Exam 2 Practice Assessment
A nurse is caring for a client who is experiencing a panic attack. which of the following actions should the nurse take? A. Distract the client with a television show B. Show the client how to change his behavior C. Discuss new relaxation techniques D. Stay with the client and remain quiet
D. Stay with the client and remain quiet
A nurse is caring for a young adult client who says he is experiencing anxiety and an inability to concentrate. Which of the following responses should the nurse make? A. "It sounds like you're having a difficult time." B. "Have you talked to your parents about this yet?" C. "Why do you think you are so anxious?" D. "How long has this been going on?
A. "It sounds like you're having a difficult time."
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 techniques? A. "I should say the first thing that comes to my mind." B. "I can learn to express myself in a nonaggressive manner." C. "I may begin to associate my therapist with important people in my life." D. "I will write down my dreams as soon as I wake up."
A. "I should say the first thing that comes to my mind."
A nurse in a hospital is caring for a client who has agoraphobia. Which of the following statements by the client indicates understanding of the goals of treatment? A. "I plan to sit on a park bench for a few minutes each day." B. "I can try participating in group therapy every week." C. "I will join a book club in my neighborhood." D. "I should avoid entering elevators and other closed spaces."
A. "I plan to sit on a park bench for a few minutes each day."
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. "I will schedule the client for daily TMS treatments for several weeks." B. "TMS is indicated for clients with schizophrenia" C. "TMS treatments usually last 5-10 minutes." D. "I will provide post anesthesia care following TMS."
A. "I will schedule the client for daily TMS treatments for several weeks."
A nurse is caring for a client who has bipolar disorder. Which of the following actions by the client should the nurse interpret as displaying manic behavior? (Select all that apply) A. Talking in rapid, continuous speech B. Interacting with others in a flirtatious way C. Spending large sums of money D. Sleeping for long periods of time E. Dressing in black or grey clothing
A, B, C
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. "It must be scary to hear voices." B. "Are the voices telling you to hurt yourself?" C. "When did you start hearing the voices?" D. "Why are the voices talking to only you?" E. "The voices are not real, or else we would both hear them."
A, B, C
A nurse is caring for a client who is to undergo electroconvulsive therapy (ECT) for the treatment of depression. Which of the actions should the nurse take prior to the schedules ECT? (Select all that apply) A. Request an ECG B. Witness the informed consent C, Check the client's blood pressure D. Obtain a serum parathyroid hormone level E. Obtain a urine specimen
A, B, C
A nurse is creating a plan of care for a client who is experiencing mania. Which of the following interventions should the nurse include in the plan? (Select all that apply) A. Offer finger foods to the client every 2 hours B. Maintain an environment with low stimuli C. Monitor vital signs every 1 to 2 hours throughout the day D. Discourage the client from taking a nap during the day E. Weigh client every 3 to 4 days
A, B, C
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. Dysphagia B. Neck pain C. Voice changes D. Disorientation E. Seizure activity
A, B, C
A nurse is assessing a client who has illness anxiety disorder. Which of the following findings should the nurse expect? (Select all that apply) A. Depressive disorder B. History of childhood abuse C. Avoidance of health care providers D. Obsessive thoughts about disease E. Narcissistic personality
A, B, C, D
A nurse is preparing to assist with electroconvulsive therapy (ECT). which of the following pieces of equipment should the nurse set up in the room prior to the treatment. (Select all that apply) A. Electroencephalogram (EEG) monitor B. Blood pressure monitor C. Ophthalmoscope D. Cardiac monitor E. Portable x-ray machine
A, B, D
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. Restlessness D. Need for reassurance E. Delayed reflexes
A, C, D
A nurse working on an acute mental health unit is caring for a client who has PTSD. Which of the following should the nurse expect? (Select all that apply) A. Difficulty concentrating on tasks B. Diminished reflexes C. Recurring nightmares D. Negative self-image E. Obsessive need to talk about trauma
A, C, D
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. Low self-esteem E. Chronic pain
A, C, D, E
A nurse is caring for a client who has OCD. Which of the following characteristics are expected findings of OCD? (Select all that apply) A. Difficulty relaxing B. Irrational fear of certain objects C. Rule-conscious behavior D. Unaware of compulsions E. Perfectionist behavior
A, C, E
A nurse is caring for a client who has schizophrenia. Which of the following statements by the client indicates concrete thinking? A. "I am aware that each problem has only one solution." B. "I am a prophet of the most high king." C. "The voices tell me that I must avoid large crowds." D. "I know that you and the other nurses are trying to poison me."
A. "I am aware that each problem has only one solution."
A nurse is admitting a client who has a new diagnosis of bipolar and is scheduled to begin lithium therapy. When collecting a medical history from the client's adult daughter, which of the following statements is the priority to report to the provider? A. "My mother is currently on furosemide for her congestive heart failure." B. "My mother has diabetes that is controlled by her diet." C. "My mother received her flu vaccine last month." D. "My mother recently completely a course of prednisone for acute bronchitis."
A. "My mother is currently on furosemide for her congestive heart failure."
A nurse is caring for a client who has major depressive disorder and is scheduled for electroconvulsive therapy (ECT). The client's spouse asks the nurse about the possible side effects of the ECT. Which of the following responses should the nurse make? A. "The main side effects are temporary, and may include mild confusion, headache, and short term memory loss." B. "Most clients have no adverse effects to this treatment, but muscle cramping may result from the induced seizure." 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. "The most common side effects are directly related to the use of anesthesia."
A. "The main side effects are temporary, and may include mild confusion, headache, and short term memory loss."
A nurse is caring for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following responses should the nurse make first? A. "What are the voices telling you?" B. "How often do you hear the voices?" C. "I know you hear the voices, but I do not." D. "The voices are part of your illness."
A. "What are the voices telling you?"
A nurse is caring for an adolescent client who has a new diagnosis of schizophrenia. The client's parents are tearful and express feelings of guilt. Which of the following statements should the nurse make? A. "You said that you feel guilty about your daughter's diagnosis. Let's talk about what is causing you to feel this way." B. "You should not feel guilty about your daughter's diagnosis. Schizophrenia is unpreventable." C. "I'm sure your daughter's diagnosis is very difficult to deal with, but everything will be all right once she receives proper treatment." D. "Your provider has explained that causes of schizophrenia. Why do you feel guilty about you daughter's diagnosis?"
