What situation would qualify for an involuntary mental health admission?
A. A client reports past suicidal attempts.
B. The client is unable to provide for basic needs.
C. The client is homeless and doesn’t feel safe.
D. The client refuses admission
Which statements(s) most clearly reflect the stigma of mental illness? (Select all that apply)
A. “many mental illnesses are hereditary.”
B. “Mental illness can be evidence of a brain disorder.”
C. “People claim mental illness so they can get disability checks”
D. “if people with mental illness went to church they would be fine”
E. “mental illness is a result of a breakdown of the American family”
While working with a client in crisis the nurse understand which of the following interventions would be a priority.
A. Identifying previous experiences and coping methods used.
B. Calling client’s support systems for additional support.
C. Decreasing the client’s anxiety.
D. Ensuring the client’s safety.
Which statement by the nurse demonstrates an understanding of nonverbal communication?
A. “It’s always easier to understand nonverbal communication
B. “If a client avoids others, I’m sure he is depressed.”
C. “Most communication is verbal, nonverbal.”
D. “It’s important to check for congruence in verbal and nonverbal responses.”
A nurse is caring for a client admitted to a mental health facility who asks. “Can I refuse the electroconvulsive therapy (ECT) treatment scheduled for tomorrow?” Which of the following responses by the nurse would be most appropriate?
A. “You have given signed consent for the treatments after they were explained to you.”
B. “You will feel better after the course of treatments.”
C. “You can refuse the but the provider believes they are necessary.”
D. “You have the right to refuse even though the consent form has been signed.”
A nurse is assessing a client who graduated from college with a 4.0-grade average. She is now obsessing about her incompetence in her new job. The nurse understands which therapy challenges the client to evaluate their thought process and how it relates to their feelings?
A. Interpersonal
B. Milleu
C. Cognitive-behavioral
D. Psychoanalytical
A client is threatening to harm other clients and his visitor. The visitor is removed from the unit. The nurse has instructed staff to stay with him and prescribed medication for agitation is prepared. He refuses both and tries to hit the nurse. What statement made by the nurse to other staff members is accurate?
A. “It is okay to defend yourself when you have been assaulted.”
B. “Medication can be given, but only after he agrees to take it.”
C. “We do not have to tolerate this behavior. I will call for the crisis prevention team.
D. “For safety, we can first restrain the client, and I will immediately get the order.”
Which statement regarding informed consent is correct?
A. Informed consent is mandated by federal but not start law.
B. Informed consent must reveal expected benefits.
C. Informed consent requires concealing any known risks.
D. Informed consent allows the Registered Nurse to discuss information needed to obtain consent.
Which tasks are included during the working phase of the nurse-client relationship? (Select all that apply.)
A. Provide education about the disorder.
B. Promote symptom management.
C. Identify goals and objectives.
D. Gather more data/information
E. Review person feeling before nurse-client interaction.
Which nursing intervention constitutes false imprisonment?
A. A client is confused and combative. The nurse restrains him then immediately seeks a physician’s order
B. A client has been seeking the attention of the nurses at the nurses’ station much of the day. The nurse escorts him to this room and tells him to stay there, or he will be put into seclusion.
C. A psychotic client admitted involuntary runs out of the psychiatric unit. The nurse follows him and succeeds in talking the client into returning to the unit.
D. A client hospitalized as an involuntary admission, attempts to leave the unit. The nurse call the security team and acting on established protocol; they prevent him from leaving.
Which nursing action demonstrates the ethical principle of autonomy?
A. Refusing to administer a placebo
B. Staying with a client is very anxious
C. Taking a course to increase knowledge regarding client rights.
D. Respecting the client’s decision not to have treatments.
12. What is the situation in which the Health Insurance Portability and Accountability Act (HIPPA) rule can be breached?
A. A duty to warn a client’s potential victim of harm.
B. Informing the client’s family when the client is threatening self-harm
C. Informing the spiritual counselor of the client’s desire for self-harm.
D. After the client harm others, this law does not apply.
13. A nurse is caring for a client who is having an adverse medication reaction. “The client states, The nurse told me not to drink when taking the medication, but she didn’t tell me having just one drink could cause a problem.” The nurse should negative the client is exhibiting which of the following defense mechanism?
A. Denial
B. Displacement
C. Rationalization
D. Reaction formation
14. A client asks the nurse. “What should I do about my wife’s drinking problem?” Which response by the nurse shows the use of reflecting?
