Mental Health Nursing Exam 1
a nurse is caring for a group of clients at a mental health facility. the nurse should identify that which of the following clients is exhibiting a warning sign of suicide?
a client who is giving away their possessions
a nurse is reviewing the physical environment of a child inpatient unit. which of the following contradicts milieu therapy?
a craft room with scissors and art supplies
A nurse is reinforcing teaching with a client about the purpose of psychoanalytic therapy. Which of the following statements should the nurse include in the teaching?
psychoanalytic therapy helps you see yourself as an individual and learn adaptive coping skills.
A nurse is teaching another nurse about Freud's psychoanalytic theory related to human behavior. Which of the following statements regarding the id should the nurse include in the teaching?
the Id is often an area that is used for instant gratification.
A nurse is discussing treatment options with a client. The client asks, "What alternatives are available to help me with my depression other than the inpatient facility?" Which of the following responses should the nurse take?
"A community health center can provide counseling sessions, medication follow up, support groups, and home care visits."
A charge nurse manager is reinforcing teaching to a newly licensed nurse about ways to provide culturally competent care. Which of the following instructions should the charge nurse provide?
Seek assistance from an interpreter for language barriers.
A nurse is working in a mental health facility in an occupational role. Which of the following activities is a function of the occupational role of the nurse?
Reinforcing client education on risk factors
A nurse is helping a client develop a plan for successful behavior change. Which of the following interventions should the nurse include in the plan?
Schedule an appointment with a provider who lives within walking distance of the client.
A nurse is caring for a school-aged child who is experiencing significant functional impairment at school and reporting feelings of worthlessness and hopelessness. Which of the following recommendations should the nurse give to the child's parents?
"Due to the severity of symptoms, it is recommended that you seek professional care for your child very soon and monitor their mood for any worsening symptoms."
A nurse is using the Cultural Formulation Interview (CFI) tool while collecting a health history from a client who is from a different culture than the nurse. Which of the following statements should the nurse make?
"I am wondering what you believe the cause of the problem is."
A nurse is caring for a client who states, "I really like you. Can we get together socially after I am discharged?" Which of the following responses should the nurse make?
"I appreciate your comment. However, I am your nurse, and it would be inappropriate for us to engage socially outside of the treatment"
A nurse is collecting data from a client in the community center. Which of the following statements by the client suggests they are at risk for experiencing manifestations of a mental illness?
"I have been living in my car for more than a month."
A nurse is explaining what "duty to warn" means to a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding?
"If a client threatens to harm another person, health care providers have a responsibility to inform that person." A health care provider has a "duty to warn" when there is a threat from a client to another person to cause harm to them.
A nurse is interviewing a client who states they are unsure whether they should continue with their medication therapy. Which of the following responses should the nurse make to evoke client motivation?
"On a scale of 0 to 10, how confident are you that you could adhere to your medication regimen if you tried?"
A nurse is interviewing a client who is contemplating a behavior change. Which of the following statements should the nurse make to engage with the client?
"Tell me about the things that are important to you in your life."
A nurse is caring for a client who states, "I don't think medications are for me." Which of the following statements should the nurse make?
"Tell me more about what you feel would work best for you."
A nurse is using the CFI tool while collecting a health history from a client who is from a culture different than the nurse. Which of the following statements should the nurse make?
"Tell me some of the coping skills that have previously helped you."
A nurse is discussing the diagnostic and statistical manual of mental disorders fifth edition text revisions (DSM-5 TR) with a new licensed practical nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the DSM-5?
"The DSM-5 TR assists in planning nursing interventions for clients who have a mental health disorder." Nurses often use the DSM-5 TR diagnostic information to assist with planning, implementing, and evaluating client care. This information can guide nursing interventions for specific needs.
A nurse is reinforcing teaching with a client about therapy. Which of the following statements should the nurse include?
"Therapy can be used in conjunction with your medications to improve your health."
A nurse is interviewing a client who states they are thinking about smoking cessation by using patches. Which of the following responses should the nurse use to focus with the client?
"This might not be the best method for you, but we can discuss some options have found to be helpful."
A nurse manager is providing teaching to a group of newly licensed nurses about organizational culture. Which of the following statements by a newly licensed nurse indicates an understanding of organizational culture?
"This organization believes that each client should be at the center of their own care."
A nurse is preparing to interview a client and is reviewing therapeutic communication techniques. Which of the following should the nurse include in the interview to encourage the client to continue sharing feelings and information?
"What are some of the stressors that you have in your life?"
A nurse is explaining to a newly hired nurse how mental health promotion can be used for clients. Which of the following examples should the nurse use in the explanation? (Select all that apply.)
-Following suicide precautions for a client is correct -assisting the client in using adaptive coping skills -allowing the client to use exercise equipment when anxious
a nurse is discussing the different forms of complementary and alternative therapy with another nurse. Which of the following treatments would be considered in this list?
-Pet therapy -Meditation -Yoga
A nurse is reviewing the concept of bias with a newly licensed nurse. Which of the following scenarios should the nurse use to demonstrate biased treatment?
A client is not permitted to attend the group therapy activity because they practice the Buddhist faith. Bias is when treatment of a client is verified in the form of stereotyping, prejudice, or discrimination. Therefore, this scenario demonstrates biased treatment.
A nurse is providing teaching to a small group of newly licensed nurses about stigma. Which of the following client scenarios should the nurse include as an example of self-stigma?
