A nurse in a mental health facility is reviewing confidentiality requirement with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of this information?
I should keep personal information private even after a client dies
A nurse in an outpatient mental health clinic is interviewing a client who has schizophrenia and appears to be experiencing auditory hallucinations. Which of the following actions should the nurse take first?
Explore what the voices are saying to the client
A nurse is administering an oral sedative to a client who is receiving care following an involuntary admission. The client states "I'm not taking any more medication." Which of the following actions should the nurse perform?
Document the client's refusal of the medication in the medical record
A nurse is interviewing a client who has a new diagnosis of major depression. Which of the following questions is the nurse's pritority?
Have you thought about hurting yourself?
A nurse is caring for a client who has a substance use disorder and was involuntarily admitted by court order for 90 days. When the nurse attempts to administer prescribed oral lorazepam to decrease the manifestations of withdrawal, the client aggressivel
Place the lorazepam on hold
A nurse is creating a plan of care for a client who has Alzheimer's disease with moderate cognitive decline. Which of the following interventions should the nurse include to orient the client to the present?
Talk with the client about scheduled daily activities
A nurse is creating a plan of care for a client who has borderline personality disorder and exhibits manipulative behaviors. Which of the following interventions should the nurse include to address limit-setting?
Establish and explain consequences for the client's behavior
A nurse is caring for a client who has panic disorder and is experiencing anxiety at the panic level. Which of the following actions should the nurse take first?
Instruct the client to take slow, deep breaths
A nurse in a long-term care facility is caring for a client who has dementia and becomes increasingly agitated in the afternoon. Which of the following actions should the nurse take first?
Offer diversionary activities for the client
A nurse is caring for a client who is postoperative following an amputation of the left lower leg. The client states, "I can't believe this has happened to me. I don't deserve this." Which of the following responses should the nurse provide?
Tell me what you're feeling about what has happened
A nurse is talking with a client about his admission to a mental health unit. The client states "I just don't know if I should be here. What will my family think?" Which of the following responses by the nurse uses the therapeutic communication technique
It sounds like you are concerned about your family's reaction
A nurse is caring for a client who has schizophrenia and is admitted to the mental health unit. The client has a history of aggression and is observed continually pacing the hallway in an agitated manner over the past hour. Which of the following response
You are pacing back and forth. Can you tell me what you are feeling?
A nurse is talking with a client who has major depressive disorder. Which of the following client statements should the nurse identify as a covert statement of suicidal ideation?
I won't have to deal with things much longer
A nurse is caring for a client who has schizophrenia. Which of the following client statements should the nurse identify as a persecutory delusion?
The government is after me because I know top-secret information.
A nurse is talking with the partner of a client who has alcohol use disorder. Which of the following statements by the client's partner should the nurse identify as an indication of codependence?
I call my partner's boss when she's drunk and can't go to work
A nurse is caring for a client who was hospitalized several days ago following a suicide attempt. The client states, "I do not want visitor today because I look and feel terrible"' Which of the following responses should the nurse make?
Would you like to talk about why you feel this way?
A nurse is caring for a client who has Alzheimers' disease. The client's adult son states the client has begun wandering away from her home. Which of the following responses should the nurse offer?
Place a complex lock at the top of each door that leads outside
A nurse is caring for a client who has OCD and feels compelled to pace the floor for a specific number of times each day or "something bad will happen" Which of the following responses should the nurse make?
It may help if we talk about why you find it necessary to pace the floor
A nurse is developing a plan of care for a client who has alcohol use disorder. Which of the following medications should the nurse plan to administer?
Diazepam
A nurse is caring for a client with schizophrenia and is hearing voices. Which of the following actions is the nurses's priority?
Ask the client what the voices are saying
A nurse is assessing a client who was recently admitted following a suicide attempt. Which of the following behaviors is the priority for the nurse to report to the adolescent's treatment team?
Giving away possession
A nurse is communicating with a newly admitted client. Which of the following rationales identifies the nurse's purpose for using therapeutic communication with the client?
Therapeutic communication builds a relationship that will allow expression of mutual concerns
A nurse is caring for a client who has bipolar disorder and has been prescribed lithium. The client's adult child states "I'm upset that my father is taking this medication" Which of the following responses should the nurse make?
Tell me what worries you about tour father taking this medication
A nurse is planning care for a client who has bipolar disorder and has acute mania. Which of the following interventions should the nurse include in the plan?
Encourage the client to have frequent rest periods
A nurse is interviewing a client who is seeking help for intimate partner violence. Which of the following client statements should the nurse identify as an indication that the client is in the tension-building phase of the cycle of violence?
