MH HESI
A client states that she hears God's voice telling her that she has sinned and needs to punish herself. Which response by the nurse is most important? 1) "How do you think you will be punished?" 2) "Please tell staff when you think you need to punish yourself." 3) "What exactly do you think you have done to be punished?" 4) "Let's talk about your strengths"
"Please tell staff when you think you need to punish yourself."
A client diagnosed with paranoid schizophrenia is still withdrawn, unkept, and unmotivated to get out of bed. A mental health aide asks the nurse why the client is this way after being on fluphenazine (Prolix) 10 mg for 7 days. The nurse should tell the health aide: 1) "Prolixin is the most effective with positive symptoms of schizophrenia." 2) "The client will be less withdrawn and unmotivated when the Prolixin takes effect." 3) "The client's Prolix dose probably needs to be increased again." 4) "Lack of motivation is a common side effect of the Prolixin."
"Prolixin is the most effective with positive symptoms of schizophrenia."
A client with schizophrenia has been started on medication therapy with clozapine. The nurse should assess the results of which laboratory study to monitor for adverse effects from this medication? 1. Platelet count 2. Blood glucose level 3. Liver function studies 4. White blood cell count
White blood cell count
Which statement demonstrates the best understanding of the nurse's role regarding ensuring that each client's rights are respected? 1) "Autonomy is the fundamental right of each and every client." 2) "A client's rights are guaranteed by both state and federal laws." 3) "Being respectful and concerned will ensure that I'm attentive to my clients' rights." 4) "Regardless of the client's condition, all nurses have the duty to respect client rights."
"Being respectful and concerned will ensure that I'm attentive to my client's rights."
On admission assessment, the nurse is obtaining subjective data about a client's sexual and reproductive status. The client states, "I don't want to discuss this; it's private and personal." Which response by the nurse is the most therapeutic? 1) "I'd hate being asked these sorts of questions too, but it's a necessary part of providing you with the best care." 2) "This is difficult for you to speak about, but I need this information from you in order to perform a complete assessment." 3) "I am a professional registered nurse, and, as such, I'll have you know that all your information is certainly kept confidential." 4) "I know that some of these questions are difficult for you, but, as a professional nurse, I am obligated to respect your confidentiality."
"I know that some of these questions are difficult for you, but, as a professional nurse, I am obligated to respect your confidentiality."
A nurse determines that the wife of an alcoholic client is benefitting from attending an Al-Anon group when the nurse hears the wife say: 1) "I no longer feel that I deserve the meetings my husband inflicts on me." 2) "My attendance at the meetings has helped me to see that I provoke my husbands violence." 3) "I enjoy attending the meetings because they get me out of the house and away from my husband." 4) "I can tolerate my husband's destructive behaviors now that I know they are common with alcoholics."
"I no longer feel that I deserve the meetings my husband inflicts on me."
A client is being successfully treated with clozapine (Clozaril). Which of the following statements by the client reflects a need for further teaching about managing the drug's adverse effects? 1) "If I eat too many fruits, I'll get constipated." 2) I need to take the medicine with food to avoid nausea." 3) "I have to get up slowly so I don't get dizzy." 4) "Sometimes I have to push myself because I'm sleepy."
"If I eat too many fruits, I'll get constipated."
A female victim of sexual assault is being seen in the crisis center. The client states that she still feels "as though the rape just happened yesterday," even though it has been a few months since the incident. The appropriate nursing response is which of the following? 1) "You need to try and be realistic. The rape did not just occur." 2) "It will take some time to get over these feelings about your rape." 3) "Tell me more about the incident that causes you to feel like the rape just occurred." 4) "What do you think that you can do to alleviate some of your fears about being raped again?"
"Tell me more about the incident that causes you to feel like the rape just occurred."
A nurse is conducting an initial assessment on a client in crisis. When assessing the client's perception of the precipitating event that lead to the crisis, the appropriate question to ask is: 1) "With whom do you live?" 2) "Who is available to help you?" 3) "What leads you to seek help now?" 4) "What do you usually do to feel better?"
"What leads you to seek help now?"
A client says to a nurse, "I'm going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this. After all, I'm the one who's dying." The therapeutic response by the nurse is: 1) "Have you shared your feelings with your family?" 2) "I think we should talk more about your anger with your family." 3) "You're feeling angry that your family continues to hope for you to be cured." 4) "Well, it sounds like you're being pretty pessimistic. After all, years ago, people died of pneumonia."
"You're feeling angry that your family continues to hope for you to be cured."