A. "You said that you feel guilty about your daughter's diagnosis. Let's talk about what is causing you to feel this way."
A nurse is reviewing abnormal laboratory values for four clients who have schizophrenia and take clozapine. For which of the following clients should the nurse withhold the medication and notify the provider immediately to have clozapine therapy discontinued? A. A client who has a WBC count of 2,900 cells/mm3 B. A client who has a hematocrit of 55% C. A client who has a serum potassium of 3.3 mEq/L D. A client who has a BUN of 22 mg/dL
A. A client who has a WBC count of 2,900 cells/mm3
A nurse is admitting a client who is in the manic phase of bipolar disorder. The nurse should plan to make which of the following room assignments for the client? A. A private room in a quiet location on the unit B. A semi-private room with a roommate who has a similar diagnosis C. A private room close to the nurse's station D. A seclusion room until the client's activity level becomes more subdued
A. A private room in a quiet location on the unit
A nurse is performing an admission assessment for a client who has schizophrenia. Which of the following findings should the nurse identify as a negative symptom? A. Affective flattening B. Bizarre behavior C. illogicality D. Somatic delusions
A. Affective flattening
A nurse is caring for a client who has a depressive disorder. The client states, "I just can't feel any happiness or joy in life." Which of the following terms should the nurse use when documenting this finding? A. Anhedonia B. Anergia C. Anosognosia D. Akathisia
A. Anhedonia
A nurse is caring for a client 3 days after admission for treatment of depression. the client leaves for current activity, approaches the nurse and states, "There's no reason to go on living. I just want to end it all." Which of the following actions should the nurse take? A. Ask the client if she has a plan to commit suicide B. Recognize the attempt as manipulation and escort the client back to her activity C. Assist the client to her room and follow her to rest before resuming activity D. Notify the client's family and request a visitor to stay with the client until thoughts of suicide are gone.
A. Ask the client if she has a plan to commit suicide
A nurse is caring for a client who has schizophrenia. The client states that he hears voices telling him to do "bad things." The nurse correctly identifies this finding as which of the following? A. Command hallucination B. Gustatory hallucination C. Cognitive hallucination D. Somatic hallucination
A. Command hallucination
A home-health nurse is assessing a client who has OCD and finds that the client demonstrates constant repetitive cleaning. The nurse knows that this behavior is an attempt to accomplish which of the following? A. Decrease anxiety B. Prevent aggressive and impulsive behaviors C. Manipulate others D. Decrease the time available for interaction with people
A. Decrease anxiety
A nurse is caring for a client who has severe manifestations of schizophrenia and is medicated PRN for agitation with haloperidol. The nurse should assess the client for which of the following adverse effects? A. Dysrhythmias B. Cataracts C. Pancreatitis D. Bleeding
A. Dysrhythmias
A nurse is teaching a newly licensed nurse about the use of ECT for the treatment of Bipolar disorder. Which of the following statements by the newly licensed nurse indicates an understanding? A. ECT is effective for client's who are experiencing severe mania B. ECT is the recommended initial treatment for bipolar disorder C. ECT is contraindicated for clients who have suicidal ideation D. ECT is prescribed to prevent relapse of bipolar disorder
A. ECT is effective for client's who are experiencing severe mania
A nurse is caring for a client who has been hospitalized for treatment of bipolar disorder and will be discharged with a prescription for lithium. The nurse's discharge teaching should include information cautioning against which of the following factors that may cause lithium toxicity? A. Experiencing diarrhea B. Exercising moderately C. Increasing sodium intake D. Drinking green tea
A. Experiencing diarrhea
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. Gradually expose the client to an elevator while practicing relaxation techniques. B. Demonstrate riding in an elevator, and then ask the client to imitate the behavior C. Advise the client to say "stop" out loud every time he begins to feel an anxiety response related to an elevator D. Stay with the client in an elevator until his anxiety response diminishes
A. Gradually expose the client to an elevator while practicing relaxation techniques.
A nurse is providing teaching to a client who has schizophrenia and a new prescription for risperidone. Which of the following statements should the nurse include in the teaching? A. Increase your fluid and fiber intake to prevent constipation B. Have your blood pressure checked frequently for hypertension C. Expect to have your blood checked weekly for serum electrolyte imbalances D. Increase caloric intake to prevent weight loss
A. Increase your fluid and fiber intake to prevent constipation
A nurse on an acute mental health unit is caring for a client who has major depressive disorder. Which of the following interventions is the nurse's priority? A. Monitor for risk of self-harm B. Administer prescribed antidepressants C. Encourage adequate fluid intake D. Assist with activities of daily living
A. Monitor for risk of self-harm
A nurse 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? A. Placing the client on one-to-one observation B. Encouraging the client to participate in counseling C. Teaching the client about medication adverse effects D. Assisting the client to perform ADLs
A. Placing the client on one-to-one observation
A nurse is caring for a client who requires a crisis intervention for acute anxiety. Which of the following actions is the highest priority? A. Protecting the client from injury B. Determining the cause of the client's anxiety C. Ensuring that the client feels safe D. Identifying the client's coping skills
A. Protecting the client from injury
A nurse is caring for a client who reports acute, moderate anxiety. Which of the following is the priority nursing action? A. Remain with the client B. Provide a diverting activity C. Encourage verbalization of feelings D. Instruct the client to remember past coping mechanisms.
A. Remain with the client
A nurse is caring for a client who has major depressive disorder. Which of the following findings should the nurse expect? A. Significant change in weight B. Hyperexcitability C. Exaggerated response to stimuli D. Attention seeking behavior
A. Significant change in weight
A nurse is planning a unit orientation for a newly admitted client who has severe depression. Which of the following should be the nurse's approach? A. Sit with the client and offer simple, direct information B. Have the client attend group therapy immediately C. Explain the unity policies tot he client and answer any questions he might have D. Take the client on a tour of the unit and introduce him to all the staff members on duty
A. Sit with the client and offer simple, direct information
A nurse is teaching a client who has depression about electroconvulsive therapy (ECT). Which of the following information should the nurse include in the teaching? A. Temporary memory loss is the most common adverse effect of ECT. B. Medications are given to prevent seizure activity during ECT. C. The greatest risk of ECT is brain damage D. ECT is effective in the treatment is substance use disorder
