B
1. At the first meeting of a group of older adults at a daycare center for the elderly, the nurse asks one of the members what kinds of things she would like to do with the group. The older woman shrugs her shoulders and says, "You tell me, you're the lea
C
Over a period of several weeks, one male participant of a socialization group at a community day care center for the elderly monopolizes most of the group's time and interrupts others when they are talking. What is the best action for the nurse to take in
C.
An 86-year-old female client with Alzheimer's disease is wandering the busy halls of the extended care facility and asks the nurse, "Where should I stand for the parade?" Which response is best for the nurse to provide?
A "Anywhere you want to stand as lo
B
Physical examination of a 6-year-old reveals several bite marks in various locations on his body. X-ray examination reveals healed fractures of the ribs. The mother tells the nurse that her child is always having accidents. Which initial response by the n
C
A child is brought to the emergency room with a broken arm. Because of other injuries, the nurse suspects the child may be a victim of abuse. When the nurse tries to give the child an injection, the child's mother becomes very loud and shouts, "I won't le
A.
.
A 38-year-old female client is admitted with a diagnosis of paranoid schizophrenia. When her tray is brought to her, she refuses to eat and tells the nurse, "I know you are trying to poison me with that food." Which response would be most appropriate fo
D.
A 25-year-old female client has been particularly restless and the nurse finds her trying to leave the psychiatric unit. She tells the nurse, "Please let me go! I must leave because the secret police are after me." Which response is best for the nurse to
c
. A 45-year-old male client tells the nurse that he used to believe that he was Jesus Christ, but now he knows he is not. Which response is best for the nurse to make?
A "Did you really believe you were Jesus Christ?"
B "I think you're getting well."
C "O
C
. A nurse working in the emergency room of a children's hospital admits a child whose injuries could have resulted from abuse. Which statement most accurately describes the nurse's responsibility in cases of suspected child abuse?
A The nurse should obtai
B
. A client who is being treated with lithium carbonate for bipolar disorder develops diarrhea, vomiting, and drowsiness. What action should the nurse take?
A Notify the healthcare provider immediately and prepare for administration of an antidote.
B Notif
B
A client on the psychiatric unit appears to imitate a certain nurse on the unit. The client seeks out this particular nurse and imitates the nurse's mannerisms. The nurse knows that the client is using which defense mechanism?
A Sublimation.
B Identificat
D
A client, who is on a 30-day commitment to a drug rehabilitation unit, asks the nurse if he can go for a walk on the grounds of the treatment center. When he is told that his privileges do not include walking on the grounds, the client becomes verbally ab
B
The nurse is planning the care for a 32-year-old male client with acute depression. Which nursing intervention would be best in helping this client deal with his depression?
A Ensure that the client's day is filled with group activities.
B Assist the clie
D
. An anxious client expressing a fear of people and open places is admitted to the psychiatric unit. What is the most effective way for the nurse to assist this client?
A Plan an outing within the first week of admission.
B Distract her whenever she expre
C
. A client with bipolar disorder on the mental health unit becomes loud, and shouts at one of the nurses, "You fat tub of lard! Get something done around here!" What is the best initial action for the nurse to take?
A Have the orderly escort the client to
A
. A 35-year-old male client who has been hospitalized for two weeks for chronic paranoia continues to state that someone is trying to steal his clothing. The most appropriate action for the nurse to take is to
A encourage the client to actively participat
D
On admission, a highly anxious client is described as delusional. The nurse understands that delusions are most likely to occur with which class of disorder?
A Neurotic.
B Personality.
C Anxiety.
D. Psychotic
D.
A client is admitted with a diagnosis of depression. The nurse knows that which characteristic is most indicative of depression?
A Grandiose ideation.
B Self-destructive thoughts.
C Suspiciousness of others.
D. A negative view of self and the future
C.
A 45-year-old female client is admitted to the psychiatric unit for evaluation. Her husband states that she has been reluctant to leave home for the last six months. The client has not gone to work for a month and has been terminated from her job. She has
A.
. A client who has been admitted to the psychiatric unit tells the nurse, "My problems are so bad that no one can help me." Which response is best for the nurse to make?
A "How can I help?"
B "Things probably aren't as bad as they seem right now."
C "Let'
A
A woman brings her 48-year-old husband to the outpatient psychiatric unit and describes his behavior to the admitting nurse. She states that he has been sleepwalking, cannot remember who he is, and exhibits multiple personalities. The nurse knows that the
C
. An adult male client who was admitted to the mental health unit yesterday tells the nurse that microchips were planted in his head for military surveillance of his every move. Which response is best for the nurse to provide?
A "You are in the hospital,
B
. A male adolescent is admitted with bipolar disorder after being released from jail for assault with a deadly weapon. When the nurse asks the teen to identify his reason for the assault, he replies, "Because he made me mad!" Which goal is best for the nu
A
. A male client with schizophrenia tells the nurse that the voices he hears are saying, "You must kill yourself." To assist the client in coping with these thoughts, which response is best for the nurse to provide?