A client is preparing to attend at Gamblers Anonymous meeting for the first time. The prototype used by this group is the 12-step program developed by Alcoholics Anonymous. Number in order of priority how the steps would be addressed. 1) Admitting to oneself and to another human being the exact nature of one's wrongs 2) Acknowledging that one is entirely ready to have his or her defects of character removed 3) Admitting that oneself is powerless over gambling and that one's life has become unmanageable 4) Making an effort to practice the 12-step principles in all affairs, and to carry out this message to other compulsive gamblers 5) Making direct amends wherever possible to all people that have been hurt, expect when to do so would further harm them or others
3)Admitting that oneself is powerless over gambling and that one's life has become unmanageable 1) Admitting to oneself and to another human being the exact nature of one's wrongs 2) Acknowledging that one is entirely ready to have his or her defects of character removed 5) Making direct amends wherever possible to all people that have been hurt, expect when to do so would further harm them or others 4) Making an effort to practice the 12-step principles in all affairs, and to carry out this message to other compulsive gamblers
A client's medication sheet contains a prescription for sertraline (Zoloft). To ensure safe administration of the medication, a nurse would administer the dose: 1) On an empty stomach 2) At the same time each evening 3) Evenly spaced around the clock 4) As needed when the client complains of depression
At the same time each evening
A client with an eating disorder is planning to attend group meetings with Overeaters Anonymous. The nurse describes this group to the client, knowing that which finding(s) are characteristic of this form of self-help group? Select all that apply. 1) A common goal is shared by all members 2) Members are required to remain anonymous 3) The leader is a professional mental health care provider 4) Attendance must be prescribed by the health care provider 5) The program is designed to provide support and bring about personal change 6) The group is composed of individuals who are experiencing similar problems
A common goal is shared by all members The program is designed to provide support and bring about personal change The group is composed of individuals who are experiencing similar problems
On review of the client's record, the nurse notes that the admission was voluntary. Based on this information, the nurse anticipates which client behavior: 1) Fearfulness regarding treatment measures 2) Anger and aggressiveness directed towards others 3) An understanding of the pathology and symptoms of the diagnosis. 4) A willingness to participate in the planning the care and treatment plan.
A willingness to participate in the planning the care and treatment plan.
A nurse employed in a mental health unit of a hospital is the leader of a group psychotherapy session. The nurses's role in the termination stage of group development is to: 1) Encourage problem solving 2) Encourage accomplishment of the group's work 3) Acknowledge the contributions of each group member 4) Encourage members to become acquainted with one another
Acknowledge the contributions of each group member
A client is scheduled for discharge and will be taking phenobarbital for an extended period. The nurse would place highest priority on teaching the client which point that directly relates to client safety? 1. Take the medication relates to client safety 2. take the medication only with meals. 3. Use a dose container to help prevent missed doses 4. Avoid drinking alcohol while taking this medication
Avoid drinking alcohol while taking this medication
A client with schizophrenia is experiencing distressful thoughts secondary to paranoia. Which intervention(s) should the nurse include in the plan of care? Select all that apply. 1) Avoid laughing when near the client 2) Whisper when communicating near the client 3) Increase socialization of the client among his peers 4) Have the client sign a written release of information form 5) Provide food items that are in containers that need to be opened 6) Begin to educate the client about social supports in the community
Avoid laughing when near the client Provide food items that are in containers that need to be opened
A newly admitted client describes her mission in life as one of saving her son by eliminating the "provocative sluts" of the world. There are several attractive young women on the unit. What should the nurse do first? 1) Ask the client for her definition of "provocative sluts" 2) Ask the young female clients on the unit to dress less provocatively 3) Ask the client to discuss her concerns in the next group session 4) Ask the client to inform the staff if she has negative thoughts about other clients
Ask the client to inform the staff if she has negative thoughts about other clients
The nurse calls security and has physical restrains applied when a client who was admitted voluntarily becomes both physically and verbally abusive while demanding to be discharged from the hospital. Which represents the possible legal ramifications for the nurse associated with these interventions? Select all that apply. 1) Libel 2) Battery 3) Assault 4) Slander 5) False Imprisonment
Battery Assault False Imprisonment
A client receiving tricyclic antidepressants arrives at the mental health clinic. Which observation would indicate that the client is following the medication plan correctly? 1. Client reports not going to work for the past week. 2. Client complains of not being able to "do anything" anymore. 3. Client arrives at the clinic neat and appropriate in appearance. 4. Client reports sleeping 12 hours per night and 3 to 4 hours during the day.