A client refuses to pick up their prescription for an antidepressant because they do not want the pharmacist to know that they are on an antidepressant. Self-stigma is when an individual has a negative view or internalized shame regarding their mental illness, often due to the public stigma of mental illness.
A nurse is communicating via telephone with a client who reports a history of a depressive disorder and is currently experiencing suicidal ideation. To which of the following facilities should the nurse refer the client?
A crisis stabilization facility
A nurse is reviewing the medical records of a group of clients. The nurse should identify that which of the following factors places the client at risk for mental illness?
A history of abuse. A history of abuse places a client at risk for mental illness.
A nurse is collecting data about disparities in access to mental health care for clients who live in a rural area. Which of the following primary consequences should the nurse expect?
A longer period of time between the onset of symptoms of mental illness and treatment
A nurse is discussing ethical principles with another nurse. Which of the following should the nurse include as an example of the principle of nonmaleficence?
A nurse evaluates the client's desire for autonomy while considering the personal safety of other clients on the unit. The principle of nonmaleficence involves doing no harm. By weighing the risks and benefits of the client's desire for autonomy while considering the safety of the other clients on the unit, the nurse is practicing nonmaleficence.
A nurse is planning care for a client who has a mental health disorder and a substance use disorder. To which of the following facilities should the client be referred for treatment?
A substance use disorder center
A nurse on a mental health unit is discussing laws that guide the care of clients on the unit with a newly hired staff member. Which of the following statements by the staff member indicated an understanding?
A) "A claim of assault can only be substantiated if there is evidence of physical harm" B) "False imprisonment only refers to seclusion of clients" C) "Battery is the most common unintentional tort" D) "A physical injury does not need to occur for a client to make a claim of battery" Answer: D. Battery is making contact with another person without their consent. The person does not need to be injured for battery to occur; the contact must simply be unwanted or offensive to the person
A nurse is discussing milieu therapy with a group of newly licensed nurses. Which of the following statements should the nurse make?
A) "Create an environment where structure is promoted over autonomy" B) "Create an environment that is safe and beneficial for recovery" C) "The mental health provider is responsible for the structure and maintenance of therapeutic milieu" D) "Ensure spontaneous changes in activities throughout the client's daily schedule" Answer: B
A nurse is discussing the purpose of ethics with a newly licensed nurse. Which of the following statements should the nurse make?
A) "Ethics describes conflict between two or more actions where each action has a favorable and unfavorable consequence" B) "Ethics involves reasoning about what one should do as a guide for what one actually does" C) "Ethics provides a system of moral principles or standards for governing conduct" D) "Ethics explains the moral inquiry into issues raised by advances in the medicine & life sciences" Answer: C. Ethics provides the nurse w/ a set of mora; principles & standards, & is a basis for determining intentions, motives, & actions. A nurses ethics is the basis from which conduct, including practices & decisions, is made
A nurse is caring for a client who has a serious mental illness (SMI). The client states, "I am so glad to be here because I know I will be healed here and can go on with a normal life!" Which of the following responses should the nurse give?
A) "It sounds like you are motivated to work toward recovery and setting up routines that will work for your life" B) "You should see full recovery once you start your new medications" C) "It will take many months of treatment before you are symptom-free" D) "You should see a marked difference in your symptoms once you begin the group therapy sessions" Answer: A. It is appropriate to work with the client in developing a plan that will have realistic goals within the framework of their disorder
A nurse on a mental health unit is discussing types of admissions with a newly licensed nurse. Which of the following statements should the nurse make?
A) "Most states require two providers to assess a client to confirm the need for an involuntary admission" B) "When a voluntarily admitted client requests discharge, the provider must legally do so within 8 hours of the request" C) "Clients who are involuntarily admitted are not able to testify on their own behalf in a commitment hearing" D) "When a client is admitted involuntarily, they do not have to have a diagnosis of a mental illness" Answer: A.
A nurse is teaching the concept of recovery to the family of a client who has a serious mental illness (SMI). Which of the following statements should the nurse include in the teaching?
A) "Recovery means that the client will be symptom-free" B) "Recovery means the same as it does for a client who has a medical diagnosis" C) "Recovery means that the client pursues life goals within the context of their mental illness" D) "Recovery means that the client is completely independent" Answer: C
A nurse is discussing false imprisonment with a group of newly hired staff members. Which of the following information should the nurse include?
A) A client cannot claim a false imprisonment if they were restrained by use of an injectable antipsychotic medication B) Claims of false imprisonment can be made if a nurse verbally threatens to place a client in seclusion C) Claims of false imprisonment are most often made in reference to the use of seclusion or restraints D) A client cannot claim false imprisonment if they are involuntarily admitted without being assessed by a provider Answer: C. False imprisonment is the confinement of a client when there is no legal reason to do so. Most claims of false imprisonment results from the use of seclusion or restraints
A nurse is planning an in-service about client confidentiality for a group of newly hired nurses. Which of the following examples should the nurse include when discussing exceptions for maintaining client confidentiality. (Select all that apply)
A) A client tells a nurse that they intend to kill a coworker B) A nurse is subpoenaed to testify in court about a client they cared for C) An older adult client reports their caregiver allows them to eat one meal per day D) A client tells a nurse that they stole a watch from a friend's house E) A client tells a nurse that they plan to hang themselves when they are discharged Answer: A, B, C, E
A nurse in a mental health clinic is reviewing clients' medical records. Which of the following clients should the nurse recognize as having a serious mental illness (SMI)?