A. “What do you think is the best thing to do?”
B. “You need more time to make a plan.”
C. “It seems like you need marriage counseling.”
D. “Why don’t you ask your doctor?”
The client tells the nurse. “You are the best nurse here you are the only nurse who listens and understands me.” The next day the client requests to be reassigned to a different nurse stating. “That nurse doesn’t understand how to care for people like me. That nurse is the worst nurse here.” The client is using which defense mechanism?
A. Splitting-maladaptive
B. Denial-adaptive
C. Rationalization-adaptive
D. Undoing-maladaptive
16. The nurse is preparing the client for electroconvulsive therapy (ECT) the following day. The teaching will include what information regarding side effects?
A. “You may have memory loss and disorientation immediately after the treatment.”
B. “Agitation and confusion are side effects of ECT.”
C. “Tachycardia and dyspnea often occur but you are constantly monitored.”
D. “There are no side effects that should concern you.”
17. The nurse demonstrates “active listening” by what action?
A. Paying close attention and remaining silent during the entire conversation.
B. Listening attentively and providing sympathetic response.
C. Concentrating on what the client says and responding.
D. Using interpretation as a communication technique.
18. A nurse is caring for a devout Catholic on the psychiatric unit. The client has been unable to attend mass and receive which nursing diagnosis would be most relevant to the situation?
A. Risk for impaired self-esteem
B. Risk for ineffective coping
C. Risk for spiritual distress
D. Risk for impaired family coping
The nurse is working with a client who is afraid of dogs and experienced a recent dog bite by the neighbor’s poodle. When the client is asked to join counseling therapy. The client states. “ I must finish my admission paperwork and get organized before I can think about counseling. “ The nurse understands the client is using which defense mechanism?
A. Suppression-maladaptive
B. Altruism-maladaptive
C. Reaction formation-adaptive
D. Displacement-adapt
20. A nurse is preparing to administer buspirone 15 mg PO every 12 hours. Available is buspirone 30 mg/tablet. How Many tablets will the nurse administer per dose? (Write the number only, do not include the label. Record the answer to the nearest tenth, or one decimal place. Use a leading zero if it applies. Do not use a trailing zero.) ___ tablet(s)
0.5
_________
21. which of the following nursing actions would be performed to ensure client safety? (Select all that apply)
A. Place the client in a private room.
B. Observe the client every 15 minutes
C. Explain the safety rules to the client
D. Search the client’s belonging for safety hazards
E. Allow all personal belongings on the unit with the client.
22. The nurse is asked to explain “informed consent” Which statement by the nurse is accurate?
A. “Its is the right of all voluntary clients to be explained the treatment process.”
B. “All clients have the right to understand the treatment process before consenting to treatment.”
C. “It is the process by which consent is obtained for a procedure to be carried out for an incompetent client.
D. It is solely the nurse’s responsibility to determine if the client is competent to sign the consent for treatment.”
Which of the following terms could be used to describe and document a client’s motor activity on a mental health assessment?
A. Tics
B. Restless
C. Flat
D. Echopraxia
E. Guilty
24. Which nursing behavior is consistent with therapeutic communication?
A. Offering opinions
B. Active listening
C. Begin speaking in periods of silence
D. Approving of behavior
25. The nurse informs the client that smoking is not permitted on the hospital campus and offers the client a nicotine patch. The client becomes frustrated and throws the nicotine patch on the floor, stating “ this is not the same as smoking I am going to demand a transfer to a facility that allows smoking” What defense mechanism is the client demonstrating?
A. Regression-maladaptive
B. Reaction formation-adaptive
C. Sublimination-maladaptive
D. Repression-adaptive
26.A nurse set limits a client with a borderline personality disorder. The client tells the nurse, You used to care about me. I thought you were wonderful.Now I can see I was mistaken. You’re terrible “ This outburst can be assessed as which of the following?
Denial
Splitting
Reaction formation
Separation-individuation strategies
A nurse is developing a care plan for a client with post traumatic stress disorder. Which of the following should be completed first?
Instruct the client to use distraction techniques to cope with flashbacks.
Encourage the client to put the past in proper perspective.
Encourage the client to verbalize thoughts and feelings about the trauma.
Avoid discussing the traumatic event with the client.
28. A child is admitted to the inpatient psychiatric unit with a diagnosis of conduct disorder. The nurse would expect to find which of the following symptoms?
High anxiety related to the seperation from home and family.
Constant complaints of physical symptoms such as headaches and abdominal discomfort.
A history of cruelty towards people and animals.
Confabulation when confronted with inappropriate behaviors
29. Which of the following is a therapeutic approach to setting limits which clients diagnosed with antisocial personality disorder?
Convey acceptance for behavior.
Use a friendly manner and ask for cooperation.
Establish restrictive goals for these clients
Clarify the rules for all and make expectations clear.
