ATI Metal health 1-17

2. A charge nurse is discussing TMS with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. "TMS is indicated for clients who have schizophrenia spectrum disorders." B. "I will provide postanesthesia care following TMS." C. "TMS treatments usually last 5 to 10 minutes." D. "I will schedule the client for TMS treatments 3 to 5 times a week for the first several weeks."

. A. TMS is indicated for the treatment of major depressive disorder that is not responsive to pharmacological treatment. ECT is indicated for the treatment of schizophrenia spectrum disorders. B. Post anesthesia care is not necessary after TMS because the client does not receive anesthesia and is alert during the procedure. C. The TMS procedure lasts 30 to 40 min. D. CORRECT: TMS is commonly prescribed 3 to 5 times a week for the first four to six weeks.

1. A nurse is caring for a client who has substance-induced psychotic disorder and is experiencing auditory hallucinations. The client states, "The voices won't leave me alone!" Which of the following statements should the nurse make? (Select all that apply.) A. "When did you start hearing these things?" B. "The voices are not real, or else we would both hear them." C. "It must be scary to hear voices." D. "Are the voices you hear telling you to hurt yourself?" E. "Why are the voices talking to only you?"

1. A. CORRECT: Ask the client directly about the hallucination. B. Do not argue with the client's view of the situation. C. CORRECT: Focus on the client's feelings rather than agreeing with the client's hallucination. D. CORRECT: Assess for command hallucinations and the client's risk for injury to self or others. E. Avoid asking a "why" question, which is non therapeutic and can promote a defensive client response.

1. A nurse working on an acute mental health unit is caring for a client who has posttraumatic stress disorder (PTSD). Which of the following findings should the nurse expect? (Select all that apply.) A. Difficulty concentrating on tasks B. Obsessive need to talk about the traumatic event C. Negative self-image D. Recurring nightmares E. Diminishedreflexes

1. A. CORRECT: Manifestations of PTSD include the inability to concentrate on or complete tasks. B. A client who has PTSD is reluctant to talk about the traumatic event that triggered the disorder. C. CORRECT: Manifestations of PTSD include feeling guilty and having a negative self-image. D. CORRECT: Manifestations of PTSD include recurring nightmares or flashbacks. E. A client who has PTSD has an increased

1. A nurse is caring for a client who has early stage Alzheimer's disease and a new prescription for donepezil. The nurse should include which of the following statements when teaching the client about the medication? A. "You should avoid taking over-the-counter acetaminophen while on donepezil." B. "You should take this medication before going to bed at the end of the day." C. "You will be screened for underlying kidney disease prior to starting donepezil." D. "You should stop taking donepezil if you experience nausea or diarrhea."

1. A. Clients taking donepezil should avoid NSAIDs, rather than acetaminophen, due to risk for gastrointestinal bleeding. B. CORRECT: Clients should take donepezil at the end of the day, just before going to bed, with or without food. C. Clients should be screened for underlying heart and pulmonary disease, rather than kidney disease, prior to treatment. D. Gastrointestinal adverse effects are common with donepezil and can result in a dosage reduction. However, the client should not abruptly stop the medication without consulting a provider.

1. A nurse is planning care for a client who has bipolar disorder and is experiencing a manic episode. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) A. Provide flexible client behavior expectations. B. Offer concise explanations. C. Establish consistent limits. D. Disregard client concerns. E. Use a firm approach with communication

1. A. Establish consistent client behavior expectations to decrease the risk for client manipulation. B. CORRECT: Offering concise explanations improves the client's ability to focus and comprehend the information. C. CORRECT: Establishing consistent limits decreases the risk for client manipulation. D. Respond to valid client concerns to foster a trusting nurse-client relationship. E. CORRECT: Using a firm approach with client communication promotes structure and minimizes inappropriate client behaviors.

A nurse is caring for a client who has major depressive disorder. Which of the following should the nurse identify as a risk factor for depression? (Select all that apply.) A. Male sex B. History of chronic bronchitis C. Recent death in client's family D. Family history of depression E. Personal history of panic disorder

1. A. Females are twice as likely as males to experience a depressive disorder. B. CORRECT: Depressive disorders are more common in a client who has a chronic medical condition. C. CORRECT: Depressive disorders are more likely to occur in a client who is experiencing a high amount of stress (when grieving the death of a family member). D. CORRECT: Depressive disorders are more likely to occur in a client whose has a family history of depression. E. CORRECT: A history of an anxiety or personality disorder increases a client's risk for depressive disorder.

1. A charge nurse is conducting a class on therapeutic communication with a group of newly licensed nurses. Which of the following aspects of communication should the nurse identify as a component of verbal communication? A. Personal space B. Posture C. Eye contact D. Intonation

1. A. Personal space is a component of nonverbal communication. B. Posture is a component of nonverbal communication. C. Eye contact is a component of nonverbal communication. D. CORRECT: Identify intonation as a component of verbal communication. Intonation is the tone of one's voice and can communicate a variety of feelings.

1. A nurse manager is discussing the care of a client who has a personality disorder with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. "I can promote my client's sense of control by establishing a schedule." B. "I should encourage clients who have a schizoid personality disorder to increase socialization." C. "I should practice limit-setting to help prevent client manipulation." D. "I should implement assertiveness training with clients who have antisocial personality disorder."

1. A. Rather than establishing a schedule, the nurse should ask for the client's input and offer realistic choices to promote the client's sense of control. B. Avoid trying to increase socialization for a client who has a schizoid personality disorder. C. CORRECT: When caring for a client who has a personality disorder, limit-setting is appropriate to help prevent client manipulation. D. Implement assertiveness training for clients who have dependent and histrionic personality disorders.

