During the orientation phase of the nurse-client relationship, what takes place? A) Rapport is established B) Information regarding the client is obtained from the chart C) One's feelings are examined D) Identify problem-solving skills

A) Rapport is established

A client uses the defense mechanism sublimation in dealing with her alcohol problem. How is A) The client states she does not have a problem B) She states she tries hard not to think about it C) The client blames others for her problem D) She speaks with adolescents about the dangers of substance abuse

A) The client states she does not have a problem

Which of the following behaviors suggest a breach of professional boundaries? (select all that apply) A) The nurse shares the details about her family problems. B) The nurse makes plans to have lunch with the client after discharge C) The nurse agrees to keep secret with the client D) The nurse allows a client to hold her hand before chemotherapy

A) The nurse shares the details about her family problems. B) The nurse makes plans to have lunch with the client after discharge C) The nurse agrees to keep secret with the client

The client states that you remind him of his very stern aunt. This statement is an example of what can happen in therapy? A) Transference B) Countertransference C) Making a judgment D) Giving recognition

A) Transference

What is the situation in which HIPAA privacy rule can be breached? A) A duty to warn a clients potential victim of harm B) Informing the clients family when the client is threatening self-harm C) Informing the spiritual counselor of the client's desire for self-harm D) After the client harms others this law does not apply

A) A duty to warn a clients potential victim of harm

Therapeutic communication is the foundation of a client centered interaction. Which of the following is not considered therapeutic? A) Advising B) Restating C) Seeking clarification D) Exploring

A) Advising

The nurse is explaining milleu therapy to a new nurse in the psychiatric unit. What would be reviewed with the employee?(select all that apply) A) We continuously monitor environment for safety B) If a client becomes hostile we can restrain or seclude C) When we admit a client, we orient and explain the group therapy schedule D) You will be taught crisis prevention techniques

A) We continuously monitor environment for safety B) If a client becomes hostile we can restrain or seclude C) When we admit a client, we orient and explain the group therapy schedule

A client asks the nurse, What should I do about my wife's drinking problem? The nurse uses therapeutic technique reflecting to respond. What does she say? A) What do you think is the right thing to do? B) You need more time............. A plan C) It seems like you need marriage counseling D) Why don't you ask your doctor

A) What do you think is the right thing to do?

Which response by the nurse indicates an understanding of the therapeutic communication tec... broad opening? A) Yes I see go on B)Please explain what you mean C) You seem upset D) What would you like to talk about?

A) Yes I see go on

A client becomes agitated and shouts at the nurse. If you come any closer, I will hit you. What is the best response by the nurse? A) You need to stay calm you are responsible for your behavior B) I am not planning to .. my closer. What is happening now? C) I am going to get your medication. Try to relax while I am gone D) I am calling for assistance. You have until then to get it together

A) You need to stay calm you are responsible for your behavior

The client demonstrating symptoms of extreme anxiety and is pacing rapidly about the unit. Which approach by the nurse? A) Continue to observe....... For increased agitation B) Walk with client ...... him about his feelings C) Medicate the client to prevent escalation of restlessness D) Instruct all other clients to avoid the situation

C) Medicate the client to prevent escalation of restlessness

A client tries to embarrass a nurse by making a sexually explicit comment. How should the nurse-client? A) I am going to leave now B) I am no longer going ..... this conversation C) That comment is inappropriate D) Let's talk about the weather

C) That comment is inappropriate

A female client asks about her male nurses girlfriend and social activities. What is the best response A) The nurse shares information to be polite B) The nurse limits information and focuses on a client-centered conversation C) The nurse asks to be assigned to same-gender clients D) The nurse explains that if she continues he cannot work with her

B) The nurse limits information and focuses on a client-centered conversation

What is the most significant trigger for the development of a nurse focused countertransference A) The degree of authority the nurse has B) The nature of the client diagnosis C) The similar histories of the nurse and client D) The similarities between client and nurses mother

C) The similar histories of the nurse and client

1. A nurse is caring for a client who professes a deep and everlasting love for his girlfriend's one day, and the next day refuses to speak to her or allow her to visit. The nurse recognizes this client behavior which of the following defense mechanism? A. Sublimation B. Repression C. Undoing D. Splitting

C. Undoing

What percent of communication is nonverbal? A) 10-20% B) 30-40% C) 50-60% D) 70-80%

D) 70-80%

What non-therapeutic techniques may be used if the nurse becomes uncomfortable during nurse client interaction? (select all that apply) A) The probing technique can be used B) The nurse may change subject C) Silence may be used D) Exploring is a non therapeutic technique that may be used

B) The nurse may change subject C) Silence may be used

address the cultural needs of the client. What action will the nurse take? A) Provide the same care to all the client to prevent misunderstanding B) Read literature on the culture of the client C) Ask the other nurses regarding the specific culture needs D) Ask the client what cultural needs are important to him

D) Ask the client what cultural needs are important to him

How is the defense mechanism reaction formation demonstrated? A) An individual would like to be in a stable loving relationship but insists she will never settle B) An individual is afraid of animals and becomes a veterinarian to please her parents. She presents at a career fair about the satisfaction of the career C) An individual learns of the death of a dear friend from college days and becomes busy planning a reunion with others from the school

C) An individual learns of the death of a dear friend from college days and becomes busy planning a reunion with others from the school

The nurse is assessing the clients spiritual needs. Which of the following demonstrates the nurse the initial action related to the clients belief assessment? A) Arranging a visit by the hospital chaplain B) Offering to pray with the client C) Asking the role spirituality has in his life D) Initiating changes to adjust care based on documented religion.