30.A 28 year old male client has poor relationships and is suspicious of others. According to Erikson’s Theory of Psychological Adjustment, at what stage were tasks unmet?
A.Trust vs. mistrust
B. Autonomy vs. shame and doubt
C. Initiative vs. guilt
D. Industry vs. inferiority
31. A client states she is hearing voices that tell her to cut herself. She already has several superficial marks on her wrists from scratching herself with the plastic eating utensils. She will not contract for safety. What is the priority nursing interventions.
Obtain an order for seclusion until she denies suicidal intent.
Conduct 15-minute checks so she will not get the one-to-one attention she seeks.
Remove the plastic eating utensils from the unit.
Place on one-to-one, constant observation to ensure she does not harm herself.
A 16-year-old is admitted to the adolescent unit with a diagnosis of conduct disorder. This condition is often manifested by what behavior?
A. Physical aggression in violation of others.
B.Inability to complete age-appropriate tasks.
C. Verbal aggression in expressing the needs for independence.
D. Anger- related too restrictive rules.
33.A female adolescent client says to the nurse, Hey you stupid blonde, what are you looking at? Which of the following responses would be inappropriate for the nurse to make?
“That kind of language is unexceptable.”
“What’s that all about?”
“I don’t understand that comment.”
“ Don’t you ever talk to me like that again.”
34.A client has been prescribed buspirone for a new diagnosis of generalized anxiety disorder (GAD). Which statement by the client indicates an understanding of the medication?
A “ I will only need to take this when I feel anxious.”
B. “ I should begin to feel better in a few days.”
C. “I will let my physician know if I become addicted.”
D. “I will need to take this medication for awhile before I see how well it works for me.”
35. A client is diagnosed with antisocial personality disorder. She has a violent verbal, physically threatening outburst in the unit’s dayroom when the nurse explains she cannot smoke in the hospital. What is the priority action the nurse should take?
Call for help to restrain the client/
Use a firm, controlling approach in explaining the rules.
Insist that she immediately give him the cigarettes.
Remove all other clients from the dayroom to ensure safety.
36. A child is diagnosed with oppositional defiant disorder begins to yells at staff members when asked to leave group therapy because of inappropriate behaviors. Which nursing intervention would be most appropriate?
Assist the child in recognizing how to separate feelings from reactions
Accompany the child to a quiet area to decrease external stimuli.
Institute seclusion following the facilities’ protocol.
Allow the child to remain in the group therapy and continue to monitor.
37. The nurse observes a client diagnosed with anorexia nervosa doing repeated, vigorous sit-ups in her room. What is the most therapeutic intervention by the nurse?
Tell the client exercise is not allowed.
Allow the client to continue to exercise
Interrupt the routine and offer to walk with her.
Restrict the client from her room.
38. A school-age child is talking with her grandmother, who is dying. What should the nurse say to the client?
Talk loudly so she can hear you.
Hold her hand since she probably can’t hear you.
Although she cannot hear you, she can feel your presence.
Even though she may not answer you, she can hear you.
39. A nurse is assessing a client following a natural disaster who is experiencing difficulty sleeping due to nightmares, feelings of survivor guilt and difficulty concentrating. Which of the following diagnosis describe the client’s symptoms?
Generalized anxiety disorder
Post- traumatic stress syndrome
Histrionic personality disorder
Dissociative identity syndrome
40.A client is admitted with post traumatic stress disorder following a fire in his home in which family members died. Which of the following should the nurse recognize as an adaptive defense mechanism?
The client begins reading a book when he experiences hand tremors in response to loud noise.
The client decides to postpone a needed surgery
The client focuses on discussing his daily routine when asked about the fire
The client develops stomach pains when fire is seen on television
41. A client has blindness released to conversion disorder. To assist the client with eating, which of the following interventions should the nurse implement?
Establish a “buddy” system with other clients who can feed this client at each meal.
Expect the client to feed himself after explaining the arrangement of the food on the tray.
Address the needs of other clients in the dining room, then feed this client.
Place the food tray on a table in front of the client.
42.A nurse is preparing to administer haloperidol 75 mg IM per week. Available is haloperidol decanote 100mg/ml for injection. How many ml should the nurse administer per dose? (Round the answer to the nearest hundredth, or two decimal places. Use a leading zero if it applies. Do not use a trailing zero. Type the number only do not incluse label). 0.75
43. A nurse is teaching a group of students about the risk factors and complications of anorexia nervosa. Which of the following complications should be stressed as the most serious?
Ineffective coping
Depression
Family relationships
Increased risk of mortality
44.A nurse is bathing a toddler and notices that she has several bruises. Which of the following actions should the nurse take first?
