nclex mental health

8/17/2019 NCLEX Mental Health

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Mental Health

1. The home care nurse is visiting an older client whose

spouse died 6 months ago. Which behavior by the client

indicates ineffective coping?

1. Neglecting personal grooming

2. Looing at old snapshots of family

!. "articipating in a senior citi#ens$ program

%. &isiting their spouse$s grave once a month

1. Neglecting personal grooming

2. ' client with a diagnosis of ma(or depression who has

attempted suicide says to the nurse) *+ should have died.

+$ve always been a failure. Nothing ever goes right for me.*

Which response demonstrates therapeutic communication?

1. *,ou have everything to live for.*

2. *Why do you see yourself as a failure?*

!. *-eeling lie this is all part of being depressed.*%. *,ou$ve been feeling lie a failure for a while?*

%. *,ou$ve been feeling lie a failure for a while?*

!. When the mental health nurse visits a client at home) the

client states) *+ haven$t slept at all the last couple of nights.*

Which response by the nurse illustrates a therapeutic

communication response to this client?

1. *+ see.*2. *eally?*

!. *,ou$re having difficulty sleeping?*

%. */ometimes) + have trouble sleeping too.*

!. *,ou$re having difficulty sleeping?*


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%. ' client e0periencing disturbed thought processes believes

that his food is being poisoned. Which communication

techniue should the nurse use to encourage the client to

eat?1. sing open3ended uestions and silence

2. /haring personal preference regarding food choices

!. 4ocumenting reasons why the client does not want to eat

%. 5ffering opinions about the necessity of adeuate

nutrition

1. sing open3ended uestions and silence

. ' client admitted to a mental health unit for treatment of psychotic behavior spends hours at the loced e0it door

shouting) *Let me out. There$s nothing wrong with me. +

don$t belong here.* What defense mechanism is the client

implementing?

1. 4enial

2. "ro(ection

!. egression%. ationali#ation

1. 4enial

6. ' client diagnosed with terminal cancer says to the nurse)

*+$m going to die) and + wish my family would stop hoping

for a cure7 + get so angry when they carry on lie this. 'fter

all) +$m the one who$s dying.* Which response by the nurse

is therapeutic?

1. *8ave you shared your feelings with your family?*

2. *+ thin we should tal more about your anger with your

family.*

!. *,ou$re feeling angry that your family continues to hope


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for you to be cured?*

%. *,ou are probably very depressed) which is

understandable with such a diagnosis.*

!. *,ou$re feeling angry that your family continues to hope for you to be cured?*

9. 5n review of the client$s record) the nurse notes that the

mental health admission was voluntary. :ased on this

information) the nurse anticipates which client behavior?

1. -earfulness regarding treatment measures.

2. 'nger and aggressiveness directed toward others.

!. 'n understanding of the pathology and symptoms of the

diagnosis.%. ' willingness to participate in the planning of the care

and treatment plan.

%. ' willingness to participate in the planning of the care and treatment plan.

;. When reviewing the admission assessment) the nurse notes

that a client was admitted to the mental health unit

involuntarily. :ased on this type of admission) the nurseshould provide which intervention for this client?

1.


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this phase?

1. "lanning short3term goals

2.


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1. 4enial

12. ' client$s unresolved feelings related to loss would

be most likely observed during which phase of the

therapeutic nurse3client relationship?1. Trusting

2. Woring

!. 5rientation

%. Termination

%. Termination

1!. The nurse is woring with a client who despite mainga heroic effort was unable to rescue a neighbor trapped in a

house fire. Which client3focused action should the nurse

engage in during the woring phase of the nurse3client

relationship?

1. @0ploring the client$s ability to function

2. @0ploring the client$s potential for self3harm

!. +nuiring about the client$s perception or appraisal of

why the rescue was unsuccessful%. +nuiring about and e0amining the client$s feelings for

any that may bloc adaptive coping

%. +nuiring about and e0amining the client$s feelings for any that may bloc adaptive

coping

1%. The nurse employed in a mental health unit of a

hospital is the leader of a group psychotherapy session.

What is the nurse$s role during the termination stage of

group development?