C) Asking the role spirituality has in his life

The nurse understand that to assess the client's spiritual needs, the nurse should A) Assess the clients need for appropriate clergy B) Complete a spiritual statement questionnaire C) Assess the effects of spiritual needs on clients care D) Self-assess for their own spiritual beliefs and values

C) Assess the effects of spiritual needs on clients care

A nurse is assessing a client who graduated from college with a 4.0grade point average her incompetence in her new job. The nurse understands which therapy challenges the thought process and how it relates to their feelings? A) Interpersonal B) Milleu C) Cognitive-behavioral D) psychoanalytical

C) Cognitive-behavioral

The nurse demonstrates active listening by what action? A) Paying close attention remaining silent during the conversation B) Listening attentively and providing sympathetic responses C) Concentrating on what the client says and responding D) Using interpretation as a communication technique

C) Concentrating on what the client says and responding

The nurse places a client in a seclusion room until he admits to starting a fight in the dayroom ...... the nurse behavior constitutes? A) Assault B) Battery C) False imprisonment D) malpractice

C) False imprisonment

What statement is an example of a stereotyped comment? A) You are going to be fine. B) Why would you say C) Hang in there D) I don't understand

C) Hang in there

The client states, Who is he? I don't understand. What is the meaning of all this? Which statement clarify the clients questions? A) Did he tell you what he meant? B) Who is he? C) I don't understand explain what you mean. D) How do you feel about him?

C) I don't understand explain what you mean.

The nurse is caring for a client with an admission nursing diagnosis of potential for self harm the evaluation process. What happens during this step of the nursing process? A) A contract is obtained the client will not harm self. B) The client prognosis will e discussed with the client C) Interventions reviewed to determine if they have assisted the client in meeting outcome D) A concept map is developed

C) Interventions reviewed to determine if they have assisted the client in meeting outcome

The client expresses the loneliness she feels to the nurse. Which response by the nurse demonstrate a therapeutic relationship? A) Have you thought about ways to locate other lonely people? B) You need to get involved in community activities C) Loneliness can be a painful and difficult emotion D) Let's see if we have any common interests

C) Loneliness can be a painful and difficult emotion

1. A nurse is preparing to administer ziprasidone 10 mg IM every 6 hr. Available is ziprasidone 28mg/mL. How many mL should the nurse administer per dose? Round the answer to the nearest tenth.

ANSWER 0.4

nurse is preparing to administer haloperidol 75mg IM per week. Available is haloperidol decanoate 100 mg/mL for injection. How may mL should the nurse administer per dose? Round to the nearest hundredth.

ANSWER 0.75

A client was involuntarily admitted to a behavioral health facility after trying to harm himself..... demonstrates the need to educate the client regarding his rights? A) You cant tell my boss I attempted suicide B) I can understand why you restrained me when I threatened you C) I can leave anytime I tell you I'm not going to hurt myself D) I may be here, but I still have the right to vote

B) I can understand why you restrained me when I threatened you

An adult client is grieving about the loss of his spouse. What statement by the client would want nursing intervention? A) I often feel a tightness throughout my body B) I would be better off dead C) I feel so guilty about her death D) What causes my constant headache?

B) I would be better off dead

1. The nurse is preparing to administer lithium 30 mg PO every 8 hr. Available is lithium carbonate 150mg capsules. How many capsules should the nurse administer per dose? Round to the nearest whole number

ANSWER: 0.2

1. A nurse is preparing to administer amantadine 150 mg PO every 12hr. Available is amantadine 50mg/5mL syrup. How many mL should the nurse administer per does?

ANSWER: 15

1. A nurse is preparing to administer fluoxetine 40 mg PO daily. The amount available is fluoxetine 20mg/5mL. How many mL should the nurse administer? Round to the nearest whole number

Answer: 10

What is nursing behavior consistent with therapeutic communication? A) Offering opinions B) Active listening C) Begin speaking in periods of silence D) Approving of behavior

B) Active listening

The nurse is preparing the client for electroconvulsive therapy(ECT) the following day. The information regarding side effects? A) You may have memory loss and disorientation immediately after the treatment B) Agitation and confusion are side effects of ECT C) Tachycardia and dyspnea often occur, but you are constantly monitored D) There are no side effects that should concern you.

