Mental Health NCLEX-RN Exam New Latest Version Updated 2023, Exams of Nursing

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1. The nurse determines that the wife of an alcoholic client is benefiting from

attending an Al-Anon group if the nurse hears the wife make which statement?

1."I no longer feel that I deserve the beatings my husband inflicts on me."

2."My attendance at the meetings has helped me to see that I provoke my

husband's 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 among alcoholics.": 1."I no longer feel that I deserve the beatings my

husband inflicts on me."

Al-Anon support groups are a protected, supportive opportunity for spouses and

significant others to learn what to expect and to obtain excellent pointers about

successful behavioral changes. The correct option is the healthiest response be-

cause it exemplifies an understanding that the alcoholic partner is responsible for

his behavior and cannot be allowed to blame family members for loss of control.

Option 2 is incorrect because the nonalcoholic partner should not feel responsible

when the spouse loses control. Option 3 indicates that the group is viewed as an

All Questions from Actual Past Exam and 100% Correct Answers

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escape, not as a place to work on issues. Option 4 indicates that the wife remains

codependent.

2. A client diagnosed with delirium becomes disoriented and confused at

night. Which intervention should the nurse implement initially?

1. Move the client next to the nurses' 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.: 2.Use an

indirect light source and turn off the television.

Provision of a consistent daily routine and a low stimulating environment is important

when a client is disoriented. Noise, including radio and television, may add to the

confusion and disorientation. Moving the client next to the nurses' station may

become necessary but is not the initial action.

The nurse is caring for an older adult client who has recently lost her husband. The client says, "No one cares about me anymore. All the people I loved are dead." Which response by the nurse is therapeutic? -------- Correct Answer -------- "You must be feeling all alone at this point." A mother of a teenage client with an anxiety disorder is concerned about her daughter's progress during discharge. She states that her daughter "stashes food, eats all the wrong things that make her hyperactive," and "hangs out with the wrong crowd." While helping the mother prepare for her daughter's discharge, the nurse should make which suggestion? -------- Correct Answer -------- The mother should restrict the amount of chocolate and caffeine products in the home. A client with a history of victim abuse has which signs/symptoms of the physical effects of living with a severe level of anxiety and chronic stress? Select all that apply. -------- Correct Answer -------- Irritability Hypertension Gastrointestinal disturbances The nursing student is asked to identify the characteristics of bulimia nervosa. Which characteristic if identified by the student indicates a need to further research the disorder? -------- Correct Answer -------- Body weight well below ideal range The nurse is assigned to care for a client experiencing disturbed thought processes. The nurse is told that the client believes that their food is being poisoned. Which communication technique should the nurse plan to use to encourage the client to eat? -------- Correct Answer -------- Open-ended questions and silence A client is admitted to the psychiatric nursing unit. When collecting data from the client, the nurse notes that the client was admitted on an involuntary status. Based on this type of admission, which would the nurse expect to note? -------- Correct Answer -------- The client presents a harm to self. In planning activities for the depressed client, especially during the early stages of hospitalization, which action is best? -------- Correct Answer -------- Encourage the client to participate in a structured daily program of activities.

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3 / 4 The nurse working in a detoxification unit is admitting a client for alcohol withdrawal. The client's spouse states, "I don't know why I don't get out of this rotten situation." Which would be a therapeutic response by the nurse? -- ------ Correct Answer -------- "What aspects of this situation are the most difficult for you?" A client who is experiencing suicidal thoughts says to the nurse, "It just doesn't seem to be worth it anymore. Why not just end it all?" Which initial nursing response is appropriate? -------- Correct Answer -------- "What do you mean by that?" The nurse is reviewing the health care record of a client admitted to the psychiatric unit. The nurse notes that the admission nurse has documented that the client is experiencing anxiety as a result of a situational crisis. The nurse should determine that this type of crisis could be caused by which event? -------- Correct Answer ------ -- The death of a loved one The licensed practical nurse is assisting in the admittance of a client who has been involuntarily committed to the behavioral health unit. Which actions by the client before hospitalization led to the commitment? Select all that apply. -------- Correct Answer -------- Client threatened to commit suicide. Client threatened to kidnap his spouse. The nurse is caring for a client who is hospitalized because of severe depression. Which statements would be most helpful in assisting this client? Select all that apply. -------- Correct Answer -------- "I notice you are wearing a blue shirt." "Do you have any plans of harming yourself? "I will sit here with you even if you choose not to talk with me." The nurse is collecting data from a client who has recently been violently raped. Which data indicates that the client is experiencing rape-trauma syndrome? -------- Correct Answer -------- The client reports nightmares involving being stalked when alone at night. A client is admitted to a psychiatric unit for treatment of a psychotic disorder. The client is at the locked exit door and is shouting, "Let me out! There's nothing wrong with me! I don't belong here!" The nurse identifies this behavior as which defense mechanism? -------- Correct Answer -------- Denial A visitor brings a suicidal client a brightly packaged gift. The nurse accompanies the visitor to the client's room and takes which action? -------- Correct Answer -------- Has the client open the gift with the nurse present The nurse is caring for a client diagnosed with catatonic stupor. The client is lying on the bed, with the body pulled into a fetal position. Which is the appropriate nursing intervention? -------- Correct Answer -------- Sit beside the client in silence and verbalize occasional open-ended questions. The nurse prepares the plan of care for a client with late-stage Alzheimer's disease who resides in a long-term care facility. Which would be priority concerns to include? Select all that apply. -------- Correct Answer -------- Risk for injury Risk for infection Risk for aspiration Impaired verbal communication

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4 / 4 The nurse is monitoring a client with anorexia nervosa. Which statement by the client would indicate to the nurse that treatment has been effective? -------- Correct Answer -------- "My friends and I went out to lunch today." A client who has terminal cancer has been experiencing a significant increase in pain. However, today the client is no longer complaining of pain but is quiet and isolative. Which types of therapeutic communication should the nurse employ? Select all that apply. -------- Correct Answer -------- Sit by client's bed holding his or her hand. Reminisce with the client and share a humorous story that the client enjoys. The nurse asks: "What can I do, that might make you feel more comfortable today?" The nurse asks: "I noticed you grimacing earlier when I walked in your room. Are you in pain?" The nurse states: "It must be very frustrating to be in pain and not be able to get complete relief from your pain." The nurse must choose a roommate for a client who is in a state of starvation due to anorexia nervosa. The nurse should avoid choosing which client as a roommate for the client with anorexia nervosa? -------- Correct Answer -------- A client with pneumonia The nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal delirium. The nurse should monitor for which symptoms? -------- Correct Answer -------- Hypertension, disorientation, hallucinations Which are the major roles the nurse can play in advocating for psychiatric evaluation and intervention for clients with a history of depression, schizophrenia, obsessive-compulsive disorder, generalized anxiety disorder, or bipolar disorder? Select all that apply. -------- Correct Answer -------- Medication management Monitoring and documenting behavioral changes Notifying the health care provider of behavioral changes Planning care for the needs of those clients with mental illness A client with a history of depression and several suicide attempts is admitted to the mental health unit reporting severe suicidal thoughts. The nurse would focus the initial data collection on which information? -------- Correct Answer -------- The presence of existing suicidal thoughts Which data indicate to the nurse that a client is experiencing effective coping following the loss of a spouse? Select all that apply. -------- Correct Answer -------- Looks at old snapshots of family Visits the spouse's grave once a month Visits the senior citizens' center once a month The nurse is assessing a client with a diagnosis of bipolar affective disorder-mania. Which characteristics appropriately describe this client's diagnosis? Select all that apply. -------- Correct Answer -------- Outlandish behaviors Purposeless arousal and movement Grandiose delusions of being King Arthur