1. 'cnowledging that the group has identified goals

2. @ncouraging the accomplishment of the group$s wor

!. 'cnowledging the contributions of each group member


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%. @ncouraging members to become acuainted with one

another

!. 'cnowledging the contributions of each group member

1. Which are characteristics of the termination stage of

group development? Select all that apply.

1. The group evaluates the e0perience.

2. The real wor of the group is accomplished.

!. roup interaction involves superficial conversation.

%. roup members become acuainted with each other.

. /ome structuring of group norms) roles) and

responsibilities taes place.6. The group e0plores members$ feelings about the group

and the impending separation.

o 1. The group evaluates the e0perience.

o 6. The group e0plores members$ feelings about the group and the impending

separation.

16. When a client is admitted to an inpatient mental healthunit with the diagnosis of anore0ia nervosa) a cognitive

behavioral approach is used as part of the treatment plan.

The nurse understands that which is the purpose of this

approach?

1. "roviding a supportive environment

2. @0amining intrapsychic conflicts and past issues

!. @mphasi#ing social interaction with clients whowithdraw

%. 8elping the client to e0amine dysfunctional thoughts and

beliefs

%. 8elping the client to e0amine dysfunctional thoughts and beliefs


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19. The nurse understands that which best describes

estalt therapy?

1. +t emphasi#es self3e0pression) self3e0ploration) and self3

awareness in the present.2. +t promotes the individual$s comfort in the group) which

then transfers to other relationships.

!. The therapist focuses on how irrational beliefs and

thoughts contribute to psychological distress.

%. The therapist$s goal is to help others e0press their

feelings toward one another during group sessions.

1. +t emphasi#es self3e0pression) self3e0ploration) and self3awareness in the present.

1;. ' client is preparing to attend a amblers 'nonymous

meeting for the first time. The nurse should tell the client

that which is the first step in this 123step program?

1. 'dmitting to having a problem

2. /ubstituting other activities for gambling

!. /tating that the gambling will be stopped

%. 4iscontinuing relationships with people who gamble1. 'dmitting to having a problem

1=. Which describes the primary focus of milieu therapy?

1. ' form of behavior modification therapy

2. ' cognitive approach to changing behavior

!. ' living) learning) or woring environment

%. ' behavioral approach to changing behavior

!. ' living) learning) or woring environment

2>. While being treated) a client is introduced to short

periods of e0posure to the phobic ob(ect while in a rela0ed

state. What term is used to describe this form of behavior


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modification?

1.


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2!. Which type of therapeutic approach has the

characteristic that all team members are seen as eually

important in helping clients meet their goals?

1.


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care for the client that includes which intervention?

1. @ncouraging uiet reading and writing for the first few

days

2. +dentification of physical activities that will providee0ercise

!. No sociali#ing activities) until the client ass to

participate in milieu

%. ' structured program of activities in which the client can

participate

%. ' structured program of activities in which the client can participate

29. When planning the discharge of a client with chronican0iety) the nurse directs the goals at promoting a safe

environment at home. Which is the most

appropriate maintenance goal?

1. /uppressing feelings of an0iety

2. +dentifying an0iety3producing situations

!. Bontinued contact with a crisis counselor

%. @liminating all an0iety from daily situations2. +dentifying an0iety3producing situations

2;. ' client is unwilling to go out of the house for fear of

*maing a fool of myself in public.* :ecause of this fear)

the client remains homebound. :ased on these data) which

mental health disorder is the client e0periencing?

1. 'goraphobia

2. /ocial phobia

!. Blaustrophobia

%. 8ypochondriasis

2. /ocial phobia


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2=. The nurse is conducting a group therapy session.

4uring the session) a client diagnosed with mania

consistently disrupts the group$s interactions. Which

intervention should the nurse initially implement?1. /etting limits on the client$s behavior

2. 'sing the client to leave the group session

!. 'sing another nurse to escort the client out of the group

session

%. Telling the client that they will not be able to attend any

future group sessions

1. /etting limits on the client$s behavior

!>. ' client is admitted to a medical nursing unit with a

diagnosis of acute blindness after being involved in a hit3

and3run accident. When diagnostic testing cannot identify

any organic reason why this client cannot see) a mental

health consult is prescribed. Which condition will be the

focus of this consult?