A nurse is caring for a client who smokes and has lung cancer. The client reports, "I'm coughing because I have that cold that everyone has been getting." The nurse should identify that the client is using which of the following defense mechanisms? A. Reaction formation B. Denial C. Displacement D. Sublimation

1. A. This is not an example of reaction formation, which is overcompensating or demonstrating the opposite behavior of what is felt. B. CORRECT: This is an example of denial, which is pretending the truth is not reality to manage the anxiety of acknowledging what is real. C. This is not an example of displacement, which is shifting feelings related to an object, person, or situation to another less threatening object, person, or situation. D. This is not an example of sublimation, which is dealing with unacceptable feelings or impulses by unconsciously substituting acceptable forms of expression.

1. A nurse is talking with a client who is at risk for suicide following their partner's death. Which of the following statements should the nurse make? A. "I feel very sorry for the loneliness you must be experiencing." B. "Suicide is not the appropriate way to cope with loss." C. "Losing someone close to you must be very upsetting." D. "I know how difficult it is to lose a loved one."

1. A. This statement focuses on the nurse's feelings and is sympathetic rather than empathetic. B. This statement implies judgment and is therefore not an empathetic or therapeutic response. C. CORRECT: This statement is an empathetic response that attempts to understand the client's feelings. D. This statement focuses on the nurse's experiences rather than the client's and is therefore not therapeutic.

2. A nurse is completing an admission assessment for a client who has schizophrenia. Which of the following findings should the nurse document as positive symptoms? (Select all that apply.) A. Auditory hallucination B. Lack of motivation C. Use of clang associations D. Delusion of persecution E. Constantly waving arms F. Flat affect

2. A. CORRECT: Hallucinations are an example of a positive symptom. B. Lack of motivation, or avolition, is an example of a negative symptom. C. CORRECT: Alterations in speech are an example of a positive symptom. D. CORRECT: Delusions are an example of a positive symptom. E. CORRECT: Bizarre motor movements are an example of a positive symptom. F. Flat affect is an example of a negative symptom.

A charge nurse is discussing the characteristics of a nurse-client relationship with a newly licensed nurse. Which of the following characteristics should the nurse include in the discussion? (Select all that apply.) A. The needs of both participants are met. B. An emotional commitment exists between the participants. C. It is goal-directed. D. Behavioral change is encouraged. E. A termination date is established.

2. A. A therapeutic nurse-client relationship focuses on the needs of the client. B. An emotional commitment between the participants is characteristic of an intimate or social relationship rather than one that is therapeutic. C. CORRECT: A therapeutic nurse-client relationship is goal-directed. D. CORRECT: A therapeutic nurse-client relationship encourages positive behavioral change. E. CORRECT: A therapeutic nurse-client relationship has an established termination date.

2. A nurse is caring fora client who has avoidant personality disorder. Which of the following statements is expected from a client who has this type of personality disorder? A. "I'm scared that you're going to leave me." B. "I'll go to group therapy if you'll let me smoke." C. "I need to feel that everyone admires me." D. "I sometimes feel better if I cut myself."

2. A. CORRECT: Clients who have avoidant personality disorder often have a fear of abandonment. This type of statement is expected.

A nurse working on an acute mental health unit is admitting a client who has major depressive disorder and comorbid anxiety disorder. Which of the following actions is the nurse's priority? Placing the client on one-to-one observation Assisting the client to perform ADLs Encouraging the client to participate in counseling Teaching the client about medication adverse effects

2. A. CORRECT: The greatest risk for a client who has MDD and comorbid anxiety is injury due to self-harm. The highest priority intervention is placing the client on one-to-one observation.

2. A nurse is discussing acute vs. prolonged stress with a client. Which of the following effects should the nurse identify as an acute stress response? (Select all that apply.) A. Chronic pain B. Depressed immune system C. Increased blood pressure D. Panic attacks E. Unhappiness

2. A. Chronic pain indicates a prolonged or maladaptive stress response. B. CORRECT: A depressed immune system is an indicator of acute stress. C. CORRECT: Increased blood pressure is an indicator of acute stress. D. Panic attacks indicate a prolonged or maladaptive stress response. E. CORRECT: Unhappiness is an indicator of acute stress.

A nurse is providing preoperative teaching for a client who was informed of the need for emergency surgery. The client has a respiratory rate 30/min, and says, "This is difficult to comprehend. I feel shaky and nervous." The nurse should identify that the client is experiencing which of the following levels of anxiety? A. Mild B. Moderate C. Severe D. Panic

2. A. In mild anxiety, the client's ability to understand information may actually increase. B. CORRECT: Moderate anxiety decreases problem-solving and may hamper the client's ability to understand information. Vital signs may increase somewhat, and the client is visibly anxious. C. Severe anxiety causes restlessness, decreased perception, and an inability to take direction. D. During a panic attack, the person is completely distracted, unable to function, and may lose touch with reality.

2. A nurse is involved in a serious and prolonged mass casualty incident in the emergency department. Which of the following strategies should the nurse use to help prevent developing a trauma-related disorder? (Select all that apply) A. Avoid thinking about the incident when it is over. B. Take breaks during the incident for food and water. C. Debrief with others following the incident. D. Avoid displays of emotion in the days following the incident. E. Take advantage of offered counseling.

2. A. Thinking and talking about a traumatic incident can help prevent development of a trauma-related disorder. B. CORRECT: Taking breaks and remembering to drink water and eat nutritious foods while working during a traumatic incident can help prevent development of a trauma-related disorder. C. CORRECT: Debriefing with others following a traumatic incident can help prevent development of a trauma-related disorder. D. Displaying emotions following a traumatic incident can help prevent development of a trauma-related disorder. E. CORRECT: Taking advantage of counseling offered by an employer or others can help prevent development of a trauma-related disorder.

