Mental Health Exam
The parents of a 14-year-old boy bring their son to the hospital. He is lethargic, but responsive. The
mother states, "I think he took some of my pain pills." During initial assessment of the teenager, what
information is most important for the nurse to obtain from the parents?
A. If he has seemed depressed recently.
B. If a drug overdose has ever occurred before.
C. If he might have taken any other drugs.
D. If he has a desire to quit taking drugs
The nurse should hold the next scheduled dose of a child's haldoperidol (Haldol) based on which
assessment findings?
A. Dizziness when standing.
B. Shuffling gait and hand tremors.
C. Urinary retention.
D. Fever of 102 F
A 65-year-old female complains to the nurse that recently she has been hearing voices. What question
should the nurse ask this client first?
A. "Do you have problems with hallucinations?"
B. "Are you ever alone when you hear the voices?"
C. "Has anyone in your family had hearing problems?"
D. "Do you see things that others cannot see?"
The charge nurse is collaborating with the nursing staff about the plan of care for a client who is very
depressed. What is the most important intervention to implement during the first 48 hours after the
client's admission to the unit?
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A. Monitor appetite and observe intake at meals.
B. Maintain safety in the client's milieu.
C. Provide ongoing, supportive contact.
D. Encourage participation in activities.
Within several days of hospitalization, a client is repeatedly washing the top of the same table. Which
intervention is best for the nurse to implement to help the client cope with anxiety related to this
behavior?
A. Administer a prescribed PRN antianxiety medication.
B. Assist the client to identify stimuli that precipitates the ritualistic activity.
C. Allow time for the ritualistic behavior, then redirect the client to other activities.
D. Teach the client relaxation and thought stopping techniques.
A female client with depression attends groups and states that she sometimes misses her medication
appointment because she feels very anxious about riding the bus. Which statement is the nurse's best
response?
A. "Can your case manager take to you to your appointment?"
B. "Take your medication for anxiety before you ride the bus."
C. "Let's talk about what happens when you feel very anxious."
D. "What are some ways that you can cope with your anxiety?"
A nurse working on a mental health unit receives a community call from a person who is tearful and
states, "I just feel so nervous all the time. I don't know what to do about my problems. I haven't been
able to sleep at night and hardly eaten for the past 3 to 4 days." The nurse should initiate a referral based
on which assessment?
A. Altered thought processes
B. Moderate levels of anxiety.
C. Inadequate social support.
D. Altered health maintenance.
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A female client refuses to take an oral hypoglycemic agent because she believes the drug is being
administered as part of an elaborate plan by the Mafia to harm her. Which nursing intervention is most
important to include in this client's plan of care?
A. Reassure the client that no one will harm her while she is in the hospital.
B. Ask the healthcare provider to give the client the medication.
C. Explain that the diabetic medication is important to take.
D. Reassess client's mental status for thought processes and content.
The nurse is planning discharge for a male client with schizophrnia. The client insists that he is returning
to his apartment, although the healthcare provider informed him that he will be moving to a boarding
home. What is the most important nursing diagnosis for discharge planning?
A. Ineffective denial related to situational anxiety.
B. Ineffective coping related to inadequate support.
C. Social isolation related to difficult interactions.
D. Self-care deficit related to cognitive impairment.
A male client is admitted to the mental health unit because he was feeling depressed about the loss of
his wife and job. The client has a history of alcohol dependency and admits that he was drinking alcohol
12 hours ago. Vitals are: temperature 100F, pulse 100, and BP 142/100. The nurse plans to give the client
lorazepam (Ativan) based on which priority nursing diagnosis?
A. Risk for injury related to suicidal ideation.
B. Risk of injury related to alcohol detoxification. C. Knowledge deficit related to
ineffective coping.
D. Health seeking behaviors related to personal crisis.
An elderly client with advanced dementia is admitted to the hospital with a fractured hip. The client
repeatedly tells the staff, "take me home. I want my Mommy." Which response is best for the nurse to
provide?
A. Orient the client to the tie, place, and person.
B. Tell the client that the nurse is there and will help her.
C. Remind the client that her mother is no longer living.
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