1. 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." ...
1 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 t
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,1. 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."
2. 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.
3. 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.
4. 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.
,5. A nurse is planning a peer group discussion 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.
6. 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
7. 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
8. 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 health care team because it
concerns the health and safety of the client and others.
, 9.
D. Report the incident to the health care team, but do not inform the client of the
intention to do so.
10.AA 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."
11. 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?
12.
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.
13.AA 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 whats wrong. Have you asked the doctor about your concerns?"
D. "I understand you're concerned. Let's discuss what concerns you specifically."
14. 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
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