Practice Test Assessment Performance

The parents of a 14-year-old boy bring their son to the hospital. He is lethargic, but responsive. The mother states, "I think he took some of my pain pills." During initial assessment of the adolescent, what information is most important for the nurse to obtain from the parents?

If he might have taken any other drugs.

A 35-year-old male client on the psychiatric unit of a general hospital believes that someone is trying to poison him. The nurse understands that a client's delusions are most likely related to which client assessment finding?

erroneous interpretation of reality.

The nurse should include which interventions in the plan of care for a severely depressed client with neurovegetative symptoms? (Select all that apply.)

- Permit rest periods as needed. - Speaking slowly and simply. - Observe and encourage food and fluid intake. - Place the client on suicide precautions. Rationale Neurovegetative symptoms that accompany the mood disorder of depression include physiological disruptions, such as anorexia, constipation, sleep disturbance, and psychomotor retardation. The client's plan of care should include measures that promote the client's comfort and well-being, such as rest, nutrition, suicide precautions, and simple communications. Vigorous exercise and long walks are not indicated for clients in a neurovegetative state.

A client who is known to abuse drugs is admitted to the psychiatric unit. Which medication should the nurse anticipate administering to a client who is exhibiting benzodiazepine withdrawal symptoms?

Chlordiazepoxide (Librium).

A 38-year-old female client is admitted with a diagnosis of paranoid schizophrenia. When her tray is brought to her, she refuses to eat and tells the nurse, "I know you are trying to poison me with that food." Which response is best for the nurse to make?

I'll leave your tray here. I am available if you need anything else.

A client on the psychiatric unit appears to imitate a certain nurse on the unit. The client seeks out this particular nurse and imitates the nurse's mannerisms. Which defense mechanism is the client using?

Identification

The nurse is planning discharge for a male client with schizophrenia. The client insists that he is returning to his apartment, although the healthcare provider informed him that he will be moving to a boarding home. What is the most important nursing problem for discharge planning?

Ineffective denial related to situational anxiety.

The wife of a male client recently diagnosed with schizophrenia asks the nurse, "What exactly is schizophrenia? Is my husband all right?" Which response is best for the nurse to provide to this family member?

It is a chemical imbalance in the brain that causes disorganized thinking.

When preparing a teaching plan for a client who is to be discharged with a prescription for lithium carbonate (Lithonate), which instruction is most important for the nurse to include?

Keep your dietary salt intake consistent.

A male client is admitted to a mental health unit on Friday afternoon and is very upset on Sunday because he has not had the opportunity to talk with the healthcare provider. Which response is best for the nurse to provide this client?

Let me call and leave a message for your healthcare provider.

An older female client with Alzheimer's disease is wandering the busy halls of the extended care facility and asks the nurse, "Where should I stand for the parade?" Which response should the nurse provide?

Let's go back to the activity room and see what is going on in there. Rationale It is common for those with Alzheimer's disease (AD) to use the wrong words. Redirecting the client, using an accepting non-judgmental dialogue, to a safer place and familiar activities is most helpful because clients with AD experience short-term memory loss. The other responses dismiss the client's attempt to find order, do not help her relate to the surroundings, and are frustrating which increase anxiety level.

A client who is being treated with lithium carbonate for bipolar disorder develops diarrhea, vomiting, and drowsiness. What action should the nurse take?

Notify the healthcare provider of the symptoms prior to the next administration of the drug. Rationale Early side effects of lithium carbonate that occur with a serum lithium levels below 2.0 mEq/L generally follow a progressive pattern beginning with diarrhea, vomiting, drowsiness, and muscular weakness. The nurse should notify the healthcare provider before giving the next dose, which can contribute to higher serum drug levels that may cause ataxia, tinnitus, blurred vision, and large dilute urine output. The other actions are not indicated.

The nurse is conducting discharge teaching for a client with schizophrenia who plans to live in a group home. Which statement is most indicative of the need for careful follow-up after discharge?

Only my belief in God can help me.

A female client with depression attends group and states that she sometimes misses her medication appointments because she feels very anxious about riding the bus. Which statement is the nurse's best response?

