1. 4. Encourage and praise perseverance in performing ADLs, and assist theclient to
dress and groom daily: 1073. A client in a long-term care facility who had multiple
sclerosis is embarrassed about the need to use a wheelchair and the muscle spasms that are
readily visible in her legs. Which approach is therapeutic inassisting the client to cope?
1. Keep the client in her room as much as possible .
2. Assist the client with all activities of daily living (ADLs).
3. Tell the client that many of the people in the facility have these same sorts of
problems.
4. Encourage and praise perseverance in performing ADLs, and assist the client todress
and groom daily.
2. 4. Provides assistance with grooming and nutrition until the client's thinkingis
cleared: 1074. The nurse uses which approach when caring for a client with a diagnosis of
acute undifferentiated schizophrenia?
1. Repeatedly points out inconsistencies in the client's communication .
2. Allows the client to set his or her own treatment goals for the plan of care.
3. Lets the client act out initially and uses the quiet room and restraints as needed.
4. Provides assistance with grooming and nutrition until the client's thinking is
cleared.
3. 3. Assigning a staff member to the client who will remain with the client atall
times: 1075. A client is admitted to the mental health unit after a suicide attemptby
hanging. The nurse's most important aspect of care is to maintain client safety. The is best
accomplished by which action?
1. Requesting that a peer remain with the client at all times.
2. Removing the client's clothing and placing the client in a hospital gown.
3. Assigning a staff member to the client who will remain with the client at all times.
4. Admitting the client to a seclusion room where all potentially dangerous articles are
removed.
4. 3. A same-gendered Muslim should handle the body if possible.: 1076. The nurse
providing end-of-life care to a Muslim client understands that which practice is accurate
regarding end-of-life care?
1. The client's head should be positioned below the body.
2. Discussions about death are usually welcomed and open.
3. A same-gendered Muslim should handle the body if possible.
4. Stopping medical treatment is allowed if permitted by the family.
5. 4. " I know that some of these questions are difficult for you, but, as a professional
nurse, I am obligated to respect your confidentiality.": 1077. On admission assessment,
the nurse is obtaining subjective data about a client's sexualand reproductive status. The
client states, "I don't want to discuss this; it's private
, Saunders Mental Health Questions
and personal." Which response by the nurse is most therapeutic?
1. "I'd hate being asked these sorts of questions too, but it's a necessary part of
providing you with the best care."
2. "This is difficult for you to speak about, but I need this information from you in orderto
perform a complete assessment."
3. "I am a professional registered nurse, and , as such, I'll have you know that allyour
information is certainly kept confidential."
4. " I know that some of these questions are difficult for you, but, as a professionalnurse, I
am obligated to respect your confidentiality."
6. 2. Individualized goals and objectives.
3. Attendance at group therapy sessions.
4. Self-care measures to improve hygiene.: 1078. The nurse should include which
information in the nursing plan of care for a client with obsessive-compulsive disorder
(OCD)? Select all that apply.
1. The medical diagnosis of the client.
2. Individualized goals and objectives.
3. Attendance at group therapy sessions.
4. Self-care measures to improve hygiene.
5. Interruption of all compulsive behaviors.
7. 3. Providing a safe, therapeutic environment for clients.: 1079. A client asksthe
nurse to explain what milieu therapy is. The nurse responds, knowing that the primary
focus of milieu therapy can be best described by which statement?
1. Changing behavior through crisis intervention.
2. A cognitive approach to changing client behavior.
3. Providing a safe, therapeutic environment for clients.
4. A behavioral approach to changing behavior appropriately.
8. 3. " Although it's not unusual to experience some lapses of memory, let's discuss
your concerns.": 1080. An older adult client states to the nurse, "Lately I'mgetting forgetful
about things. Do you think I'm getting Alzheimer's disease?" Whichresponse by the nurse
is most therapeutic?
1. "Oh, I'm certain it's not Alzheimer's disease because everyone forgets things
sometimes."
2. " No, I don't think we really need to discuss this because I' sure it is just normalaging."
3. " Although it's not unusual to experience some lapses of memory, let's discussyour
concerns."
4. " I am so forgetful, too. I never needed lists of things that I had to do, but that
changed as I got older."
, Saunders Mental Health Questions
9. 1. Use open-ended questions to encourage client dialogue.
5. Offer the client food in closed containers, such as in cans that have to be opened.:
1081. A client in the mental health unit believes that the food is being poisoned. Which
intervention(s) would be helpful when attempting to encourage theclient to eat? Select all
that apply.
1. Use open-ended questions to encourage client dialogue.
2. Offer opinions about the necessity for adequate nutrition.
3. Focus on the client's self-disclosure about food preferences.
4. Identify the reasons that the client had for not wanting to eat.
5. Offer the client food in closed containers, such as in cans that have to be opened.
10. 1. " What aspects of this situation are most difficult for you?": 1082. Thespouse of
a client who abuses alcohol states, " I wish I could just get out of
this situation and far away from my spouse." Which response by the nurse is
therapeutic?
1. " What aspects of this situation are most difficult for you?"
2. " In order to ensure your safety, it's probably best that you leave."
3. "Maybe you should make this decision when your spouse is stable."
4. "I don't think that's what is best for you or your spouse now. Besides, where wouldyou
go?"
11. 4. Keep the client talking, and signal another staff
member to trace the call so that appropriate help can be sent.: 1083. A crisiscenter
nurse receives a telephone call from
a client who states that he wants to kill himself and that he had a bottle of sleepingpills in
from of him. What is the appropriate nursing action?
1. Keep the client talking, and allow him to ventilate his feelings.
2. Use therapeutic communication techniques, especially the reflection of feelings.
3. Insist that the client give you his name and address so that you can get the policethere
immediately.
4. Keep the client talking, and signal another staff member to trace the call so that
appropriate help can be sent.
12. 1. A client's response to a crisis is individualized.
3. A crisis state does not mean that the individual has a mental illness.: 1084. Which
description(s) are characteristic(s) of a crisis state for a client. Select all thatapply.
1. A client's response to a crisis is individualized.
2. A crisis state will always last from 3 to 5 days.
3. A crisis state does not mean that the individual has a mental illness.
4. Presenting symptoms in a crisis situation are similar for all individuals.
5. A crisis state indicates that the individual is suffering from an emotional illness.
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