1. "sychosis2. epression

!. Bonversion disorder

%. 4issociative disorder

!. Bonversion disorder

!1. ' manic client begins to mae se0ual advance towards

visitors in the dayroom. When the nurse firmly states that

this is inappropriate and will not be allowed) the client

becomes verbally abusive and threatens physical violence

to the nurse. :ased on the analysis of this situation) which

intervention should the nurse implement?

1. "lace the client in seclusion for !> minutes.


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2. Tell the client that the behavior is inappropriate.

!. @scort the client to their room) with the assistance of

other staff.

%. Tell the client that their telephone privileges are revoedfor 2% hours.

!. @scort the client to their room) with the assistance of other staff.

!2. Which nursing interventions are appropriate for a

hospitali#ed client with mania who is e0hibiting

manipulative behavior? Select all that apply.

1. Bommunicate e0pected behaviors to the client.

2. @nsure that the client nows that they are not in chargeof the nursing unit.

!. 'ssist the client in identifying ways of setting limits on

personal behaviors.

%. -ollow through about the conseuences of behavior in a

nonpunitive manner.

. @nforce rules by informing the client that they will not

be allowed to attend therapy groups.6. 8ave the client state the conseuences for behaving in

ways that are viewed as unacceptable.

o 1. Bommunicate e0pected behaviors to the client.

o !. 'ssist the client in identifying ways of setting limits on personal behaviors.

o %. -ollow through about the conseuences of behavior in a nonpunitive manner.

o 6. 8ave the client state the conseuences for behaving in ways that are viewed as

unacceptable.

!!. The nurse observes that a client is pacing) agitated)

and presenting aggressive gestures. The client$s speech

pattern is rapid) and affect is belligerent. :ased on these


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observations) what is the nurse$s immediate priority of

care?

1. "rovide safety for the client and other clients on the unit.

2. "rovide the clients on the unit with a sense of comfortand safety.

!. 'ssist the staff in caring for the client in a controlled

environment.

%. 5ffer the client a less stimulating area to calm down in

and gain control.

1. "rovide safety for the client and other clients on the unit.

!%. The nurse is preparing a client with a history ofcommand hallucinations for discharge by providing

instructions on interventions for managing hallucinations

and an0iety. Which statement in response to these

instructions suggests to the nurse that the client understands

the instructions?

1. *


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!. /it beside the client in silence with occasional open3

ended uestions.

%. Tae the client into the dayroom with other clients so

that they can help watch him.!. /it beside the client in silence with occasional open3ended uestions.

!6. The nurse is caring for a client who is e0periencing

disturbed thought processes as a result of paranoia. +n

formulating nursing interventions with the members of the

health care team) what best instruction should the nurse

provide to the staff?

1. +ncrease sociali#ation of the client with peers.2. 'void laughing or whispering in front of the client.

!. :egin to educate the client about social supports in the

community.

%. 8ave the client sign a release of information to

appropriate parties for assessment purposes.

2. 'void laughing or whispering in front of the client.

!9. The nurse is planning activities for a client diagnosed

with bipolar disorder with aggressive social behavior.

Which activity would be most appropriate for this client?

1. Bhess

2. Writing

!. "ing pong

%. :asetball

2. Writing

!;. The home health nurse visits a client at home and

determines that the client is dependent on drugs. 4uring the

assessment) which action should the nurse tae to plan


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appropriate nursing care?

1. 's the client why he started taing illegal drugs.

2. 's the client about the amount of drug use and its

effect.!. 's the client how long he thought that he could tae

drugs without someone finding out.

%. Not as any uestions for fear that the client is in denial

and will throw the nurse out of the home.

2. 's the client about the amount of drug use and its effect.

!=. Which interventions are most appropriate for caring

for a client in alcohol withdrawal? Select all that apply.1.


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!. *+ en(oy attending the meetings because they get me out

of the house and away from my husband.*

%. *+ can tolerate my husband$s destructive behaviors now

that + now they are common with alcoholics.*1. *+ no longer feel that + deserve the beatings my husband inflicts on me.*

%1. ' hospitali#ed client with a history of alcohol abuse

tells the nurse) *+ am leaving now. + have to go. + don$t want

any more treatment. + have things that + have to do right

away.* The client has not been discharged and is scheduled

for an important diagnostic test to be performed in 1 hour.