What are some ways that you can cope with your anxiety? Rationale An open-ended question that assists the client in problem-solving ways to cope with the anxiety engages the client in self management. The other responses do not allow the client to explore ways to cope with anxiety.

The nurse observes a female client with schizophrenia watching the news on televison. She begins to laugh softly and says, "Yes, my love, I'll do it." When the nurse questions the client about her comment she states, "The news commentator is my lover and he speaks to me each evening. Only I can understand what he says." What is the best response for the nurse to make?

What do you believe the news commentator said to you?

The nurse is taking a history for a female client who is requesting a routine female exam. Which assessment finding requires follow-up?

"Black-out" after one drink last night on a date.

The nurse is assessing a client who is admitted with a diagnosis of depression. Which findings is characteristic of depression?

A negative view of self and the future.

An older female client reports to the nurse that recently she has been hearing voices. Which question should the nurse ask this client first?

Are you ever alone when you hear the voices?

A young adult male client, diagnosed with paranoid schizophrenia, believes that world is trying to poison him. What intervention should the nurse include in this client's plan of care?

Ask one nurse to spend time with the client daily.

The nurse should withhold the next scheduled dose of a client's haloperidol (Haldol) based on which assessment finding?

Fever of 102 F.

A client who is diagnosed with schizophrenia is admitted to the hospital. The nurse assesses the client's mental status. Which assessment finding is characteristic of a client with schizophrenia?

Flat affect.

An adult male client who was admitted to the mental health unit yesterday tells the nurse that microchips were planted in his head for military surveillance of his every move. Which response is best for the nurse to provide?

Go to occupational therapy and start a project.

A young adult male client is admitted to the emergency center following a suicide attempt. His records reveal that this is his third suicide attempt in the past two years. He is conscious, but does not respond to verbal commands for treatment. Which assessment finding should prompt the nurse to prepare the client for gastric lavage?

He is unresponsive to instructions and is unable to cooperate with emetic therapy.

A male client with mental illness and substance dependency tells the mental health nurse that he has started using illegal drugs again and wants to seek treatment. Since he has a dual diagnosis, which person is best for the nurse to refer this client to first?

His case manager.

A client who has been admitted to the psychiatric unit tells the nurse, "My problems are so bad that no one can help me." Which response is best for the nurse to make?

How can I help?

An adult female client who has been taking antipsychotic neuroleptic medication for the past three days has a decrease in psychotic behavior and appears to be responding well to the medication. On the fourth day, the client's blood pressure increases, she becomes pale and febrile, and demonstrates muscular rigidity. Which action should the nurse initiate?

Immediately transfer the client to intensive care unit.

The nurse is assessing the parents of a nuclear family who are attending a support group for parents of adolescents. According to Erikson, these parents who are adapting to middle adulthood should exhibit which characteristic?

Increased self-understanding.

A child is brought to the emergency room with a broken arm. Because of other injuries, the nurse suspects the child may be a victim of abuse. When the nurse tries to give the child an injection, the child's mother becomes very loud and shouts, "I won't leave my son! Don't you touch him! You'll hurt my child!" What is the best behavioral interpretation of the mother's statements?

Projecting feelings onto the nurse.

An adult female client is admitted to the psychiatric hospital with a diagnosis of bipolar disorder, manic phase. She is demanding and active. Which intervention should the nurse include in this client's plan of care?

Provide a structured environment with little stimuli.

On admission, a client who is highly anxious describes a delusion. The nurse understands that delusions are most likely to occur with which class of disorder?

Psychotic

A male client is admitted to the mental health unit because he was feeling depressed about the loss of his wife and job. The client has a history of alcohol dependency and admits that he was drinking alcohol 12 hours ago. Vital signs are: temperature 100o F, pulse 100 beats/minute, and blood pressure 142/100. The nurse plans to give the client lorazepam (Ativan) based on which priority client problem?

Risk for injury related to alcohol detoxification.