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5 / 4 Incessant talking that includes sexual innuendos A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I don't want help. I have other things to attend to that are more important." The nurse attempts to discuss the client's concerns, but the client dresses and begins to walk out of the hospital room. The nurse should take which action? -------- Correct Answer -------- Call for the registered nurse. The nurse is collecting data on a client in crisis. Which question should the nurse ask to determine the client's perception of the precipitating event that led to the crisis? -------- Correct Answer -------- "What leads you to seek help now?" The nurse is preparing a discharge plan for a client who attempted suicide. The nurse understands that the plan of care should focus on which intervention? -------- Correct Answer -------- Contracts and immediate available crisis resources The nurse informs a client with an eating disorder about group meetings with Overeaters Anonymous. Which statement by the client indicates a need for further teaching about this self-help group? -------- Correct Answer -- ------ "The leader of this self-help group is the nurse or psychiatrist." A licensed practical nurse (LPN) is caring for a client with a diagnosis of schizophrenia. The LPN observes behaviors indicative of paranoia and reports these observations to the registered nurse (RN). The LPN assists the RN in developing a plan of care for the client and suggests inclusion of which intervention in the plan of care? -------- Correct Answer -------- Avoid joking or laughing in the presence of the client. The nurse observes that a client with a potential for violence is agitated, pacing up and down in the hallway, and making aggressive and belligerent gestures at other clients. Which statement is appropriate to make to this client? -------- Correct Answer -------- "What is causing you to become agitated?" A client with a potential for violence is exhibiting agitated behavior. The client is using aggressive gestures and making belligerent comments to the other clients and is pacing continually in the hallway. Which comments by the nurse would be therapeutic at this time? -------- Correct Answer -------- "What is causing you to become agitated?" The nurse is caring for a client who has bipolar disorder with aggressive social behavior. Which activity would be most appropriate initially for this client? -------- Correct Answer -------- Writing The nurse is assessing a client who has been diagnosed with Alzheimer's disease. The nurse knows that in the initial stages the client and family try to hide deficits in memory. Which are some of the defense mechanisms related to the progression of the disease? Select all that apply. -------- Correct Answer -------- Denial Confabulation Perseveration Avoidance of questions The police arrive at the emergency department with a client who has seriously lacerated both wrists. Which is the initial nursing action? -------- Correct Answer -------- Examine and treat the wound sites.

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6 / 4 The nurse is caring for a client who verbalizes a need to increase her self-esteem. Which action should the nurse plan to assist the client in achieving the goal of gaining self-esteem? -------- Correct Answer -------- Maintain a well-groomed appearance. When caring for a client who has been raped, which intervention should the nurse implement during the examination? -------- Correct Answer -------- Explaining procedures to be completed and why the procedures are necessary An adolescent is returning home after an acute psychiatric hospitalization following a suicide attempt. Which action would be least helpful in preparing the client to return to a safe and effective care environment? -------- Correct Answer -------- Suggest that the mother's boyfriend move out of the home. The nurse is collecting data from a newly admitted client recently diagnosed with borderline personality disorder. Which data provided by the client best supports the nurse's concern that the client is not using effective coping skills? -------- Correct Answer -------- Driving under the influence (DUI) conviction resulted in a 1-year suspended license The nurse is assisting in conducting a group therapy session and a client with a manic disorder is monopolizing the group. The appropriate nursing action is which? -------- Correct Answer -------- Suggest that the client stop talking and try listening to others. A client who has just received a diagnosis of asthma says to the nurse, "This condition is just another nail in my coffin." Which response by the nurse is therapeutic? -------- Correct Answer -------- "You seem very distressed over learning you have asthma." A client experiencing a severe major depressive episode is unable to address activities of daily living. Which is the appropriate nursing intervention? -------- Correct Answer -------- Feed, bathe, and dress the client as needed until the client can perform these activities independently. A client experiencing delusions of being poisoned is admitted to the hospital after not eating or drinking for several days. On data collection, the nurse notes no evidence of dehydration and malnutrition at this time. The nurse should immediately plan to address which client need? -------- Correct Answer -------- Safety and security A client with a diagnosis of a recurrent major depression, exhibiting psychotic features, is admitted to the mental health unit. In an attempt to create a safe environment for the client, the nurse designs a plan of care that deals specifically with which aspect of the client's disorder? -------- Correct Answer -------- Altered thought processes The nurse is admitting a client who has a history of bipolar disorder to the hospital, and the primary health care provider has indicated that the client is currently in the manic phase. Which actions should the nurse include in the plan of care? Select all that apply. -------- Correct Answer -------- Set limits on behavior. Distract or redirect the client. Decrease environmental stimulation. Provide high caloric nutritional intake. The nurse receives a telephone call from a male client who states that he wants to kill himself and has a bottle of sleeping pills in front of him. Which would be the best response by the nurse? -------- Correct Answer -------- Keep the client talking and signal to another staff member to send help to the client.

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7 / 4 During a conversation with a depressed client on a psychiatric unit, the client says to the nurse, "My family would be better off without me." The nurse should make which therapeutic response to the client? -------- Correct Answer -------- "You sound very upset. Are you thinking of hurting yourself?" The registered nurse has written an outcome statement of, "Client will feel less anxious by the end of session," for a client with generalized anxiety disorder. Which interventions should the licensed practical nurse use to assist this client in meeting this goal? Select all that apply. -------- Correct Answer -------- Stay with the client. Administer anxiolytics medications if prescribed. Ensure the client is in an environment with little stimuli. A client is scheduled to have electroconvulsive therapy (ECT). Which problem should the nurse include in the plan as a priority? -------- Correct Answer -------- Risk for aspiration The nurse is caring for a client who was recently admitted to the inpatient unit of a psychiatric hospital with a diagnosis of delusions. Which are some therapeutic communication interventions the nurse needs to use when communicating with this client? Select all that apply. -------- Correct Answer -------- Refer to hallucinations as if they are real. Ask the client directly about the hallucinations. Watch the client for cues that he or she is hallucinating, such as eyes tracking an unheard speaker, muttering, or talking to self. Address any underlying emotion, need, or theme that seems to be indicated by the hallucination, such as fear with menacing voices or guilt with accusing voices. The nurse caring for a client who has been diagnosed with stage 3 Alzheimer's disease should expect to observe which behaviors in this client? Select all that apply. -------- Correct Answer -------- Misplacing a valuable object Difficulty coming up with the right word A client diagnosed with schizophrenia is experiencing an acute dystonic reaction. Which interventions should the licensed practical nurse (LPN) initiate? Select all that apply. -------- Correct Answer -------- Monitor airway. Notify the registered nurse (RN). Remain with the client to provide support. Administer a prescribed intramuscular (IM) antiparkinsonian medication. The mother of 6-year-old twins says to the nurse, "My mother-in-law doesn't think our children should come to the funeral service for their grandfather. What do you advise?" Which response made by the nurse would be most appropriate? -------- Correct Answer -------- "What do you and your husband believe is the right thing for your children?"