'fter the nurse discusses the client$s concerns with theclient) the client dresses and begins to wal out of the

hospital room. What action should the nurse tae?

1. Ball the nursing supervisor.

2. Ball security to bloc all e0it areas.

!. estrain the client until the health care provider C8B"D

can be reached.

%. Tell the client that the client cannot return to this hospitalagain if the client leaves now.

1. Ball the nursing supervisor.

%2. The nurse is preparing to perform an admission

assessment on a client with a diagnosis of bulimia nervosa.

Which assessment findings does the nurse e0pect to

note? Select all that apply.

1. 4ental decay

2.


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o 1. 4ental decay

o !. Loss of tooth enamel

o %. @lectrolyte imbalances

%!. The nurse is caring for a female client who was

admitted to the mental health unit recently for anore0ia

nervosa. The nurse enters the client$s room and notes that

the client is engaged in rigorous push3ups. Which nursing

action is most appropriate?

1. +nterrupt the client and weigh her immediately.

2. +nterrupt the client and offer to tae her for a wal.

!. 'llow the client to complete her e0ercise program.

%. Tell the client that she is not allowed to e0ercise

rigorously.

2. +nterrupt the client and offer to tae her for a wal.

%%. ' client with a diagnosis of anore0ia nervosa) who is

in a state of starvation) is in a two3bed room. ' newly

admitted client will be assigned to this client$s room. Whichclient would be the best choice as a roommate for the client

with anore0ia nervosa?

1. ' client with pneumonia

2. ' client undergoing diagnostic tests

!. ' client who thrives on managing others

%. ' client who could benefit from the client$s assistance at

mealtime2. ' client undergoing diagnostic tests

%. The nurse is monitoring a hospitali#ed client who

abuses alcohol. Which findings should alert the nurse to the

potential for alcohol withdrawal delirium?


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1. 8ypotension) ata0ia) hunger

2. /tupor) lethargy) muscular rigidity

!. 8ypotension) coarse hand tremors) lethargy

%. 8ypertension) changes in level of consciousness)hallucinations

%. 8ypertension) changes in level of consciousness) hallucinations

%6. The spouse of a client admitted to the mental health

unit for alcohol withdrawal says to the nurse) *+ should get

out of this bad situation.* What is the most helpful

response by the nurse?

1. *Why don$t you tell your wife about this?*2. *What do you find difficult about this situation?*

!. *This is not the best time to mae that decision.*

%. *+ agree with you. ,ou should get out of this situation.*

2. *What do you find difficult about this situation?*

%9. ' client with anore0ia nervosa is a member of a

predischarge support group. The client verbali#es that shewould lie to buy some new clothes) but her finances are

limited. roup members have brought some used clothes to

the client to replace the client$s old clothes. The client

believes that the new clothes were much too tight and has

reduced her calorie intae to ;>> calories daily. 8ow

should the nurse evaluate this behavior?

1. Normal behavior

2. @vidence of the client$s disturbed body image

!. egression as the client is moving toward the community

%. +ndicative of the client$s ambivalence about hospital

discharge


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2. @vidence of the client$s disturbed body image

%;. The nurse in the emergency department is caring for a

young female victim of se0ual assault. The client$s physical

assessment is complete) and physical evidence has beencollected. The nurse notes that the client is withdrawn)

confused) and at times physically immobile. 8ow should

the nurse interpret these behaviors?

1. /igns of depression

2. Normal reactions to a devastating event

!. @vidence that the client is a high suicide ris

%. +ndicative of the need for hospital admission2. Normal reactions to a devastating event

%=. The nurse is reviewing the assessment data of a client

admitted to the mental health unit. The nurse notes that the

admission nurse documented that the client is e0periencing

an0iety as a result of a situational crisis. The nurse

determines that this type of crisis could be caused by which

event?1. Witnessing a murder

2. The death of a loved one

!. ' fire that destroyed the client$s home

%. ' recent rape episode e0perienced by the client

2. The death of a loved one

>. The nurse is conducting an initial assessment on aclient in crisis. When assessing the client$s perception of the

precipitating event that led to the crisis) what is the most

appropriate uestion?

