A charge nurse is discussing the mental status examinations 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)
A. To assess cognitive ability, i should ask the client to count backward by sevens
B. To assess affect, i should observe the clients facial expression
C. To assess language ability, i should instruct client to write a sentence D. To
assess remote memory, i should have the client repeat a list of objects E. To
assess the clients abstract thinking, i should ask the client to identify our most
recent presidents - ANS-A, B, C
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? A.
Assist the client with systematic desensitization therapy
B. Teach the client appropriate coping mechanisms
C. Assess the client for comorbid health conditions
D. Monitor the client for adverse effects of medications - ANS-D
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?
A. Coordinate holistic care with social services
B. Identify the client's perception of their mental health status
C. Include the client's family in the interview
D. Teach the client about their current mental health disorder - ANS-B
A nurse is planning a peer group discussion about the diagnostic and statistical manual
of mental disorders 5th edition (DSM-5). Which of the following information is
appropriate to include in the discussion? (Select all that apply)
A. The DSM-5 includes client education handouts for mental health disorders. B.
The DSM-5 establishes diagnostic criteria for individual mental health disorders. C.
The DSM-5 indicates recommended pharmacological treatment for mental health
disorders.
D. The DSM-5 assists nurse in planning care for clients who have mental health
, disorders.
E. The DSM-5 indicates expected assessment findings of mental health disorders. -
ANS-B, D, E
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?
A. A client who has schizophrenia with delusions of grandeur
B. A client who has manifestations of depression and attempted suicide a year ago C.
A client who has borderline personality disorder and assaulted a homeless man with a
metal rod
D. A client who has bipolar disorder and paces quickly around the room while talking to
themselves - ANS-C
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 nurses actions are an example of which of the following torts? A. Invasion of
privacy
B. False imprisonment
C. Assault
D. Battery - ANS-B
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 threatening me." Which of the
following actions should the nurse take?
A. Keep the clients communication confidential but talk to the client daily using
therapeutic communication to convince them to admit to hiding the knife B. Keep the
clients communication confidential but watch the client and their roommate closely
C. Tell the client that this must be reported to the health care team because it concerns
the health and safety of the client and others
D. Report the incident to the health care team but do not inform the client of the
intention to do so - ANS-C
A nurse is caring for a client who is in mechanical restraints. Which of the following
statements should the nurse included in the documentation (select all) A. Client
ate most of their breakfast
B. Client was offered 8oz of water every hour
C. Client shouted obscenities at assistive personnel
D. Client received chlorpromazine 15mg by mouth at 1000
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