A) A client who has schizophrenia B) A client who has anxiety C) A client who has a fear of public speaking D) A client who was arrested for a DUI Answer: A. Schizophrenia is an example of a SMI
A nurse is meeting with an interprofessional team to discuss the clients who will be referred to Assertive Community Treatment (ACT) upon discharge. Which of the following clients should the nurse refer?
A) A client who was diagnosed w/ dementia this week B) A client who sees a counselor for loneliness C) A client who is socially awkward & will not speak in front of groups D) A client who has schizophrenia & takes antipsychotic medication daily & has been hospitalized three times this year answer: D.
A nurse tells a client that they will return in 30 min with their medication. The nurse returns in 30 min later with the client's medication. Which of the following ethical principles is the nurse demonstrating?
A) Beneficence B) Autonomy C) Veracity D) Justice Answer: C. Veracity involves being truthful & honoring the verbal commitment made to a client
A nurse is developing a client-centered plan of care for a client. Which of the following actions should the nurse include in the plan?
A) Contact the client's family to build the client's schedule for the day B) Have the client select their nurse for each shift C) Have the client select a therapy session time from available slots D) Consult with the charge nurse on which nursing interventions to include in the plan of care answer: C. With client centered care, the client can make decisions when given choices pertaining to their care
A nurse is caring for several children who experienced trauma. One of the children goes to group therapy wearing a cape and pretending to be a superhero. The nurse should identify that which of the following interprofessional team members should lead the group session?
A) Drama therapist B) Art therapist C) Occupational Therapist D) Social worker Answer: A. A drama therapist encourages clients to act out feelings that may be difficult for them to express in words.
A nurse is discussing responsibilities in milieu therapy with a group of newly hired nurses. Which of the following should the nurse include? (select all that apply)
A) Explain unit rules, including expectations & client rights B) Provide orientation, including a tour of the unit, rules, & expectations C) Select activities based on preferences of available staff D) Ensure that culturally-sensitive care is provided E) Use a trauma-informed approach to client care Answer: A, B, D, E
A nurse is caring for a client who has a serious mental illness (SMI) and is recovering from substance use disorder. The client has been taught that abstinence and looking at recovery as an ongoing process is the most effective way to view recovery. The nurse should identify this model as which of the following?
A) Harm reduction model B) Social ecological (SE) model C) Rehabilitation model D) Trauma-informed care model Answer: A. The harm reduction model outlines recovery as a process and an outcome incorporating abstinence in its treatment for clients who have substance use disorder
A nurse should identify that which of the following US congressional act that mandates mental health parity?
A) Health Insurance Portability and Accountability Act B) Affordable Care act of 2010 C) No surprise act D) Nurse practice act Answer: B. Parity is equal coverage for physical and mental health care, which is guaranteed under the affordable care act of 2010
A nurse is sitting with a client who is extremely anxious until they fall asleep. The nurse should identify that this is an example of which of the following ethical principles?
A) Justice B) Autonomy C) Nonmaleficence D) Beneficence Answer:: Beneficence. Beneficence involves acting in a manner that is "for the good" or in a way that benefits others
A nurse is preparing a client who has schizophrenia for a magnetic resonance imaging (MRI) of their head to determine if they have a brain injury or a new onset of dementia. The nurse should identify that which of the following members of the interprofessional team likely prescribed the MRI?
A) Licensed clinical social worker B) Psychologist C) Psychiatrist D) Occupational therapist Answer: C. Psychiatrists are medical doctors who can diagnose & prescribe medical procedures, tests, & medications
A nurse is discussing privacy & confidentiality with a client. Which of the following US congressional act that sets the standards for client privacy & confidentiality?
A) No surprise act B) Health Insurance Portability and Accountability Act C) Affordable Care Act of 2010 D) Nurse practice act Answer: B. HIPAA protects the privacy & confidentiality of a client's health information
A nurse in the emergency department is caring for a client who experienced abuse by an intimate partner and is scared to return home. To which of the following interprofessional team members should the nurse refer the client?
A) Occupational Therapist B) Social worker C) Substance use counselor D) Pharmacist Answer: B. Social workers provide client support & advocacy related to living situations
A nurse is caring for a client who has been sexually assaulted. Which of the following actions should the nurse take first to develop therapeutic relationship with the client?
A) Orient the client to the unit schedule B) Maintain a safe milieu C) Review the client's past mental health history D) Assist the client in choosing goals for their facility stay Answer: B
A nurse is caring for a client who is in physical restraints. The nurse should identify which of the following complications can results from inadequate monitoring of the client? (select all that apply)
A) Positional Asphyxia B) Food aspiration C) Cardiac Arrest D) Infection E) Somnolence Answer: A, B, C
A nurse is reviewing the medical record of a client on a chemical dependency unit and notes the provider refers to the recovery and the rehabilitation models. The nurse should identify that which of the following goals are similar in both models?
A) Promotion of frequent hospitalizations to adjust medications B) Promotion of dependence on family members C) Promotion of reliance on medication D) Promotion of independence answer: D
A nurse on a mental health unit is caring for a client who becomes agitated. The nurse encourages the client to return to their room to calm down. Which of the following de-escalation techniques is the nurse using?
A) Seclusion B) Time out C) Restraints D) Distraction Answer: B. Time out involves getting the client time to regain control of their emotions, calm down, & end the behavior
A nurse is discussing burnout among nurses with a colleague. Which of the following is a strategy to reduce burnout?