A. Temporary memory loss is the most common adverse effect of ECT.
A client is admitted with PTSD following a fire in his home in which family members died. Which of the following should the nurse recognize as an adaptive defense mechanism? A. The client begins reading a book when he experiences hand tremors in response to loud noise B. The client makes a decision to postpone a needed surgery C. The client focuses on discussing his daily routine when asked about the fire D. The client develops stomach pains when fire is seen on television
A. The client begins reading a book when he experiences hand tremors in response to loud noise
A community mental health nurse is assessing a client who has schizophrenia. Which of the following findings indicates the client might be relapsing? A. The client reports difficulties with sleeping and concentrating B. The client states he has started smoking again C. The client is wearing mismatched clothing D. The client reports feelings of anger toward her provider
A. The client reports difficulties with sleeping and concentrating
A nurse is providing discharge teaching to a client who has bipolar disorder and will be discharged with a prescription for lithium. the nurse should teach the client that which of the following factors puts her at risk for lithium toxicity? A. the client runs 4 miles outdoors every afternoon B. The client drinks 2 liters of liquids daily C. The client eats 2 to 3 gm of sodium-containing foods daily D. The client eats foods high in tyramine
A. the client runs 4 miles outdoors every afternoon
A nurse is planning care for a client who is in the manic phase of bipolar disorder. Which of the following interventions should the nurse include in the client's plan of care? A. Provide a stimulating environment B. Have consistent unit routine C. Discourage daytime napping D. Schedule daily seclusion time
B. Have consistent unit routine
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. Disregard client complaints B. Establish consistent limits C. Use a firm approach with communication D. Provide flexible client behavior expectations E. Offer concise explanations
B, C, E
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. Diaphragmatic breathing B. Priority restructuring C. Journal keeping D. Meditation E. Monitoring thoughts
B, C, E
A charge nurse is discussing manifestations of schizophrenia with a newly licensed nurse. Which of the following manifestations should the charge nurse identify as being effectively treated by first generation antipsychotics? (Select all that apply) A. Withdrawal from social situations B. Delusions of grandeur C. Severe agitation D. Auditory hallucinations E. Anhedonia
B, C, D
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. Establish rapport with the client C. Identify the cause of anxiety D. Validate the client's feelings C. Develop a flexible crisis intervention plan
B, C, D
A nurse is attending a group therapy session and is listening to clients who have bipolar disorder discuss coping strategies. Which of the following statements by the clients indicate adaptive coping? (Select all that apply) A. "I exercise aerobically three times a day for 30 minutes at a time." B. "I get 7 hours of sleep at night by skipping afternoon naps." C. "I think about being on my favorite beach vacation when I get anxious." D. "I tense and release my muscles, starting with my feet." E. "I see the glass as half-full when it starts looking empty."
B, C, D, E
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. Confusion C. Memory loss D. Paralytic ileus E. Nausea
B, C, E
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. Anhedonia is a clinical manifestation of a depressive relapse C. Participating in psychotherapy can help prevent a relapse D. Begin taking your medications as soon as a relapse begins E. Difficulty sleeping can indicate a relapse
B, C, E
A nurse us 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. Take advantage of offered counseling D. Hold emotions in check in the days following the incident E. Debrief with others following the incident
B, C, E
A nurse is discussing the risk factors for somatic symptom disorder with a newly licensed nurse. Which of the following risk factors should the nurse include? (Select all that apply) A. Coronary artery disease B. Anxiety disorder C. Obesity D. Female gender E. Age older than 65 years
B, D
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. Urinary retention and constipation B. Tongue thrusting and lip smacking C. Fine hand tremors and pill rolling D. Facial grimacing and eye blinking E. Involuntary pelvic rocking and hip thrusting movements
B, D, E
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 nurse's priority response? A. "Do you really think your family would be better off without you?" B. "Are you thinking of harming yourself?" C. "Tell me what is happening right now." D. "When did you first start feeling this way?"
B. "Are you thinking of harming yourself?"
A nurse notices that a client who has moderate anxiety is pacing the hall and mumbling. As the nurse approaches the client, he states, "I am at the end of my rope. I don't think I can take any more bad news." Which of the following responses should the nurse make? A. "Most clients with anxiety issues benefit from lying down." B. "Come with me to an area where we can talk without interruption" C. "Providers usually recommend relaxation exercises for clients whoa re as upset as you are." D. "An antianxiety pill works best for situations like this."
B. "Come with me to an area where we can talk without interruption"
A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The client is doing calisthenics in the client dining room during lunchtime instead of eating. Which of the following statements should the nurse make? A. "You are already too thin and exercises is not good for you. Go sit down somewhere and eat something." B. "Come with me. Here is a milkshake to drink." C. "We need you to decide what activities you will do today." D. "You will need to leave the dining room right now and go somewhere else to exercise."
B. "Come with me. Here is a milkshake to drink."
A nurse is working in an outpatietn clinic is providing teaching to a client who has a new diagnosis of premenstrual dysphoric disorder. 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 am aware that my PMDD causes me to have rapid mood swings." C. "I should increase my caloric intake with a nutritional supplement when my PMDD is active." D. "I will use light therapy 30 minutes a day to prevent further recurrences of PMDD."
B. "I am aware that my PMDD causes me to have rapid mood swings."
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. "You should know that giving away your money is inappropriate." D. "I can request that your case manager discuss appropriate charity options with you."
B. "I am here to provide care and cannot accept this from you"
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 an immortal." B. "I am no one, and everyone is me." C. "I know that everyone is stealing my thoughts." D. "I feel monsters pinching me all over."
B. "I am no one, and everyone is me."
A nurse is caring for a client who has borderline personality disorder. As part of the client's plan of care, the nurse reviews the day's schedule with the client each morning. As the nurse begins to review the schedule with the client, the client says, "Why don't you shut up already? I can read it myself, you know!" Which of the following responses should the nurse give the client? A. "We do this everyday. Why are you so angry with me this morning?" B. "I don't like it when you address me with that tone of voice." C. "I know you can, but are you going to read it or not?" D. "Fine. Here is the schedule, and I will expect you to be on time to your therapies."
B. "I don't like it when you address me with that tone of voice."
A nurse is caring for a client who has schizophrenia. Which of the following statements by the client indicates an understanding of a relapse prevention plan? A. "I can remember when my hallucinations first began." B. "I know which of my hallucinations trigger a relapse." C. "I record the number of hallucinations I have each day." D. "I will read as much information as I can about schizophrenia."
