Exam (elaborations)
(NURS 171) MENTAL HEALTH VERIFIED FINAL ACTUAL EXAM GRADED PASS
- Course
- N172
- Institution
- Saddleback College
(NURS 171) MENTAL HEALTH VERIFIED FINAL ACTUAL EXAM GRADED PASS
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(NURS 171) MENTAL HEALTH VERIFIED FINAL ACTUAL EXAM GRADEDPASS
1. A nurse is admitting a child and observes multiple irregular bruises. Which
action should the nurse take next?
1. Ask parents to leave the room during the admission process
2. Continue with a detailed interview and physical examination
3. Notify the charge nurse and the social worker
4. Promise not to tell anyone if the child reveals abuse
2. A client with obsessive-compulsive disorder (OCD) has been cleaning a
bathroom for most of the morning. When the roommate demands that the
client leave the bathroom so that the roommate can shower, the client
becomes angry and says, "You can't make me leave, everything is still dirty."
What is the best nursing action?
1. Engage other staff members to remove the client from the bathroom
2. Give a reminder that the client has been cleaning the bathroom for 1½ hours and it is
time to take a break
3. Tell the client that the bathroom is very clean and that this behavior is unreasonable
4. Tell the roommate to use the shower in another room
3. A nursing home client with major depressive disorder reports difficulty going
to sleep until late at night. The client gets up, paces the hallway, wrings the
hands, and appears teary. What interventions should be included in the
client's nursing care plan? Select all that apply.
1. Allow the client to receive at least 20 minutes of natural sunlight each day
2. Encourage the client to take naps during the day to make up for lost sleep
3. Have the client engage in strenuous physical exercise just before bedtime
4. Spend time with the client in a quiet environment just before bedtime
5. Suggest that the client take a warm bath before going to bed
4. The nurse cares for a client newly diagnosed with acute stress disorder
following a traumatic event. Which of the following communications by the
nurse are appropriate? Select all that apply.
1. "How has this situation affected your relationships with family and friends?"
2. "It is important to focus on coping strategies and not dwell on the event."
3. "It is normal to experience difficult symptoms after a traumatic event."
4. "Please tell me about your current use of alcohol and any drugs."
5. "Share with me any thoughts or plans of self-harm that you have had."
5. The nurse is speaking with the spouse of a client following a family discussion
with the health care provider about the client's terminal condition and
eligibility for hospice care. The spouse states, "I don't think I can make this
decision right now. What would you do?" How should the nurse respond?
,1. "I find it helpful to investigate the options. I will get you a pamphlet about hospice
services."
2. "It's hard to say what the best decision is, but I know hospice provides wonderful
care."
3. "These decisions are challenging. Tell me your spouse's beliefs about end-of-life."
4. "You seem overwhelmed. I'll contact a chaplain to come and talk with you about the
options."
6. A recently widowed client becomes tearful at a routine clinic visit and states, "I
just can't get over my spouse's death." Which of the following responses by
the nurse are appropriate? Select all that apply.
1. "A friend of mine passed away recently. I know how hard losses can be."
2. "I see that you're upset. I will step out while you process these feelings."
3. "It may take a while, but coming to terms with loss gets easier with time."
4. "This is a difficult time. Tell me about how you have been coping."
5. "What are your thoughts about attending a grief support group?"
7. The nurse on the mental health unit recognizes the use of which defense
mechanism when a client leaves a stressful family meeting and immediately
begins to verbally abuse a roommate?
1. Compensation
2. Displacement
3. Projection
4. Reaction formation
8. The nurse in the outpatient treatment facility evaluates the plan of care for a
client with alcohol use disorder. Which of the following client statements
indicate positive progress toward recovery? Select all that apply.
1. "Drinking led to my divorce and the loss of my children."
2. "I am in control now; I drink only on special occasions."
3. "I will have no desire to drink once I get over my divorce."
4. "My focus is now on fitness training and going back to college."
5. "When cravings occur, I call my Alcoholics Anonymous sponsor."
9. A client with a history of major depressive disorder with psychotic features
was rescued before jumping off a dam. The client is pacing, picking at the
arms, and repeatedly mumbling, "I have to die. You cannot stop me." When the
health care provider recommends electroconvulsive therapy (ECT) as the
initial treatment, the client's spouse says to the nurse, "I can't allow such a
cruel treatment. Why can't they just give my spouse medication?" Which is the
best response by the nurse?
1. "ECT is safe and your spouse will not feel anything."
, 2. "It could take up to 3 weeks for medication to become effective."
3. "Your spouse could die by not receiving this treatment."
4. "Your spouse is very ill and ECT might be the best treatment at this time. What are
your concerns about ECT?"
10. The nurse plans care for a client newly admitted with obsessive-compulsive
disorder who is repeatedly counting magazines in the commons room. Which
of the following should the nurse include in the initial plan of care? Select all
that apply.
1. Assist the client to identify circumstances that increase anxiety
2. Provide positive feedback when the client attends a group activity
3. Refrain from judgmental comments about counting magazines
4. Remove the magazines from the commons room
5. Teach the client how to use the technique of thought stopping
11. The nurse is reviewing the records of an adolescent client. Which findings
suggest that the client may need referral for depression screening? Select all
that apply.
1. Client has had school disciplinary issues due to absenteeism and angry outbursts
2. Client has lost approximately 8 lb (3.64 kg) over the last 3 weeks without trying
3. Client is often found sleeping during class or activities
4. Client quit sports despite receiving previous athletic awards and trophies
5. Client voices concern about appearance related to facial acne
12. The nurse is providing care to a client experiencing posttraumatic stress
disorder following a terrorist attack at the client's place of worship. What is the
priority nursing action?
1. Acknowledge the client's feelings of anger
2. Assess the client's support system
3. Encourage the client to talk about the trauma
4. Offer the client a PRN sleep medication
13. A newly admitted client with schizophrenia has been exhibiting severe social
withdrawal, odd mannerisms, and regressive behavior. The client is sitting
alone in the room when the nurse enters, says "good morning," and proceeds
to sit down next to the client. Without responding, the client stands up and
starts to leave. Which of the following actions is best for the nurse to take?
1. Ask where the client is going
2. Immediately follow the client out the door
3. In a loud voice, direct the client to come back to the room
4. Remain silent and allow the client to leave
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