Client arrives at the clinic neat and appropriate in appearance.
Select the nursing interventions for a hospitalized client with mania who is exhibiting manipulative behavior. Select all that apply. 1) Communicate expected behaviors to the client 2) Ensure that the client knows that he or she is not in charge of the nursing unit 3) Assist the client in identifying ways of setting limits on personal behaviors 4) Follow through about the consequences of behavior in a non punitive manner 5) Enforce rules and inform the client that he or she will not be allowed to attend therapy groups 6) Be clear with the client regarding the consequences of exceeding limits that have been set regarding behavior
Communicate expected behaviors to the client Assist the client in identifying ways of setting limits on personal behaviors Follow through about the consequences of behavior in a nonpunitive manner Be clear with the client regarding the consequences of exceeding limits that have been set regarding behavior
A client with a leg amputation is upset about his appearance. The nurse intends to address which most closely associated psychosocial problem? 1) Inability to be mobile 2) Isolating self from others 3) Inability to tolerate activity 4) Concern about body persona
Concern about body persona
A client is admitted to a medical nursing unit with a diagnosis of acute blindness. Many tests are performed, and there seems to be no organic reason why this client cannot see. The client became blind after witnessing a hit-and-run car accident, when a family of three was killed. A nurse suspects that the client may be experiencing a: 1) Psychosis 2) Repression 3) Conversion Disorder 4) Dissociative Disorder
Conversion Disorder
A hospitalized client is started on monoamine oxidase inhibitor (MAOI) for the treatment of depression. The nurse should instruct the client that which foods are acceptable to consume while taking this medication? SATA 1. Figs 2. Yogurt 3. Crackers 4. Aged cheese 5. Tossed salad 6. Oatmeal raisin cookies
Crackers Tossed salad
Which of the following liquids should the nurse administer to a client who is intoxicated on PCP to hasten excretion of the chemical? 1) Water 2) Milk 3) Cranberry juice 4) Grape juice
Cranberry juice
A client who has just been sexually assaulted is calm and quiet. The nurse analyzes this behavior as indicating which defense mechanism? 1) Denial 2) Projection 3) Rationalization 4) Intellectualization
Denial
The wife of a client diagnosed with paranoid schizophrenia visits 2 days after her husband;s admission and states to the nurse, "Why isn' he eating? He's still talking about his food being poisoning." With of the following appraisals by the nurse is most accurate? 1) The wife's inquiry is reasonable 2) Education about her husband's medication is needed 3) Her expectations of her husband are realistic 4) An increase in the client's medication is needed
Education about her husband's medication is needed
A client in a long-term care facility who has multiple sclerosis is embarrassed about the need to use a wheelchair and the muscle spasms that are readily visible in her legs. Which approach is therapeutic in assisting the client to cope? 1) Keep the client in her room as much as possible 2) Assist the client with all activities of daily living 3) Tell the client that many of the people in the facility have these same sorts of problems 4) Encourage and praise perseverance in performing ADLs, and assist the client to dress and groom daily
Encourage and praise perseverance in performing ADLs, and assist the client to dress and groom daily
A nurse is preparing to care for a dying client, and several family members are at the client' bedside. Select the therapeutic techniques that the nurse would use when communicating with the family. Select all that apply. 1) Discourage reminiscing 2) Make decisions for the family 3) Encourage expression of feelings, concerns, and fears 4) Explain everything that is happening to all family members 5) Touch and hold the client's or family member's hands if appropriate 6) Be honest and let the client and family know that they will not be abandoned by the nurse
Encourage expression of feelings, concerns, and fears Touch and hold the client's or family member's hands if appropriate Be honest and let the client and family know that they will not be abandoned by the nurse
the nurse is administering risperidone to a client with schizophrenia who is scheduled to be discharged. Before discharge, which instruction should the nurse provide to the client? 1. Get adequate sunlight 2. Continue driving as usual 3. Avoid foods rich in potassium 4. Get up slowly when changing positions.
Get up slowly when changing positions.