B) Agitation and confusion are side effects of ECT

A client is threatening to harm other clients and his visitor. The visitor is removed from the unit. Instructed staff to stay with him and prescribed medication for agitation is prepared. He refuses the nurse. What statement the nurse to other staff members is accurate? A) It is okay to defend yourself when you have been assaulted B) Medication can be given but only after he agrees to take it. C) We do not have to tolerate this behavior. I will call for the crisis prevention team D) For safety, we first restrain the client and I will immediately get the order.

D) For safety, we first restrain the client and I will immediately get the order.

What statement by the nurse reflects empathy for the client? A) It may overwhelming, but things will get better B) I'm not sure how you ... I hear what you are saying C) I am sure things will be better. We are here to help D) I have experienced the same thing in the past

D) I have experienced the same thing in the past

A client asks the nurse about the purpose of group therapy. What is the best response by the nurse? A) Group therapy will help you gain insight and self esteem. B) You may understand family dynamics and improve relationships. C) This is for you to meet others and communicate with them on the unit D) Interaction with other and feedback often help in gaining insight.

D) Interaction with other and feedback often help in gaining insight.

which statement by the nurse demonstrates an understanding of nonverbal communication A) Its always easier to understand nonverbal communication B) If a client avoids others..... sure he is depressed C) Most communication is verbal, not nonverbal D) It's important to check ... congruence in verbal and nonverbal responses

D) It's important to check ... congruence in verbal and nonverbal responses

The nurse is caring for a client who has difficulty hearing. What should the nurse do to facilitate communication? A) Stand within 3 feet when talking with the client B) Use monosyllabic words when possible C) Ask dose ended question D) Make sure the client can visualize lip movement

D) Make sure the client can visualize lip movement

Which nursing intervention demonstrates the ethical principle of autonomy? A) Refusing to administer a placebo B) Staying with a client is very anxious C) Taking a course to increase .knowledge regarding client rights D) Respecting the client's decision not to have treatments.

D) Respecting the client's decision not to have treatments.

What is a primary preventative technique to ensure client safety? A) Place the client in a private room B) Observe the client .... C) Explain the safety rules to the client D) Search the client belonging for safety hazards

D) Search the client belonging for safety hazards

A client tells you she is going to return to school next semester. What is the most therapeutic response A) I think that is a wonderful idea B) Your parents will be proud C) Can you afford that. D) Tell me more about your plan

D) Tell me more about your plan

The nurse uses the term labile in describing a client's mood and behavior. What does this term.. A) The client is angry and showing signs of hostility B) The client is overacting........ C) The client is sad and ............ D) The client has mood swings and is unpredictable

D) The client has mood swings and is unpredictable

What would be the criteria for involuntary mental health admission? A) The client reports past suicidal attempts B) The clients is unable to provide for basic needs C) The client is homeless and doesn't feel safe D) The client refuses admission

D) The client refuses admission

During an interdisciplinary treatment team meeting, a short- term outcome is established for a client with depressive symptoms. Which goal is most appropriate? A) The client will make statements that he feels less depressed by end of the first day of admission B) The client will express demonstrate increases in energy by the third day of admission C) The client will reduce self-rating on the depression scale by 10% by second-day admission D) The client will demonstrate increased interaction with other clients by discharge

D) The client will demonstrate increased interaction with other clients by discharge

1. A nurse on a crisis hotline is speaking to a client who says, "I just took an entire bottle of amitriptyline". Which of the following responses should the nurse make? A. You must have been feeling pretty depressed to do that B. Do you know how many pills were in the bottle? C. Were you trying to kill yourself by taking an overdose? D. I'm glad you called, and I want to send an ambulance to help you

D. I'm glad you called, and I want to send an ambulance to help you

1. A nurse at a college campus mental health counseling center is caring for a student that just failed an examination. The student spends the session berating the teacher and the course. The nurse should recognize this behavior as which of the following defense mechanisms? a. Conversion b. Regression c. Undoing d. Projection

D. Projection

1. A nurse is caring for a client who has schizophrenia and is experiencing a variety of hallucinations. Which of the following hallucinations is the priority for the nurse to address? a. Command hallucination b. Gustatory hallucination c. Tactile hallucination d. Visual hallucination

a. Command hallucination

1. A nurse in an emergency department is assessing a client who has traumatic injuries following an assault. The client sits quietly and calmly in the examination room and states, "I'm fine". The nurse should recognize the clients behavior as which of the following reactions? a. Denial b. Projection c. Displacement d. Undoing

a. Denial

1. A nurse is performing an admission assessment for a client who is receiving treatment following a situational crisis. Which of the following assessments by the nurse is the highest priority? a. Determining if the client has psychotic thinking b. Asking the client to identify the cause of the crisis c. Identifying the clients coping skills d. Identifying the clients support system

a. Determining if the client has psychotic thinking

1. A nurse is caring for a client with a new diagnosis of chronic kidney disease. Which of the following statements should the nurse identify as an indication of anticipatory grieving? a. I just cant believe that this dialysis is going to ruin my whole life b. I know that kidney disease runs in my family, but I can prevent it c. I can now eat whatever I want. The dialysis will remove it from my system d. I know that I will get a kidney transplant. I am a good candidate