Which diet selection by a client who is depressed and taking the MAO inhibitor tranylcypromine sulfate (Parnate) indicates to the nurse that the client understands the dietary restrictions imposed by this medication regimen?

Roast beef, baked potato with butter, and iced tea.

An adult male who is a sales manager tells the nurse, "I am thinking about a job change. I don't feel like I am living up to my potential." Which of Maslow's developmental stages is the client attempting to achieve?

Self-Actualization.

A 40-year-old male client diagnosed with schizophrenia and alcohol dependence has not had any visitors or phone calls since admission. He reports he has no family that cares about him and was living on the streets prior to this admission. According to Erikson's theory of psychosocial development, which stage is the client in at this time?

Stagnation.

A male adolescent is admitted with bipolar disorder after being released from jail for assault with a deadly weapon. When the nurse asks the teen to identify his reason for the assault, he replies, "Because he made me mad!" Which goal is best for the nurse to include in the client's plan of care?

Suggest actions to control impulsive responses toward self and others. Rationale: Those with bipolar disorder often exhibit poor impulse control, and the most important goal for this client at this time is to learn to control impulsive behavior so that he can avert the social consequences related to such behaviors. The other goals do not address the acute issue of impulse control, which is necessary to minimize the likelihood of self harm and harm to others.

A young adult female client with a diagnosis of anorexia nervosa wants to help serve dinner trays to other clients on a psychiatric unit. What action should the nurse take?

Suggest another way for this client to participate in the unit's activities.

Physical examination of a school-aged child reveals several bite marks in various locations on the body. X-ray examination reveals healed fractures of the ribs. The mother tells the nurse that the child is always having accidents. Which initial response is best for the nurse to make?

Tell me more specifically about your child's accidents.

A nurse working in the emergency room of a children's hospital admits a child whose injuries could have resulted from abuse. Which statement most accurately describes the nurse's responsibility in cases of suspected child abuse?

The nurse should report any case of suspected child abuse to the nurse in charge. Rationale It is the nurse's legal responsibility to report all suspected cases of child abuse. Notifying the charge nurse starts the legal reporting process.

Which statement about contemporary mental health nursing practice is accurate?

The psychiatric nursing client may be an individual, family, group, organization, or community.

An adult female client is admitted to the psychiatric unit for evaluation. Her husband states that she has been reluctant to leave home for the last six months. The client has not gone to work for a month and has been terminated from her job. She has not left the house since that time. Which condition is this client likely manifesting?

Agoraphobia

At the first meeting of a group of older adults at a daycare center for the elderly, the nurse asks one of the members what kinds of things would one like to do with the group. The older woman shrugs her shoulders and says, "You tell me, you're the leader." What is the best response for the nurse to make?

I will be leading this group. What would you like to accomplish during this time?

An older female client is admitted to the psychiatric unit with a diagnosis of major depression. Which client statement indicates to the nurse that further assessment is indicated?

I will die if my cat dies.

The nurse is assessing a client's intelligence. Which factor should the nurse remember during this part of the mental status exam?

Intelligence is influenced by social and cultural beliefs.

A female client refuses to take an oral hypoglycemic agent because she believes that the drug is being administered as part of an elaborate plan by the Mafia to harm her. Which nursing intervention is most important to include in this client's plan of care?

Reassess client's mental status for thought processes and content.

A client with bipolar disorder on the mental health unit becomes loud, and shouts at one of the nurses, "You fat tub of lard! Get something done around here!" What is the best initial action for the nurse to take?

Redirect the client's energy by asking him to tidy the recreation room.

A male client with schizophrenia tells the nurse that the voices he hears are saying, "You must kill yourself." To assist the client in coping with these thoughts, which response is best for the nurse to provide?

Tell yourself that the voices are unreasonable.

A client is receiving substitution therapy during withdrawal from benzodiazepines. Which expected therapeutic response has the highest priority during pharmacological managment for withdrawal?

Excessive CNS stimulation will be reduced.

An anxious client expressing a fear of people and open places is admitted to the psychiatric unit. What is the most effective way for the nurse to assist this client?