3. A nurse is assessing a client who has generalized anxiety disorder. Which of the following findings should the nurse expect? (Select all that apply.) A. Excessive worry for 6 months B. Impulsive decision making C. Delayed reflexes D. Restlessness E. Sleep disturbance

3. A. CORRECT: Generalized anxiety disorder is characterized by uncontrollable, excessive worry for more than 6 months. B. Generalized anxiety disorder is characterized by procrastination in decision making. C. Generalized anxiety disorder is characterized by muscle tension. D. CORRECT: Generalized anxiety disorder is characterized by restlessness. E. CORRECT: Generalized anxiety disorder is characterized by the presence of sleep disturbances (the inability to fall asleep).

A nurse is communicating with a client whowas admitted for treatment of a substance use disorder. Which of the following communication techniques should the nurse identify as a barrier to therapeutic communication? A. Offering advice B. Reflecting C. Listening attentively D. Giving information

3. A. CORRECT: Offering advice to a client is a barrier to therapeutic communication that should be avoided. Advice tends to interfere with the client's ability to make personal decisions and choices. B. The technique of reflection directs the focus back to the client in order for the client to examine his feelings. C. The skill of active listening is an important therapeutic technique to help hear and understand the information and messages the client is trying to convey. D. Giving information informs the client of needed information to assist in the treatment planning process.

3. A home health nurse is making a visit to a client who has Alzheimer's disease to assess the home for safety. Which of the following suggestions should the nurse make to decrease the client's risk for injury? A. Install extra locks at the top of exit doors. B. Place rugs over electrical cords. C. Put cleaning supplies on the top of a shelf. D. Place the client's mattress on the floor. E. Install light fixtures above stairs.

3. A. CORRECT: Placing door locks up high where they are difficult to reach can prevent exiting the home and wandering outside. B. Rugs create a fall risk hazard and should be removed. Electrical cords should be secured to baseboards rather than covered. C. Cleaning supplies should be placed in locked cupboards. Marking the supplies with colored tape does not prevent the client's access to hazardous materials. D. CORRECT: Placing the client's mattress on the floor reduces the risk for falls out of bed. E. CORRECT: Stairs should have adequate lighting to reduce the risk for falls. NCLEX® Connection: Safety and Infec

3. A nurse is preparing to implement cognitive reframing techniques for a client who has an anxiety disorder. Which of the following techniques should the nurse include in the plan of care? (Select all that apply.) A. Priority restructuring B. Monitoring thoughts C. Diaphragmatic breathing D. Journal keeping E. Meditation

3. A. CORRECT: Priority restructuring is a cognitive reframing technique. B. CORRECT: Monitoring thoughts is a cognitive reframing technique. C. Diaphragmatic breathing is a form of behavioral therapy rather than a cognitive reframing technique. D. CORRECT: Journal keeping is a cognitive reframing technique. E. Meditation is a form of behavioral therapy rather than a cognitive reframing technique.

3. A nurse is assessing a client immediately following an ECT procedure. Which of the following findings should the nurse expect? (Select all that apply.) A. Hypotension B. Paralytic ileus C. Memory loss D. Polyuria E. Confusion

3. A. Immediately following ECT, the client's blood pressure is expected to be elevated. B. Paralytic ileus is not an expected finding of ECT. C. CORRECT: Transient short-term memory loss is an expected finding immediately following ECT. D. Polyuria is not an expect finding of ECT. E. CORRECT: Confusion is an expected finding immediately following ECT.

4. A nurse is assisting with a court-ordered evaluation of a client who has antisocial personality disorder. Which of the following findings should the nurse expect? (Select all that apply.) A. Demonstrates extreme anxiety when placed in a social situation B. Often engages in magical thinking C. Attempts to convince other clients to relinquish their belongings D. Becomes agitated if personal area is not neat and orderly E. Blames others for personal past and current problems

4. A. Anxiety in social situations is an expected finding of clients who have avoidant personality disorder. B. Magical thinking and odd beliefs are findings observed in clients who have schizotypal personality disorder. C. CORRECT: Exploitation and manipulation of others is an expected finding of antisocial personality disorder. D. Perfectionism with a focus on orderliness and control is an expected finding of clients who have obsessive-compulsive personality disorder. E. CORRECT: Failure to accept personal responsibility is an expected finding of clients who have antisocial personality disorder.

4. A nurse caring for a client who has anorexia nervosa. Which of the following examples demonstrates the nurse's use of interpersonal communication? A. The nurse discusses the client's weight loss during a health care team meeting. B. The nurse examines their own personal feelings about clients who have anorexia nervosa. C. The nurse asks the client about personal body image perception. D. The nurse presents an educational session about anorexia nervosa to a large group of adolescents.

4. A. The nurse's discussion of client information with members of the health care team is an example of small-group communication. B. The nurse's self-assessment of feelings is an example of intrapersonal communication. C. CORRECT: The nurse's one-on-one communication with the client is an example of interpersonal communication. D. The nurse's educational presentation to a large group of adolescents is an example of public communication.

5. A nurse is caring for a group of clients. Which of the following clients should a nurse consider for referral to an assertive community treatment (ACT) group? A. A client in an acute care mentalhealth facility who has fallen several times while running down the hallway B. A client who lives at home and keeps "forgetting" to come in for a scheduled monthly antipsychotic injection for schizophrenia C. A client in a day treatment program who reports increasing anxiety during group therapy D. A client in a weekly grief support group who reports still missing a deceased partner who has been dead for 3 months

5. A. A client in acute care who has been running and falling should be helped by the treatment team on the client's unit. B. CORRECT: An ACT group works with clients who are nonadherent with traditional therapy (the client in a home setting who keeps "forgetting" a scheduled injection). C. A client who has anxiety might be referred to a counselor or mental health provider. D. A client who is grieving for a deceased partner who died 3 months ago is currently involved in an appropriate intervention.