Ask the toddler what caused the bruises
Notify the provider
Ask the parents what caused the bruises
Notify social services
45. The nurse is caring for a 12-year-old client diagnosed with oppositional defiant disorder. The client’s mother ask what type of medication is usually prescribed for this diagnosis. Which of the following is the most appropriate response by the nurse?
Though medications may be used; typically the client will outgrow the behavioral problem without specific treatment plan.
Though medications may be used to treat symptoms, the focus will be on behavioral therapy.
There have been no medications approved for this condition.
Often medications such as a mood-stabilizers are used in an off-label manner
46. A young adult is being evaluated for a possible eating disorder. Which nursing intervention is most directly related to a commonly observed complication related to bulimia nervosa?
Increasing potassium-rich foods in the daily diet.
Adding fiber to the diet to help minimize constipation
Medicating the client for migraine headaches as the occur.
Monitoring the client for signs of developing contact dermatitis.
47. A client is admitted with a diagnosis of dependent personality disorder. Which question by the nurse indicates an understanding of the essential features of the disorder?
Do you feel awkward in social situations?
Place the food tray on a table in front of the client.
42.A nurse is preparing to administer haloperidol 75 mg IM per week. Available is haloperidol decanote 100mg/ml for injection. How many ml should the nurse administer per dose? (Round the answer to the nearest hundredth, or two decimal places. Use a leading zero if it applies. Do not use a trailing zero. Type the number only do not incluse label). 0.75
43. A nurse is teaching a group of students about the risk factors and complications of anorexia nervosa. Which of the following complications should be stressed as the most serious?
Ineffective coping
Depression
Family relationships
Increased risk of mortality
44.A nurse is bathing a toddler and notices that she has several bruises. Which of the following actions should the nurse take first?
Ask the toddler what caused the bruises
Notify the provider
Ask the parents what caused the bruises
Notify social services
45. The nurse is caring for a 12-year-old client diagnosed with oppositional defiant disorder. The client’s mother ask what type of medication is usually prescribed for this diagnosis. Which of the following is the most appropriate response by the nurse?
Though medications may be used; typically the client will outgrow the behavioral problem without specific treatment plan.
Though medications may be used to treat symptoms, the focus will be on behavioral therapy.
There have been no medications approved for this condition.
Often medications such as a mood-stabilizers are used in an off-label manner
46. A young adult is being evaluated for a possible eating disorder. Which nursing intervention is most directly related to a commonly observed complication related to bulimia nervosa?
Increasing potassium-rich foods in the daily diet.
Adding fiber to the diet to help minimize constipation
Medicating the client for migraine headaches as the occur.
Monitoring the client for signs of developing contact dermatitis.
47. A client is admitted with a diagnosis of dependent personality disorder. Which question by the nurse indicates an understanding of the essential features of the disorder?
Do you feel awkward in social situations?
Place the food tray on a table in front of the client.
42.A nurse is preparing to administer haloperidol 75 mg IM per week. Available is haloperidol decanote 100mg/ml for injection. How many ml should the nurse administer per dose? (Round the answer to the nearest hundredth, or two decimal places. Use a leading zero if it applies. Do not use a trailing zero. Type the number only do not incluse label). 0.75
43. A nurse is teaching a group of students about the risk factors and complications of anorexia nervosa. Which of the following complications should be stressed as the most serious?
Ineffective coping
Depression
Family relationships
Increased risk of mortality
44.A nurse is bathing a toddler and notices that she has several bruises. Which of the following actions should the nurse take first?
Ask the toddler what caused the bruises
Notify the provider
Ask the parents what caused the bruises
Notify social services
45. The nurse is caring for a 12-year-old client diagnosed with oppositional defiant disorder. The client’s mother ask what type of medication is usually prescribed for this diagnosis. Which of the following is the most appropriate response by the nurse?
Though medications may be used; typically the client will outgrow the behavioral problem without specific treatment plan.
Though medications may be used to treat symptoms, the focus will be on behavioral therapy.
There have been no medications approved for this condition.
Often medications such as a mood-stabilizers are used in an off-label manner
46. A young adult is being evaluated for a possible eating disorder. Which nursing intervention is most directly related to a commonly observed complication related to bulimia nervosa?
Increasing potassium-rich foods in the daily diet.
Adding fiber to the diet to help minimize constipation
Medicating the client for migraine headaches as the occur.
Monitoring the client for signs of developing contact dermatitis.
47. A client is admitted with a diagnosis of dependent personality disorder. Which question by the nurse indicates an understanding of the essential features of the disorder?
Do you feel awkward in social situations?
Place the food tray on a table in front of the client.