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8 / 4 The wife of a client who abuses alcohol tells the nurse she cannot "do it alone" any longer and asks the nurse about the availability of any free support services for "people like me." The nurse refers the client's wife to which community group? -------- Correct Answer -------- Al-Anon After 5 days in the psychiatric unit, a manic client is able to tolerate short periods in the dayroom. The nurse overhears the client telling another client that he is a journalist posing as a client in order to write an article for a magazine. Which response is the nurse's best action? -------- Correct Answer -------- Privately confront the client with reality. The student nurse is learning about leadership and management. The student knows that which are the main styles of group leadership? Select all that apply. -------- Correct Answer -------- Autocratic leader Democratic leader Laissez-faire leader An unlicensed assistive personnel (UAP) is assigned to work with the nurse to care for a client who is at risk for suicide. Which statement made by the UAP indicates to the nurse that the UAP understands suicide? -------- Correct Answer -------- "Discussing suicide with a client is not harmful." The day nurses in a psychiatric unit are receiving report from the night shift. During report, a client approaches the nurses' station, becomes very loud and angry, and demands to be seen by the primary health care provider immediately. Which nursing intervention is appropriate? -------- Correct Answer -------- Offer to assist the client to an examination room until the primary health care provider is notified. A client hospitalized with a paranoid disorder refuses to turn off the lights in the room at night and states, "My roommate will steal me blind." Which is an appropriate response by the nurse? -------- Correct Answer -------- "I hear what you are saying, but I don't share your belief." A client with depression reports to the nurse that she has not been sleeping or eating adequately. The nurse should plan to do which to assist the client in meeting nutritional needs? -------- Correct Answer -------- Provide small, frequent meals. A client who has successfully adjusted to a colostomy declines the invitation to speak to a support group on the subject of alteration in body image. The client reports an extreme fear of public speaking. The nurse recognizes that this client is suffering from social phobia. Which are some other manifestations of social phobias? Select all that apply. -------- Correct Answer -------- Performing badly on stage Looking awkward while eating or drinking in public Not being able to answer questions in a classroom Fear of saying something that sounds foolish in public The nurse is reading about the four different levels of anxiety. Which different categories distinguish and describe each level? Select all that apply. -------- Correct Answer -------- Effects on problem solving Effects on perceptual field Physical and other defining characteristics

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9 / 4 The nurse is monitoring a client with a diagnosis of depression. Which behavior observed by the nurse indicates that suicide precautions should be instituted for this client? -------- Correct Answer -------- The client asks to meet with a lawyer to take care of unfinished business. The nurse is monitoring a client with a history of opioid abuse for signs/symptoms of withdrawal. The nurse monitors this client for which signs/symptoms associated with opioid withdrawal? -------- Correct Answer -------- Depression, high drug craving, fatigue with altered sleep (insomnia or hypersomnia), agitation, and paranoia Following a group therapy session, a client approaches the nurse and verbalizes a need for seclusion because of uncontrollable feelings. The nurse reports the findings to the registered nurse (RN) and expects that the RN will take which action? -------- Correct Answer -------- Get a written prescription from the primary health care provider (PHCP) and obtain an informed consent. The nurse is caring for a client with seasonal affective disorder (SAD). Which type of therapy is considered a first-line treatment for this disorder? -------- Correct Answer -------- light therapy A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I have to go. I don't want any more treatment. I have things that I have to do right away." The client has not been discharged. In fact, the client is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. Which is the appropriate nursing action? -------- Correct Answer -------- Call the nursing supervisor. The nurse is caring for a client diagnosed with somatic symptom disorder who continuously complains of a severe headache. Which interventions are most appropriate when planning care for this client? -------- Correct Answer -------- Shift the focus from the client's somatic concerns to feelings and coping skills. The licensed practical nurse is assisting the registered nurse in admitting a client with an exacerbation of schizophrenia and knows that which signs/symptoms displayed by the client are considered positive symptoms? Select all that apply. -------- Correct Answer -------- Hallucinations Delusions Neologisms The nurse is caring for a client who has been treated with long-term antipsychotic medication. The nurse plans to monitor for tardive dyskinesia. Which signs should the nurse observe with tardive dyskinesia? -------- Correct Answer -------- Abnormal movements and involuntary movements of the mouth, tongue, and face The nurse is having a therapeutic discussion with a client and knows that which statements by the client should be immediately reported to the charge nurse? Select all that apply. -------- Correct Answer -------- "I hid my silverware from dinner last night." "I know that by this time tomorrow all my troubles will be over." A client in a manic state emerges from her room. The client is dressed in a low-cut blouse and a miniskirt. She is not wearing underwear and she proceeds to sit on a male client's lap and begins to make sexual remarks and gestures to the male client. The nurse should take which action? -------- Correct Answer -------- Approach the client quietly, take her to her room, and assist her in getting dressed.

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10 / 4 The nurse is reviewing the record of a client admitted to the mental health unit and notes that the client was admitted by voluntary status. The nurse makes which determination? -------- Correct Answer -------- The client has the right to demand and obtain release from the hospital. The nurse notes that a client with acquired immunodeficiency syndrome (AIDS) appears anxious and is reluctant to ask questions. Which action should the nurse take to best address these observations? -------- Correct Answer -------- Discuss common fears and questions expressed by other clients with the same diagnosis. The nurse is caring for a client with schizophrenia who states, "I decided not to take my medication because I realize that it really can't help me. Only I can help me." Which nursing response would be therapeutic? -------- Correct Answer -------- "Do you recall needing to be hospitalized because you stopped your medication?" The nurse is assessing a client who takes antipsychotic medication for which signs/symptoms that might indicate the development of neuroleptic malignant syndrome? Select all that apply. -------- Correct Answer -------- Diaphoretic Temperature of 104.8° F Blood pressure of 210/130 mm Hg The nurse collecting data from a 35-year-old client determines that the client has gained more than 100 pounds in an 18-month period. The client confided in the nurse that she was sexually molested at the age of 7 and began putting on weight after that time. The client presently weighs 422 pounds. The nurse determines that obesity for this client most likely represents which reason? -------- Correct Answer -------- Protection from the risk of intimacy The nurse reviews the treatment prescribed for a client with a mental health disorder. The nurse understands that a form of psychotherapy in which the client enacts situations that are of emotional significance is identified by which term? -------- Correct Answer -------- Psychodrama The student nurse is studying the cellular composition of the brain composed of approximately 100 billion neurons or nerve cells. Although neurons come in a great variety of shapes and sizes, all carry out the same three types of physiological actions. Which are these types of actions? Select all that apply. -------- Correct Answer -------- Respond to stimuli Conduct electrical impulses Release chemicals called neurotransmitters The nurse is assigned to care for a client admitted to the hospital after sustaining an injury from a house fire. The client attempted to save a neighbor involved in the fire, but despite the client's efforts, the neighbor died. Which action should the nurse take to enable the client to work through the meaning of the crisis? -------- Correct Answer -------- Inquiring about the client's feelings that may affect coping Which client is most likely at risk to become a victim of elder abuse? -------- Correct Answer -------- A 90-year-old woman with advanced Alzheimer's disease A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a two-bed hospital room. A newly admitted client will be assigned to this client's room. Which client should be an appropriate choice as this client's roommate? -------- Correct Answer -------- A client receiving diagnostic tests