A manic client announces to everyone in the day room that a stripper is coming to perform this evening. When a nurse firmly states that this is inappropriate and will not happen, the client becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of this situation, the nurse determines that the appropriate action would be to: 1) Orient the client to time, person, and place 2) Tell the client that the behavior is inappropriate 3) Escort the manic client to her room, with assistance 4) Tell the client that smoking privileges are revoked for 24 hours
Escort the manic client to her room, with assistance
A client gives a home health nurse a bottle of clomipramine. The nurse notes that the medication has not been taken by the client in 2 months. Which behavior observed in the client would validate noncompliance with this medication? 1. Complaints of insomnia 2. Complaints of hunger and fatigue 3. A pulse rate less than 60 beats per minute 4. Frequent hand washing with hot, soapy water
Frequent hand washing with hot, soapy water
A nurse is preforming a follow-up teaching session with a client discharged 1 month ago. The client is taking fluoxetine (Prozac). What information would be important for the nurse to obtain during this client visit regarding the side effects of the medication? 1) Cardiovascular symptoms 2) Gastrointestinal dysfunctions 3) Problems with mouth dryness 4) Problems with excessive sweating
Gastrointestinal dysfunctions
A client diagnosed with undifferentiated schizophrenia is being discharged on aripiprazole (Ability) 5 mg every night. When developing the teaching plan about the most common adverse effects, which of the following should the nurse include? Select all that apply. 1) Headaches that will subside in a few weeks 2) Transient mild anxiety 3) Insomnia 4) Torticollis 4) Pill rolling movements
Headaches that will subside in a few weeks Transient mild anxiety Insomnia
The nurse is teaching a client who is being started on imipramine about the medication. The nurse should inform the client to expect maximum desired effects at which time period following initiation of the medication? 1. In 2 months 2. In 2 to 3 weeks 3. During the first week 4. During the sixth week of administration
In 2 to 3 weeks
The nurse is describing the medication side and adverse effects to a client who is taking amitriptyline. Which information should the nurse incorporate in the discussion? 1. Consume a low fiber diet 2. Increase fluids and bulk in the diet 3. Rest if the heart begins to beat rapidly 4. Walk if you have difficulty urinating because this is a normal side effect
Increase fluids and bulk in the diet
A moderatley depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to a nurse "I'm finally cured." The nurse interprets this behavior as a cue to modify the treatment plan by: 1) Suggesting a reduction of medication 2) Allowing increased "in-room" activities 3) Increasing the level of suicide precautions 4) Allowing the client off-unit privileges as needed
Increasing the level of suicide precautions
The nurse should include which information in the nursing plan of care for a client with obsessive-compulsive disorder (OCD)? Select all that apply. 1) The medical diagnosis of the client 2) Individualized goals and objectives 3) Attendance at group therapy sessions 4) Self-care measures to improve hygiene 5) Interruption of all compulsive behaviors
Individualized goals and objectives Attendance at group therapy sessions Self-care measures to improve hygiene
An emergency department nurse is caring for an adult client who is a victim of family violence. Which priority instruction would be included in the discharge instructions? 1) Information regarding shelters 2) Instructions regarding calling the police 3) Instructions regarding self-defense classes 4) Explaining the importance of leaving the violent situation
Information regarding shelters
A nurse is working with a client who has sought counseling after trying to rescue a neighbor involved in a house fire. Despite the client's efforts, the neighbor died. Which action does the nurse engage in with the client during the working phase of the nurse-client relationship? 1) Exploring the client's ability to function 2) Exploring the client's potential for self-harm 3) Inquiring about the client's perception of appraisal of the neighbor's death 4) Inquiring about and examine the client's feelings that may block adaptive coping
Inquiring about and examine the client's feelings that may block adaptive coping
When caring for a client who has overdosed on PCP, the nurse should be especially caucus about which of the following client behaviors? 1) Visual hallucinations 2) Violent behavior 3) Bizarre behavior 4) Loud screaming
Violent behavior
A nurse is preparing a client for the termination phase of the nurse-client relationship. The nurse prepares to implement which nursing task appropriate for this phase? 1) Planning short-term goals 2) Making appropriate referrals 3) Developing realistic solutions 4) Identifying expected outcomes
Making appropriate referrals
An outpatient clinic who has been receiving haloperidol (Haldol) for 2 days develops muscular rigidity, altered consciousness, a temperature of 103, and trouble breathing on day 3. The nurse interest these findings as indicating which of the following. 1) Neuroleptic Malignant Syndrome 2) Tardive dyskinesia 3) Extrapyramidal adverse effects 4) Drug-induced parksonism
Neuroleptic Malignant Syndrome
