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  • April 14, 2024
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,A client on the mental health unit is becoming more agitated, shouting at the staff, and pacing in the
hallway. When the PRN medication is offered, the client refuses the medication and defiantly sits on
the floor in the middle of the unit hallway. What nursing intervention should the RN implement first?
A. Transport of the client to the seclusion room.
B. Quietly approach the client with additional staff members.
C. Take other clients in the area to the client lounge.
D. Administer medication to chemically restrain the patient.


A client is admitted to the mental health unit and reports taking extra antianxiety medication because,
“I’m so stressed out. I just want to go to sleep.” The RN should plan one-on-one observation of the
client based on which statement?
A. “What should I do? Nothing seems to help.”
B. “I have been so tired lately and needed to sleep.”
C. “I really think that I don’t need to be here.”
D. “I don’t want to walk. Nothing matters anymore.”


A male hospital employee is pushed out the way by a female employee because of an oncoming
gurney. The pushed employee becomes very angry and swings at the female employee. Both
employees are referred for counseling with the staff psychiatric RN. Which factor in the pushed
employee’s history is most related to the reaction that occurred?
A. Is worried about losing his job to a woman.
B. Tortured animals as a child.
C. Was physically abused by his mother.
D. Hates to be touched by anyone.


The RN documents the mental status of a female client who has been hospitalized for several days
by court order. The client states, “I don’t need to be here” and tells the RN that she believes the
television talks to her. The RN should document these assessment findings in which section of the
mental status exam/
A. Level of concentration.
B. Insight and judgement.
C. Remote memory.
D. Mood and affect.


A client is admitted to the mental health unit reports shortness of breath and dizziness. The client tells
the RN, “I feel like I’m going to die”. Which nursing problem should the RN include in this client’s plan

,of care?
A. Mood disturbance.
B. Moderate anxiety.
C. Altered thoughts.
D. Social isolation.


A female client who is wearing dirty clothes and has foul body odor, comes to the clinic reporting
feeling scared because she is being stalked. What action is most important for the RN to take?
A. Offer the client a safe place to relax before interviewing her.
B. Ask the client to describe why she is being stalked.
C. Recommend that the client talk with a social worker.
D. Assure the client that the HCP will see her today.

The RN leading a group session of adolescent clients gives the members a handout about anger
management. One of the male clients is fidgety, interrupts peers when they try and talk, and talks
about his pets at home. What nursing action is best for the RN to take?
A. Explore the client’s feelings about his pets and home life.
B. Encourage his peers to help involve him in the activity.
C. Give the client permission to leave and return in 10 minutes.
D. Redirect him by encouraging him to read from the handout.


A male adolescent was admitted to the unit two days ago for depression. When the mental health RN
tries to interview the client to establish rapport, he becomes very irritated and sarcastic. Which action
is best for the RN to take? A. Report the behavior to the next shift.
B. Offer to play a game of cards with the client.
C. Document the behavior in the chart.
D. Plan to talk with the client the next day.


A male adult is admitted because of an acetaminophen (Tylenol) overdose. After transfer to the
mental health unit, the client is told he has liver damage. Which information is most important for the
nurse to include in the client's discharge plan?
A. Do not take any over the counter meds.
B. Eat a high carb, low fat, low protein diet.
C. Call the crisis hotline if feeling lonely.
D. Avoid exposure to large crowds.


After receiving treatment for anorexia, a student asks the school RN for permission to work in the
school cafeteria as part of the school’s work study program. What action should the RN take?

, A. Refer the student to a psychiatrist for further discussion.
B. Recommend assignment to the receptionist’s office.
C. Suggest that student work in the athletic department.
D. Determine the parent’s opinion of the work assignment.


The Rn accepts a transfer to the metal health unit and understands that the client is distractible and is
exhibiting a decreased ability to concentrate. The RN only has 15 minutes to talk to the client. To
develop treatment plan for this client, which assessment is most important for the RN to obtain?
A. Motivation of treatment.
B. History of substance use.
C. Medication compliance.
D. Mental status examination.


A male client who recently lost a loved one arrives at the mental health center and tells the RN he is
no longer interested is his usual activities and has not slept for several days. Which priority nursing
problem should the RN include in the client’s plan of care?
A. Risk for suicide.
B. Sleep deprivation.
C. Situational low self-esteem.
D. Social isolation.

A male client with long history of alcohol dependency arrives in the emergency department describing
the feelings of bugs crawling on his body. His blood pressure is 170/102, his pulse rate is 110 bpm,
and is blood alcohol level is 0mg/dL. Which prescription should the RN administer?
A. Haloperidol (Haldol).
B. Thiamine (Vitamin B1).
C. Diphenhydramine (Benadryl).
D. Lorazepam (Ativan).


A client who refuses antipsychotic medications disrupts group activities, talks with nonsensical words
and wanders into client’s rooms. The RN decides that the client needs constant observation based on
which of these assessment findings?
A. Wanders into the clients rooms.
B. Refuses antipsychotic medications.
C. Talks with nonsensical words.
D. Disrupts group activities.


A client with schizophrenia explains that she has 20 children and then very seriously points to the RN

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