I only got shoved a little bit, and it was my fault for coming home late
A client who has hypertension tells the nurse in a provider's office that she feels the considerable amount of stress at work is affecting her blood pressure control. The nurse should instruct the client to do which of the following when the stress is una
Improve her ability to cope with identified stressors
A nurse is interviewing an older adult client about possible abuse by her caregiver. Which of the following techniques should the nurse use?
Maintain a nonjudgmental tone
A nurse in a mental health clinic is assessing a client who has a history of mania. Which of the following findings indicates that the client is experiencing a relapse?
Pressured Speech
A nurse is admitting a client who has antisocial personality disorder to an acute care unit. The client is admitted under a court order following the theft and destruction of a car. Which of the following behaviors should the nurse expect the client to di
Anger with the nursing staff for hospitalizing him against his will
A nurse is an acute substance disorder unit is assessing a client who received treatment in the emergency department for a heroin overdose. Which of the following findings should the nurse anticipate during heroin withdrawal?
Muscle aches
A nurse is caring for a client who has severe anxiety disorder and is in a state of panic in the dayroom. Which of the following actions should the nurse take?
Speak to the client in a calm voice
A nurse asks an older adult client, "Did you have any visitors yesterday?" The client responds "yes, several members of my church choir came to see me" The nurse knows that only the client's daughter visited on the day in question. Which of the following
Confabulation
A nurse is performing an admission assessment for a client who has restricitng-type anorexia nervosa. The nurse should expect which of the following findings?
Decreased caloric intake
A nurse is caring for a client who has major depressive disorder and recently started taking an antidepressant. The nurse should identify which of the following client statements as the priority?
I have it all figured out. Everything is going to be okay now.
A nurse in the emergency department is caring for a toddler who has a fractured arm. Which of the following findings should the nurse identify as a possible indication of physical abuse?
The parent provides a history that is inconsistent with the child's injury.
A nurse is establishing a therapeutic relationship with a client who has hallucinations. Which of the following actions should the nurse take during the orientation phase?
Identify the client's perception of the reason for therapy
A nurse is assessing a client who is experiencing moderate-level anxiety. Which of the following findings should the nurse expect?
The client has difficulty concentrating
A nurse is caring for a client who has dementia. The client states to the nurse, "Everyone wants to kill me." Which of the following responses should the nurse make?
You must feel very frightened to think someone wants to hurt you
A nurse is caring for a client who reminds her of a negative person in her past. These memories cause the nurse to unconsciously displace negative feelings onto the client. The nurse should recognize that she is demonstrating which fo the following behavi
Countertransference
A nurse is caring for a client whose adolescent child just died in a motor-vehicle crash. The client is crying inconsolably. Which of the following actions should the nurse take?
Stay with the client and allow the client to cry
A nurse is counseling a client who seems relaxed initially but then becomes restless and begins wringing his hands. The nurse states that the client seems tense and the client agrees. Which of the following statements should the nurse make?
What were we discussing when you began to feel uncomfortable?
A nurse in an acute mental health facility is caring for a client who has schizophrenia. The client asks the nurse "Can I vote in the upcoming presidential election?" Which of the following responses should the nurse offer?
We can work together to find out how you can get a mail-in ballot
A nurse is caring for a clien with borderline personality disorder (BPD) who exhibits a pattern of behavior of playing a staff member against another. Which of the following actions should the nurse take?
Explore with the client his use of clinging and distancing behaviors
A nurse is talking with an adolescent client who has major depressive disorder. The client tells the nurse about a situation in which he feels a friend betrayed him. Which of the following responses should the nurse make?
How does this situation make you feel?
A nurse is caring for a client who has bipolar disorder and is experiencing hypomania. During a conversation with other clients, she becomes agitated and begins speaking in a loud, angry voice. Which of the following actions should the nurse take?
Ask the client to take a walk
A nurse is interacting with a client who has a psychotic disorder. The client suddenly turns her head as if she is listening to something and says, "The boss says she is going to hit me with a stick" Which of the following responses should the nurse make?
I don't see anyone, but it sounds like you are frightened
A nurse is interacting with a client in the dayroom of an acute mental health facility. The client accuses the nurse of being "too bossy" and states the nurse does not have the right to pressure anyone. Which of the following responses should the nurse of
Tell me what I said to make you uncomfortable
A client recently diagnosed with terminal cancer states to the nurse, "I wish I were dead. I have no reason to live" Which of the following responses should the nurse make?