a. I just cant believe that this dialysis is going to ruin my whole life

1. A nurse is discussing the manifestations of alcohol withdrawal with a client who has a history of alcohol use disorder. Which of the following client statement indicates understanding? a. I should expect tremors to start less than 24 hours after I stop drinking b. Disulfiram will block my cravings for alcohol c. My symptoms should last about 5 to 7 days once they begin d. It is important that I take vitamin C to prevent cirrhosis other or liver damage

a. I should expect tremors to start less than 24 hours after I stop drinking

1. A nurse is caring for several clients at various developmental stages. The nurse should explain that, according to Erikson, acceptance of death is a primary task of which of the following stages of psychosocial development? a. Integrity vs despair b. Generativity vs stagnation c. Identity vs role confusion d. Autonomy vs shame and doubt

a. Integrity vs despair

1. A nurse is caring for a client who was admitted with acute psychosis and is being treated with haloperidol. The nurse should suspect that the client may be experiencing tardive dyskinesia when the client exhibits which of the following? Select all that apply a. Involuntary pelvic rocking and hip thrusting movements b. Tongue thrusting and lip smacking c. Facial grimacing and eye blinking d. Fine hand tremors and pill rolling e. Urinary retention and constipation

a. Involuntary pelvic rocking and hip thrusting movements b. Tongue thrusting and lip smacking c. Facial grimacing and eye blinking

1. A nurse is caring for an adolescent who is experiencing indications of depression. Which of the following findings should the nurse expect? Select all that apply a. Irritability b. Euphoria c. Insomnia d. Chronic pain quizlet said this but not sure e. Low self-esteem

a. Irritability c. Insomnia d. Chronic pain quizlet said this but not sure e. Low self-esteem

1. A nurse is caring for a client who has delusions behavior and states, "I can't go to group therapy today. I am expecting a high-level official to visit me!". The nurse responds, "I understand, but it is time for group therapy, and we expect everyone to attend. Let's walk over together". For which of the following is the nurse's response considered therapeutic? a. It clearly articulates what is expected of the client b. It sets limits on the clients manipulative behavior c. It uses reflection when talking with the client d. It demonstrates empathy towards the client

a. It clearly articulates what is expected of the client

1. A nurse is leading to a group therapy session for clients who are newly diagnosed with cancer. Which of the following statements should the nurse make? a. Let's discuss what you mean when you say that you cannot ever return to work b. I notice you keep clenching your fists. This needs to stop c. Antidepressants are not your solution, but this therapy group is d. You need to work hard on resolving conflict with those closest to you

a. Let's discuss what you mean when you say that you cannot ever return to work

1. A client has become aggressive on the inpatient unit and is throwing chairs and threatening to hit staff members. Attempts to verbally de-escalate the patient and administer medication have failed so patient is placed on restraints. While the patient is in restraints what nursing interventions should the nurse apply? Select all that apply a. Monitor patients' circulation in his limbs b. Withhold food and water while restraints in place c. Offer patient hydration and nutrition d. Monitor patient's vital signs e. Assess patient for readiness for restraint removal f. Withhold toileting while restraints in place

a. Monitor patients' circulation in his limbs c. Offer patient hydration and nutrition d. Monitor patient's vital signs e. Assess patient for readiness for restraint removal

1. A nurse is caring for a client who has severe depression and is scheduled to receive electro convulsive therapy. The nurse should recognize that the client will receive succinylcholine to prevent which of the following adverse effects a. Muscle distress b. Aspiration c. Elevated blood pressure d. Decrease respiration

a. Muscle distress

1. A nurse is teaching a client who has schizophrenia about her new prescription for risperidone. Which of the following statements should the nurse include in the teaching? a. You should continue this medication if you develop muscle rigidity b. You will experience weight loss while taking this medication c. You will notice your symptoms improve within 24 hrs. of taking this medication d. You should increase your consumption of complex carbohydrates

a. You should continue this medication if you develop muscle rigidity

1. The nurse is caring for multiple patients on the unit. He knows that which of the following among them is at the highest risk for suicide? a. A patient diagnosed with major depressive disorder reporting decreased anxiety b. A patient with schizophrenia that is experiencing command hallucinations c. A patient with bipolar I in a manic state whose current lithium level is 1.2 d. A patient diagnosed with bipolar II in a hypomanic state

b. A patient with schizophrenia that is experiencing command hallucinations

1. A nurse in an acute care mental health facility is preparing to administer morning medication for a client who has been taking lithium for 2 weeks and has a current lithium level of 1.0 mEq/L. Which of the following actions should the nurse take? a. Prepare for gastric lavage due to an extremely elevated lithium level b. Administer the morning dose of lithium c. Check the clients medication record to assess whether the client has been refusing her lithium d. Hold the medication and assess to early manifestations of toxicity

b. Administer the morning dose of lithium

1. nurse is preparing to assist with electroconvulsive therapy. Which of the following pieces of equipment should the nurse set up in the room prior to the treatment? Select all that apply a. Ophthalmoscope b. Cardiac monitor c. Portable x-ray machine d. Electroencephalogram (EEG) monitor e. Blood pressure monitor

b. Cardiac monitor d. Electroencephalogram (EEG) monitor e. Blood pressure monitor