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11 / 4 A client who excessively uses alcohol and who is motivated to stop tells the nurse, "I know that there is a medication that can help people like me quit drinking." Which medication should the nurse explain is available for this purpose? -------- Correct Answer -------- Disulfiram The nurse is working with a victim of rape in a clinic setting and assists in developing a plan of care for the client. Which is an inappropriate short-term initial goal? -------- Correct Answer -------- The client will resolve feelings of fear and anxiety related to the rape trauma. The spouse of a client admitted to the hospital for alcohol withdrawal says to the nurse, "I should get out of this bad situation." The most helpful response by the nurse should be which statement? -------- Correct Answer -------

• "What do you find difficult about this situation?" A client is admitted to the psychiatric unit following a serious suicide attempt by a drug overdose. Which action should the nurse implement? -------- Correct Answer -------- Remain with the client at all times. The nurse is assisting in a group therapy session. Besides cost savings, which advantages does group therapy have over individual therapy? Select all that apply. -------- Correct Answer -------- Mutual learning Increased feedback Instilling a sense of belonging An opportunity to practice new skills in a relatively safe environment Which nursing approach is important when administering an antianxiety agent to a client with acute, severe anxiety? -------- Correct Answer -------- Stay with the client until the medication becomes effective. The nurse is assisting in preparing a plan of care for a client with an autistic disorder. A behavior modification approach (operant conditioning) is being used to care for the client to improve communication. Which action would be appropriate for the nurse to suggest including in the plan of care? -------- Correct Answer -------- Reward the client when a desired behavior is performed. The nurse is caring for a client with a somatic disorder and knows that which interventions would be most helpful to this client? Select all that apply. -------- Correct Answer -------- Reinforce the client's problem-solving abilities. Assess "secondary gains" that the somatic illness provides the client. A 2-year-old child is a suspected victim of child abuse. The nurse is interviewing the child's parent. Which statement made by the parent indicates a characteristic associated with child abuse? -------- Correct Answer ----- --- "When I tell my child to do something once, I don't expect to have to repeat it." The nurse has been caring for a client with a diagnosis of depression. The client says to the nurse, "I wish you would just be my friend." The appropriate response by the nurse is which? -------- Correct Answer -------- "Our relationship is a therapeutic and a helping one." The nurse is caring for a client who has a history of opioid abuse and is monitoring the client for signs of withdrawal. Which observation is indicative of the signs/symptoms associated with withdrawal from opioids? ----- --- Correct Answer -------- Fever, yawning, irritability, diaphoresis, and diarrhea

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12 / 4 The student nurse is being taught by the registered nurse (RN) how to collect data from a client and is attempting to obtain subjective data regarding the client's sexual reproductive status. The client states, "I don't want to discuss this; it's private and personal." Which response by the student nurse indicates a need for further teaching? -------- Correct Answer -------- "I am the nurse and, as such, I'll have you know that all information is kept confidential." The nurse employed in a psychiatric unit receives a client assignment for the day. Which client assigned to the nurse is at the highest risk for committing suicide? -------- Correct Answer -------- A client with severe depression and terminal cancer The nurse is working with a client who is delusional. The client says to the nurse, "The leaders of a religious cult are being sent to assassinate me." Which is the best response by the nurse? -------- Correct Answer -------- "I don't know about a religious cult. Are you afraid that people are trying to hurt you?" A woman whose husband died 2 months ago says to the visiting nurse, "My daughter came over yesterday to help me move my husband's things out of our bedroom, and I was so angry with her for moving his slippers from where he always kept them under his side of our bed. She doesn't know how much I'm hurting." Which statement by the nurse would be therapeutic? -------- Correct Answer -------- "It's okay to grieve and be angry with your daughter and anyone else for a time." The nurse is assigned to care for a client at risk for alcohol withdrawal. The client's spouse asks the nurse, "When will the first signs of withdrawal appear?" The nurse should give which reply? -------- Correct Answer ------ -- "Within a few hours" The nurse is assessing a client diagnosed with posttraumatic stress disorder (PTSD). The nurse knows that according to current references, PTSD signs/symptoms can be grouped into which three main categories? Select all that apply. -------- Correct Answer -------- Avoidance Hyperarousal Reexperiencing A client admitted with depression 3 days ago could hardly get out of bed without coaxing and needed constant encouragement to get dressed and participate in unit activities. Today the client appears in the dayroom dressed and well groomed, without any guidance from the staff. The client appears to be calm and relaxed, yet more energetic than before. The nurse should take which initial action after noting this client's behavior? -------- Correct Answer -------- Speak to the client personally about the nurse's observations and ask if the client is thinking about suicide. The nurse is assessing a newly admitted client recently diagnosed with depression. Which data best supports that the client is at risk for self-harm? -------- Correct Answer -------- Reported hopelessness The nurse is preparing a client for the termination phase of the nurse-client relationship. Which task should the nurse appropriately plan for during this phase? -------- Correct Answer -------- Assist with making appropriate referrals. A 15-year-old client who is pregnant and unwed, says, "My life was unbearable before I met Johnny. My mother beats me up every day and my dad has been sleeping with me since I was 10 years old!" Which response is appropriate for the nurse to make? -------- Correct Answer -------- "It seems that you needed help to separate from your family. Do you feel you are ready to have a baby with Johnny?"