B. "I know which of my hallucinations trigger a relapse."
A nurse observes that a client who has depression is sitting alone in the room crying. As the nurse approaches, the client states, "I'm feeling really down and don't want to talk to anyone right now." Which of the following responses should the nurse make? A. "It might help you feel better if you talk about it." B. "I'll just sit here with you for a few minutes then." C. "I understand. I've felt like that before, too." D. "Why are you feeling so down?"
B. "I'll just sit here with you for a few minutes then."
A nurse is assessing a client who reports an increase in anxiety. Which of the following responses should the nurse make? A. "Do you think your anxiety is worse than everyone else's?" B. "Tell me what has been happening lately." C. "It doesn't appear as though you are feeling anxious." D. "I think you should see a therapist."
B. "Tell me what has been happening lately."
A nurse is teaching a client who is scheduled for electroconvulsive therapy (ECT). Which of the following statements should the nurse include in the teaching? A. "You will require a breathing tube during the procedure." B. "There is a small chance you will have memory loss after this procedure." C. "there is little risk of having a seizure during this procedure." D. "You will receive IV or oral contrast prior this procedure."
B. "There is a small chance you will have memory loss after this procedure."
A nurse in an acute care mental health facility is sitting with a client who has schizophrenia. The client whispers to the nurse, "I'm being kept in this prison against my will. Please try to get me out." Which of the following responses should the nurse make? A. "Why do you feel that you need to leave?" B. "You feel that you don't belong here?" C. "We are here to help you and give you the care that you need right now." D. "Try to take some deep breaths and i'm sure you'll feel better."
B. "You feel that you don't belong here?"
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. "You are mistaken, Nobody is lying about you or trying to poison you." B. "You seem to be having very frightening thoughts." C. "Why do you think you are being lied about and poisoned." D. "Who is lying about you and trying to poison you?"
B. "You seem to be having very frightening thoughts."
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 a weekly grief support group who says she still misses her deceased husband who has been dead for 3 months. B. A client who lives at home and keeps "forgetting" to come in for his monthly antipsychotic injection for schizophrenia. C. A client in an acute care mental health facility who has fallen several times while running down the hallway D. A client in a day treatment program who says he is becoming more anxious during group therapy
B. A client who lives at home and keeps "forgetting" to come in for his monthly antipsychotic injection for schizophrenia.
A charge nurse is admitting a client who has bipolar disorder and who is in the manic phase. Which of the room assignments should the nurse give the client? A. A semi-private room across from the day room B. A private room in a quiet location C. A private room across from the exercise room D. A semi-private room across from the snack area
B. A private room in a quiet location
A nurse is speaking with a client who has schizophrenia when he is suddenly seems to stop focusing on the nurse's questions and begins looking at the ceiling and talking to himself. 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. Continue the interview without comment on the client's behavior. D. Tell the client, "You seem to be looking for something on the ceiling. I see something there, too."
B. Ask the client, "Are you seeing something on the ceiling?"
A nurse is caring for a client who has body dysmorphic disorder. Which of the following actions should the nurse plan to take first? A. Encouraging the client to participate in treatment decisions B. Assessing the client's risk for self harm C. Encouraging the client to participate in group therapy sessions D. Instilling hope for positive outcomes
B. Assessing the client's risk for self harm
A nurse is caring for a young adult who has acute schizophrenic disorder and tells the nurse, "Yester noon the sun moon went over the rover to see the lawnmower." Which of the following manifestations is the client exhibiting? A. Delusional disorder B. Association looseness C. Hallucination D. Anhedonia
B. Association looseness
A nurse is planning care for a client who is schedules to receive electroconvulsive therapy (ECT). Which of the following medications should the nurse anticipate administering prior to the procedure? A. Diphenhydramine B. Atropine C. Epinephrine D. Fluoxetine
B. Atropine
A nurse is reviewing medications for a newly admitted client who has bipolar disorder and is experiencing mania. Which of the following client prescriptions should the nurse realize is expected to reduce the client's mania? A. Fluvastatin B. Carbamazepine C. Lorazepam D. Propranolol
B. Carbamazepine
A nurse is caring for a client who has schizophrenia. The client states, "The government is forcing thoughts into my brain through satellites." The nurse should document that the client is experiencing which of the following types of delusions? A. Persecution B. Control C. Erotomanic D. Somatic
B. Control
A nurse is reviewing the medical record of a client who has conversion disorder. Which of the following findings should the nurse identify as placing the client as risk for conversion disorder? A. History of migraine headaches B. Death of a child 2 months ago C. Recent weight loss of 30 Ib D. Retirement 1 year ago
B. Death of a child 2 months ago
A nurse is caring for a client who has major depressive disorder and was prescribed citalopram 2 weeks ago with a planned dosage increase 1 week ago. The client reports have improved appetite but still feels very depressed and is still have trouble sleeping. Which of the following actions should the nurse take? A. Speak to the provider about adding an MAOI to the current medication regimen B. Explain antidepressants often take several weeks to be fully effective C. Tell the client that the provider will need to change citalopram to a different medication. D. Recommend a sleep study to be done on the client
B. Explain antidepressants often take several weeks to be fully effective
A nurse is sitting in the day room at an acute care mental health facility with a group of client who are watching television. Suddenly one of the clients jumps ip screaming and runs out of the room. Which of the following actions should the nurse take? A. Ask the group what they think about the client's behavior B. Follow the client to determine the cause of the behavior C. Ignore the incident because it is an attention seeking behavior D. Stay with the group and ask another client to go and check on the situation
B. Follow the client to determine the cause of the behavior
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 a U.S. Senator." Which of the following findings is the client exhibiting? A. Flight of ideas B. Grandiosity C. Reality testing D. Derealization
B. Grandiosity
A nurse is planning care for a client who has OCD. Which of the following actions should the nurse plan to take? A. Prevent the client from performing compulsive behavior. B. Investigate what situations precipitate anxiety C. Encourage avoidance of situations that increase anxiety D. Teach the client that compulsive behavior is excessive
B. Investigate what situations precipitate anxiety
A nurse is developing a plan of care for a newly admitted client who has schizophrenia and experiences frequent hallucinations and paranoid delusions. Which of the following actions should the nurse take? A. Place the client in seclusion if visual hallucinations are present B. Limit the number of questions asked during assessments C. Use frequent touch to provide client support D. Directly tell the client that delusions are not real