1. A nurse is talking to a client with schizophrenia and the client states, "I am in pain. From the rain. I think I am insane. Is that plain?" The nurse correctly recognizes that the client is using what type of alterations of speech? a. Word salad b. Clang association c. Neologism d. Echolalia1.

b. Clang association

1. A community health nurse is providing a health education class about suicide prevention. Which of the following should the nurse include in the education as risk factors for suicide? Select all that apply. a. A client who was recently separated from their partner b. Client that has a history of schizophrenia c. A client that has a history of substance use disorder d. A client that is greater than 45 years old e. A client that is of the female gender

b. Client that has a history of schizophrenia c. A client that has a history of substance use disorder d. A client that is greater than 45 years old

1. A nurse is caring for a client that is experiencing acute manifestations of withdrawal from alcohol. Which of the following medications should the nurse anticipate administering to the client? a. Acamprosate b. Diazepam c. Naltrexone d. Disulfiram

b. Diazepam

1. A nurse is caring for a client who has bipolar disorder and is experiencing a manic episode. Which of the following actions should the nurse take? a. Encourage the client to join group activities b. Dim the lights in the clients room c. Provide detailed explanations to the client d. Administer methylphenidate

b. Dim the lights in the clients room

1. A nurse is caring for a client who has schizophrenia and is taking haloperidol. The nurse should monitor for which of the following adverse effect of haloperidol? a. Intractable hiccups b. Extrapyramidal symptoms c. Excessive salivation d. Fever

b. Extrapyramidal symptoms

1. A nurse is caring for a client receiving diazepam IV for moderate sedation. The client becomes over-sedated. Which medication should the nurse plan to administer? a. Naltrexone b. Flumanezil c. Naloxone d. Atropine

b. Flumanezil

1. A nurse is caring for an adolescent client with a history of violent behavior. The client asked the nurses to keep information confidential about the desire to kill several classmates and a school teacher. Which statement by the nurse is the best response? a. I will not violate our nurse-client relationship. The information we discuss will remain confidential between us b. I cannot promise that. I must share this information with other members of the team who are responsible for planning your care. c. I can see that you trust me, but you should share those feelings with your psychiatrist not me d. Because you are a minor, I have to share any information that I feel is important with your parents

b. I cannot promise that. I must share this information with other members of the team who are responsible for planning your care.

1. During a group therapy session, a nurse notes several clients using multiple defense mechanisms. Which of the following client statements demonstrates the maladaptive use of regression? a. I wrote a short story about a heroic woman when I was really mad at my boss b. I don't care about work anymore since I was not given promotion c. I mentally separate myself from distractions around me when I paint on canvas d. I still cannot remember the scene of my husband's car accident

b. I don't care about work anymore since I was not given promotion

1. A nurse is caring for a young adult client who says he is experiencing increased anxiety and an inability to concentrate. Which of the following responses should the nurse make? a. How long has this been going on? b. It sounds like you're having a difficult time c. Have you talked to your parents about this yet? d. Why do you think you are so anxious?

b. It sounds like you're having a difficult time

1. A nurse in an emergency dept assessing a client who has been taking haloperidol for 3 months. The client has a temperature of 103.4F, BP of 150/110 mm Hg and muscle rigidity. Which of the following complications should the nurse suspect? a. Agranulocytosis b. Neuroleptic malignant syndrome c. Akathisia d. Tardive dyskinesia

b. Neuroleptic malignant syndrome

1. A nurse is providing teaching for a client who has a recent diagnosis of depression. Which of the following should the nurse identify as a primary risk factor for this disorder? a. Having elevated levels of serotonin b. Past history of childhood abuse c. Recent history of stressful, positive life events d. Being an only child

b. Past history of childhood abuse

1. A nurse is caring for a client that requires a crisis intervention for acute anxiety. Which of the following actions is the highest priority? a. Determining the cause of the client's anxiety b. Protecting the client from injury c. Identifying the clients coping skills d. Ensuring that the client feels safe

b. Protecting the client from injury

1. A nurse is caring for a client who has prescription for phenelzine. The nurse should instruct the client to avoid which of the following over the counter medications? a. Ranitidine b. Pseudoephedrine c. Ibuprofen d. Docusate sodium

b. Pseudoephedrine

1. A nurse is caring for a client who has obsessive compulsive disorder (OCD). Which of the following characteristics are expected findings of OCD? Select all that apply a. Unaware of compulsions b. Rule conscious behavior c. Difficulty relaxing d. Irrational fear of certain objects e. Perfectionist behavior

b. Rule conscious behavior c. Difficulty relaxing e. Perfectionist behavior

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

b. Situational

1. A nurse is teaching a community education course about the physical complications related to substance use disorder. Which of the following findings should the nurse include in the discussion as a health risk of heroin use? a. Acute pancreatitis b. Slowed breathing c. Nasal septum perforation d. Permanent short-term memory loss