A) Self-scheduling work shifts B) Keeping to oneself at work C) Working extra shifts during staff shortages D) Skipping shared governance meetings Answer: A. Self-scheduling work shifts allows nurses to have more control over work-life balance & helps reduce burnout. Strategies for reducing burnout include engagement in shared governance, effective communication, supportive teams, supportive leadership, & consistent self care
A nurse on a mental health unit administered an antipsychotic medication to a combative client. The nurse goes to assess the client 30min later and finds the client sleeping in their room. Which of the following Standards of Practice is the nurse demonstrating?
A) Standard 1 Assessment B) Standard 3 Outcomes Identification C) Standard 4 Planning D) Standard 6 Evaluation Answer: D. Evaluation involves looking back at the outcomes to see if they have been met with the appropriate nursing interventions
A newly hired nurse confides in another nurse despite trying to be hopeful, they feel very depressed. Which of the following actions should the nurse take?
A) Suggest the newly hired nurse contact a mental health professional B) Notify the employee assistance program about the newly hired nurse C) Notify risk management D) Suggest the newly hired nurse try yoga Answer: A
A nurse is caring for a client who has a mental illness. The client also vapes and has a history of tachycardia and high blood pressure. The nurse should teach health promotion on which of the following topics? (Select all that apply)
A) Tobacco/vaping B) Cardiovascular diet C) Medication adherence D) Adverse Childhood experiences (ACEs) E) Regular exercise Answer: A, B, C, E
A nurse is caring for a client who has schizophrenia & has recently been diagnosed with a terminal illness. The client's interprofessional team should recommend which of the following for the client?
A) Urgent Care B) Dementia Care C) Experimental Therapy D) Hospice Care Answer: D. Hospice care focuses on the care, comfort, & quality of life for a person who has a terminal illness & is approaching the end of life
A nurse is caring for an adolescent who has a history of being physically abused. Which of the following statements should the nurse make regarding the adolescent's risk for abuse in the future?
A) We have talked with your parent, & you should not experience any more physical abuse from the, B) Why don't you create three ways you that you think will be helpful in reducing the number of abuse events C) You must take some steps to keep yourself from being abused, like keeping your mouth shut if someone screams at you D) We are providing you with a resource that helps with self-regulation & decreasing abuse in the future answer: D
A nurse is researching methods of incorporating technology in their nursing practice. Which of the following strategies should the nurse use to incorporate technology in nursing care?
Implement a video conferencing policy for clients in rural locations.
A nurse wants to improve their therapeutic communication by implementing the use of bias-free language. Which of the following actions should the nurse take to provide bias-free language?
Ask the client how they prefer to be addressed.
A nurse is caring for a client who is newly admitted to the acute psychiatric unit for alcohol use disorder. The client reports growing up in an Amish community. Which of the following actions should the nurse take?
Assess for personal bias related to alcohol use disorder before interacting with the client. To ensure the nurse does not have any bias in their treatment of the client, the nurse should first understand what their own culture and biases are to not hinder client care.
A nurse is preparing an educational lecture for bariatric clients. Which of the following should the nurse take into consideration when developing the lecture?
Audiovisuals. The content should apply to all lecture
A nurse asks a client how he learns best. The client states, I think I learn the best when I can discuss the information w/ a group of people. " This indicates that the client has a preference for which of the following learning styles.
Auditory
A nurse is collaborating on an aftercare plan with a client who was recently discharged from inpatient treatment and creates a list of local support groups for grief services. Which of the following nursing roles does this demonstrate?
Case manager
a nurse is caring for an adolescent who had an adverse childhood experience and was admitted to the inpatient unit with behavioral problems. The nurse should anticipate the provider prescribing which of the following types of treatment?
Cognitive therapy
A nurse is caring for a client who is from a different culture than them. Which of the following actions should the nurse take to provide culturally competent care?
Contact an interpreter if the client does not respond to nonverbal communication cues.
A nurse is talking with a client who says that although they do not have any mental illness, they have felt extremely depressed, and have considered suicide lately. The nurse should identify that this client is in which of the following zones of the mental health continuum?
Crisis
A nurse is learning to speak a second language to provide care to clients whose primary language is different from the nurse. Which of the following disparities is the nurse attempting to reduce?
Culturally competent care disparities
A nurse is planning a presentation regarding mental illness for a local health fair. Which of the following should the nurse include as a characteristic of mental illness?
Difficulty maintaining social relationships. Mental illnesses are associated with distress and/or problems functioning in social, work, or family activities.
a nurse is assisting a client in getting ready to have their first telehealth appointment with their therapist. Which of the following actions should the nurse take to assist the client with this type of therapy?
Ensure the Client's computer is connected to the internet.
A nurse is admitting a new client. Which of the following actions should the nurse take during the orientation phase of the nurse-client relationship?
Establish boundaries.
A nurse is preparing to teach a client how to ambulate w/ crutches and is determining the clients readiness to learn. Which of the following factors should the nurse include in this assessment.
Everything except the clients preferred learning style
A nurse is interviewing a client who is irritable and agitated. Which of the following actions should the nurse take to portray engagement with the client?
Give a slight nod throughout the interview.
A nurse is preparing an in-service for nursing staff on the concept of holistic nursing. Which of the following components should the nurse include in the teaching?
Holistic nursing considers the client's emotional health. Holistic nursing care considers the client's physical, emotional, social, spiritual, and intellectual health.
A nurse is teaching a client who has a new diagnosis of diabetes mellitus type 1. Which of the following questions by the nurse addresses the clients affective domain.