B. Limit the number of questions asked during assessments
A nurse is assessing a client who is receiving treatment with multiple antipsychotic medications and who suddenly became ill. Findings include blood pressure changes, hyperpyrexia, and diaphoresis. The nurse should recognize that which of the following adverse effects may be occurring? A. Tardive dyskinesia B. Neuroleptic Malignant syndrome C. Acute dystonia D. Pseudoparkinsonism
B. Neuroleptic Malignant syndrome
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. Recent history of stressful, positive life events. B. Past history of childhood trauma C. being an only child D. Having elevated levels of serotonin
B. Past history of childhood trauma
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 as this time? A. Suggest that the client rest in bed B. Remain with the client for a while C. Medicate the client with a sedative D. Have the client join a therapy group
B. Remain with the client for a while
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 explains that her body seems to be floating above the ground B. The client states that the furniture in the room seems to be small and far away C. The client cannot recall anything that happened during the past 2 weeks D. The client has the idea that someone is trying to kill her and steal her away
B. The client states that the furniture in the room seems to be small and far away
A nurse is discussing the care of a client who has a conversion disorder with persistent aphasia with a newly licensed nurse. Which of the following statements should the nurse include about conversion? A. Conversion disorders are consciously triggered B. The condition may relapse within a year C. Testing for a pathophysiological cause of aphasia is not necessary D. Clients with conversion disorder have a flat affect
B. The condition may relapse within a year
A nurse reviews the laboratory report for a client who is receiving lithium three times daily PO. The client's current blood lithium level is 1.8 mEq/L. The nurse identifies that this lab value indicates which of the following? A. A blood lithium level of 1.8 mEq/L is not within the maintenance treatment level. B. The lithium level is at the toxic level C. The lithium level is below the therapeutic treatment level D. The lithium level is with the therapeutic level for initial treatment
B. The lithium level is at the toxic level
A nurse is teaching about electroconvulsive therapy (ECT) with a newly licensed nurse. The nurse should identify that the newly licensed nurse understands the teaching when she states that ECT treats which of the following disorders? A. Narcotic addiction B. Vegetative depression C. Personality disorder D. Eating disorder
B. Vegetative depression
A nurse is caring for a client who has bipolar disorder and is in the manic phase. The client says he is bored. Which of the following activities is approproate for the nurse to suggest to this client? A. Watching a video with a group in the day room B. Walking with the nurse in the courtyard C. Participating in a basketball game in the gym D. Joining a group discussion about a local election
B. Walking with the nurse in the courtyard
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. Repeatedly present the client with information about past events B. Work with the client on grounding techniques C. Make decisions for the client regarding routine daily activities D. Teach the client to recognize how stress brings on a personality change in the client.
B. Work with the client on grounding techniques
A nurse is preparing a client who has chronic anxiety for discharge from the psychiatric unit. Which of the following instructions should the nurse include in the client;s discharge plan? A. Contact the crisis counselor once a week B. identify anxiety-producing situations C. try to repress feelings of anxiety D. Eliminate stress and anxiety from daily life
B. identify anxiety-producing situations
A nurse is caring for a newly admitted client who has OCD. Which of the following actions should the nurse take first? A. Discuss alternative coping strategies with the client. B. identify precipitating factors for ritualistic behaviors C. instruct the client on relaxation techniques for use when anxiety increases D. provide a structured activity schedule for the client
B. identify precipitating factors for ritualistic behaviors
A nurse is caring for a client who is hospitalized for the treatment of severe depression. Which of the following nursing approaches is therapeutic to include in the client's plan of care? A. Encouraging decision-making B. Giving the client choices of activities C. Playing a game of chess with the client D. Spending time sitting with the client
D. Spending time sitting with the client
A nurse is caring for the parents of a child who has demonstrated changes in behavior and mood. When the mother of the child asks the nurse for reassurance about her son's condition, which of the following responses should the nurse make? A. "I'm sure everything will be okay. It just takes time to heal." B. "I'm not sure whats wrong. Have you asked the doctor about your concerns?" C. "I understand you're concerned. Let's discuss what concerns you specifically." D. "I think your son is getting getter. What have you noticed.
C. "I understand you're concerned. Let's discuss what concerns you specifically."
A nurse is caring for a client who takes paroxetine to treat PTSD. The client states that he grinds his teeth during the night, which causes pain in his mouth. The nurse should identify which of the following interventions as possible measures to manage the client's bruxism? (Select all that apply) A. Increasing the dose of paroxetine B. Administration of a different SSRI C. Concurrent administration of buspirone D. Use of a mouth guard. E. Changing to a different class of antianxiety medication
C, D, E
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. Lack of motivation B. Constantly waving arms C. Delusion of persecution D. Use of clang association E. Flat affect F. Auditory hallucination
C, D, F
A nurse in a mental health clinic is conducting a staff education session on schizophrenia. Which of the following manifestations should the nurse identify as negative symptoms? (Select all that apply) A. Delusions B. Hallucination C. Anhedonia D. Poor judgment E. Blunt affect
C, E
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. Gather information from the client using closed-ended questions B. Ignore the client's anxiety so that she will not be embarrassed. C. Discuss prior use of coping mechanisms with the client D. Reassure the client that everything will be okay E. Demonstrate a calm manner while using simple and clear directions
C, E
A nurse caring for a client who has depression observes the client comes to breakfast freshly bathes, wearing clean clothes, and with combed and styled hair. Which of the following responses by the nurse is therapeutic? A. "Everyone feels better after showering." B. You must be getting better. You look great!" C. "I see you have done some grooming today." D. "Why are you all dressed up today? Is it a special occasion?"
C. "I see you have done some grooming today."
A nurse in an acute mental health facility is admitting a client who reports feeling depressed, sad, moody, and overly anxious. Which of the following is the assessment priority? A. Coping abilities B. Support system C. Suicide risk D. Psychiatric history
C. Suicide risk
A nurse is caring for a client who has depression. The client refuses to get out of bed, go to activities, or participate in any of the unit's programs. Which of the following responses should the nurse make? A. "You really need to follow the rules of the unit and get out of bed." B. "If you do not get out of bed you will not receive your meal." C. "I will help you get ready and then you can rest after activities." D. "You should rest until you feel able to join the group."