1. *With whom do you live?*


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2. *Who is available to help you?*

!. *What leads you to see help now?*

%. *What do you usually do to feel better?*

!. *What leads you to see help now?*

1. The nurse is developing a plan of care for a client in a

crisis state. When developing the plan) the nurse should

consider which factor?

1. ' crisis state indicates that the client has a mental illness.

2. ' crisis state indicates that the client has an emotional

illness.

!. "resenting symptoms in a crisis situation are similar forall clients e0periencing a crisis.

%. ' client$s response to a crisis is individuali#ed and what

constitutes a crisis for one client may not constitute a crisis

for another client.

%. ' client$s response to a crisis is individuali#ed and what constitutes a crisis for one

client may not constitute a crisis for another client.

2. The nurse observes that a client with a potential for

violence is agitated) pacing up and down the hallway) and is

maing aggressive and belligerent gestures at other clients.

Which statement would be most appropriate to mae to

this client?

1. *,ou need to stop that behavior now.*

2. *,ou will need to be placed in seclusion.*

!. *,ou seem restlessE tell me what is happening.*%. *,ou will need to be restrained if you do not change your

behavior.*

!. *,ou seem restlessE tell me what is happening.*


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!. ' depressed client on an inpatient unit says to the

nurse) *


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%. The adolescent gets angry with her roommate when the

roommate borrows the client$s clothes without asing.

1. The adolescent gives away a 4&4 and a cherished autographed picture of a performer.

6. The police arrive at the emergency department with a

client who has lacerated both wrists. What is

the initial nursing action?

1. 'dminister an antian0iety agent.

2. @0amine and treat the wound sites.

!. /ecure and record a detailed history.

%. @ncourage and assist the client to ventilate feelings.

2. @0amine and treat the wound sites.

9. ' moderately depressed client who was hospitali#ed 2

days ago suddenly begins smiling and reporting that the

crisis is over. The client says to the nurse) *+$m finally

cured.* 8ow should the nurse interpret this behavior as a

cue to modify the treatment plan?

1. /uggesting a reduction of medication2. 'llowing increased *in3room* activities

!. +ncreasing the level of suicide precautions

%. 'llowing the client off3unit privileges as needed

!. +ncreasing the level of suicide precautions

;. The nurse is planning care for a client being admitted

to the nursing unit who attempted suicide.Which priority nursing intervention should the nurse

include in the plan of care?

1. 5ne3to3one suicide precautions

2. /uicide precautions with !>3minute checs


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!. Bhecing the whereabouts of the client every 1 minutes

%. 'sing the client to report suicidal thoughts immediately

1. 5ne3to3one suicide precautions

=. The emergency department nurse is caring for an adult

client who is a victim of family violence.

Which priority instruction should be included in the

discharge instructions?

1. +nformation regarding shelters

2. +nstructions regarding calling the police

!. +nstructions regarding self3defense classes

%. @0plaining the importance of leaving the violentsituation

1. +nformation regarding shelters

6>. ' female victim of a se0ual assault is being seen in the

crisis center. The client states that she still feels *as though

the rape (ust happened yesterday)* even though it has been

a few months since the incident. What is the mostappropriate nursing response?

1. *,ou need to try to be realistic. The rape did not (ust

occur.*

2. *+t will tae some time to get over these feelings about

your rape.*

!. *Tell me more about the incident that causes you to feel

lie the rape (ust occurred.*

%. *What do you thin that you can do to alleviate some of

your fears about being raped again?*

!. *Tell me more about the incident that causes you to feel lie the rape (ust occurred.*


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61. ' client is admitted to the mental health unit after an

attempted suicide by hanging. The nurse can best ensure

client safety by which action?

1. euesting that a peer remain with the client at all times2. emoving the client$s clothing and placing the client in a

hospital gown

!. 'ssigning a staff member to the client who will remain

with the client at all times

%. 'dmitting the client to a seclusion room where all

potentially dangerous articles are removed

!. 'ssigning a staff member to the client who will remain with the client at all times

62. ' client is admitted with a recent history of severe

an0iety following a home invasion and robbery. 4uring the

initial assessment interview) which statement by the client

would indicate to the nurse the possible diagnosis of

posttraumatic stress disorder? Select all that apply.