How do you feel diabetes will affect your lifestyle ?
A nurse is assisting with planning an educational presentation about adolescent mental health issues. Which of the following topics should the nurse include as primary prevention strategies?
Identifying behaviors of suicide
A nurse is planning care for a group of clients. Which of the following clients would benefit from cognitive behavioral therapy (CBT)?
a client who has Tourette's syndrome
A nurse is participating in an interdisciplinary team meeting for clients on the unit. Which of the following actions should the nurse recommend to improve inclusion among the treatment team?
Include discussion of the clients' spiritual needs in team meetings.
A nurse is participating in an interdisciplinary team meeting for clients on the unit. Which of the following actions should the nurse recommend to improve diversity among the treatment team?
Integrate clinicians from various cultural backgrounds into the team meeting.
A charge nurse is presenting a topic of mental health nursing diagnoses during a unit meeting. The charge nurse should identify that the DSM-5 TR classification is used in conjunction or paired with what other classification system?
International Classification of Disease. The DSM-5 classification is often used in conjunction or paired with the World Health Organization's International Classification of Disease (ICD).
A nurse is collecting data from a client who lives in a rural area and is experiencing symptoms of anxiety that are causing them to miss work. Which of the following is the most likely reason why this client may experience greater disparities now than the client would have in the past in receiving mental health treatment?
Many rural hospitals have closed, creating an even greater gap in availability of mental health resources.
A nurse is collecting data from a client who lives in a rural area and is seeking treatment for anxiety. Which of the following is the benefit of the nurse asking the client questions about possible mental health care disparities?
Mental health disparities can lower the quality of life for the clients who experience them.
A nurse is preparing an adult clients teaching plan and gathering information about the clients culture. Which of the following client statements helps the nurse understand the clients social organization?
My mother needs to be present for any teaching.
Which of the following should the nurse take into consideration when selecting an environment to provide client educations ?
Noise level, Size of space, lighting, temperature
A nurse is planning to collect data about the community and determine populations at high risk for a mental illness. Which of the following populations are at a higher risk for experiencing a mental illness?
Older adults who live in an urban community
A nurse is preparing a poster presentation on the priorities of Healthy People 2030. Which of the following priority goals should the nurse include?
Prevention practices related to cyber bullying Cyber bullying is a stressor that can result in mental health disorders. By implementing practices targeted at prevention of cyber bullying, the priority goal of prevention of mental health disorders is met
A nurse is preparing to discharge a client. Which of the following actions should the nurse plan to take to improve the client's level of functioning beyond the nurse-client relationship?
Provide community resource referrals.
A nurse is participating in an interdisciplinary team meeting for clients on the unit. Which of the following actions should the nurse recommend to improve equity among the clients?
Provide free or low-cost treatment options for all clients.
A nurse is collecting data with a client who struggles with being nervous and forgetful while at work. In which of the following areas of a mental health self-check should the nurse expect the client to be?
Reacting
A nurse is discussing different factors of the determinants of mental health nursing during a staff meeting. Which of the following factors should the nurse include in the discussion? (Select all that apply.)
Receiving paid maternity leave is incorrect. Unsafe drinking water is correct. Exposure to an adverse childhood event is correct. A playground in the neighborhood is correct. National policy addressing cyberbullying is correct.
A nurse is seeking to improve outcomes in mental health care by integrating technology in a local clinic. Which of the following actions should the nurse take to incorporate technology as a part of tertiary prevention interventions?
Refer clients to a support group that meets on social media.
A nurse is working in a neighborhood where the population is culturally diverse. Which of the following actions should the nurse take to ensure the delivery of culturally competent care?
Talk to the residents of the neighborhood about their culture. Cultural competence involves gaining knowledge about another individual's culture. Speaking to the residents of the neighborhood can assist the nurse in gaining this knowledge.
A newly license nurse is reviewing the American Nurses Association's core professional values of nursing. Which of the following actions by the nurse demonstrates the value of empowerment?
The nurse provides resources to the client who wants to create a living will before they have surgery. The value of empowerment involves the use of decision making to solve problems for the client. Assisting a client in accessing the resources needed to create a living will is a demonstration of this value.
A nurse is working to build rapport and trust with a new client. Which of the following actions by the nurse could serve as a barrier to building rapport?
The nurse uses clinical terminology to help the client better understand their diagnosis.
A nurse is caring for a newly admitted client who states they are concerned about their privacy and rights while on the psychiatric unit. The nurse should explain to the client that they have which of the following rights?
The right to refuse treatment The right to self-determination allows a client to refuse treatment, including medications. Medication refusals for mental illness are often due to side effects of the stigma of taking such a medication.
A nurse is preparing a toddler for surgery. Which of the following is appropriate for the nurse to take into consideration when developing the teaching plan?
Toddlers depend on their senses to learn.
A nurse is seeking to improve outcomes in mental health care by integrating technology in a local clinic. Which of the following actions should the nurse take to incorporate technology as a part of secondary prevention interventions?
Utilize a video conferencing application to perform a suicide risk screening.
A nurse is caring for a client who has new prescription for digoxin (lanoxin) Which of the following should the nurse first teach the client ?
Your provider is prescribing this medication to strengthen your hearts contractions.