A "Tell yourself that the voices are unr
B
. The nurse is assessing a client's intelligence. Which factor should the nurse remember during this part of the mental status exam?
A Acute psychiatric illnesses impair intelligence.
B Intelligence is influenced by social and cultural beliefs.
C Poor con
A.
. A 30-year-old sales manager tells the nurse, "I am thinking about a job change. I don't feel like I am living up to my potential." Which of Maslow's developmental stages is the sales manager attempting to achieve?
A Self-Actualization.
B Loving and Belo
A
. A homeless person who is in the manic phase of bipolar disorder is admitted to the mental health unit. Which laboratory finding obtained on admission is most important for the nurse to report to the healthcare provider?
A Decreased thyroid stimulating h
ABDE
. A female client with obsessive-compulsive disorder (OCD) is describing her obsessions and compulsions and asks the nurse why these make her feel safer. What information should the nurse include in this client's teaching plan? (Select all that apply.)
A
C
. The nurse observes a client who is admitted to the mental health unit and identifies that the client is talking continuously, using words that rhyme but that have no context or relationship with one topic to the next in the conversation. This client's b
B
. The nurse is assessing the parents of a nuclear family who are attending a support group for parents of adolescents. According to Erikson, these parents who are adapting to middle adulthood should exhibit which characteristic?
A Loss of independence.
B
D
. The nurse is taking a history for a female client who is requesting a routine female exam. Which assessment finding requires follow-up?
A Menstruation onset at age 9.
B Contraceptive method includes condoms only.
C Menstrual cycle occurs every 35 days.
D
. Which statement about contemporary mental health nursing practice is accurate?
A There is one approved theoretical framework for psychiatric nursing practice.
B Psychiatric nursing has yet to be recognized as a core mental health discipline.
C Contempor
C
. A woman arrives in the Emergency Center and tells the nurse she thinks she has been raped. The client is sobbing and expresses disbelief that a rape could happen because the man is her best friend. After acknowledging the client's fear and anxiety, how
ABDEF
The nurse should include which interventions in the plan of care for a severely depressed client with neurovegetative symptoms? (Select all that apply.)
A Permit rest periods as needed.
B Speaking slowly and simply.
C Place the client on suicide precautio
B
A 40-year-old male client diagnosed with schizophrenia and alcohol dependence has not had any visitors or phone calls since admission. He reports he has no family that cares about him and was living on the streets prior to this admission. According to Eri
B
The wife of a male client recently diagnosed with schizophrenia asks the nurse, "What exactly is schizophrenia? Is my husband all right?" Which response is best for the nurse to provide to this family member?
A "It sounds like you're worried about your hu
B
. On admission to a residential care facility, an elderly female client tells the nurse that she enjoys cooking, quilting, and watching television. Twenty-fours after admission, the nurse notes that the client is withdrawn and isolated. It is best for the
B
. A male client with mental illness and substance dependency tells the mental health nurse that he has started using illegal drugs again and wants to seek treatment. Since he has a dual diagnosis, which person is best for the nurse to refer this client to
A
. A male client is admitted to a mental health unit on Friday afternoon and is very upset on Sunday because he has not had the opportunity to talk with the healthcare provider. Which response is best for the nurse to provide this client?
A "Let me call an
C
. The community health nurse talks to a male client who has bipolar disorder. The client explains that he sleeps 4 to 5 hours a night and is working with his partner to start two new businesses and build an empire. The client stopped taking his medication
B
. A young adult male client, diagnosed with paranoid schizophrenia, believes that world is trying poison him. What intervention should the nurse include in this client's plan of care?
A Remind the client that his suspicions are not true.
B Ask one nurse t
C
. The nurse is planning care for a 32-year-old male client diagnosed with HIV infection who has a history of chronic depression. Recently, the client's viral load has begun to increase rather than decrease despite his adherence to the HIV drug regimen. Wh
D
. Which diet selection by a client who is depressed and taking the MAO inhibitor tranylcypromine sulfate (Parnate) indicates to the nurse that the client understands the dietary restrictions imposed by this medication regimen?
A Hamburger, French fries, a
C
. A 19-year-old female client with a diagnosis of anorexia nervosa wants to help serve dinner trays to other clients on a psychiatric unit. What action should the nurse take?
A Encourage the client's self-motivation by asking her to pass trays for the res
A
. A 72-year-old female client is admitted to the psychiatric unit with a diagnosis of major depression. Which statement by the client should be of greatest concern to the nurse and require further assessment?