42.A nurse is preparing to administer haloperidol 75 mg IM per week. Available is haloperidol decanote 100mg/ml for injection. How many ml should the nurse administer per dose? (Round the answer to the nearest hundredth, or two decimal places. Use a leading zero if it applies. Do not use a trailing zero. Type the number only do not incluse label). 0.75
43. A nurse is teaching a group of students about the risk factors and complications of anorexia nervosa. Which of the following complications should be stressed as the most serious?
Ineffective coping
Depression
Family relationships
Increased risk of mortality
44.A nurse is bathing a toddler and notices that she has several bruises. Which of the following actions should the nurse take first?
Ask the toddler what caused the bruises
Notify the provider
Ask the parents what caused the bruises
Notify social services
45. The nurse is caring for a 12-year-old client diagnosed with oppositional defiant disorder. The client’s mother ask what type of medication is usually prescribed for this diagnosis. Which of the following is the most appropriate response by the nurse?
Though medications may be used; typically the client will outgrow the behavioral problem without specific treatment plan.
Though medications may be used to treat symptoms, the focus will be on behavioral therapy.
There have been no medications approved for this condition.
Often medications such as a mood-stabilizers are used in an off-label manner
46. A young adult is being evaluated for a possible eating disorder. Which nursing intervention is most directly related to a commonly observed complication related to bulimia nervosa?
Increasing potassium-rich foods in the daily diet.
Adding fiber to the diet to help minimize constipation
Medicating the client for migraine headaches as the occur.
Monitoring the client for signs of developing contact dermatitis.
47. A client is admitted with a diagnosis of dependent personality disorder. Which question by the nurse indicates an understanding of the essential features of the disorder?
Do you feel awkward in social situations?
Place the food tray on a table in front of the client.
42.A nurse is preparing to administer haloperidol 75 mg IM per week. Available is haloperidol decanote 100mg/ml for injection. How many ml should the nurse administer per dose? (Round the answer to the nearest hundredth, or two decimal places. Use a leading zero if it applies. Do not use a trailing zero. Type the number only do not incluse label). 0.75
43. A nurse is teaching a group of students about the risk factors and complications of anorexia nervosa. Which of the following complications should be stressed as the most serious?
Ineffective coping
Depression
Family relationships
Increased risk of mortality
44.A nurse is bathing a toddler and notices that she has several bruises. Which of the following actions should the nurse take first?
Ask the toddler what caused the bruises
Notify the provider
Ask the parents what caused the bruises
Notify social services
45. The nurse is caring for a 12-year-old client diagnosed with oppositional defiant disorder. The client’s mother ask what type of medication is usually prescribed for this diagnosis. Which of the following is the most appropriate response by the nurse?
Though medications may be used; typically the client will outgrow the behavioral problem without specific treatment plan.
Though medications may be used to treat symptoms, the focus will be on behavioral therapy.
There have been no medications approved for this condition.
Often medications such as a mood-stabilizers are used in an off-label manner
46. A young adult is being evaluated for a possible eating disorder. Which nursing intervention is most directly related to a commonly observed complication related to bulimia nervosa?
Increasing potassium-rich foods in the daily diet.
Adding fiber to the diet to help minimize constipation
Medicating the client for migraine headaches as the occur.
Monitoring the client for signs of developing contact dermatitis.
47. A client is admitted with a diagnosis of dependent personality disorder. Which question by the nurse indicates an understanding of the essential features of the disorder?
Do you feel awkward in social situations?
Place the food tray on a table in front of the client.
Do you find you dont want praise for your accomplishments?
Are you afraid of being alone.
Do you have problems expressing your feeling?
48.A child drowned while swimming in a local lake two years ago. Which behaviors indicate the child’s parents are mourning ineffectively? (Select all that apply)
They forbid their other children from going swimming
They keep a place set for the deceased child at the family dinner table
They sealed their child’s room and will not allow anyone to change it
They throw flowers on the lake at each anniversary date of the accident
They have a prayer service every year on the anniversary of the death of the child
49. Which nursing intervention is of highest priority for a client with bulimia nervosa?
Assist the client in identifying triggers to binge eating
Provide remedial consequences for weight loss
Assess for signs of impulsive eating
Explore needs for health teaching
50. Which behavior best describes physical aggression?
Stomping away from the nurses’ station, going to the day room, and grabbing a pool cue from a client standing at the pool table
Bursting into tears, leaving the community meeting, and sitting on a bed hugging a pillow and sobbing
Telling the primary nurse, When you told me that I could not have a second helping at lunch, I felt angry.
Telling the medication nurse, i am not going to take that or any other medication