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13 / 4 Milieu therapy is prescribed for a client on the psychiatric unit. The nurse knows that besides overcrowding on the unit, milieu characteristics conducive to violence include which factors? Select all that apply. -------- Correct Answer -------- Poor limit setting Staff inexperience Provocative or controlling staff Arbitrary revocation of privileges The nurse is monitoring the behavior of the client and understands that the client with anorexia nervosa manages anxiety by which action? -------- Correct Answer -------- Observing rigid rules and regulations An adolescent client is admitted to the inpatient unit after medical stabilization for an overdose of acetaminophen. The history identifies that her boyfriend broke up with her 2 weeks ago and that she hasn't been eating well, resulting in a loss of 15 pounds. The nurse assists in developing a plan of care that includes which interventions? Select all that apply. -------- Correct Answer -------- Making nutritious snacks available anytime Providing meals on an isolation tray that contains plastic utensils Ensuring that her diet consists of bland, easy-to-digest foods and beverages The nurse is caring for a client with a diagnosis of depression. The nurse monitors for signs of constipation and urinary retention, knowing that these problems are likely caused by which situation? -------- Correct Answer ------ -- Psychomotor retardation and side effects of medication The nurse has been closely observing a client who has been displaying aggressive behaviors. The nurse observes that the behavior displayed by the client is escalating. Which nursing intervention is least likely to be helpful to this client at this time? -------- Correct Answer -------- Initiate confinement measures. A woman is brought to the emergency department in a severe state of anxiety after witnessing a devastating car accident that killed two people. Which nursing action should the nurse do first? -------- Correct Answer -------- Take the client to a quiet room. The nurse is assisting with planning the care of a client being admitted to the nursing unit who has attempted suicide. Which priority nursing intervention should the nurse include in the plan of care? -------- Correct Answer - ------- One-to-one suicide precautions The nurse is caring for a client who has been diagnosed with a dissociative disorder. Which interventions should the nurse use in providing care for the client? Select all that apply. -------- Correct Answer -------- Request that the client perform undemanding, self-care tasks.

Reinforce teaching the client techniques to maintain present reality.

Assist the client to reestablish relationships with significant others.

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14 / 4 A client with depression who has attempted suicide says to the nurse, "I should have died. I've always been a failure. Nothing ever goes right for me." The nurse should make which therapeutic response to the client? -------- Correct Answer -------- "You've been feeling like a failure for a while?" A client with a diagnosis of major depression becomes more anxious, reports sleeping poorly, and seems to display increased anger. The nurse should make which interpretation about the client's behavior? -------- Correct Answer -------- The client is at increased risk for suicide. A client is admitted to the psychiatric unit with a diagnosis of bipolar affective disorder and mania. The nurse identifies which signs/symptoms or behaviors as requiring immediate intervention? -------- Correct Answer -------- Constant physical activity and poor oral intake An adolescent who has been reported for drawing sexually explicit scenes in her school textbooks says to the psychiatric nurse, "I just felt like it." Which response is therapeutic for the nurse to make in order to assess abuse-related symptoms? -------- Correct Answer -------- "I am concerned about you. Are you now or have you ever been abused? The nurse is reviewing the record of a client who is hospitalized for treatment of a panic disorder. The nurse notes that the client was admitted by voluntary hospitalization. During the day, the client runs down the hallway and demands release from the hospital. The nurse notes that the client is exhibiting signs/symptoms of anxiety and attempts to assist the client back to the client's hospital room. Which is the nextappropriate nursing action at this time? -------- Correct Answer -------- Notify the registered nurse (RN). The nurse is caring for a client who says, "I don't want you to touch me. I'll take care of myself!" The nurse should make which therapeutic response to the client? -------- Correct Answer -------- "Sounds like you're feeling pretty troubled by all of us. Let's work together so you can do everything for yourself as you request." A client in a manic state emerges from her room. She is topless and is making sexual remarks and gestures toward staff and peers. Which is an appropriate nursing action? -------- Correct Answer -------- Quietly approach the client, escort her to her room, and assist her in getting dressed. The nurse is caring for a client who is suspected of being dependent on drugs. Which question should be appropriate for the nurse to ask when collecting data from the client regarding drug abuse? -------- Correct Answer -------- "How much do you use and what effect does it have on you?" The nurse is collecting data on a client with the diagnosis of anorexia nervosa. Which findings are indicative of anorexia nervosa? Select all that apply. -------- Correct Answer -------- A high achiever Personality changes Lanugo over the back and extremities A client was admitted to a medical unit with acute blindness. Many tests are performed, and there seems to be no organic reason why this client cannot see. The nurse later learns that the client became blind after witnessing a hit-and-run car crash in which a family of three was killed. The nurse suspects that the client may be experiencing which diagnosis? -------- Correct Answer -------- Conversion disorder The nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which nursing action is the priority? -------- Correct Answer -------- Removing the client from any immediate danger

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15 / 4 A client admitted with depression states to the nurse, "My life has been such a failure; nothing I do turns out right." Which response by the nurse would be therapeutic? -------- Correct Answer -------- "You seem very discouraged. Can you think of anything recently that went as you planned?" The nurse is planning care for a client who is being hospitalized because the client has been displaying violent behavior and is at risk for potential harm to others. The nurse should avoid which intervention in the plan of care? -------- Correct Answer -------- Assigning the client to a room at the end of the hall to prevent disturbing the other clients A client is admitted to the mental health unit with a diagnosis of possible somatic symptom disorder. Besides anxiety, the nursing assessment is especially important in identifying which client signs/symptoms are contributing to the somatic symptom disorder? Select all that apply. -------- Correct Answer -------- Depression Substance abuse Adverse childhood events Posttraumatic stress disorder (PTSD) The nurse is assigned to a client who is psychotic. The client is pacing, agitated, and using aggressive gestures and rapid speech. The nurse determines which action is the immediate priority of care? -------- Correct Answer -- ------ Provide safety for both the client and other clients on the unit. The nurse assists in making a plan of care for a client and is developing goals that will help the client achieve an optimal level of functioning and use resources. When the nurse enters the client's room, the client says to the nurse, "Could you ask my psychiatrist to let me have a pass for the weekend?" Which nursing response is appropriate to assist the client in achieving the goal that has been set for this client? -------- Correct Answer ------ -- "When the psychiatrist arrives on the unit, I will let her know that you have a question." A client on the mental health unit is exhibiting distancing and does not speak to his/her family or visitors. Which are some other adverse relationship patterns? Select all that apply. -------- Correct Answer -------- Cutoffs Conflict Over involvement The nurse is assigned to care for a client being admitted to the nursing unit from the emergency department who attempted suicide by ingesting several sleeping pills. The nurse implements which priority action when the client arrives to the unit? -------- Correct Answer -------- Place the client on one-to-one suicide precautions. A client is diagnosed with catatonic stupor. The client is lying on the bed, hidden under the sheets, with her body pulled into a fetal position. The nurse should take which appropriate action? -------- Correct Answer -------- Sit beside the client in silence with occasional open-ended questions. The nurse is caring for a client with depression in the mental health unit who is refusing to take the prescribed oral antidepressant. Which are the nurse's best actions in response to this client's medication refusal? Select all that apply. -------- Correct Answer -------- Document the refusal of medication.

Notify the registered nurse.