A nurse is caring for a client with anorexia nervosa. The nurse is monitoring the behavior of the client and understands that a client with anorexia nervosa manages anxiety by: 1) Engaging in immoral acts 2) Always reinforcing self-approval 3) Observing rigid rules and regulations 4) Having the need always to make the right decision
Observing rigid rules and regulations
A nurse is caring for a suicidal client. The appropriate nursing intervention in dealing with this client is to: 1) Demonstrate confidence in the client's ability to deal with stressors 2) Provide hope and reassurance that the problems will resolve themselves 3) Display an attitude of detachment, confrontation, and efficiency 4) Provide authority, action, and participation
Provide authority, action, and participation
A nurse observes that a client is pacing, agitated, and presenting aggressive gestures. The client's speech pattern is rapid, and affect is belligerent. Based on these observations, the nurse's immediate priority of care is to: 1) Provide safety for the client and other clients on the unit 2) Provide the clients on the unit with a sense of comfort and safety 3) Assist the staff in caring for the client in a controlled environment 4) Offer the client a less stimulated area to calm down and gain control
Provide safety for the client and other clients on the unit
A client who has been taking buspirone for 1 month returns to the clinic for a follow up assessment. The nurse determines that the medication is effective if the absence of which manifestation has occurred? 1. Paranoid thought process 2. Rapid heart rate or anxiety 3. Alcohol withdrawal symptoms 4. Thought broadcasting or delusions
Rapid heart rate or anxiety
A hospitalized client has begun taking bupropion as an antidepressant agent. The nurse determines that which is an adverse effect, indicating that the client is taking an excessive amount of medication? 1. Constipation 2. Seizure activity 3. Increased weight 4. Dizziness when getting upright
Seizure activity
The nurse notes that a client with schizophrenia and receiving an antipsychotic medication is moving her mouth, protruding her tongue, and grimacing as she watches television. The nurse determines that the client is experiencing which medication complication? 1. Parkinsonism 2. Tardive Dyskinesia 3. Hypertensive Crisis 4. Neuroleptic Malignant Syndrome
Tardive Dyskinesia
Unresolved feelings related to loss most likely may be recognized during which phase of the therapeutic nurse-client relationship? 1) Working 2) Trusting 3) Orientation 4) Termination
Termination
An elderly client was prescribed Ativan 1 mg three times a day to help calm her anxiety after her husband's death. The next day the client calls her daughter asking when she is picking her up to go to the graveside. The client says she has been walking up and down the driveway for the past hour waiting for her daughter. Noting the client's agitation, hyperactivity, and instance, the daughter calls the nurse to report her mother's behavior. Which of the following would the nurse suspect as the cause of the mother's behavior and what action should she suggest? 1) The client is manic and may need a sleeping pill 2) The client is experiencing a medication interaction and should go to the ED 3) The client is experiencing a paradoxical reaction to the Ativan and should stop the new medication immediately 4) The client is overcome by grief and probably needs an antidepressant
The client is experiencing a paradoxical reaction to the Ativan and should stop the new medication immediately
A nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented that the client is experiencing anxiety as a result of a situational crisis. The nurse determines that this type of crisis is caused by: 1) Witnessing a murder 2) The death of a loved one 3) A fire that destroyed the client's home 4) A recent rape episode experienced by the client
The death of a loved one
A client taking lithium reports vomiting, abdominal pain, diarrhea, blurred vision, tinnitus, and tremors. The lithium level is 2.5 mEq/L. The nurse plans care based on which representation of this level? 1. Toxic 2. Normal 3. Slightly above normal 4. Excessively below normal
Toxic
A male client with delirium becomes disoriented and confused in his room at night. The best initial nursing intervention is to: 1) Move the client next to the nurse's station 2) Use an indirect light source and turn off the television 3) Keep the television and a soft light on during the night 4) Play soft music during the night, and maintain a well-lit room
Use an indirect light source and turn off the television
A client in the mental health unit believes that the food is being poisoned. What intervention(s) would be helpful when attempting to encourage the client to eat? Select all that apply. 1) Use open-ended questions to encourage client dialogue 2) Offer opinions about the necessity for adequate nutrition 3) Focus on the client's self-disclosure about food preferences 4) Identify the reasons the client has for not wanting to eat 5) Offer the client food in closed containers, such as in cans that have to be opened
Use open-ended questions to encourage client dialogue Offer the client food in closed containers, such as in cans that have to be opened
The nurse is assessing a client who is taking an antipsychotic medication. Which of the following symptoms is uniquely indicative of neuroleptic malignant syndrome (NMS) and requires immediate attention? 1) Very high temperature 2) Muscular rigidity 3) Tremors 4) Altered consciousness
Very high temperature
