A charge nurse is discussing mental status exams with a newly licensed nurse. Which of the
following statements by the newly licensed nurse indicates an understanding of the teaching?
(Select all that apply)
A) To assess cognitive ability, I should ask the client to count backward by sevens.
B) To assess affect, I should observe the client's facial expression
C) To assess language ability, I should instruct the client to write a sentence.
D) To assess remote memory, I should have the client repeat a list of objects.
E) To assess the client's abstract thinking, I should ask the client to identify our most recent
presidents. - ANSA, B, C
A nurse is planning care for a client who has a mental health disorder. Which of the following
actions should the nurse include as a psychobiological intervention?
A) Assist the client with systematic desensitization therapy.
B) Teach the client appropriate coping mechanisms.
C) Assess the client for comorbid health conditions.
D) Monitor the client for adverse effects of the medications. - ANSD
A nurse in an outpatient mental health clinic is preparing to conduct an initial client interview.
When conducting the interview, which of the following actions should the nurse identify as the
priority?
A) Coordinate holistic care with social services.
B) Identify the client's perception of her mental health status.
C) Include the client's family in the interview.
D) Teach the client about her current mental health disorder - ANSB
A nurse is told during change of shift report that a client is stuporous. When assessing the
client, which of the following findings should the nurse expect?
A) The client arouses briefly in response to a sternal rub.
B) The client has a glasgow coma scale score less than 7.
C) The client exhibits decorticate rigidity.
D) The client is alert but disoriented to time and place. - ANSA
A nurse is planning a peer group about the DSM-5. Which of the following information is
appropriate to include in the discussion? (Select all that apply).
A) The DSM-5 includes client education handouts for mental health disorders.
B) The DSM-5 establishes diagnostic criteria for individual mental health disorders.
C) The DSM-5 indicates recommended pharmacological treatment for mental health disorders.
D) The DSM-5 assists nurses in planning care for client's who have mental health disorders.
E) The DSM-5 indicates expected assessment findings of mental health disorders. - ANSB, D, E
,A nurse in an emergency mental health facility is caring for a group of clients. The nurse should
identify that which of the following clients requires a temporary emergency admission?
A) A client who has schizophrenia with delusions of grandeur
B) A client who has manifestations of depression and attempted suicide a year ago.
C) A client who has borderline personality disorder and assaulted a homeless man with a metal
rod.
D) A client who has bipolar disorder and paces quickly around the room while talking to himself.
- ANSC
A nurse decides to put a client who has a psychotic disorder in seclusion overnight because the
unit is very short-staffed, and the client frequently fights with other clients. The nurse's actions
are an example of which of the following torts?
A) Invasion of privacy
B) False imprisonment
C) Assault
D) Battery - ANSB
A client tells a nurse, "Don't tell anyone but I hid a sharp knife under my mattress in order to
protect myself from my roommate, who is always yelling at me and threatening me." Which of
the following actions should the nurse take?
A) Keep the client's communication confidential, but talk to the client daily, using therapeutic
communication to convince him to admit to hiding the knife.
B) Keep the client's communication confidential, but watch the client and his roommate closely.
C) Tell the client that this must be reported to the healthcare team because it concerns the
health and safety of the client and others.
D) Report the incident to the health care team, but do not inform the client of the intention to do
so. - ANSD
A nurse is caring for a client who is in mechanical restraints. Which of the following statements
should the nurse include in the documentation? (Select all that apply)
A) Client ate most of his breakfast
B) Client was offered 8 oz of water every hr
C) Client shouted obscenities at assistive personnel
D) Client received chlorpromazine 15 mg by mouth at 1000
E) Client acted out after lunch - ANSB, C, D
A nurse hears a newly licensed nurse discussing a client's hallucinations in the hallway with
another nurse. Which of the following actions should the nurse take first?
A) Notify the nurse manager
B) Tell the nurse to stop discussing the behavior
C) Provide an in-service program about confidentiality
D) Complete an incident report - ANSB
, A nurse is caring for the parents of a child who has demonstrated changes in behavior and
mood. When the mother of the child asks the nurse for reassurance about her son's condition,
which of the following responses should the nurse make?
A) I think your son is getting better. What have you noticed
B) I'm sure everything will be okay. It just takes time to heal
C) I'm not sure what's wrong. Have you asked the doctor about your concerns?
D) I understand you're concerned. Let's discuss what concerns you specifically - ANSD
A nurse is caring for a client who smokes and has lung cancer. The client reports, "I'm coughing
because I have that cold that everyone has been getting." The nurse should identify that the
client is using which of the following defense mechanisms?
A) Reaction formation
B) Denial
C) Displacement
D) Sublimation - ANSB
A nurse is providing preoperative teaching for a client who was just informed that she requires
emergency surgery. The client has a respiratory rate 30/min and says, "This is difficult to
comprehend. I feel shaky and nervous." The nurse should identify that the client is experiencing
which of the following levels of anxiety?
A) Mild
B) Moderate
C) Severe
D) Panic - ANSB
A nurse is caring for a client who is experiencing moderate anxiety. Which of the following
actions should the nurse trying to give necessary information to the client? (Select all that apply)
A) Reassure the client that everything will be okay
B) Discuss prior use of coping mechanisms with the client
C) Ignore the client's anxiety so that she will not be embarrassed
D) Demonstrate a calm manner while using simple and clear directions
E) Gather information from the client using closed-ended questions - ANSB, D
A nurse is talking with a client who is at risk for suicide following the death of his spouse. Which
of the following statements should the nurse make?
A) I feel very feel very sorry for the loneliness you must be experiencing
B) Suicide is not the appropriate way to cope with loss
C) Losing someone close to you must be very upsetting
D) I know how difficult it is to lose a love one - ANSC
A nurse is talking with a client who is at risk for suicide following the death of his spouse. Which
of the following statements should the nurse make?
A) I feel very sorry for the loneliness you must be experiencing
B) Suicide is not the appropriate way to cope with loss
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