A charge nurse is discussing mental status exams with a newly licensed nurse. Which
of the following statements by the newly licensed nurse indicates an understanding of
the teaching? (Select all that apply). - ANS--To assess cognitive ability, I should ask the
client to count backward by sevens."
-To assess affect, I should observe the client's facial expression.
-To assess language ability, I should instruct the client to write a sentence."
A nurse is planning care for a client who has a mental health disorder. Which of the
following actions should the nurse include as a psychobiological intervention? -
ANS-Monitor the client for adverse effects of the medications.
A nurse in an outpatient mental health clinic is preparing to conduct an initial client
interview. When conducting the interview, which of the following actions should the
nurse identify as the priority? - ANS-Identify the client's perception of her mental health
status.
A nurse is told during change of shift report that a client is stuporous. When assessing
the client, which of the following findings should the nurse expect? - ANS-The client
arouses briefly in response to a sternal rub.
A nurse is planning a peer group discussion about the DSM-5. Which of the following
information is appropriate to include in the discussion? (Select all that apply) - ANS-The
DSM-5 establishes diagnostic criteria for individual mental health disorders. -The
DSM-5 assists nurses in planning care for client's who have mental health disorders.
-The DSM-5 indicates expected assessment findings of mental health disorders.
A nurse in an emergency mental health facility is caring for a group of clients. The nurse
should identify that which of the following clients requires a temporary emergency
admission? - ANS-A client who has borderline personality disorder and assaulted a
homeless man with a metal rod
A nurse decides to put a client who has a psychotic disorder in seclusion overnight
because the unit is very short-staffed, and the client frequently fights with other
,clients.
The nurse's actions are an example of which of the following torts? - ANS-False
imprisonment
A client tells a nurse, "Don't tell anyone but I hid a sharp knife under my mattress in
order to protect myself from my roommate, who is always yelling at me and threatening
me." Which of the following actions should the nurse take? - ANS-Report the incident to
the health care team, but do not inform the client of the intention to do so.
A nurse is caring for a client who is in mechanical restraints. Which of the following
statements should the nurse include in the documentation? (Select all that apply) -
ANS--Client was offered 8 oz of water every hr."
-Client shouted obscenities at assistive personnel."
-Client received chlorpromazine 15 mg by mouth at 1000.
A nurse hears a newly licensed nurse discussing a client's hallucinations in the hallway
with another nurse. Which of the following actions should the nurse take first? -
ANS-Tell the nurse to stop discussing the behavior
A nurse is caring for the parents of a child who has demonstrated changes in behavior
and mood. When the mother of the child asks the nurse for reassurance about her son's
condition, which of the following responses should the nurse make? - ANS-I understand
you're concerned. Let's discuss what concerns you specifically."
A nurse is caring for a client who smokes and has lung cancer. The client reports, "I'm
coughing because I have that cold that everyone has been getting." The nurse should
identify that the client is using which of the following defense mechanisms? -
ANS-Denial
A nurse is providing preoperative teaching for a client who was just informed that she
requires emergency surgery. The client has a respiratory rate 30/min and says, "This is
difficult to comprehend. I feel shaky and nervous." The nurse should identify that the
client is experiencing which of the following levels of anxiety? - ANS-Moderate
A nurse is caring for a client who is experiencing moderate anxiety. Which of the
following actions should the nurse take when trying to give necessary information to the
client? (Select all that apply.) - ANS--Discuss prior use of coping mechanisms with the
client.
-Demonstrate a calm manner while using simple and clear directions.
, A nurse is talking with a client who is at risk for suicide following the death of his
spouse. Which of the following statements should the nurse make? - ANS--Losing
someone close to you must be very upsetting."
A charge nurse is discussing the characteristics of a nurse-client relationship with a
newly licensed nurse. Which of the following characteristics should the nurse include in
the discussion? (Select all that apply) - ANS--It is goal-directed.
-Behavioral change is encouraged.
-A termination date is established.
A nurse is in the working phase of a therapeutic relationship with a client who has
methamphetamine use disorder. Which of the following actions indicates transference
behavior? - ANS-The client accuses the nurses of telling him what to do just like his
ex-girlfriend.
A nurse is planning care for the termination phase of a nurse-client relationship. Which
of the following actions should the nurse include in the plan of care? - ANS-Discussing
ways to use new behaviors
A nurse is orienting a new client to a mental health unit. When explaining the unit's
community meetings, which of the following statements should the nurse make? -
ANS-You and the other clients will meet with staff to discuss common problems.
A nurse is caring several clients who are attending community-based mental health
programs. Which of the following clients should the nurse plan to visit first? - ANS-A
client who says he is hearing a voice that tells him he is not worth living anymore.
A community mental health nurse is planning care to address the issue of depression
among older adult clients in the community. Which of the following interventions should
the nurse plan as a method of tertiary prevention? - ANS-Establishing rehabilitation
programs to decrease the effects of depression
A nurse is working in a community mental health facility. Which of the following services
does this type of program provide? (Select all that apply) - ANS--Educational groups
-Medication dispensing programs
-Individual counseling programs
-Family therapy
A nurse in an acute mental health facility is assisting with discharge planning for a client
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