Have you been thinking of hurting yourself
A nurse is caring for a client who has bipolar disorder. Which of the following manifestations is the priority finding for the nurse to identify?
Hyperactivity
A nurse is caring for a client who has antisocial personality disorder. Which of the following actions should the nurse take?
Ensure the staff members set limits on the client's behavior
A nurse is assessing a client who states that she needs help with depression. Which of the following questions is the nurse's priority?
Have you thought about harming yourself in any way?
A nurse is caring for a client who is experiencing panic-level anxiety. Which of the following actions should the nurse take?
Speak to the client firmly and authoratatively
A nurse is assessing a client who has schizophrenia and takes haloperidol 3 times daily. The client has developed involuntary writhing movements of the tongue and constant lip smacking. The nurse should identify that these manifestations indicate which of
Tardive Dyskenesia
A nurse is evaluating teaching for a client who has bipolar disorder and a new prescription for lithium. Which of the following statements by the client indicates an understanding of the teaching?
I am likely to gain weight while taking lithium
A nurse in an acute mental health facility is reviewing the medication records of a group of clients. The nurse should expect a prescription for memantine for a client who has which of the following diagnoses?
Sever Alzheimer's Disease
A nurse is providing teaching to a client who has schizophrenia and is taking quetiapine fumarate. Which of the following blood tests should be performed periodically?
Glucose
A nurse is providing teaching to a client who has a new prescription for chlorpromazine. Which of the following statements should the nurse make?
This medication is an antipsychotic that control manifestations of schizophrenia
A nurse is assessing a client who has been taking an antipsychotic medication for 6 years. The provider has started tapering off the client's dosage. The nurse should monitor the client for which of the following manifestations?
Involuntary tongue protrusion
A nurse is providing teaching to a client who has a new prescription for clozapine. Which of the following statements should the nurse include in the teaching?
You should have your white blood cell count checked once per week for 6 months
A nurse is assessing a client who is taking buspirone to treat generalized anxiety disorder. Which of the following findings should the nurse identify as an adverse effect of this medication?
Xerostomia (dry mouth)
A nurse is assessing a client prior to administering lithium. The client began taking lithium 1 week ago for the treatment of mania. For which of the following findings should the nurse withhold the dose?
Report of nausea with frequent episodes of emesis
A nurse is planning care for a client who is scheduled to undergo ECT. Which of the following interventions should the nurse include?
Reorient the client to the environment after ECT
A nurse is interviewing a client who has anorexia nervosa. Which of the following findings should the nurse expect?
Strenuous exercise regimen
A nurse on an impatient unit is assessing a client who has claustrophobia. The nurse determines the client's conditions has improved when he can perform which of the following tasks?
Ride in an elevator
A nurse is planning an in-service session about involuntary commitment to mental health facilities for a group of newly licensed nurses. Which of the following pieces of information should the nurse include?
The client can challenge hospitalization following emergency treatment
A nurse is caring for a client who has end-stage lung cancer. Which of the following client statements should the nurse identify as an indication that the client is experiencing the bargaining stage of Kubler-Ross' stages of grief?
I would give anything to live to see my grandchild born
A nurse is caring for a child who has Tourette's disorder. Which of the following behaviors should the nurse expect?
Multiple motor and vocal tics
A school nurse is providing care to a student is and angry and states "My parents don't know I'm gay, so I can't visit my girlfriend in the hospital while she receives cancer treatment" Which of the following forms of grief is the client experiencing?
Disenfranchised Grief
A nurse is caring for 4 clients in a community mental health facility. For which of the following clients should the nurse provide a tertiary care intervention?
A client who is recovering from a crisis and asks for help in completing the recovery process
A nurse is assessing a client who has a new diagnosis of major depressive disorder. Which of the following questions is the priority for the nurse to ask?
Do you ever think about suicide?
A nurse is speaking with a client whose partner was killed unexpectedly. The client states "I just don't know what to do now" Which of the following actions should the nurse take?
Talk to the client about available community resources
A nurse is preparing to care for a client who was brought to a community health facility by her caregiver, who states that the client refuses to eat. The nurse notes the client has lost weight, avoids making eye contact, and defers questions to the caregi
Identify sources of stress for the caregiver
A nurse is teaching a client who has seasonal affective disorder (SAD) about the use of light therapy. Which of the following statements should the nurse make?
Light therapy suppresses the natural nighttime release of melatonin
A nurse is teaching a client who has major depressive disorder and is scheduled to begin ECT. Which of the following pieces of information should the nurse include?
You can expect to wake up about 15 minutes after the procedure
A nurse is caring for a client who has dementia. Which of the following actions should the nurse take?