Accompany the client outside for an increasing amount of time each day. Rationale The process of gradual desensitization by controlled exposure to the situation which is feared, is the treatment of choice in phobic reactions. The other options are not indicated in the initial phase of desensitization.

A 45-year-old male client tells the nurse that he used to believe that he was Jesus Christ, but now he knows he is not. Which response is best for the nurse to make?

Others have had similar thoughts when under stress. Rationale The nurse should offer support by assuring the client that others have suffered as he has. The other responses are not therapeutic and not indicated.

On admission to a residential care facility, an older female client tells the nurse that she enjoys cooking, quilting, and watching television. Twenty-fours after admission, the nurse notes that the client is withdrawn and isolated. Which activity should the nurse encourage the client to become involved and participate?

Participate in a group quilting project.

The nurse is leading a "current events group" with client who have chronic psychiatric illnesses. One group member states, "Clara Barton was my nurse during my last hospitalization. She was a very mean nurse and wasn't nice to me." Which response is best for the nurse to make?

Clara Barton started the American Red Cross.

The nurse observes a client who is admitted to the mental health unit and identifies that the client is talking continuously, using words that rhyme but that have no context or relationship with one topic to the next in the conversation. This client's behavior and thought processes are consistent with which syndrome?

Schizophrenia.

A client, who is on a 30-day commitment to a drug rehabilitation unit, asks the nurse if he can go for a walk on the grounds of the treatment center. When he is told that his privileges do not include walking on the grounds, the client becomes verbally abusive. Which approach should the nurse take?

Calmly address the client's inappropriate behavior. Rationale Calmly addressing inappropriate behavior minimizes escalation of the issue, specifically that the behavior is unacceptable. The other approaches are not indicated.

A woman arrives in the Emergency Center and tells the nurse she thinks she has been raped. The client is sobbing and expresses disbelief that a rape could happen because the man is her best friend. After acknowledging the client's fear and anxiety, how should the nurse respond?

Rape is not limited to strangers and frequently occurs by someone who is known to the victim.

An older female client with advanced dementia is admitted to the hospital with a fractured hip. The client repeatedly tells the staff, "Take me home. I want my Mommy." Which response is best for the nurse to provide?

Tell the client that the nurse is there and will help her.

Based on noncompliance with the medication regimen, an adult client with a diagnosis of substance abuse and schizophrenia recently had a change in prescriptions from oral fluphenazine HCl (Prolixin) to fluphenazine decanoate (Prolixin IM). What is most important to teach the client and family about this change in medication regimen?

The effects of alcohol and drug interaction.

A male client with schizophrenia who is taking fluphenazine decanoate (Prolixin) is being discharged in the morning. A repeat dose of medication is scheduled for 20 days after discharge. The client tells the nurse that he is going on vacation in the Bahamas and will return in 18 days. Which statement by the client indicates a need for health teaching?

When I return from my tropical island vacation, I will go to the clinic to get my Prolixin injection.

Within several days of hospitalization, a client is repeatedly washing the top of the same table. Which initial intervention is best for the nurse to implement to help the client cope with anxiety related to this behavior?

Allow time for the ritualistic behavior, then redirect the client to other activities.

A nurse working on a mental health unit receives a community call from a person who is tearful and states, "I just feel so nervous all of the time. I don't know what to do about my problems. I haven't been able to sleep at night and have hardly eaten for the past 3 or 4 days." Which assessment findi ng should the nurse reference when initiating a referral?

Moderate levels of anxiety.

The nurse is preparing to administer phenelzine sulfate (Nardil) to a client on the psychiatric unit. Which side effect reported by the client is related to administration of this drug?

My mouth feels like cotton.

At a support meeting for parents of a teenager with polysubstance dependency, a parent states, "Each time my son tries to quit taking drugs, he gets so depressed that I'm afraid he will commit suicide." The nurse's response should be based on which information?

Careful monitoring should be provided during withdrawal from the drugs.

An older male client in the intensive care unit who has been oriented suddenly becomes disoriented and fearful. Assessment of vital signs and other physical parameters reveal no significant change and the nurse formulates the client's problem as confusion related to ICU psychosis. Which intervention is most important for the nurse implement?