C. "I will help you get ready and then you can rest after activities."
A nurse observes a client sitting alone in her room crying. As the nurse approaches her, the client states, "I'm feeling sad. I don't want to talk now." Which of the following responses should the nurse make? A. :It will help you feel better if you talk about it." B. "I'll come back when you feel like talking." C. "Ill stay with you for a few minutes." D. "Coming with me to the day room will take your mind off your troubles."
C. "Ill stay with you for a few minutes."
A charge nurse is providing teaching to a staff nurse about assisting the provider with electroconvulsive therapy (ECT). Which of the following responses by the staff indicates understanding of the teaching? A. "ECT is an effective treatment for personality disorders." B. "I should monitor the client closely for hypotension following ECT." C. "Informed consent should be obtained prior to ECT." D. "It is a myth that clients experience seizures during ECT."
C. "Informed consent should be obtained prior to ECT."
A nurse is caring for a client who is undergoing electroconvulsive therapy (ECT). which of the following statements indicates an understanding of the teaching? A. 'I will be awake during the procedure." B. "I will undergo treatments for one year." C. "My memory loss will last several minutes after treatment." D. "I will be monitored closely for seizure activity."
C. "My memory loss will last several minutes after treatment."
A nurse is discussing OCD with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the underlying reason clients with OCD perform ritualistic behaviors? A. "The ritualistic behavior provides sexual satisfaction." B. "The client performs ritualistic behavior to boost self esteem." C. "The ritualistic behavior temporarily relieves anxiety." D. "The client performs ritualistic behavior to decrease feelings of shame."
C. "The ritualistic behavior temporarily relieves anxiety."
A nurse is talking with a client who has 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. "You need to tell the voices to leave you alone." B. "You need to understand that there are no voices." C. "What are the voices telling you to do?" D. " Why do you think you are hearing the voices?"
C. "What are the voices telling you to do?"
A nurse is assisting a client who has schizophrenia prepare a relapse plan which of the following statements should the nurse make? A. "You should be aware that excessive sleeping is an early sign of relapse." B. "Relapse is an indication that you are not taking your medications properly" C. "You should keep your provider's and therapist's number with you" D. "Taking an additional dose of medication is appropriate as soon as signs of relapse appear."
C. "You should keep your provider's and therapist's number with you"
A nurse is providing teaching for a client who has major depressive disorder and is seeking voluntary admission to an acute mental health facility. Which of the following statements should the nurse include? A. "You will give up your right to refuse antidepressant medications upon admission." B. "Your provider is required to notify your employer of your admission." C. "You will still need to give informed consent for treatments after admission." D. "You cannot leave the facility until your provider completes the discharge summary."
C. "You will still need to give informed consent for treatments after admission."
A nurse is assessing a client who has a mood disorder to determine his readiness for discharge. Which of the following statements by the client indicates he is ready for discharge? A. "Right now, I can't bathe or dress myself, but that's not important." B. "When I get home, I'm going to let the people who put me in here know how angry I am." C. "i will take my medicines as I should and know to call the number you gave me if I have bad thoughts." D. "Taking care of myself is important, but it's okay if I want to take a break and not do anything."
C. "i will take my medicines as I should and know to call the number you gave me if I have bad thoughts."
A nurse is caring for a client who has schizophrenia who consistently does the opposite of what the nurse asks of him. The nurse recognizes this as which of the following alterations in behavior? A. Automatic obedience B. Waxy flexibility C. Active negativism D. Impaired impulse control
C. Active negativism
A nurse is caring for a client who has schizophrenia and is experiencing hallucination. Which of the following actions should the nurse take? A. Act to the client as of the hallucination is real. B. Instruct the client to argue with the voices that are a part of the hallucination C. Ask the client direct questions about the hallucination D. Tell the client that the hallucination is not a part of reality
C. Ask the client direct questions about the hallucination
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. Attempt to reduce anxiety
A nurse is leading a peer group discussion about the indication for ECT. Which of the following indications should the nurse include in the discussion? A. Acute withdrawal related to a substance use disorder B. Dysphoric disorder C. Bipolar disorder with rapid cycling D. Borderline personality disorder
C. Bipolar disorder with rapid cycling
A nurse is planning care for a client who has paranoid schizophrenia. Which of the following interventions should be included in the plan of care? A. Rotate staff assignments for this client B. Use touch to calm the client during periods of anxiety C. Check the client's mouth after the client takes medication D. Assign an assistive personnel to feed the client at mealtimes.
C. Check the client's mouth after the client takes medication
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. Visual hallucination B. Gustatory hallucination C. Command hallucination D. Tactile hallucination
C. Command hallucination
A nurse is planning care for a client newly admitted with major depressive disorder. Which of the following actions should the nurse plan to use? A. Ask the client to create her own schedule of daily activities B. Teach the client to use passive communication when interacting with others C. Determine the client's need for assistance with grooming D. Limit the client's involvement in unit activities
C. Determine the client's need for assistance with grooming
A nurse is developing a plan of care for a client who has conversion disorder. Which of the following actions should the nurse include? A. Encourage the client to spend time alone in his room B. Allow the client unlimited time to discuss physical manifestations C. Discuss alternative coping strategies with the client D. Monitor the client for self-harm once per day
C. Discuss alternative coping strategies with the client
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 take? A. Implement the client's behavioral modification plan. B. Document the size and location of the cuts C. Inspect the cuts for debris D. Administer a tetanus antitoxin
C. Inspect the cuts for debris
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 perform first? A. Implement the client's behavioral modification plan B. Document the size and location of the cuts C. Inspect the cuts for debris D. Administer a tetanus antitoxin
C. Inspect the cuts for debris
A nurse is planning care for a client who demonstrates manipulative behavior. Which of the following interventions should be included in the plan of care? A. Allow manipulation so as to not raise the client's anxiety B. Avoid discussing past behaviors with the client C. Institute consequences for manipulative behavior D. Bargain with the client to discourage manipulative behavior.