b. Slowed breathing

1. A nurse is providing teaching about disorder management for a client who has posttraumatic stress disorder (PTSD). Which of the following statements should the nurse include in the teaching? a. Avoiding stimuli that trigger memories of the trauma can help you overcome your PTSD b. Talking about the traumatic experience is recommended c. Response prevention is an effective treatment for PTSD d. You should try to limit the number of hours that you sleep each day

b. Talking about the traumatic experience is recommended

1. A nurse in a substance abuse clinic is assessing a client who recently started taking disulfiram. The client reports having discontinued the medication after experiencing severe nausea and vomiting. Which of the following reasons should the nurse suspect to be a likely cause of clients distress? a. The client experienced a common side effects to the medication b. The client consumed alcohol while taking this medication c. The client demonstrated an allergic response to the medication d. The client took an overdose of the medication

b. The client consumed alcohol while taking this medication

1. A nurse is caring for a client with schizophrenia and generalized anxiety disorder. The client has a prescription for alprazolam 0.25 mg PO every 8hr PRN anxiety. For which of the following client statements should the nurse consider administering alprazolam? a. The client tells the nurse he is a government agent b. The client states my heart is pounding out of my chest c. The client states I see purple bugs crawling on the wall d. The client tells the nurse that he is too tired to attend the group meeting

b. The client states my heart is pounding out of my chest

1. A nurse is caring for a client with major depressive disorder and is scheduled for electroconvulsive therapy (ECT). The clients spouses asks the nurse about the possible side effects of the ECT. Which of the following responses should the nurse make? a. The most common side effects are directly related to the use of anesthesia b. The main side effects are temporary, and may include mild confusion, a headache, and short-term memory loss. c. Some clients have been known to have a myocardial infarction, but we will monitor your spouse closely to be certain this does not happen. d. Most clients have no adverse effects to this treatment, but muscle cramping may result from the induced seizure.

b. The main side effects are temporary, and may include mild confusion, a headache, and short-term memory loss.

1. A nurse is caring for a client who is experiencing a crisis related to anxiety. Which of the following actions should the nurse take? Select all that apply a. Avoid eye contact to prevent escalation of anxiety b. Validate the client's feelings c. Establish rapport with the client d. Identify the cause if the anxiety e. Develop a flexible crisis intervention plan

b. Validate the client's feelings c. Establish rapport with the client d. Identify the cause if the anxiety

1. A patient on the unit was just diagnosed with bipolar disorder. The patient states, "the doctor just told me I have bipolar disorder. Can this be cured, or do I have to deal with this for the rest of my life? I am worried". The nurse responds, "It is true there is no cure for bipolar disorder, however, there are many therapies and medications that you can use to cope and live a normal life". a. Justice b. Veracity c. Beneficence d. Autonomy

b. Veracity

1. A nurse is talking with a client with schizophrenia. Suddenly the client states, "I'm frightened. Do you hear that? The voices are telling me to do terrible things". Which of the following responses by the nurse is appropriate? a. Why do you think you are hearing the voices? b. What are the voices telling you to do? c. You need to understand that there are no voices d. You need to tell the voices to leave you alone

b. What are the voices telling you to do?

1. A nurse is evaluating the outcomes for an outpatient client who has depression. Which of the following client statements indicates a need for further evaluation? a. I had a great trip to the smokey mountains b. Going back to work has been okay c. I just don't like going to the movies like I used to d. I cant wait to have my family together next weekend

c. I just don't like going to the movies like I used to

1. A nurse is caring for a client who is prescribed massage therapy to treat panic disorder. The client states " I can stand to be touched by another person". Which of the following responses should the nurse make? a. Why don't you like to be touched by others b. Don't worry about it. Your anxiety will lessen once the massage begins c. I will tell your provider that you would like a treatment other than a massage d. I will request that the massage therapist wear gloves during your treatment

c. I will tell your provider that you would like a treatment other than a massage

1. A nurse is instructing clients in the community about relationship development. The nurse should explain that according to Erikson, establishing relationships with commitment is a primary task, of which of the following stages of psychosocial development? a. Trust vs mistrust b. Generativity vs stagnation c. Intimacy vs isolation d. Identity vs role diffusion

c. Intimacy vs isolation

1. A child is admitted with a suspected diagnosis of factitious disorder by proxy. What is an important consideration in the care of this child? a. Teaching the parents how to obtain necessary specimens b. Supporting the parents as they cope with diagnosis of a chronic illness c. Monitoring the parents whenever they are with the child d. Reassuring the parents that the cause of the disorder will be found

c. Monitoring the parents whenever they are with the child

1. The nurse is reviewing symptoms of alcohol withdrawal with a clients family. Which of the following symptoms should the nurse include in the teaching? Select all that apply a. Euphoria b. Hypotension c. Nausea and vomiting d. Tremors e. Diaphoresis