A "I will die if my cat dies." Correct
B "I do
C>
. A 22-year-old male client is admitted to the emergency center following a suicide attempt. His records reveal that this is his third suicide attempt in the past two years. He is conscious, but does not respond to verbal commands for treatment. Which ass
C
. A client who is known to abuse drugs is admitted to the psychiatric unit. Which medication should the nurse anticipate administering to a client who is exhibiting benzodiazepine withdrawal symptoms?
A Perphenazine (Trilafon).
B Diphenhydramine (Benadryl
C
. A client is receiving substitution therapy during withdrawal from benzodiazepines. Which expected outcome statement has the highest priority when planning nursing care?
A Client will not demonstrate cross-addiction.
B Co-dependent behaviors will be decr
A
The nurse is preparing to administer phenelzine sulfate (Nardil) to a client on the psychiatric unit. Which complaint related to administration of this drug would the nurse expect this client to make?
A "My mouth feels like cotton." Correct
B "That stuff
B
. When preparing a teaching plan for a client who is to be discharged with a prescription for lithium carbonate (Lithonate), it is most important for the nurse to include which instruction?
A "It may take 3 to 4 weeks to achieve therapeutic effects."
B "K
B
. An elderly female client with advanced dementia is admitted to the hospital with a fractured hip. The client repeatedly tells the staff, "Take me home. I want my Mommy." Which response is best for the nurse to provide?
A Orient the client to the time, p
B
. A male client is admitted to the mental health unit because he was feeling depressed about the loss of his wife and job. The client has a history of alcohol dependency and admits that he was drinking alcohol 12 hours ago. Vital signs are: temperature, 1
D
. A 27-year-old female client is admitted to the psychiatric hospital with a diagnosis of bipolar disorder, manic phase. She is demanding and active. Which intervention should the nurse include in this client's plan of care?
A Schedule her to attend vario
D
. The nurse plans to help an 18-year-old female intellectually disabled client ambulate the first postoperative day after an appendectomy. When the nurse tells the client it is time to get out of bed, the client becomes angry and tells the nurse, "Get out
B
A 46-year-old female client has been on antipsychotic neuroleptic medication for the past three days. She has had a decrease in psychotic behavior and appears to be responding well to the medication. On the fourth day, the client's blood pressure increase
C
A male client is admitted to the psychiatric unit with a medical diagnosis of paranoid schizophrenia. During the admission procedure, the client looks up and states, "No, it's not MY fault. You can't blame me. I didn't kill him, you did." What action is b
C
. A 35-year-old male client on the psychiatric unit of a general hospital believes that someone is trying to poison him. The nurse understands that a client's delusions are most likely related to his
A early childhood experiences involving authority issue
D
. A client who is diagnosed with schizophrenia is admitted to the hospital. The nurse assesses the client's mental status. Which assessment finding is most characteristic of a client with schizophrenia?
A Mood swings.
B Extreme sadness.
C Manipulative beh
C
. The nurse is conducting discharge teaching for a client with schizophrenia who plans to live in a group home. Which statement is most indicative of the need for careful follow-up after discharge?
A "Crickets are a good source of protein."
B "I have not
A
. The nurse is planning discharge for a male client with schizophrenia. The client insists that he is returning to his apartment, although the healthcare provider informed him that he will be moving to a boarding home. What is the most important nursing d
D
. A female client refuses to take an oral hypoglycemic agent because she believes that the drug is being administered as part of an elaborate plan by the Mafia to harm her. Which nursing intervention is most important to include in this client's plan of c
B
. A nurse working on a mental health unit receives a community call from a person who is tearful and states, "I just feel so nervous all of the time. I don't know what to do about my problems. I haven't been able to sleep at night and have hardly eaten fo
D
. A female client with depression attends group and states that she sometimes misses her medication appointments because she feels very anxious about riding the bus. Which statement is the nurse's best response?
A "Can your case manager take you to your a
C
. Within several days of hospitalization, a client is repeatedly washing the top of the same table. Which initial intervention is best for the nurse to implement to help the client cope with anxiety related to this behavior?
A Administer a prescribed PRN
B
. The charge nurse is collaborating with the nursing staff about the plan of care for a client who is very depressed. What is the most important intervention to implement during the first 48 hours after the client's admission to the unit?
A Monitor appeti
B
. A 65-year-old female client complains to the nurse that recently she has been hearing voices. What question should the nurse ask this client first?
A "Do you have problems with hallucinations?"
B "Are you ever alone when you hear the voices?"
C "Has any
D
. The nurse should hold the next scheduled dose of a client's haloperidol (Haldol) based on which assessment finding(s)?
A Dizziness when standing.
B Shuffling gait and hand tremors.
C Urinary retention.
D Fever of 102 F.
A
. A homeless person who is in the manic phase of bipolar disorder is admitted to the mental health unit. Which laboratory finding obtained on admission is most important for the nurse to report to the healthcare provider?
A Decreased thyroid stimulating h