A nurse is caring for an older adult client who has major depressive disorder. The client states, "I don't think I am financially prepared for retirement, yet I am eligible to retire this year." The nurse should identify that the client is in which of the following stages of Erikson's stages of development?
ego integrity vs despair
A nurse and a newly licensed nurse in a mental health facility are discussing their roles related to therapy. Which of the following interventions should the nurse discuss with the newly licensed nurse?
ensuring a therapeutic nurse-client relationship with those on the unit
A nurse is providing discharge teaching for an adolescent client. Which of the following teaching strategies is appropriate for the nurse to use when teaching this client.
everything except focus teaching and use of reminiscence when discussing info.
a nurse is observing a group of children interacting. the nurse notes anytime a question is asked, all the children want to answer and will often talk over each other. The nurse should recognize that this behavior is indicative of which of the following stages of kohlberg's theory?
instrumental relativity orientation
A nurse is preparing to interview a client and is reviewing therapeutic communication techniques. Which of the following statements should the nurse make to affirm the client's behavior change?
"You completed your antibiotic regimen. You are serious about improving your health."
a newly licensed nurse asks a charge nurse. "what is the difference between a suicide attempt and self harm?" which of the following responses should the charge nurse give?
"a suicide attempt is when a person harms themselves with the intent to die but does not. Self harm is when a client intentionally inflicts harm on themselves but does not have intention to kill themselves."
A nurse in a mental health facility is caring for a client who asks, "Why can't you be my therapist?" Which of the following therapeutic responses should the nurse give?
"i am glad you are comfortable talking with me. but your therapy is most beneficial from a therapist with additional training to best guide and talk with you."
A nurse is discussing scope of practices related to mental health with a peer. Which of the following statements by the nurse explains practice focus for a mental health nurse?
A) "It is important to consider mental health needs related to population health are based on the social determinants of health" B) "Nursing remains unchanged and the majority of a nurse's responsibility is for the hospitalized client" C) "Nursing in New Life care does not focus on mental health care, but on labor and delivery" D) "School nursing is focused on immunizations and medical needs of children, rather than mental health" Answer: A. Nurses should focus their practice & expand their responsibilities to include care of clients in all populations related to mental health needs as outlined by the social determinants of health
A nurse is asked to evaluate a quantitative study to help prepare for an in-service about client aggression. Which of the following studies should the nurse evaluate?
A) A formal research review of studies on IM medications for client aggression B) A study surveying the opinions of the nursing staff who are administering fewer IM medications for client aggression C) A study reporting a reduction in the use of IM medications for client aggression D) A study looking at thoughts and feelings from clients who received IM medications for aggression answer: C
A nurse on a pediatric mental health unit is discussing the importance of setting boundaries with another nurse. Which of the following statements by the nurse explains why setting boundaries is important?
A) "Setting boundaries will cause the children to try and leave the unit" B) "Children will automatically rebel against all boundaries set on the unit, so you must let them know the consequences" C) "Setting boundaries increases a child's sense of security through knowing the consequences of behaviors" D) "Children are not able to understand boundaries or consequences of their behavior" Answer: C. Setting Boundaries reduces any misunderstanding, establishes behaviors, and provides and understanding of consequences
A nurse is teaching a group of adolescents about the effects of adverse childhood experiences (ACEs). Which of the following statements should the nurse include?
A) "There can be issues with brain development" B) "There is concern regarding medication adverse effects" C) "There is concern about the ability to understand the meaning of ACEs" D) "There are generally no effects from ACEs" Answer: A. ACEs can affect the adolescents brain
A nurse is caring for a client who states, "I hate having to shower at night. At home, I shower in the morning to start my day." Which of the following responses should the nurse give to focus on the client-centered care?
A) "We have other clients who are on the morning shower list at this time, so you will need yo shower in the evening" B) "We can arrange for you to take your showers in the morning" C) "Does it really make much difference what time you shower?" D) "You should shower at night, so you can go to bed clean" Answer: B
A nurse in a pediatric provider's clinic is caring for four adolescents. Which of the following adolescents should the nurse identify as having a risk of sustaining an adverse childhood experience (ACE)?
A) A 15 year old adolescent who states their partner broke up w/ them after 1 month of dating B) A 12 year old adolescent who states they are struggling w/ understanding their math homework C) A 17 year old adolescent who states their parent has alcohol use disorder D) A 16 year old adolescent who states one of their parents often has to travel for work answer: C
A charge nurse on a mental health unit is discussing the concept of client competency with a group of newly licensed nurses. Which of the following information should the charge nurse include?
A) A client can be deemed legally competent via confirmation by two mental health providers B) A client is automatically deemed to be incompetent upon admission to the facility if they are experiencing psychosis C) A client who is deemed incompetent will be unable to make decisions for themselves D) A client is considered mentally competent until deemed incompetent by a judge in a legal hearing Answer: D
A nurse is discussing the effects of adverse childhood experiences (ACEs) have on the brain with a client who has a history of ACEs. Which of the following statements should the nurse include?
A) ACEs does not have an effect on the brain B) ACEs force clients to live in survival mode C) ACEs block memories so that long-term memory is much less effective D) ACEs increase the awareness of clients' surroundings and has a positive effect on memory answers: B. ACEs have a negative effect on clients because it forces these clients to live in survival mode, which makes it difficult for them to self-regulate and manage daily life
A nurse is discussing the effects of workplace violence by clients and their family members on health care professionals with a peer. The nurse should identify that which of the following organizations provides oversight for nurses regarding workplace violence?