c. Nausea and vomiting d. Tremors e. Diaphoresis

1. A nurse is caring for a client who is taking amitriptyline. The nurse should monitor for which of the following adverse effects? a. Drooling b. Metallic taste in mouth c. Orthostatic hypotension d. Diarrhea

c. Orthostatic hypotension

1. A nurse in a mental facility is planning care for a client who has obsessive-compulsive disorder (OCD) and is newly admitted to the unit. Which of the following actions should the nurse plan to take regarding the clients compulsive behavior? a. Set strict limits on the behaviors so that the client can conform to the unit rules and schedules b. Confront the client about the senseless nature of the repetitive behaviors c. Plan the clients schedule to allow time for rituals d. Isolate the client for a period of time

c. Plan the clients schedule to allow time for rituals

1. A nurse is planning care for a group of clients on a mental health unit. Which of the following actions should the nurses plan to take to create a therapeutic environment? a. Allow client to determine the boundaries of the nurse-client relationship b. Plan to discuss any topic that is presented c. Provide continuity of care by assigning the same staff d. Focus on client weaknesses to increase adaption

c. Provide continuity of care by assigning the same staff

A nurse is caring for a client in an in-patient mental health unit. According to the patient self-determination Act, clients have the right to be treated in the least restrictive environment. The nurse understands that this includes which rights? Select all that apply. ***NOT SURE ABOUT THIS ONE,. COULDN'T FIND IT**** a. Right to receive mail and visitors, but no telephone calls. b. Right to freedom from restraint or seclusion c. Right to refuse medication d. Right to individualized treatment plan and to participate

c. Right to refuse medication d. Right to individualized treatment plan and to participate

1. A nurse in the emergency department is caring for a client who reports chest pain, headache, and shortness of breath. He continues to state, "I don't know why my wife left me". The client receives a diagnosis of anxiety. The nurse realizes the client's findings support which level of anxiety? a. Panic b. Mild c. Severe d. Moderate

c. Severe

1. A nurse on a mental health unit is caring for a client who has bipolar disorder. Which of the following behaviors should the nurse interpret as manic when observed by the client? Select all that apply. a. The client is sleeping for long periods of time b. The client is dressing in black or grey clothing c. The client is spending large sums of money d. The client is acting in a flirtatious way e. The client is talking in rapid speech

c. The client is spending large sums of money d. The client is acting in a flirtatious way e. The client is talking in rapid speech

1. A nurse is teaching a client who has a depressive disorder about fluoxetine. Which of the following information should the nurse include in the teaching? a. You will notice an improvement in your depressive symptoms in 2 to 3 days b. You may experience drooling while taking this medication c. You may experience a decreased sex drive while taking this medication d. You may notice that you have less appetite while taking this medication

c. You may experience a decreased sex drive while taking this medication

1. A client at 36 weeks' gestation has just delivered a stillborn baby. Which of the following statement should the nurse make? a. I have called for the chaplain to come and stay with you b. This is for the best. Your baby was very ill c. You may hold your baby as long as you want d. I understand your grief. I lost a baby also

c. You may hold your baby as long as you want

1. A nurse is reviewing laboratory values for four clients taking clozapine for schizophrenia. The nurse should withhold the medication and notify the health care provider immediately for which client? a. A client who has a hematocrit of 55% b. A client who has a BUN of 22 mg/dl c. A client which has a serum potassium of 3.3 mEq/L d. A client who has a WBC OF 2,500 cells.mm3

d. A client who has a WBC OF 2,500 cells.mm3

A nurse on an acute mental health unit is caring for a group of clients. For which of the following clients is seclusion contraindicated? a. An adolescent client who throws objects at other clients b. A school-age client who attempts to repeatedly bite staff c. An older adult client who is manic and crying due to overstimulation d. An adult client following a suicide attempt

d. An adult client following a suicide attempt

1. A client who has major depressive disorder states to the nurse that he and his family would be better off if he were gone. Which of the following is the nurses priority response? a. Tell me what is happening right now b. When did you first start feeling this way? c. Do you really think your family would be better off without you? d. Are you thinking of harming yourself?

d. Are you thinking of harming yourself?

1. A nurse is assessing a client who is taking bupropion. The nurse should recognize which of the following findings as an indication that the medication is effective? a. Increase weight gain b. Increased urinary output c. Decreased sexual function d. Decreased urge to smoke

d. Decreased urge to smoke

1. A nurse is caring for 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 U.S senator". Which of the following findings is this client exhibiting? a. Reality testing b. Flight of ideas c. Derealization d. Grandiosity

d. Grandiosity

1. A client becomes very dejected and states, "No one really cares what happens to me. Life isn't worth living anymore". Which of the following responses should the nurse make? a. Tell me who you think doesn't care about you b. Why do you feel that? c. Of course, people. Your family comes to visit every day d. I care about you, and I am concerned that you feel so sad

d. I care about you, and I am concerned that you feel so sad

1. A nurse is teaching a newly licensed nurse about appropriate actions to take when a client threatens to harm a specific individual. Which statement by the newly licensed nurse indicates understanding of the instruction? a. I need to keep the information confidential due to the clients right to privacy b. I can only discuss the clients threats with a court order c. I should verbally report this information to the psychiatrist d. I need to make sure that the potential victim is warned

d. I need to make sure that the potential victim is warned

1. A nurse in a mental health facility is caring for a client who is upset about the loss of privileges due to repetitive negative behavior. Which of the following statements by the nurse demonstrates the effective use of assertive communication? a. You need to calm down before discussing this matter any further b. Why did you make the choice the behavior negatively? c. You were made aware of the consequences of negative behavior d. I understand that you are angry. However, I followed the appropriate protocol.