Cluster care so brief periods of rest can be scheduled during the day.

An adult female client has been increasingly restless, and the nurse finds her trying to leave the psychiatric unit. She tells the nurse, "Please let me go! I must leave because the secret police are after me." Which response is best for the nurse to make?

Come with me to your room and I will sit with you.

The community health nurse talks to a male client who has bipolar disorder. The client explains that he sleeps 4 to 5 hours a night and is working with his partner to start two new businesses and build an empire. The client stopped taking his medications several days ago. What nursing problem has the highest priority?

Medication management.

Over a period of several weeks, a male participant of a socialization group at a community day care center for the elderly monopolizes most of the group's time and interrupts others when they are talking. What is the best action for the nurse to take in this situation?

Allow the group to handle the problem. Rationale: The phase the group process is in--initial, working, or termination--this will help determine communication styles between the group members. After several weeks, the group is in the working phase and the group members should be allowed to determine the direction of the group. The nurse should ignore the client's comments and allow the group to address the situation.

The nurse is planning care for a 32-year-old male client diagnosed with HIV infection who has a history of chronic depression. Recently, the client's viral load has begun to increase rather than decrease despite his adherence to the HIV drug regimen. What should the nurse do first while taking the client's history on admission to the hospital?

Ask the client if he takes St. John's Wort routinely.

A male client is admitted to the psychiatric unit with a medical diagnosis of paranoid schizophrenia. During the admission procedure, the client looks up and states, "No, it's not MY fault. You can't blame me. I didn't kill him, you did." What action is best for the nurse to take?

Assess the content of the hallucinations by asking the client what he is hearing. Rationale Further assessment is indicated and the nurse should obtain information about what the client believes the voices are telling him--they may be telling him to kill himself or the nurse. The other actions are not indicated.

The nurse plans to help an 18-year-old female intellectually disabled client ambulate the first postoperative day after an appendectomy. When the nurse tells the client it is time to get out of bed, the client becomes angry and tells the nurse, "Get out of here! I'll get up when I'm ready!" Which response is best for the nurse to make?

I'll be back in 30 minutes to help you get out of bed and walk around the room.

The charge nurse is collaborating with the nursing staff about the plan of care for a client who is very depressed. What is the most important intervention to implement during the first 48 hours after the client's admission to the unit?

Maintain safety in the client's milieu.

A female client with obsessive-compulsive disorder (OCD) is describing her obsessions and compulsions and asks the nurse why these make her feel safer. What information should the nurse include in this client's teaching plan? (Select all that apply.)

- Compulsions relieve anxiety. - Anxiety is the key reason for OCD. - Obsessive thoughts are linked to levels of neurochemicals. - Antidepressant medications increase serotonin levels.

The nurse is planning the care for an adult client with acute depression. Which intervention should the nurse implement to help the client deal with depression?

Assist the client in exploring feelings of shame, anger, and guilt. Rationale Depression is associated with feelings of shame, anger, and guilt. Exploring such feelings with the client is an important nursing intervention for a client who is acutely depressed. The other interventions are not indicated.

The nurse suspects child abuse when assessing a 3-year-old boy with several small, round burns on his legs and trunk that appear to be the result of cigarette burns. Which parental behavior provides the greatest validation for such interpretation?

The parents tell the nurse that the child was burned in a house fire which is incompatible with the nurse's observation of the type of burn.

A homeless person who is in the manic phase of bipolar disorder is admitted to the mental health unit. Which laboratory finding obtained on admission is most important for the nurse to report to the healthcare provider?

Decreased thyroid stimulating hormone level.

A woman brings her husband to the outpatient psychiatric unit and describes his behavior to the admitting nurse. She states that he has been sleepwalking, cannot remember who he is, and exhibits multiple personalities. Which disorder manifests these behaviors?

Dissociative disorder.

An adult client who has been hospitalized for two weeks for chronic paranoia continues to state that someone is trying to steal the client's clothing. Which action should the nurse to take?

Encourage the client to actively participate in assigned activities on the unit.