A) American Hospital Association B) Department of health and human services C) Occupational safety and health administration D) The joint commission Answer: C. OSHA is the organization that is tasked with ensuring worker safety, including providing oversight for workplace violence
A nurse is caring for a client who is agitated & requires chemical restraints. Which of the following types of medication should the nurse expect the provider to prescribe?
A) Antidepressant B) Sedative C) Steroid D) N-methyl-D-aspartate receptor (NMDA) inhibitor Answer: B
A nurse is caring for a client and asks the client for their name, date of birth, and what day and time it is. Which of the following steps of the nursing process is the nurse performing?
A) Assessment B) Evaluation C) Implementation/ intervention D) Planning answer: A
A nurse is finding housing for a client who has a serious mental illness (SMI) and is being discharged. Which of the following factors should the nurse consider?
A) Available recreational activities B) Length of time since the diagnosis of the SMI C) Scheduled counseling appointments D) The degree of freedom the client will have to make decisions answer: D. Supported housing allows more independence for clients. it offers some degree of independence and some degree of support by staff living in the home
A nurse encourages each client in a group session to speak & be heard. The nurse should identify that this is an example of which of the following ethical principles?
A) Beneficence B) Autonomy C) Nonmaleficence D) Justice Answer: D. Justice involves caring for all clients equally & with the same level of fairness
A nurse is caring for a newly admitted client who expresses concern that their insurance will not cover their care. The nurse should identify that which of the following is a U.S. congressional act that requires providers to inform their clients of the cost for the treatment & whether their insurance will cover it?
A) Health Insurance Portability and Accountability Act B) Affordable Care Act of 2010 C) No Surprise Act D) Nurse practice act Answer: C. No surprise act requires providers to inform clients of the cost of treatment & whether providers are covered by their insurance
A nurse overhears unit staff workers making jokes about a nursing student. This is an example of which of the following?
A) Incivility B) Anger C) Sexual Harassment D) Bullying Answer: A. Incivility is an act or behavior that shows disrespect & lack of courtesy. Such acts, whether intended or unintended, are considered acts of aggression and can affect the well-being of the individual & negatively impact the work environment
A nurse is caring for a group of children who have experienced trauma. During group therapy, the children create drawings representing their family & community. Which of the following interprofessional team members is likely leading this group?
A) Psychologist B) Art therapist C) Social worker D) Registered nurse Answer: B. An art therapist uses different media, including painting, drawing, & pottery, to help clients explore their experience & express their feelings
A nurse on an inpatient mental health unit is providing care to clients. Which of the following actions by the nurse is within the scope of practice for an RN on this unit?
A) Psychotherapy B) Coordination care C) Consultation D) Biological therapies answer: B. coordination of care, which is standard 5A, helps maintain a safe environment for the promotion of health
A nurse is leading a group session when a client begins cursing and running around the room shouting. Which of the following actions should the nurse take?
A) Suggest the client go someplace quiet and compose themselves B) Administer an anxiolytic to the client C) Insist the client go to the seclusion room where monitoring can be done D) Notify the entire treatment team to secure the area Answer: A. Suggest the client go someplace quiet and compose themselves indicates that the nurse will not tolerate their behavior. This is an example of less restrictive alternative to restraints and will give the client a chance to change their behavior prior to returning to the group
A nurse is assessing a client who has schizophrenia with an exacerbation of auditory hallucinations. The client is from a culture that stigmatizes mental health concerns. Which of the following responses should the nurse expect when they ask about the nature and the frequency of the hallucinations?
A) The client will be silent and give no eye contact B) The client will smile and give a detailed explanation of the hallucinations C) The client will give an angry look and yell that they do not have hallucinations D) The client will give eye contact and cry out saying they hear voices now Answer: A. Clients who are from cultures that stigmatize mental health concerns are often not comfortable sharing manifestations with people outside of their family
A nurse is beginning a debrief with staff about a behavioral emergency that resulted in physically restraining a client. The nurse should identify that which of the following is the purpose of debriefing?
A) To determine what to say to the client about the incident B) To determine which team members did not perform well C) To carefully document the entire incident D) To improve the quality of future responses Answer: D. Debriefing provides staff & clients with the opportunity to discuss how the situation evolved, their feelings, & to promote recovery for the client
A nurse in the emergency department (ED) is caring for a client. Which of the following statements by the nurse should initiate a therapeutic relationship with the client?
A) You know you should take the medication offered to you in the ED, if you want your symptoms to go away B) Would you be willing to spend some time talking with me about your thoughts on treatment for your concerns today C) I need to get your blood pressure and pulse first. I will be back to talk with you later, as I have another client to see first D) I understand you were not willing to work with the nurses in the ED today who were trying to help you. Why are you here answer: B
a nurse is reviewing humanistics theorists. which of the following theorists were primarily involved in developing humanistic theory?
Abraham Maslow
a nurse is planning to reinforce teaching with a client about behavioral therapy. which of the following statements should the nurse plan to include?
Behavioral therapy is a type of psychotherapy that helps you modify your maladaptive behavioral patterns.
A nurse is seeking to improve outcomes in mental health by incorporating technology as a part of primary prevention interventions. Which of the following actions should the nurse take?
Distribute a video discussing risk factors for suicide and depression at a local high school.
A nurse is researching methods of incorporating technology in their nursing practice. Which of the following strategies should the nurse use to incorporate technology in nursing care?
Implement a client-centered self-schedule smartphone application.
A nurse is caring for a client who has been admitted to a state mental health facility by a court order. The nurse should identify that clients who have been admitted by court order will typically remain at the facility for a minimum of which of the following durations?