5. A charge nurse is preparing a staff education session on personality disorders. Which of the following personality characteristics associated with all of the personality disorders should the charge nurse include in the teaching? (Select all that apply.) A. Difficulty in getting along with other members of a group B. Belief in the ability to become invisible during times of stress C. Display of defense mechanisms when routines are changed D. Claiming to be more important than other persons E. Difficulty understanding why it is inappropriate to have a personal relationship with staff

5. A. CORRECT: Difficulty with social and professional relationships is a personality characteristic that can be seen with all personality disorder types. B. Clients who have schizotypal personality disorder can display magical thinking or delusions. However, this is not associated with all personality disorder types. C. CORRECT: Maladaptive response to stress is a personality characteristic that can be seen in clients who are experiencing personality disorders. D. Clients who have narcissistic personality disorder can display grandiose thinking. However, this is not associated with all personality disorder types. E. CORRECT: Difficulty understanding personal boundaries is a personality characteristic that can be seen with all personality disorder types.

5. A nurse is planning care for a client following surgical implantation of a VNS device. The nurse should plan to monitor for which of the following adverse effects? (Select all that apply.) A. Voice changes B. Seizure activity C. Disorientation D. Cough E. Neck pain

5. A. CORRECT: Voice changes are a common adverse effect of VNS due to the proximity of the implanted lead on the vagus nerve to the larynx and pharynx. B. Seizure activity is associated with ECT rather than VNS. C. Disorientation is associated with ECT rather than VNS. D. CORRECT: Coughing is a potential adverse effect of VNS. E. CORRECT: Neck pain is a potential adverse effect of VNS. However, this usually subsides with time.

5. A nurse is discussing relapse prevention with a client who has bipolar disorder. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. Use caffeine in moderation to prevent relapse. B. Difficulty sleeping can indicate a relapse. C. Begin taking your medications as soon as a relapse begins. D. Participating in psychotherapy can help prevent a relapse. E. Anhedonia is a clinical manifestation of a depressive relapse.

5. A. The client who has bipolar disorder should avoid the use of caffeine because it can precipitate a relapse. B. CORRECT: The client should be alert for sleep disturbances, which can indicate a relapse. C. The client who has bipolar disorder should take prescribed medications to prevent and minimize a relapse. D. CORRECT: The client who has bipolar disorder can participate in psychotherapy to help prevent a relapse. E. CORRECT: The onset of anhedonia, the inability to feel pleasure, is a manifestation of depression which can indicate a relapse of bipolar disorder.

5. A nurse is performing an admission assessment for a client who has delirium related to an acute urinary tract infection. Which of the following findings should the nurse expect? (Select all that apply.) A. History of gradual memory loss B. Family report of personality changes C. Hallucinations D. Unaltered level of consciousness E. Restlessness

5. A. The client who has delirium can experience memory loss with sudden rather than gradual onset. B. CORRECT: The client who has delirium can experience rapid personality changes. C. CORRECT: The client who has delirium can have perceptual disturbances (hallucinations and illusions). D. The client who has delirium is expected to have an altered level of consciousness that can rapidly fluctuate. E. CORRECT: The client who has delirium commonly exhibits restlessness and agitation.

A nurse is planning care for a client who has a mental health disorder. Which of the following actions should the nurse include as a psychobiological intervention? a.Assist the client with systematic desensitization therapy. b.Teach the client appropriate coping mechanisms. c.assess the client for comorbid health conditions. Monitor the client for adverse effects of medications.

A. Assisting with systematic desensitization therapy is a cognitive and behavioral, rather than a psychobiological intervention. B. Teaching appropriate coping mechanisms is a counseling or health teaching, rather than a psychobiological intervention. C. Assessing for comorbid health conditions is health promotion and maintenance, rather than a psychobiological, intervention. D. CORRECT: Monitoring for adverse effects of medications is an example of a psychobiological intervention.

5. A nurse is caring for a client who has generalized anxiety disorder and is experiencing severe anxiety. Which of the following statements actions should the nurse make? A. "Tell me about how you are feeling right now." B. "You should focus on the positive things in your life to decrease your anxiety." C. "Why do you believe you are experiencing this anxiety?" D. "Let's discuss the medications your provider is prescribing to decrease your anxiety."

A. CORRECT: Asking an open-ended question is therapeutic and assists the client in identifying anxiety.

4. A nurse is caring for a client who has a new prescription for disulfiram for treatment of alcohol use disorder. The nurse informs the client that this medication can cause nausea and vomiting when alcohol is consumed. Which of the following types of treatment is this method an example? A. Aversion therapy B. Flooding C. Biofeedback D. Dialectical behavior therapy

A. CORRECT: Aversion therapy pairs a maladaptive behavior

3. A nurse is teaching a client about stress-reduction techniques. Which of the following client statements indicates understanding of the teaching? A. "Cognitive reframing will help me change my irrational thoughts to something positive." B. "Progressive muscle relaxation uses a mechanical device to help me gain control over my pulse rate." C. "Biofeedback causes my body to release endorphins so that I feel less stress and anxiety." D. "Mindfulness allows me to prioritize the stressors that I have in my life so that I have less anxiety."

A. CORRECT: Cognitive reframing helps the client look at irrational cognitions (thoughts) in a more realistic light and to restructure those thoughts in a more positive way.

A charge nurse is discussing mentalstatusexaminations with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? (Select all that apply.) a "To assess cognitive ability, I should ask the client to count backward by sevens." b."To assess affect, I should observe the client's facial expression." c"To assess language ability, I should instruct the client to rite a sentence." d. "To assess remote memory, I should have the client repeat a list of objects." e. "To assess the client's abstract thinking, I should ask the client to identifyour most recent presidents."

A. CORRECT: Counting backward by 7s is an appropriate technique to assess a client's cognitive ability. B. CORRECT: Observing a client's facial expression is appropriate when assessing affect. C. CORRECT: Writing a sentence is an indication of language ability. D. Asking the client to repeat a list of objects is appropriate to assess immediate, rather than remote, memory. E. Asking the client to identify recent presidents is appropriate to assess cognitive knowledge rather than abstract thinking.