1. *+$m afraid of spiders.*

2. *+ eep reliving the robbery.*!. *+ see his face everywhere + go.*

%. *+ don$t want anything to eat now.*

. *+ might have died over a few dollars in my pocet.*

6. *+ have to wash my hands over and over again many

times.*

o 2. *+ eep reliving the robbery.*

o !. *+ see his face everywhere + go.*

o . *+ might have died over a few dollars in my pocet.*

6!. The emergency department nurse is caring for a client

who has been identified as a victim of physical abuse. +n


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planning care for the client) which is the priority nursing

action?

1. 'dhering to the mandatory abuse3reporting laws

2. Notifying the case worer of the family situation!. emoving the client from any immediate danger

%. 5btaining treatment for the abusing family member

!. emoving the client from any immediate danger

6%. The nurse assesses a client with the admitting

diagnosis of bipolar affective disorder) mania. Which client

symptoms reuire the nurse$s immediate action?

1. +ncessant taling and se0ual innuendoes2. randiose delusions and poor concentration

!. 5utlandish behaviors and inappropriate dress

%. Nonstop physical activity and poor nutritional intae

%. Nonstop physical activity and poor nutritional intae

6. The nurse is performing an assessment on a client with

dementia. Which data gathered during the assessmentindicates a manifestation associated with dementia?

1. ses confabulation

2. +mprovement in sleeping

!. 'bsence of sundown syndrome

%. "resence of personal hygienic care

1. ses confabulation

66. The nurse is caring for a client with anore0ia nervosa.

Which behavior is characteristic of this disorder and

reflects an0iety management?

1. @ngaging in immoral acts

2. 'lways reinforcing self3approval


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!. 5bserving rigid rules and regulations

%. 8aving the need always to mae the right decision

!. 5bserving rigid rules and regulations

69. ' depressed client verbali#es feelings of low self3

esteem and self3worth typified by statements such as *+$m

such a failure. + can$t do anything right.* 8ow should the

nurse plan on responding to the client$s statement?

1. eassure the client that things will get better.

2. Tell the client that this is not true and that we all have a

purpose in life.

!. +dentify recent behaviors or accomplishments thatdemonstrate the client$s sills.

%. emain with the client and sit in silenceE this will

encourage the client to verbali#e feelings.

!. +dentify recent behaviors or accomplishments that demonstrate the client$s sills.

6;. ' client with diabetes mellitus is told that amputation

of the leg is necessary to sustain life. The client is veryupset and tells the nurse) *This is all my health care

provider$s fault. + have done everything +$ve been ased to

do7* Which nursing interpretation is best for this situation?

1. 'n e0pected coping mechanism

2. 'n ineffective coping mechanism

!. ' need to notify the hospital lawyer

%. 'n e0pression of guilt on the part of the client


6=. ' client e0periencing a great deal of stress and an0iety

is being taught to use self3control therapy. Which statement

by the client indicates a need for further teaching about


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the therapy?

1. *This form of therapy can be applied to new situations.*

2. *'n advantage of this techniue is that change is liely

to last.*!. *Taling to oneself is a basic component of this form of

therapy.*

%. *This form of therapy provides a negative reinforcement

when the stimulus is produced.*

%. *This form of therapy provides a negative reinforcement when the stimulus is produced.*

9>. The nurse is caring for a client who is at ris forsuicide. What is the priority nursing action for this client?

1. "rovide authority) action) and participation.

2. 4isplay an attitude of detachment) confrontation) and

efficiency.

!. 4emonstrate confidence in the client$s ability to deal

with stressors.

%. "rovide hope and reassurance that the problems willresolve themselves.

1. "rovide authority) action) and participation.

91. ' client comes to the emergency department after an

assault and is e0tremely agitated) trembling) and

hyperventilating. What is the priority nursing action for

this client?

1. :egin to teach rela0ation techniues.2. @ncourage the client to discuss the assault.

!. emain with the client until the an0iety decreases.

%. "lace the client in a uiet room alone to decrease

stimulation.