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16 / 4

Ask the client why he is refusing the medication. The nurse is assigned to care for a client who is agitated. On entering the room, the client screams, "Why don't you just leave me alone?" The nurse should make which therapeutic response to the client? -------- Correct Answer -------- "I can see that you are upset. I'll be back in a few minutes to see how you are doing." A depressed client verbalizes feelings of low self-esteem and self-worth typified by statements such as "I'm such a failure. I can't do anything right!" Which action should the nurse take? -------- Correct Answer -------- Identify recent behaviors or accomplishments that demonstrate skill or ability. The nurse notices a "paranoid stare" during a conversation with the client diagnosed with posttraumatic stress disorder (PTSD). The client then begins to fidget and gets up to pace around the room. Which action by the nurse would be most beneficial? -------- Correct Answer -------- Share the observation with the client and help the client recognize his or her feelings. A client who has been drinking alcohol on a regular basis admits to having "a problem" and is asking for assistance with the problem. The nurse should encourage the client to attend which community group? -------- Correct Answer -------- Alcoholics Anonymous The nurse is having a conversation with a depressed client in an inpatient psychiatric unit. The client says to the nurse, "Things would be so much better for everyone if I just wasn't around." Which response by the nurse would be appropriate at this time? -------- Correct Answer -------- "You sound very unhappy. Are you thinking of harming yourself?" The nurse is collecting data on a client diagnosed with mild depression. The client says to the nurse, "I haven't had an appetite at all for the last few weeks." Which response by the nurse would be therapeutic? -------- Correct Answer -------- "You haven't had an appetite at all?" The nurse reviews the activity schedule for the day and determines that which supervised activity is the best option for the manic client? -------- Correct Answer -------- Ping-pong A client states to the nurse, "I haven't slept at all the last couple of nights." The nurse should make which therapeutic response to the client? -------- Correct Answer -------- "Tell me about your difficulty sleeping." An oriented client is scheduled to have aversion therapy to change behavior. Before initiating any aversive protocol, the therapist, treatment team, or society must answer which questions? Select all that apply. -------- Correct Answer -------- Is it in the best interest of society? Does its use violate the client's rights? Is this therapy in the best interest of the client? A client with moderate depression who was admitted to the mental health unit 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally cured." The nurse interprets this behavior as a cue to modify the treatment plan by taking which action? -------- Correct Answer -------- Increasing the level of suicide precautions The nurse is caring for a female client who was recently admitted to the hospital for anorexia nervosa. The nurse enters the client's room and notes that the client is doing vigorous push-ups. Which nursing action is appropriate? -------- Correct Answer -------- Interrupt the client and offer to take her for a walk.

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17 / 4 A client is admitted to the psychiatric unit after a serious suicidal attempt by hanging. What is the nurse's most important intervention to maintain client safety? -------- Correct Answer -------- Assign a staff member to the client who will remain with him or her at all times. The nurse is caring for an older depressed client whose son was killed in an armed robbery after murdering two people. The client says, "I don't know what I did wrong. His dad died a hero in Vietnam when he was only 2 years old, but he's had everything. When he threw the cat up against the wall to see if it landed on its feet and stole money from me and denied it, his sister covered for him." The nurse plans to make which therapeutic response to the client? -------- Correct Answer -------- "It seems as if you or your daughter feel regret?" The nurse is collecting data on a newly admitted client with conversion disorder. The nurse knows which voluntary motor or sensory function deficits might be present in this client? Select all that apply. -------- Correct Answer -------- Paralysis Blindness Paresthesia Movement disorder A client with a phobia will be treated for the condition using a behavior modification technique known as systematic desensitization. The nurse describes the components of this form of therapy to the client and reinforces which client instruction? -------- Correct Answer -------- The client will be introduced to short periods of exposure to the phobic object while in a relaxed state. The nurse is preparing a client for the termination phase of the nurse-client relationship. Which task should the nurse appropriately plan for during this phase? -------- Correct Answer -------- Assist with making appropriate referrals. The nurse enters a client's room, and the client immediately demands to be released from the hospital. During review of the client's record, the nurse notes that the client was admitted 2 days ago for the treatment of an anxiety disorder and that the admission was a voluntary one. The nurse reports the findings to the registered nurse (RN) and expects that the RN will take which action? -------- Correct Answer -------- Contact the primary health care provider (PHCP). The nurse is gathering data from a client diagnosed with a phobia. Which are some of the clinically recognized names of common phobias? Select all that apply. -------- Correct Answer -------- Zoophobia Xenophobia Agoraphobia Glossophobia A client says to the home care nurse, "I can't believe that my wife died yesterday. I keep expecting to see her everywhere I go in this house ready to plan our activities for the day." Which is the therapeutic nursing response? -------- Correct Answer -------- "It must be hard to accept that she has passed away."

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18 / 4 An older client is a victim of elder abuse, and the client's family has been attending weekly counseling sessions. Which statement by the abusive family member indicates that he or she has learned positive coping skills? ------ -- Correct Answer -------- "I feel better able to care for my father now that I know where to obtain assistance." Which behaviors observed by the nurse might lead to the suspicion that a depressed adolescent client could be suicidal? -------- Correct Answer -------- The client gives away a DVD and a cherished autographed picture of the performer. A client is admitted to a psychiatric unit for observation following severe anxiety attacks. On admission, the client states, "There's nothing wrong with me. I shouldn't even be here. I am taking up a room, and there is probably someone else who really needs it." Although the nurse interprets this response as denial, which findings support a severe level of anxiety? Select all that apply. -------- Correct Answer -------- Inability to think clearly

Inability to problem solve A client is found to have rape-trauma syndrome. The nurse plans care for the client, knowing that rape-trauma syndrome is a condition that involves which? -------- Correct Answer -------- Reexperiencing recollections of the trauma A hospitalized client who recently experienced the loss of a spouse is grieving. The client progresses well and is approaching discharge. Which is an appropriate outcome for this client? -------- Correct Answer -------- The client verbalizes stages of grief and plans to attend a community grief group. The nurse is caring for a client with an eating disorder and knows that which signs/symptoms indicate that the client is dealing with anorexia nervosa? Select all that apply. -------- Correct Answer -------- Lanugo

Amenorrhea The nurse is caring for a client who has a history of opioid abuse and is monitoring the client for signs of withdrawal. Which manifestations are specifically associated with withdrawal from opioids? -------- Correct Answer -------- Age less than 32 years

Practicing a religion

Married over 10 years The nurse is educating a community group about risk factors for suicide and knows a member needs further teaching when which criteria are chosen as risk factors? Select all that apply. -------- Correct Answer -------- Age less than 32 years 4.Practicing a religion 5.Married over 10 years The nurse is working with an older client who has a diagnosis of depression. To work most effectively with this client, the nurse recalls that which information is accurate regarding depression and the older client? Select all that apply. -------- Correct Answer -------- Suicide is a frequent cause of death among the older population.

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19 / 4 Some indications of dementia may actually originate as depression.