Several months
A nurse is reflecting on their performance after engaging with a client in an interview. Which of the following actions should the nurse plan to implement to improve receptiveness in their next client interview?
Sit at a slight angle across from the client.
A nurse is screening a group of clients for mental health disorders. The nurse should identify that male clients have a higher risk than female clients of developing which of the following conditions?
Substance use disorder
A nurse is reinforcing teaching about adverse effects of a newly prescribed medication to a client who lives 45 miles from the outpatient clinic. Which of the following resources should the nurse consider using for continued monitoring of the client?
Telehealth services
A nurse is evaluating a clients ability to self administer insulin. Which of the following behaviors is reflective of the mechanism level of the psycho motor domain?
The client demonstrates confidence in a performing an insulin injection.
A nurse is caring for a client who is in the excelling zone on the mental health continuum. Which of the following findings should the nurse expect to observe?
The client reports they are having positive experiences in their relationships at work and home.
A nurse is planning to add a client to an established therapy group on the unit. The group currently includes a 13-year-old adolescent who has depression, a 15-year-old adolescent who has a history of self-harm, and a 14-year-old adolescent who recently threatened to kill themselves. Which of the following adolescents should the nurse add to this group?
a 12 year old adolescent who has anxiety & depression
A nurse is reinforcing teaching about psychodynamic theory with a newly licensed nurse. Which of the following should the nurse include as an example related to this theory?
a client who reports being afraid of storms because they experienced a tornado as a child.
A nurse is explaining to a client who has a mental illness why mental health promotion is important. The nurse should inform the client that mental health promotion has a wide variety of benefits including which of the following?
mental health promotion promotes positive mental health which in turns helps prevent you from missing work due to mental illness.
A nurse is discussing what to do about feelings of burnout with a group of nurses. Which of the following is the best strategy the nurse should implement?
A) Suggest that nurses who are experiencing burnout get treatment or quit their position B) Reduce meetings for shared governance C) Request an increase in pay D) Meet with other nurses to create a plan to support each other Answer: D
A nurse is planning care for a client. Which of the following characteristics are essential for the nurse to effectively implement therapeutic use of self? (Select all that apply)
A) emotional balance B) assertive in facing life's challenges C) goal-directed D) compassionate care for clients E) advanced skills in medication administration answer: A, B, C, D
A nurse is talking w/ a client who has been diagnosed w/ a phobia. The nurse states, "Tell me more about your fear of elevators." Which of the following therapeutic communication techniques is the nurse demonstrating?
A) exploring B) clarification C) restating D) paraphrasing answer: A. Exploring is when the nurse asks for more information to better understand what the client is communicating
A nurse is interviewing a newly admitted client who has major depressive disorder to determine if they might be having thoughts of suicide. Which of the following steps of the nursing process is the nurse performing?
A) planning B) evaluation C) assessment D) implementation answer: C
A nurse on a mental health unit is teaching a newly licensed nurse about the social ecological (SE) model when caring for clients who have a serious mental illness and need housing. Which of the following are factors of the SE model that the nurse should include? (select all that apply)
A) religion B) organizational C) individual D) physical E) policy F) community H) Interpersonal Answer: B, C, E, F, H
A nurse is reviewing the chart of a client who has paranoid schizophrenia. The nurse should identify that the Diagnostic Statistical Manual of Mental Disorders, 5th edition Text Revision (DSM-5 TR) distinguished the different types of schizophrenia based on which of the following criteria?
The client's full history. The DSM-5 TR criteria can be broken down based on the client's manifestations obtained during the complete health history.
A nurse is using considerations from Leininger's Transcultural Nursing Theory to plan care for a client who is from a different culture than the nurse. Which of the following actions should the nurse plan to take to demonstrate the consideration of cultural preservation?
Request specific meal tray items to support a client's spiritual beliefs.
A nurse is assisting with the care of a client who has been taking antidepressants for 6 weeks. Which of the following findings should the nurse identify as an indication that the client is in the "thriving zone" of the mental health continuum?
The client reports using relaxation techniques to manage negative emotions.
A nurse is planning care for a client who is completing a diversion program. Which of the following goals is appropriate for a client in this type of program?
The client will achieve integration back into the community after incarceration.
A nurse is assisting a client to develop a plan to reduce caloric intake. Which of the following interventions should the nurse include in the plan as a measurable goal for this client?
The client will record consuming no more than 1,800 calories per day.
A nurse is caring for a client who reports that they are having a hard time completing their ADLs due to feeling anxious. The client also reports feeling tired, difficulty sleeping, and having a poor appetite. The nurse should anticipate they would fall in which end of the mental health continuum?
The client would fall closer towards the mental illness end or struggling. The mental health continuum is a range of responses a person displays in response to life events. The ends vary between positive and negative responses, often viewed as mental health versus mental illness.
A nurse is presenting information on mental health services over the last 50 years to a group of newly licensed nurses. In 1956, the National Mental Health Act was signed into law which resulted in which of the following?
The creation of the National Institute for Mental Health. The National Mental Health Act created the National Institute of Mental Health. The need for psychiatric services has increased over the years, specifically following World War II. The National Mental Health Act was signed in 1946 by President Harry Truman. This called for a National Institute of Mental Health, and the first meeting of the council took place that same year. The National Institute of Mental Health is a federal agency that researches mental illness and was a pioneer in assisting in the transformation of treatment and understanding of mental illnesses.