A - ANS-While interviewing a client, the nurse takes notes to assist with accurate
documentation later. Which statement is most accurate regarding note-taking during an
interview?
A. The nurse' ability to directly observe the client's nonverbal communication is limited
with note taking.
B. Taking notes during an interview is a legal obligation of the examining nurse. C.
The client's comfort level is increased when the nurse breaks eye contact to take
note to take note.
D. The interview process is enhanced with note taking and allows the client speak at
normal pace.
B - ANS-An adolescent male receives a prescription for an antidepressant drug
because he is exhibiting a depressed affect. While the client is taking the
antidepressant, which comparison of the client's behavior before and after taking the
drug is most important for the nurse to obtain?
A. His appetite.
B. The emotional quality of his attitude
C. His level of activity.
D. The interactions he has with others.
B C D - ANS-A nurse is providing education about strategies for a safety plan for a
female client who is a victim of intimate partner violence. Which strategies should be
included in the safety plan? Select all that apply.
A. Purchase a gun to use for protection
B. Establish a code with family and friends to signify violence.
C. Plan an escape route to use if the abuser blocks the main exit.
D. Have a bag ready that has extra clothes for self and children
B - ANS-While sitting in the dayroom of the mental health unit, a male adolescent
avoids eye contact, looks at the floor, and talks softly when interacting verbally with the
nurse. The two trade places, and the nurse demonstrate the client's behavior. What is
the main goal of this therapeutic techniques?
A. Discuss the client's feeling when he responds.
,B. Allow the client to identify the way he interacts.
C. Initiate a non-threatening conversation with the client.
D. Dialog about the ineffectiveness of his interactions.)
C - ANS-A client with depression remains in bed most of the day, and declines activities.
Which nursing problem has the greatest priority for this client?
A. Loss of interest in diversional activity.
B. Social isolation.
C. Refusal to address nutritional needs.
D. Low self-esteem.
B - ANS-The RN is preparing medications for a client with bipolar disorder and notices
that the client discontinued antipsychotic medication for several days. Which medication
should also be discontinued?
a. Lithium. (Lithotabs)
b. Benzotropine (Cogentin).
c. Alprazolam (Xanax).
d. Magnesium (Milk of Magnesia).
A - ANS-A female client requests that her husband be allowed to stay in the room
during the admission assessment. When interviewing the client, the RN notes a
discrepancy between the client's verbal and nonverbal communication. What action
does the RN take?
A. Pay close attention and document the nonverbal messages.
B. Ask the client's husband to interpret the discrepancy.
C. Ignore the nonverbal behavior and focus on the client's verbal messages.
D. Integrate the verbal and nonverbal messages and interpret them as one.
B - ANS-A male client approaches the RN with an angry expression on his face and
raises his voice, saying "My roommate is the most selfish, self-centered, angry person I
have ever met. If he loses his temper one more time with me, I am going to punch him
out!" The RN recognizes that the client is using which defense mechanism? A. Denial.
B. Projection.
C. Rationalization.
D. Splitting.
A - ANS-A male client with bipolar disorder who began taking lithium carbonate five
days ago is complaining of excessive thirst, and the RN finds him attempting to drink
water from the bathroom sink faucet. Which intervention should the RN implement?
,A. Report the client's serum lithium level to the HCP.
B. Encourage the client to suck on hard candy to relieve the symptoms.
C. No action is needed since polydipsia is a common side effect.
D. Tell the client that drinking from the faucet is not allowed.
B - ANS-The RN is teaching a client about the initiation of the prescribed abstinence
therapy using disulfiram (Antabuse). What information should the client acknowledge
understanding?
A. Completely abstain from heroin or cocaine use.
B. Remain alcohol free for 12 hours prior to the first dose.
C. Attend monthly meetings of alcoholics anonymous.
D. Admit to others that he is a substance user.
D - ANS-A male client with schizophrenia is admitted to the mental health unit after
abruptly stopping his prescription for ziprasidone (Geodon) one month ago. Which
question is most important for the RN to ask the client?
A. Have you lost interest in the things that you used to enjoy?
B. Is your ability to think or concentrate decreased?
C. How many continuous hours do you sleep at night?
D. Do you hear sounds or voices that others do not hear?
D - ANS-During an annual physical by the occupational RN working in a corporate
clinic, a male employee tells the RN that is high-stress job is causing trouble in his
personal life. He further explains that he often gets so angry while driving to and from
work that he has considered "getting even" with other drivers. How should the RN
respond?
A. "Anger is contagious and could result in major confrontation."
B. "Try not to let your anger cause you to act impulsively."
C. "Expressing your anger to a stranger could result in an unsafe situation."
D. "It sounds as if there are many situations that make you feel angry."
B - ANS-A client who has agoraphobia (a fear of crowds) is beginning desensitization
with the therapist, and the RN is reinforcing the process. Which intervention has the
highest priority for this client's plan of care?
A. Encourage substitution of positive thoughts and negative ones.
B. Establish trust by providing a calm, safe environment.
C. Progressively expose the client to larger crowds.
D. Encourage deep breathing when anxiety escalates in a crowd.
, A D E - ANS-Which nursing actions are likely to help promote the self-esteem of a male
client with modern depression?
A. Ask the client what his long term goals are.
B. Discuss the challenges of his medical condition.
C. Include the client in determining treatment protocol.
D. Encourage the client to engage in recreational therapy.
E. Provide opportunities for the client to discuss his concerns.
D - ANS-A male client is admitted to the psychiatric unit for recurrent negative
symptoms of chronic schizophrenia and medication adjustment of Risperidone
(Risperdal). When the client walks to the nurse's station in a laterally contracted
position, he states that something has made his body contort into a monster. What
action should the RN take?
A. Medicate the client with the prescribed antipsychotic thioridazine (Mellaril). B.
Offer the client a prescribed physical therapy hot pack for muscle spasms. C.
Direct client to occupational therapy to distract him from somatic complaints. D.
Administer the prescribed anticholinergic benztropine (Cogentin) for dystonia.
A - ANS-A mental health worker is caring for a client with escalating aggressive
behavior. Which action by the MHW warrant immediate intervention by the RN?
A. Is attempting to physically restrain the patient.
B. Tells the client to go to the quiet area of the unit.
C. Is using a loid voice to talk to the client.
D. Remains at a distance of 4 feet from the client.
C - ANS-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.
D - ANS-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."
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