d. I understand that you are angry. However, I followed the appropriate protocol.

1. A client who has bipolar disorder approaches the nurse and reveals fresh, self-inflicted, superficial cuts going up and down his right arm. Which of the following actions should the nurse takes first? a. Implement the clients behavioral modification plan b. Administer a tetanus antitoxin c. Document the size and location of the cuts d. Inspect the cuts for debris

d. Inspect the cuts for debris

1. A nurse is admitting a client about to undergo surgery for benign prostatic hypertrophy. The client states, "I don't know what I will do if they find I have cancer". Which of the following responses should the nurse make? a. Why do you think you might have cancer when your diagnosis is benign condition? b. I'm looking at your chart here and I don't see any reason for you to worry about that c. I think that's something you need to discuss with your primary health care provider d. It sounds like you are worried that your condition might lead to a diagnosis of cancer

d. It sounds like you are worried that your condition might lead to a diagnosis of cancer

1. A nurse is reviewing discharge instructions with a client who has bipolar disorder and is taking lithium. Which of the following manifestations should the nurse include as an indication of mild toxicity? a. Constipation b. Hyperactivity c. Urinary retention d. Muscle weakness

d. Muscle weakness

1. A nurse is caring for a client who is exhibiting severe manifestations of serotonin syndrome. Which of the following is the priority nursing intervention? a. Administering an anticonvulsant b. Applying a cooling blanket c. Padding side rails to prevent injury d. Preparing for artificial ventilation

d. Preparing for artificial ventilation

1. nurse manager is providing staff education about working with clients that have a history of anger and aggression. Which of the following should the nurse include in the education? Select all that apply a. Do not stand in a corner when talking with the client b. Only wear items around your neck that have a breakaway latch c. Call security for all client interactions d. Provide immediate feedback for escalating behavior e. Stand in front of the client when talking

d. Provide immediate feedback for escalating behavior

1. A nurse is discussing legal exceptions to client confidentiality with nursing staff. Which of the following statements by a staff member indicates an understanding of the instruction? a. Staff members are required to divulge information to attorneys if they call for information b. The legal requirement for client confidentiality ceases if the client is decreased c. Health care workers are not required to answer a courts request for information about a client's disclosure d. Providers are required to warn individuals if the client threatens harm

d. Providers are required to warn individuals if the client threatens harm

1. An older client is brought to the mental health clinic by her daughter. The daughter reports that her mother is not eating and seems uninterested in routine activities. The daughter states "Im so worried that my mother is depressed". Which of the following responses should the nurse make? a. Everyone get depressed from time to time b. You shouldn't worry about this because depressive disorder is easily treated c. Older adults are usually diagnosed with depressive disorder is easily treated d. Tell me the reasons you think your mother is depressed

d. Tell me the reasons you think your mother is depressed

1. A nurse in a rehabilitation center is planning care for a newly admitted client with a history of alcohol use disorder. Which of the following client goals is the highest priority? a. The client will acknowledge alcohol dependence and need for treatment b. The client will rebuild damaged interpersonal relationships c. The client will implement alternative strategies for managing anxiety d. The clients withdrawal from alcohol will be managed without complications

d. The clients withdrawal from alcohol will be managed without complications

1. A nurse on a mental health unit is caring for a client who has generalized anxiety disorder. The client received a telephone call that was upsetting and now the client is pacing up and down the corridors of the unit. a. Have a staff member escort the client to her room b. Instruct the client to sit down and stop pacing c. Allow the client to pace alone until physically tired d. Walk with the client at a gradually slower pace

d. Walk with the client at a gradually slower pace

1. A nurse is reviewing the medical record of a client taking olanzapine for schizophrenia. Which of the following findings should the nurse identify as an adverse effect of olanzapine? a. Delusions of grandeur b. Oral candiasis c. Heart rate 60/min d. Weight gain of 3lb in 2 weeks

d. Weight gain of 3lb in 2 weeks

1. A nurse is caring for a client who has schizophrenia and tells the nurse, "They lie about me all the time and they are trying to poison my food". Which of the following statements should the nurse make? a. Who is lying about you and trying to poison you? b. Why do you think you are being lied about and poison? c. You are mistaken. Nobody is lying about you or trying to poison you d. You seem to be having very frightening thoughts

d. You seem to be having very frightening thoughts