4. A nurse is planning care for the termination phase of a nurse-client relationship. Which of the following actions should the nurse include in the plan of care? A. Discussing ways to use new behaviors B. Practicing new problem-solving skills C. Developing goals D. Establishing boundaries

A. CORRECT: Discussing ways for the client to incorporate new healthy behaviors into life is an appropriate task for the termination phase. B. Practicing new problem-solving skills is an appropriate task for the working phase. C. Developing goals is an appropriate task for the orientation phase.D. Establishing boundaries is an appropriate task for the orientation phase.

1. A nurse is preparing an educational seminar on stress for other nursing staff. Which of the following information should the nurse include in the discussion? A. Excessive stressors cause the client to experience distress. B. The body's initial adaptive response to stress is denial. C. Absence of stressors results in homeostasis. D. Negative, rather than positive, stressors produce a biological response.

A. CORRECT: Distress is the result of excessive or damaging stressors (anxiety or anger).

3. A nurse is working in a community mental health facility. Which of the following services does this type of program provide? (Select all that apply.) A. Educational groups B. Medication dispensing programs C. Individual counseling programs D. Detoxification programs E. Family therapy

A. CORRECT: Educational groups are services provided in a community mental health facility. B. CORRECT: Medication dispensing programs are services provided in a community mental health facility. C. CORRECT: Individual counseling programs are services provided in a community mental health facility. D. Detoxification programs are services provided in a partial hospitalization program. E. CORRECT: Family therapy is a service provided in a community mental health facility.

4. A nurse is planning care for a client who has body dysmorphic disorder. Which of the following actions should the nurse plan to take first? A. Assess the client's risk for self-harm B. Instill hope for positive outcomes C. Encourage the client to participate in group therapy sessions D. Assist the client to participate in treatment decisions

A. CORRECT: The greatest risk to a client who has an anxiety or obsessive-compulsive disorder is self-harm or suicide. Therefore, the first action to take is to assess the client's risk for self-harm to ensure that the client is provided with a safe environment.

4. A nurse in an acute mental health facility is assisting with discharge planning for a client who has a severe mental illness and requires supervision. The client's partner works all day but is home by late afternoon. Which of the following strategies should the nurse suggest for follow-up care? A. Receiving daily care from a home health aide B. Having a weekly visit from a nurse case worker C. Attending a partial hospitalization program D. Visiting a community mental health center on a daily basis

A. Daily care provided by a home health aide will not provide adequate supervision for this client. B. Weekly visits from a case worker will not provide adequate care and supervision for this client. C. CORRECT: A partial hospitalization program can provide treatment during the day while allowing the client to spend nights at home, as long as a responsible family member is present. D. Daily visits to a community mental health center will not provide consistent supervision for this client.

5. A nurse is orienting a new client to a mental health unit. When explaining the unit's community meetings, which of the following statements should the nurse make? A. "You and a group of other clients will meet to discuss your treatment plans." B. "Community meetings have a specific agenda that is established by staff." C. "You and the other clients will meet with staff to discuss common problems." D. "Community meetings are an excellent opportunity to explore your personal mental health issues."

A. Individual treatment plans are discussed during individual therapy rather than a community meeting. B. Community meetings may be structured so that they are client-led with decisions made by the group as a whole. C. CORRECT: Community meetings are an opportunity for clients to discuss common problems orissues affecting all members of the unit. D. Personal mental health issues are discussed during individual therapy rather than a community meeting.

A nurse in an outpatient mental health clinic is preparing to conduct an initial client interview. When conducting the interview, which of the following actions should the nurse identify as the priority? Coordinate holistic care with social services. b.Identify the client's perception of their mental health status. c.Include the client's family in the interview. d. Teach the client about their current mental health disorder.A nurse is talking with the caregiver of a child who has demonstrated recent changes in behavior and mood. When the caregiver of the child asks the nurse for reassurance about their child's condition, which of the following responses should the nurse make? A. "I think your child is getting better. What have you noticed?" B. "I'm sure everything will be okay. It just takes time to heal." C. "I'm not sure what's wrong. Have you asked the doctor about your concerns?" D. "I understand you're concerned. Let's discuss what concerns you specifically."

A. It is appropriate to coordinate holistic care for the client with social services as part of case management. However, another action is the priority. B. CORRECT: Assessment is the priority action when using the nursing process approach to client care. Identifying the client's perception of their mental health status provides important information about the client's psychosocial history. C. If the client wishes, it is appropriate to include the client's family in the interview. However, another action is the priority. D. It is appropriate to teach the client about their disorder. However, another action is the priority.

2. A nurse in an acute mental health facility is communicating with a client. The client states, "I can't sleep. I stay up all night." The nurse responds, "You are having difficulty sleeping?" Which of the following therapeutic communication techniques is the nurse demonstrating? A. Offering general leads B. Summarizing C. Focusing D. Restating

A. Offering general leads allows the nurse to take the direction of the discussion. B. Summarizing enables the nurse to bring together important points of discussion to enhance understanding. C. Focusing concentrates the attention on one single point. D. CORRECT: Restating allows the nurse to repeat the main idea expressed.

A nurse is caring for a client who is experiencing moderate anxiety. Which of the following actions should the nurse take when trying to give necessary information to the client? (Select all that apply.) A. Reassure the client that everything will be okay. B. Discuss prior use of coping mechanisms with the client. C. Ignore the client's anxiety so that she will not be embarrassed. D. Demonstrate a calm manner while using simple and clear directions. E. Gather information from the client using closed-ended questions.

A. Providing false reassurance is an example of nontherapeutic communication. B. CORRECT: Discussing the prior use of coping mechanisms assists the client in identifying ways of effectively coping with the current stressor. C. Recognizing the client's current level of anxiety assists the client to begin the process of problem solving. D. CORRECT: Providing a calm presence assists the client in feeling secure and promotes relaxation. Clients experiencing moderate levels of anxiety often benefit from the direction of others. E. Using open-ended questions for client communication encourages the client to express feelings and identify the source of the anxiety.