Depression in an older person is likely to have physical manifestations. During the termination phase of the nurse-client relationship, the clinic nurse observes that the client continuously demonstrates bursts of anger. Which interpretation should the nurse make of this behavior? -------- Correct Answer -------- The client is displaying typical behaviors that can occur during termination. A client who was recently paroled as a sex offender is in therapy for pedophilia. The client says, "I've served my sentence and I'm still in therapy, so why does this group have posters of me all over the neighborhood? It has my picture on it and tells all about me." Which would be a therapeutic response by the nurse? -------- Correct Answer -------- "Are you saying that you understand people are afraid for their children but that you feel you are being unfairly treated?" The nurse is caring for a client who is diagnosed with anxiety. The nurse knows that according to Hildegard Peplau, there are different levels of anxiety that include which? Select all that apply. -------- Correct Answer ------ -- Mild Panic Severe Moderate The nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group when the nurse hears the wife make which statement? -------- Correct Answer -------- "I no longer feel that I deserve the beatings my husband inflicts on me." The nurse in the emergency department is assisting in caring for a young female victim of sexual assault. The client's physical assessment is complete, and physical evidence has been collected. The nurse notes that the client is withdrawn, confused, and at times physically immobile. Which interpretation should the nurse make of these behaviors? -------- Correct Answer -------- They are expected reactions to a devastating event. The nurse is assessing a client with bipolar disorder who is taking lithium carbonate and who has a lithium level of 1.7 mEq/L. The nurse would expect to find which sign/symptoms of lithium toxicity associated with this level? Select all that apply. -------- Correct Answer -------- Incoordination Mental confusion Muscle hyperirritability A client has been brought to the emergency department after attempting to commit suicide by hanging. The nurse should take which nursing action first? -------- Correct Answer -------- Examine the neck area and assess the airway. The nurse working the evening shift is assisting clients in getting ready to go to sleep. A client diagnosed with obsessive-compulsive disorder (OCD) becomes upset and agitated and asks the nurse to sit down and talk. Which response by the nurse would be best at this time? -------- Correct Answer -------- "I can see that you're upset. I'm willing to listen."

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20 / 4 The nurse is assisting with the data collection on a client admitted to the psychiatric unit. After review of the obtained data, the nurse should identify which as a priority concern? -------- Correct Answer -------- The client's report of self-destructive thoughts While the nurse is providing care, a client angrily reports to the nurse that the primary health care provider purposefully provided wrong information about her diagnosis and states, "The doctor lied to me." Which nursing response would likely be a barrier to further communication with the client? -------- Correct Answer -------- "The primary health care provider would never lie to you." A female victim of a 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. Which nursing response is appropriate? -------- Correct Answer -------- "Tell me more about what causes you to feel like the rape just occurred." The nurse on the mental health unit is collecting data on a client diagnosed with obsessive-compulsive disorder (OCD). The nurse expects to note which behavioral characteristics of OCD? Select all that apply. -------- Correct Answer -------- Rigidity Inflexibility Repetitive thoughts Ritualistic behavior During data collection, which behavior should the nurse expect a client diagnosed with agoraphobia to describe? -------- Correct Answer -------- A fear of leaving the house A client who is suicidal tells the nurse, "All I want to do is end it all." Which is the appropriate nursing response? -------- Correct Answer -------- "What do you mean by that?" A female client with anorexia nervosa is a member of a support group. The client has verbalized that she would like to buy some new clothes, but her finances are limited. Group members have brought some used clothes for the client to replace her old clothes. The client believes that the new clothes were much too tight, so she has reduced her calorie intake to 800 calories daily. The nurse identifies this behavior as which finding? -------- Correct Answer -------- Evidence of the client's altered and distorted body image The nurse having strong negative feelings toward a fellow employee tends to use the defense mechanism of projection. This nurse is likely to react to a disagreement with this fellow employee by which action? -------- Correct Answer -------- Telling a friend that this employee hates her The nurse is preparing for the hospital discharge of a client with a history of command hallucinations to harm self or others. The nurse instructs the client about interventions for hallucinations and anxiety and determines that the client understands the interventions when the client makes which statement? -------- Correct Answer ---- ---- "I can call my therapist when I'm hallucinating so I can talk about my feelings and plans and not hurt anyone." The nurse is caring for a client with anorexia nervosa. The nurse planning care for the client recognizes that which manifestation is likely to be present? -------- Correct Answer -------- Amenorrhea A manic client announces to everyone in the dayroom that a stripper is coming to perform that evening. When the psychiatric nurse's aide firmly states that the client's behavior is not appropriate, the manic client becomes verbally abusive and threatens physical violence to the nurse's aide. Based on the analysis of this situation, the nurse determines that the appropriate action should be which intervention? -------- Correct Answer -------- Escort the manic client to his or her room.

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21 / 4 A client who was hospitalized for depression is being prepared by the nurse for discharge. In evaluating the coping strategies learned during hospitalization, the nurse should recognize which statement by the client is an indication that further teaching is needed? -------- Correct Answer -------- "I know that I won't become depressed again." The nurse is assessing a client with a diagnosis of bipolar affective disorder-mania. Which characteristics appropriately describe this client's diagnosis? Select all that apply. -------- Correct Answer -------- Outlandish behaviors Purposeless arousal and movement Grandiose delusions of being King Arthur Incessant talking that includes sexual innuendos Which nursing interventions are most helpful when caring for a client who is displaying signs/symptoms of panic level anxiety? Select all that apply. -------- Correct Answer -------- Speak slowly. Use simple statements. Provide the client with high-calorie beverages. A client who was admitted to the mental health unit 1 month ago with agoraphobia is cooperative, sharing with peers, and makes appropriate suggestions during group discussions. The nurse concludes that this client's behavior is most consistent with which behavior? -------- Correct Answer -------- Improvement A long-term care resident with a history of paranoid schizophrenia refuses to eat and tells the nurse that she believes that someone is poisoning the food. The nurse should make which therapeutic response to the client? - ------- Correct Answer -------- The nurse observes that a client is psychotic, pacing, and agitated and is making aggressive gestures. The client's speech pattern is rapid, and the client's effect is belligerent. Based on these observations, which is the nurse's immediate priority of care? -------- Correct Answer -------- A client with delirium becomes agitated and confused at night. The best initial intervention by the nurse is which action? -------- Correct Answer -------- The parents of a teenager diagnosed with anorexia nervosa ask the nurse what part they can play during the long recovery period. The nurse accurately relates that which actions should the parents take? -------- Correct Answer -------- A client with obsessive-compulsive disorder (OCD) who continually cleans the bathroom becomes enraged with the roommate for using the bar of bathing soap for cleaning the bathroom. The client begins to yell and slaps the roommate. Which action should the nurse take first? -------- Correct Answer -------- The nurse is providing care for a client admitted to the hospital with a diagnosis of anxiety disorder. The nurse is talking with the client, and the client says, "I have a secret that I want to tell you. You won't tell anyone about it, will you?" Which is the appropriate nursing response? -------- Correct Answer -------- The nurse is assessing a client diagnosed with severe anxiety. Which objective data should the nurse expect to find? Select all that apply. -------- Correct Answer -------- Oblivious to surroundings Unable to focus on anything Engaging in purposeless activity (walking around aimlessly)