Maintain a low-stimulation environment
A nurse is speaking with parents who are at a clinic for a 2-week follow-up visit after the birth of their second child. They report that their 5-year-old daughter has started to wet the bed at night after being toilet trained for 2 years. The nurse shoul
Regression
A nurse is assessing a client who has a history of methamphetamine use. Which of the following findings indicates that the client is currently under the influence of this drug?
Paranoia
A nurse is counseling a client following a recent death in the family. Which of the following situations should the nurse identify as a risk factor for maladaptive grieving?
The death was a result of violence
A nurse in the emergency department is treating a child who has bruises. The nurse suspects child abuse, but the provider disagrees and discharges the client. Which of the following actions should the nurse take?
Report the suspected abuse to law enforcement
A nurse is caring for a client who has an alcohol use disorder and is currently undergoing alcohol detoxification. Which of the following interventions should the nurse provide at this time?
Administer substitution therapy medications
A nurse is assessing a client who is experiencing alcohol withdrawal. For which of the following findings should the nurse anticipate the administration of lorazepam?
increased blood pressure
A nurse is caring for a client who has tardive dyskinesia. Which of the following tools should the nurse use in performing an assessment on the client?
Abnormal Involuntary Movement Scale (AIMS)
A nurse is reviewing laboratory reports for a client who is taking risperidone. The nurse should identify that which of the following results indicates a potential adverse reaction to the medication?
Elevated blood glucose
A nurse is providing teaching to a client who has a new prescription for busiprone. Which of the following statements by the client indicates an understanding fo the teaching?
I might not notice the effects of this medication for several weeks
A nurse is providing dietary teaching to a client who has a new prescription for a monoamine oxidase inhibitor (MAOI). Which of the following food selections by the client indicates an understanding of the teaching?
yogurt
A nurse is monitoring a client who has schizophrenia and is receiving treatment with fluphenazine hydrochloride. Which of the following findings is an indication of neuroleptic malignant syndrome that the nurse should report to the provider?
Elevated temperature
A nurse is assessing a client who is receiving disulfiram for alcohol aversion therapy. The client is experiencing palpitations and reports nausea, a headache and extreme thirst. The nurse should identify that which of the following situations is occuring
The client is experiencing mild acetaldehyde syndrome
A nurse is assessing a client who has ADHD and reports abruptly discontinuing his amphetamine treatment. Which of the following assessments indicates that the client is physically dependent on the amphetamines?
The client reports eating excessively
A nurse is caring for a client who has anxiety disorder. Which of the following statements by the client should the nurse recognize as demonstrating the defense mechanism of displacement?
My partner yelled at me, so I made the cat go outdoors
A nurse is caring for a client who has social anxiety disorder. Which of the following client statements should the nurse expect?
I am embarrassed to to eat in public.
A nurse is assessing a client who has bipolar disease. Which of the following actions is an indication the client is experiencing a manic stage?
the client speaks rapidly with a sense of urgency
A nurse in a provider's office is assessing a client who is crying and states "It's my child's first day of school" The nurse should recognize that the client is experiencing which of the following types of loss?
Maturational Loss
A nurse is caring for a client who has schizophrenia and is experiencing negative symptoms. Which of the following manifestations should the nurse expect?
Social Discomfort
A nurse is providing teaching to a client who has ADHD and a new prescription for a transdermal methylphenidate patch. Which of the following statements by the client indicates an understanding of the teaching?
I can take showers with the patch in place.
A nurse is providing teaching to a client who has panic disorder and a new prescription for clomipramine. Which of the following adverse effects should the nurse include in the teaching?
Sedation
A nurse is caring for a client who requests information about smoking cessation using nicotine gum. For which of the following reasons should the nurse recommend another over-the-counter smoking cessation product to the client?
The client has dentures
A nurse is providing teaching to a client who has a new prescription for varenicline for smoking cessation. Which of the following statements by the client indicates an understanding of the teaching?
I will take the medication after eating a meal
A nurse working in a retirement community is assessing an older adult client. Which of the following manifestations should the nurse identify as an expected age-related change?
Making occasional errors when balancing a chekcbook
A nurse is providing teaching to the caregiver of a child who has pica. Which of the following statements should the nurse identify as an indication that the caregiver understands the teaching?
My child might try to eat dirt when we are at the playground
A nurse on an eating disorders acute care unit is assessing a client and observes the presence of lanugo on her skin. The nurse should identify that this finding is consistent with which of the following eating disorders?
Anorexia Nervosa