4. A nurse is planning a peer group discussion about the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). Which of the following information is appropriate to include in the discussion? (Select all that apply.) A. The DSM-5 includes client education handouts for mental health disorders. B. The DSM-5 establishes diagnostic criteria for individual mental health disorders. C. The DSM-5 indicates recommended pharmacological treatment for mental health disorders. D. The DSM-5 assists nurses in planning care for client's who have mental health disorders. E. The DSM-5 indicates expected assessment findings of mental health disorders.

A. The DSM-5 is used by mental health professionals. However, it does not include client education handouts. B. CORRECT: The DSM-5 establishes diagnostic criteria for mental health disorders. C. The DSM-5 does not indicate pharmacological treatment for mental health disorders. D. CORRECT: Nurses use the DSM-5 to plan, implement, and evaluate care for client's who have mental health disorders. E. CORRECT: The DSM-5 identifies expected findings for mental health disorders.

1. Anurseisplanningcareforseveralclientswhoare attending community-based mental health programs. Which of the following clients should the nurse visit first? A. A client who received a burn on the arm while using a hot iron at home B. A client who requests a change of antipsychotic medication due to some new adverse effects C. A client who reports hearing a voice saying that life is not worth living anymore D. A client who tells the nurse about experiencing manifestations of severe anxiety before and during a job interview

A. This client has needs that should be met, but there is another client whom the nurse should see first. B. This client has needs that should be met, but there is another client whom the nurse should see first. C. CORRECT: A client who hears a voice saying life is not worth living anymore is at greatest risk for self-harm, and the nurse should visit this client first. D. This client has needs that should be met, but there is another client whom the nurse should see first.

A nurse is in the working phase of a therapeutic relationship with a client who has methamphetamine use disorder. Which of the following actions indicates transference behavior? A. The client asks the nurse if they will go out to dinner together. B. The client accuses the nurse of being controlling just like an ex-partner. C. The client reminds the nurse of a friend who died from substance toxicity. D. The client becomes angry and threatens to engage in self harm.

A. This indicates the need to discuss boundaries but does not indicate transference. B. CORRECT: When a client views the nurse as having characteristics of another person who has been significant to their personal life (an ex-partner) this indicates transference. C. This indicates countertransference rather than transference. D. This indicates the need for safety intervention but does not indicate transference.

2. A community mental health nurse is planning care to address the issue of depression among older adult clients in the community. Which of the following interventions should the nurse implement as a method of tertiary prevention? A. Educating clients on health promotion techniques to reduce the risk of depression B. Performing screenings for depression at community health programs C. Establishing rehabilitation programs to decrease the effects of depression D. Providing support groups for clients at risk for depression

A. This intervention is an example of primary prevention.B. This intervention is an example of secondary prevention. C. CORRECT: Rehabilitation programs are an example of tertiary prevention. Tertiary prevention deals with prevention of further problems in clients already diagnosed with mental illness. D. This intervention is an example of primary prevention.

A nurse is talking with the caregiver of a child who has demonstrated recent changes in behavior and mood. When the caregiver of the child asks the nurse for reassurance about their child's condition, which of the following responses should the nurse make? A. "I think your child is getting better. What have you noticed?" B. "I'm sure everything will be okay. It just takes time to heal." C. "I'm not sure what's wrong. Have you asked the doctor about your concerns?" D. "I understand you're concerned. Let's discuss what concerns you specifically."

A. This nontherapeutic response interjects the nurse's opinion and can cause the caregiver to withhold their thoughts and feelings. B. This nontherapeutic response interjects the nurse's opinion and provides false reassurance which can cause the caregiver to withhold their thoughts and feelings. C. This nontherapeutic response avoids addressing the caregiver's concerns directly and indicates disinterest by the nurse for wanting to discuss the concerns with the parents. D. CORRECT: This therapeutic response reflects upon, and accepts, the caregivers' feelings, and it allows them to clarify what they are feeling.

4. A nurse is caring for a client on an acute mental health unit. The client reports hearing voices that are stating, "kill your doctor." Which of the following actions should the nurse take first? A. Encourage the client to participate in group therapy on the unit. B. Initiate one-to-one observation of the client. C. Focus the client on reality. D. Notify the provider of the client's statement.

B. CORRECT: A client who is experiencing a command hallucination is at risk for injury to self or others. Safety is the priority, and initiating one-to-one observation is the first action the nurse should take.

5. A nurse is speaking with a client who has schizophrenia when the client suddenly seems to stop focusing on the nurse's questions and begins looking at the ceiling and talking to themselves. Which of the following actions should the nurse take? A. Stop the interview at this point, and resume later when the client is better able to concentrate. B. Ask the client, "Are you seeing something on the ceiling?" C. Tell the client, "You seem to be looking at something on the ceiling. I see something there, too." D. Continue the interview without comment on the client's behavior.

B. CORRECT: Ask the client directly about the hallucination to identify client needs and assess for a potential risk for injury.

4. A nurse is talking with a client who reports experiencing increased stress because a new partner is "pressuring me and my kids to go live with him. I love him, but I'm not ready to do that." Which of the following recommendations should the nurse make to promote a change in the client's situation? A. Learn to practice mindfulness. B. Use assertiveness techniques. C. Exercise regularly. D. Rely on the support of a close friend.

B. CORRECT: Assertive communication allows the client to assert their feelings and then make a change in the situation.

1. A nurse is teaching a client who has an anxiety disorder and is scheduled to begin classical psychoanalysis. Which of the following client statements indicates an understanding of this form of therapy? A. "Even if my anxiety improves, I will need to continue this therapy for 6 weeks." B. "The therapist will focus on my past relationships during our sessions." C. "Psychoanalysis will help me reduce my anxiety by changing my behaviors." D. "This therapy will address my conscious feelings about stressful experiences."