C. Institute consequences for manipulative behavior
A nurse is assessing a client who has schizophrenia. Which of the following behaviors should the nurse anticipate? A. Periods of elation with unusual talkativeness B. Preoccupied with folding clothes C. Invents words that have no meaning D. Recurrent thought of past trauma
C. Invents words that have no meaning
A home health nurse drives up to the house of her client, who has schizophrenia with manic episodes. The client is sitting on his porch with a shotgun in his arms. Which of the following actions should the nurse take? A. Honk the car horn to get the client's attention B. Calmly speak the client's name out of the car window C. Keep driving in a path that is going away from the client's house D. Stop the car in the client's driveway and call the authorities
C. Keep driving in a path that is going away from the client's house
A nurse in an acute care mental facility is caring for a client who has depression. After 3 days of treatment, the nurse notices that the client suddenly seems cheerful and relaxed and there are no longer signs of a depressive state. Which of the following interventions is appropriate to include in the plan of care? A. Encourage family to take the client out of the facility for short periods of time B. Reward the client for her change in behavior C. Monitor the client's whereabouts at all times D. Ask the client why her behavior has changed
C. Monitor the client's whereabouts at all times
A nurse is reading the medical record for a client who has schizophrenia which indicates that the client exhibits depersonalization. Which of the following statements by the client confirms that she is experiencing depersonalization? A. "I have broken off all my past relationships because my friends and family are trying to kill me." B. "I hear voices telling me that I have been bad." C. My hands and feet are much smaller than they used to be." D. Everything in this room has changed and I don't recognize it anymore."
C. My hands and feet are much smaller than they used to be."
A nurse overhears a client who has schizophrenia talking to herself. The client keeps stating, "The flakalas are here. The flakalas are here." The nurse correctly recognizes the client's use of the word flakala as an example of which of the following alterations in speech? A. Echolalia B. Clang association C. Neologism D. Word salad
C. Neologism
A nurse in a mental health facility is planning care for a client who has OCD and is newly admitted to the unit. Which of the following actions should the nurse plan to take regarding the client's compulsive behaviors? A. Isolate the client for a period of time B. Confront the client about the senseless nature of the repetitive behaviors C. Plan the client's schedule to allow time for rituals D. Set strict limits on the behaviors so that the client can conform to the unit rules and schedules
C. Plan the client's schedule to allow time for rituals
A nurse is counseling a client for the management of anxiety. The client is consistently late for appointments and ignores household chores. The client states, "I'm just too stressed. I need someone to take care of me." The nurse identifies this behavior as an example of which of the following defense mechanisms? A. Dissociation B. Introjection C. Regression D. Repression
C. Regression
A nurse is caring for a client who is experiencing a manic episode. Other clients begin to complain about her disruptive behavior on the unit. Which of the following actions should the nurse take? A. Warn the client that further disruptions will result in seclusion B. Ignore the client's behavior, realizing it is consistent with her illness C. Set limits on the client's behavior and be consistent in approach D. Ask the client to recommend consequences for her disruptive behavior.
C. Set limits on the client's behavior and be consistent in approach
A nurse is caring for a client who has bipolar disorder and is running around the unit asking people to dance with her. Which of the following interventions should the nurse take? A. Turn on a dance video so the client can burn off excess energy B. Offer the client a low calorie snack in return for stopping the behavior C. Take the client outside and sit with her in the garden area D. Observe the client closely for the development of aggressive behavior
C. Take the client outside and sit with her in the garden area
A nurse is caring for a client who is in the manic phase of bipolar disorder. The client is running around the unit trying to organize competitive games with the clients. Which of the following is an appropriate intervention? A. Recommend a game of table tennis with another client B. Suggest the client exercise on a stationary bike C. Take the client outside for a walk D. Praise the client's efforts to engage in social interaction
C. Take the client outside for a walk
A nurse in an acute mental health unit is admitting a client who has bipolar disorder. Which of the following findings supports the admitting diagnosis of acute mania? A. The client's spouse reports the client has recently gained weight B. The client is dressed in all black C. The client responds to questions with disorganized speech D. The client reports that voices are telling him to write a novel
C. The client responds to questions with disorganized speech
A nurse in an acute care mental health facility is assessing a client who has bipolar disorder. Which of the following findings indicates the client is at risk for suicide? A. The client began playing basketball with several other clients during the past month B. The client identifies with problems expressed by other clients C. The client's behavior has become impulsive in the past few weeks D. The client states she wants to go home to be with her children and partner
C. The client's behavior has become impulsive in the past few weeks
A nurse in an acute mental health facility is caring for a client who has major depressive disorder. since her admission 3 days ago, she has not put on clean clothes, washed her hair, or participates in any of the unit activities. On this day, the nurse observes that she is wearing clean clothes and has combed her hair. Which of the following responses should the nurse make? A. "Oh, I'm so pleased that you finally put on clean clothes." B. "Why did you wear clean clothes and comb your hair today?" C. "Your mood must be lifting because you have on clean clothes and combed your hair." D. "I see that you have on clean clothes and combed your hair."
D. "I see that you have on clean clothes and combed your hair."
A nurse is providing teaching for a client who is schedules to receive ECT for the treatment of major depressive disorder. Which of the following client statements indicates understanding of the teaching? A. "I should receive ECT once a week for 6 weeks." B. "I can have my depression cured if I receive a series of ECT treatments." C. "It is common to treat depression with ECT before trying medications." D. "I will receive a muscle relaxant to protect me from injury during ECT."
D. "I will receive a muscle relaxant to protect me from injury during ECT."
A nurse is caring for a client who was involved in heavy combat and observed war casualties. The nurse should suspect that the client is suffering from PTSD if the client makes which if the following statements? A. "I check any room I enter because the enemy is still after me and could be hiding anywhere." B. "My child was born with a birth defect due to exposure I has overseas." C. "I killed four enemy soldiers with my bare hands and saved my entire battalion." D. "In my dreams, all I can see are the wounded reaching out and trying to grab me."
D. "In my dreams, all I can see are the wounded reaching out and trying to grab me."
A charge nurse overhears another nurse talking with a client who has schizophrenia. Suddenly the client yells, "I am the devil! I am God! Open the gate for me!" Which of the following replies by the nurse requires intervention? A. "It sounds frightening to feel like both God and the devil at the same time." B. "I don't understand. Can you tell me what that means?" C. "Are you saying that you are both good and bad?" D. "There is no gate for me to open."
D. "There is no gate for me to open."
A nurse on an inpatient mental health unit is caring for a client who has major depressive disorder and malnutrition. Which of the following actions should the nurse take to improve the client's nutritional status? A. Enroll the client in a nutritional class on the unit B. Weigh the client at the same time every morning C. Ask provider to arrange a consultation with the facility chaplain D. Sit with the client during meals and snacks
D. Sit with the client during meals and snacks
A nurse is caring for a client admitted to a mental health facility who asks, "Can I refuse the electroconvulsive therapy (ECT) treatment schedules for tomorrow? Which of the following should be the nurse's response? A. "You have given signed consent for the treatments after they were explained to you." B. "You will feel better after the course of treatments." C. "You can refuse them, but the provider believes they are necessary." D. "You have the right to refuse even though the consent form has been signed."