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22 / 4 Showing unproductive relief behavior (stomping, wringing hands, dropping things) The nurse notes documentation in a client's record that the client is experiencing delusions of persecution. The nurse recognizes that these types of delusions are characteristic of which thoughts? -------- Correct Answer ------ -- The false belief that one is being singled out for harm by others A client says to the 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." Which therapeutic response should the nurse make to the client? -------- Correct Answer -------- "You're feeling angry that your family continues to hope for you to be 'cured'?" While providing one-to-one supervision, a client who attempted suicide tells the nurse, "I can never do anything right. I'm such a loser. It didn't even work when I tried to kill myself." Which is the appropriate nursing response? -------- Correct Answer -------- "You don't think you can ever do anything right?" A client with a potential for violence is exhibiting agitated behavior. The client is using aggressive gestures and making belligerent comments to the other clients and is pacing continually in the hallway. The nurse is considering seclusion and restraints for this client even though staffing is lacking for close supervision and direct observation. Which are some contraindications to seclusion and restraints without close supervision and observation? Select all that apply. -------- Correct Answer -------- Severe suicidal tendencies Extremely unstable medical and psychiatric conditions Desire for punishment of client or convenience of staff Delirium or dementia leading to inability to tolerate decreased stimulation Severe drug reactions or overdoses or need for close monitoring of drug dosages The psychiatric nurse is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, "How is Carol doing? She is my best friend and is seen at your clinic every week." Which is the appropriate nursing response? -------- Correct Answer -------- "I cannot discuss any client situation with you." The nurse reviews the plan of care for a suicidal client admitted to the hospital. The nurse notes documentation of the client's loss of a spouse, which occurred several years ago. The client progresses well and is approaching discharge. Which is an appropriate goal for this client's care? -------- Correct Answer -------- The client verbalizes stages of grief and plans to attend a community grief group. The nurse in the psychiatric unit is reviewing the records of the clients admitted to the nursing unit. A client with a history of violent behavior approaches the nurse and demands immediate discharge from the hospital. The nurse notes that the client was voluntarily admitted to the psychiatric unit. Which is the appropriate nursing action? -------- Correct Answer -------- Tell the client that the primary health care provider will be contacted regarding discharge. A client tells the nurse that he is feeling out of control. The nurse observes that the client is pacing back and forth. Which approach by the nurse is appropriate to maintain a safe environment? -------- Correct Answer -------- A confused and disoriented client is admitted to the psychiatric unit diagnosed with posttraumatic stress disorder (PTSD). The nurse initially plans to take which action with this client? -------- Correct Answer -------- Accept the client as a person and make the client feel safe.

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23 / 4 The nurse is gathering data from a client in crisis. When determining the client's perception of the precipitating event that led to the crisis, which is the most appropriate question to ask? -------- Correct Answer -------- The nurse in a psychiatric unit is assigned to care for a client admitted to the unit 2 days ago. During review of the client's record, the nurse notes that the admission was a voluntary one. Based on this type of admission, which would the nurse expect to note? -------- Correct Answer -------- The client will participate in the treatment plan. The nurse awakens a client on the inpatient psychiatric unit for breakfast. The client replies, "Do you realize it's Sunday? I've worked hard here all week and this is my day of rest. I'll get up at 11:30." Which would be the nurse's bestresponse? -------- Correct Answer -------- "Let me know if you change your mind, and I'll get you something to eat." The nurse is preparing a care plan for the client with obsessive-compulsive disorder (OCD). The nurse should focus on which as the primarymeans to accomplish work with this client? -------- Correct Answer -------- Goals and objectives A client is being seen at the primary care clinic for her annual gynecological examination. Which client statements are most likely associated with potential intimate partner abuse? Select all that apply. -------- Correct Answer -------- A client who attempted suicide by overdosing with a very large number of antidepressant pills has been admitted to the psychiatric unit. The nurse, being most concerned with the client's safety, should take which action? -------- Correct Answer -------- A client is being encouraged to attend music therapy as part of the individual plan of care. The client refuses to attend and states that he "cannot sing." Which response by the nurse is therapeutic? -------- Correct Answer -----

---

The nurse is monitoring a client who is in seclusion. Which statement would indicate that the client is safe to come out of seclusion? -------- Correct Answer -------- The nurse is caring for a client who received electroconvulsive therapy (ECT) for a major depressive disorder. On data collection, the nurse notes that the client's blood pressure is elevated at 160/100 mm Hg. Based on this finding, which nursing action would be appropriate? -------- Correct Answer -------- A client has reported that crying spells have been a major problem over the past several weeks and that the doctor said depression is probably the reason. The nurse observes that the client is sitting slumped in the chair, and the clothes that the client is wearing do not fit well. The nurse interprets that further data collection should focus on which assessment? -------- Correct Answer -------- During the termination phase of the nurse-client relationship, the clinic nurse observes that the client continuously demonstrates bursts of anger. Which interpretation should the nurse make of this behavior? -- ------ Correct Answer --------

3. The nurse is conducting a group therapy session. During the session, a

client diagnosed with mania consistently disrupts the group's interactions.

Which intervention should the nurse initially implement?

1.Setting limits on the client's behavior

2.Asking the client to leave the group session

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24 / 4

3. Asking another nurse to escort the client out of the group session 4.Telling

the client that they will not be able to attend any future group sessions: 1.Set-

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25 / 4

ting limits on the client's behavior

Manic clients may be talkative and can dominate group meetings or therapy sessions

by their excessive talking. If this occurs, the nurse initially would set limits on the

client's behavior. Initially, asking the client to leave the session or asking another

person to escort the client out of the session is inappropriate. This may agitate

the client and escalate the client's behavior further. Barring the client from group

sessions is also an inappropriate action because it violates the client's right to

receive treatment and is a threatening action.

4. The nurse is planning to formulate a psychotherapy group. Several clients

are interested in attending the session. The nurse plans the group, based on

which management principle?

1. Members should be of the same gender.

2. The group will decide the focus of the sessions.

3. The group should be limited to no more than 10 members.

4. The focus of the group will determine when the group will meet.: 3.The group

should be limited to no more than 10 members.

The ideal number of clients in a psychotherapy group ranges from 7 to 10. Having

more than 10 members is not recommended because the group will subdivide, which

is counterproductive. Too large a group also can create more opportunities for acting

out as opposed to working through issues. None of the other options is necessarily

true.

5. The client says to the nurse, "I wish you would just be my friend." Which is

the appropriate response by the nurse?

1. "I am your friend."

2. "Our relationship is a therapeutic and helping one."

3. "I can't be your friend. I'm the nurse, and you're the client."

4. "You have plenty of friends.You don't need me to be your friend, too.": 2."Our

relationship is a therapeutic and helping one."

Nurses may struggle with requests by clients to "be my friend." When this occurs,

the nurse should make it clear that the relationship is a therapeutic and helping one.

This does not mean that the nurse is not friendly toward the client at times. It does

mean, however, that the nurse follows the stated guidelines regarding a therapeutic

relationship. The remaining options are inappropriate, particularly in their failure to

define the relationship.

6. A client diagnosed with depression is scheduled to receive three sessions

of electroconvulsive therapy. The nurse should tell the client that he or she will