B. CORRECT: Classical psychoanalysis places a common focus on past relationships to identify the cause of the anxiety disorder.

2. A nurse is planning group therapy for clients dealing with bereavement. Which of the following activities should the nurse include in the initial phase? (Select all that apply.) A. Encourage the group to work toward goals. B. Define the purpose of the group. C. Discuss termination of the group. D. Identify informal roles of members within the group. E. Establish an expectation of confidentiality within the group.

B. CORRECT: During the initial phase, identify the purpose of the group. C. CORRECT: During the initial phase, discuss termination of the group. E. CORRECT: During the initial phase, set the tone of the group, including an expectation of confidentiality.

4. A nurse is conducting a family therapy session. The younger child tells the nurse about plans to make the older sibling look bad, believing this will earn more freedom and privileges. The nurse should identify this dysfunctional behavior as which of the following? A. Placation B. Manipulation C. Blaming D. Distraction

B. CORRECT: Manipulation is the dysfunctional behavior of using dishonesty to support an individual agenda.

3. A nurse is caringforaclientwhohasborderlinepersonality disorder. The client says, "The nurse on the evening shift is always nice! You are the meanest nurse ever!" The nurse should recognize the client's statement as an example of which of the following defense mechanisms? A. Regression B. Splitting C. Undoing D. Identification

B. CORRECT: Splitting occurs when a person is unable to see both positive and negative qualities at the same time. The client who has borderline personality disorder tends to see a person as all bad one time and all good another time.

3. A nurse is caring for a client who has schizoaffective disorder. Which of the following statements indicates the client is experiencing depersonalization? A. "I am a superhero and am immortal." B. "I am no one, and everyone is me." C. "I feel monsters pinching me all over." D. "I know that you are stealing my thoughts."

B. CORRECT: This comment indicates the client is experiencing a loss of identity or depersonalization.

4. A nurse is caring for a client who has bipolar disorder. The client states, "I am very rich, and I feel I must give my money to you." Which of the following responses should the nurse make? A. "Why do you think you feel the need to give money away?" B. "I am here to provide care and cannot accept this from you." C. "I can request that your case manager discuss appropriate charity options with you." D. "You should know that giving away your money is inappropriate."

B. CORRECT: This statement is matter-of-fact and concise and is a therapeutic response to a client who has bipolar disorder.

1. A nurse observes a client who has OCD repeatedly applying, removing, and then reapplying makeup. The nurse identifies that repetitive behavior in a client who has OCD is due to which of the following underlying reasons? A. Narcissistic behavior B. Fear of rejection from staff C. Attempt to reduce anxiety D. Adverse effect of antidepressant medication

C

A nurse is teaching a client who has a new diagnosis of premenstrual dysphoric disorder (PMDD). Which of the following statements by the client indicates understanding of the teaching? A. "I can expect my problems with PMDD to be worst when I'm menstruating." B. "I should avoid exercising when I am feeling depressed." C. "I am aware that my PMDD causes me to have rapid mood swings." D. "I should increase my caloric intake with a nutritional supplement when my PMDD is active."

C. CORRECT: A clinical finding of PMDD is emotional lability. The client can experience rapid changes in mood

3. A nurse on an acute mental health unit forms a group to focus on self-management of medications. At each of the meetings, two of the members conspire together to exclude the rest of the group. This is an example of which of the following concepts? A. Triangulation B. Group process C. Subgroup D. Hidden agenda

C. CORRECT: A subgroup is a small number of people within a larger group who function separately from that group.

5. A nurse is working with an established group and identifies various member roles. Which of the following should the nurse identify as an individual role? A. A member who praises input from other members B. A member who follows the direction of other members C. A member who brags about accomplishments D. A member who evaluates the group's performance toward a standard

C. CORRECT: An individual who brags about accomplishments is acting in an individual role that does not promote the progression of the group toward meeting goals.

1. A nurse observes a client who has OCD repeatedly applying, removing, and then reapplying makeup. The nurse identifies that repetitive behavior in a client who has OCD is due to which of the following underlying reasons? A. Narcissistic behavior B. Fear of rejection from staff C. Attempt to reduce anxiety D. Adverse effect of antidepressant medication

C. CORRECT: Clients who have OCD demonstrate repetitive behavior in an attempt to suppress persistent thoughts or urges that cause anxiety.

1. A nurse wants to use democratic leadership with a group whose purpose is to learn appropriate conflict resolution techniques. The nurse is correct in implementing this form of group leadership when demonstrating which of the following actions? A. Observes group techniques without interfering with the group process B. Discusses a technique and then directs members to practice the technique C. Asks for group suggestions of techniques and then supports discussion D. Suggests techniques and asks group members to reflect on their use

C. CORRECT: Democratic leadership supports group interaction and decision making to solve problems.

2. A nurse is teaching a newly licensed nurse about the use of electroconvulsive therapy (ECT) for the treatment of bipolar disorder. Which of the following statements by the newly licensed nurse indicates understanding? A. "ECT is the recommended initial treatment for bipolar disorder." B. "ECT is contraindicated for clients who have suicidal ideation." C. "ECT is effective for clients who are experiencing severe mania." D. "ECT is prescribed to prevent relapse of bipolar disorder."

C. CORRECT: ECT is appropriate for the treatment of severe mania associated with bipolar disorder.

4. A nurse is leading a peer group discussion about the indications for ECT. Which of the following indications should the nurse include in the discussion? A. Borderline personality disorder B. Acute withdrawal related to a substance use disorder C. Bipolar disorder with rapid cycling D. Dysphoric disorder

C. CORRECT: ECT is indicated for the treatment of bipolar disorder with rapid cycling.

A nurse is interviewing a client who has a new diagnosis of persistent depressive disorder. Which of the following findings should the nurse expect? A. Wide fluctuations in mood B. Report of a minimum of five clinical findings of depression C. Presence of manifestations for at least 2 years D. Inflated sense of self-esteem

C. CORRECT: Manifestations of persistent depressive disorder last for at least 2 years in adults.

4. A nurse is making a home visit to a client who is in the late stage of Alzheimer's disease. The client's partner, who is the primary caregiver, wishes to discuss concerns about the client's nutrition and the stress of providing care. Which of the following actions should the nurse take? A. Verify that a current power of attorney document is on file. B. Instruct the client's partner to offer finger foods to increase oral intake. C. Provide information on resources for respite care. D. Schedule the client for placement of an enteral feeding tube.