D. "You have the right to refuse even though the consent form has been signed."
A nurse is caring for a client who has major depressive disorder and attempted suicide. The client tells the nurse, "I should have died because I am totally worthless." Which of the following responses should the nurse make? A. "You have a great deal to live for." B. "Its not unusual for depressed people to feel that way." C. "Why do you feel you are worthless?" D. "You've been feeling that your life has no meaning."
D. "You've been feeling that your life has no meaning."
A nurse in a mental health clinic is assessing a client who was brought in by her adult daughter stating that her mother has not been able to leaver her home for weeks because she is afraid to be outdoors alone. The nurse should anticipate planning care for managing which of the following phobias? A. Xenophobia B. Acrophobia C. Mysophobia D. Agoraphobia
D. Agoraphobia
A charge nurse is conducting a staff education in-service about depressive disorders. Which of the following should the nurse identify as a risk factor for depression? A. Being married B. Pregnancy C. Male gender D. Chronic Illness
D. Chronic Illness
A nurse is assessing a client who has illness anxiety disorder. Which of the following findings should the nurse expect? A. Prior physical health followed by the need for two surgeries within the last three months. B. Obsession over a fictitious defect in physical appearance C. Sudden unexplained loss of peripheral sensation D. Constant worry about the undiagnosed presence of an illness
D. Constant worry about the undiagnosed presence of an illness
A nurse is caring for a client who has been diagnosed with OCD and is constantly picking up after others in the day room. The nurse should recognize that the client uses this behavior to do which of the following? A. Limit the amount of time available to interact with others B. Focus attention on meaningful tasks. C. Manipulative and control others' behaviors. D. Decrease anxiety to a tolerable level
D. Decrease anxiety to a tolerable level
A nurse is providing teaching to an adolescent client who has a new prescription for clomipramine for OCD. Which of the following information should the nurse provide? A. Check temperature daily B. Take medication first thing in the morning before eating C. Add extra calories to the diet as between-meal snacks D. Eat a diet high in fiber
D. Eat a diet high in fiber
A nurse is planning care for a client who has depression. The nurse notes that the client has weight loss, an inability to concentrate, an inability to complete daily tasks, and a preference to sleep all day. Which of the following interventions should be included in the plan of care? A. Discourage rest periods during the daytime. B. Instruct family to avoid visiting during mealtimes C. Offer three or four large meals daily D. Give the client extra time to communicate needs
D. Give the client extra time to communicate needs
A nurse is caring for a new client who exhibits manifestations of a major depressive episode. The provider states that she wants to rule out medical conditions which could also be linked to findings. The nurse should expect diagnostic testing for which of the following medical conditions? A. Pancreatitis B. Cholecystitis C. Tuberculosis D. Hypothyroidism
D. Hypothyroidism
A nurse is conducting a group therapy meeting and is sharing a humorous story. When the group laughs at the story, a client who has schizophrenia jumps up and runs out while yelling, "You are all making fun of me." Which of the following behaviors is this client displaying? A. Grandeur B. Flight of ideas C. Erotomania D. Ideas of reference
D. Ideas of reference
A nurse is assessing a client who has PTSD following a sexual assault. Which of the following is an expected finding? A. Sleeping 12 hours or more each day B. Increasing sense of attachment to others C. Constant need to talk about the event D. Increasing feelings of anger
D. Increasing feelings of anger
A nurse is assessing a client who has a diagnosis of conversion disorder. Which of the following is an expected finding? A. Frequent manic episodes B. Refusal of medication due to paranoia C. Preoccupation with manifestations of various illnesses D. Involuntary loss of sensory function
D. Involuntary loss of sensory function
A nurse in an acute mental health facility 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. Monitor the client for escalating behavior
A nurse is admitting a client who is exhibiting manic behavior. The client reports recent personal stressors including the loss of her mother and a divorce. Which of the following is the priority nursing action? A. Identify support system B. Assisting the client in identifying coping behaviors C. Encouraging self care D. Preventing self-directed violence
D. Preventing self-directed violence
A nurse is caring for a client who has schizophrenia and exhibits a lack of grooming and a flat affect. The nurse should anticipate a prescription for which of the following medications? A. Thiothixene B. Chlorpromazine C. Haloperidol D. Risperidone
D. Risperidone
A nurse in a mental health facility is preparing to interview a client who has schizophrenia. Which of the following actions should the nurse take? A. Sit on the other side of the table from the client B. Place the client in a chair higher than the nurse C. Start the interview with a question the client can answer with a "yes" or "no" D. Sit beside the client rather than facing him
D. Sit beside the client rather than facing him
A nurse is caring for a client who has major depressive disorder. Which of the following findings should the nurse expect? A. A dismissal of past failures B. Psychomotor agitation C. An increase in energy D. Sleep disturbances
D. Sleep disturbances
A nurse hears a newly licensed nurse discussing a client's hallucinations in the hallway with another nurse. Which of the following actions should the nurse take first? A. Provide an in-service program about confidentiality B. Complete an incident report C. Notify the nurse manager D. Tell the nurse to stop discussing the behavior
D. Tell the nurse to stop discussing the behavior
A charge nurse is discussing the care of a client who has MDD with a newly licensed nurse. Which of the following statements by the newly licensed indicates an understanding of the teaching? A. Medication and psychotherapy are most effective during the acute phase of MDD B. The treatment of MDD during the maintenance phase lasts for 6-12 weeks C. Care during the continuation phase focuses on treating continued manifestation of MDD. D. The client is at greatest risk for suicide during the first weeks of an MDD episode
D. The client is at greatest risk for suicide during the first weeks of an MDD episode
A nurse on the psychiatric unit is assessing a client who has moderate anxiety disorder. Which of the following findings should the nurse expect? A. Rapid speech B. Chills C. Distorted perceptual field D. Urinary frequency
D. Urinary frequency
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 corridors of the unit. Which of the following actions should the nurse take? A. Instruct the client to sit down and stop pacing B. Allow the client to pace lone until physically tired C. Have a staff member escort the client to her room D. Walk with the client at a gradually slower pace
D. Walk with the client at a gradually slower pace