C. CORRECT: Providing information on resources for respite care is an appropriate action to provide the client's partner with a break from caregiving responsibilities.

4. A nurse is caring for a client who has derealization disorder. Which of the following findings should the nurse identify as an indication of derealization? A. The client describes a feeling of floating above the ground. B. The client has suspicions of being targeted in order to be killed and robbed. C. The client states that the furniture in the room seems to be small and far away. D. The client cannot recall anything that happened during the past 2 weeks.

C. CORRECT: Stating that one's surroundings are far away or unreal in some way is an example of derealization.

5. A nurse is assisting with systematic desensitization for a client who has an extreme fear of elevators. Which of the following actions should the nurse implement with this form of therapy? A. Demonstrate riding in an elevator, and then ask the client to imitate the behavior. B. Advise the client to say "stop" out loud every time they begin to feel an anxiety response related to an elevator. C. Gradually expose the client to an elevator while practicing relaxation techniques. D. Stay with the client in an elevator until the anxiety response diminishes.

C. CORRECT: Systematic desensitization is the planned, progressive exposure to anxiety-provoking stimuli. During this exposure, relaxationtechniques suppress the anxiety response.

4. A charge nurse is discussing the care of a client who has major depressive disorder (MDD) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. "Care during the continuation phase focuses on treating continued manifestations of MDD." B. "The treatment of MDD during the maintenance phase lasts for 6 to 12 weeks." C. "The client is at greatest risk for suicide during the first weeks of an MDD episode." D. "Medication and psychotherapy are most effective during the acute phase of MDD."

C. CORRECT: The client is at greatest risk for suicide during the acute phase of MDD.

1. A nurse is providing teaching for a client who is scheduled to receive ECT for the treatment of major depressive disorder. Which of the following client statements indicates understanding of the teaching? A. "It is common to treat depression with ECT before trying medications." B. "I can have my depression cured if I receive a series of ECT treatments." C. "I should receive ECT once a week for 6 weeks." D. "I will receive a muscle relaxant to protect me from injury during ECT."

D. CORRECT: A muscle relaxant (succinylcholine) is administered to reduce the risk for injury during induced seizure activity.

2. A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take? A. Discuss new relaxation techniques. B. Show the client how to change the behavior. C. Distract the client with a television show. D. Stay with the client and remain quiet.

D. CORRECT: During a panic attack, quietly remain with the client. This promotes safety and reassurance without additional stimuli.

2. A nurse is discussing free association as a therapeutic tool with a client who has major depressive disorder. Which of the following client statements indicates understanding of this technique? A. "I will write down my dreams as soon as I wake up." B. "I might begin to associate my therapist with important people in my life." C. "I can learn to express myself in a nonaggressive manner." D. "I should say the first thing that comes to my mind."

D. CORRECT: Free association is the spontaneous, uncensored verbalization of whatever comes to a client's mind.

5. A nurse in an acute mental health facility is planning care for a client who has dissociative fugue. Which of the following interventions should the nurse add to the plan of care? A. Teach the client to recognize how stress brings on a personality change in the client. B. Repeatedly present the client with information about past events. C. Make decisions for the client regarding routine daily activities. D. Work with the client on grounding techniques.

D. CORRECT: Grounding techniques (stomping the feet, clapping the hands, or touching physical objects) are useful for clients who have a dissociative disorder and are experiencing manifestations of derealization.

2. A nurse in a long-term care facility is caring for a client who has major neurocognitive disorder and attempts to wander out of the building. The client states, "I have to get home." Which of the following statements should the nurse make? A. "You have forgotten that this is your home." B. "You cannot go outside without a staff member." C. "Why would you want to leave? Aren't you happy with your care?" D. "I am your nurse. Let's walk together to your room."

D. CORRECT: It is appropriate to introduce oneself with each new interaction and to promote reality in a calm, reassuring manner.

3. A nurse is caring for a client who has bipolar disorder. Which of the following is the priority nursing action? A. Set consistent limits for expected client behavior. B. Administer prescribed medications as scheduled. C. Provide the client with step-by-step instructions during hygiene activities. D. Monitor the client for escalating behavior.

D. CORRECT: Monitoring for escalating behavior addresses the client's priority need for safety and is therefore the priority nursing action.

3. A nurse is collecting an admission history for a client who has acute stress disorder (ASD). Which of the following client behaviors should the nurse expect? A. The client remembers many details about the traumatic incident. B. The client expresses heightened elation about what is happening. C. The client remembers first noticing manifestations of the disorder 6 weeks after the traumatic incident occurred. D. The client expresses a sense of unreality about the traumatic incident.

D. CORRECT: The client who has ASD often expresses dissociative manifestations regarding the event, which includes a sense of unreality.

5. A nurse is caring for a client who states, "I'm so stressed at work because of my coworker. I am expected to finish others' work because of their laziness!" When discussing effective communication, which of the following statements by the client to the coworker indicates client understanding? A. "You really should complete your own work. I don't think it's right to expect me to complete your responsibilities." B. "Why do you expect me to finish your work? You must realize that I have my own responsibilities." C. "It is not fair to expect me to complete your work. If you continue, then I will report your behavior to our supervisor." D. "When I have to pick up extra work, I feel very overwhelmed. I need to focus on my own responsibilities."

D. CORRECT: This response demonstrates assertive communication, which allows the client to state his feelings about the behavior and then promote a change.