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only thing the person wants is attention from family and

friends.*

1. *4iscussing suicide with a client is not harmful.*

9. Which client is most at ris for committing suicide?

1. ' 93year3old client with metastatic cancer

2. ' 913year3old client with a cardiac disorder

!. ' 2%3year3old client who (ust had an argument with her

roommate

%. ' !>3year3old newly divorced client who states she has

custody of the children

1. ' 93year3old client with metastatic cancer

96. ' nursing instructor teaches a group of nursing

students about violence in the family. Which statement by a

student indicates a need for further teaching?

1. *'busers use fear and intimidation.*

2. *'busers usually have poor self3esteem.*

!. *'busers often are (ealous or self3centered.*%. *'buse occurs more often in low3income families.*

%. *'buse occurs more often in low3income families.*

99. ' client is being prepared for electroconvulsive

therapy C@BTD. The nurse$s plan of care for the day before

@BT includes ensuring that the client follows which

guideline?1. 4oes not smoe at all

2. eceives no visitors and participates in limited unit

activities

!. eports to the clinic for blood draws and an

electrocardiogram C@BD


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%. +s placed on nothing by mouth CN"5D status for 16 to 2%

hours before the @BT

!. eports to the clinic for blood draws and an electrocardiogram C@BD

9;. ' nursing student is assisting with the care of a client

with a chronic mental illness. The nurse informs the student

that a behavior modification approach Coperant

conditioningD will be used in treatment for the client.

Which statement by the student indicates a need for

further information about the therapy?

1. *+t uses positive reinforcement.*

2. *+t uses negative reinforcement.*!. *+t increases social behaviors in the client.*

%. *+t increases the level of self3care in the client.*

2. *+t uses negative reinforcement.*

9=. The nurse is performing an admission assessment on a

client at high ris for suicide. The nurse should prepare to

as the client which assessment uestion to elicit datarelated to this ris?

1. *What are you feeling right now?*

2. *4o you have a plan to commit suicide?*

!. *8ow many times have you attempted suicide in the

past?*

%. *Why were your attempts at suicide unsuccessful in the

past?*

2. *4o you have a plan to commit suicide?*

;>. The nurse in the mental health unit is performing an

assessment in a client who has a history of multiple somatic

complaints involving several organ systems. 4iagnostic


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studies revealed no organic pathology. The care plan

developed for this client will reflect that the client is

e0periencing which disorder?

1. 4epression2. /chi#ophrenia

!. /omati#ation disorder

%. 5bsessive3compulsive disorder

!. /omati#ation disorder

;1. ' mental health nurse in a psychiatric unit is meeting

with a client who has a long history of acting out and

violent behavior. The client also is nown to have abuseddrugs on numerous occasions. 4uring the session the client

says to the nurse) *+$m feeling much better now) and +$m

ready to go straight.* Which response by the nurse would

be therapeutic?

1. *,ou have said this many times before7*

2. *Tell me what maes you feel that you are ready.*

!. *+ have not seen any changes in you to believe that youare ready to go straight.*

%. *+$m so glad to hear you taling this way. + will let your

health care provider now.*

2. *Tell me what maes you feel that you are ready.*

;2. ' client with a diagnosis of depression has been

meeting with the mental health nurse for therapy sessions

for the past 6 wees. 4uring the session the client says to

the nurse) *+ lost my (ob this wee) and +$m going to be

evicted from my apartment if + can$t pay my bill. The only

person that + have is my daughter) but + don$t want to

burden her with my problems.* Which response by the


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nurse would be therapeutic?

1. *Why did you lose your (ob?*

2. *There are homeless shelters available) and we will get

you into one if you are evicted from your apartment.*!. *+f you get evicted from your apartment) we will commit

you to the hospital) so you will have a place to eat and

sleep.*

%. *Let$s tal about contacting your daughter. Wouldn$t you

want to now if your daughter was having difficulty and try

to help her if you could?*

%. *Let$s tal about contacting your daughter. Wouldn$t you want to now if your daughter was having difficulty and try to help her if you could?*

;!. 4uring a therapy session with a client with paranoid

disorder) the client says to the nurse) *,ou loo so nice

today. + love how you do your hair) and + love that perfume

you$re wearing.* Which response by the nurse would be

therapeutic?

1. *,our comment is inappropriate.*2. *Than you for noticing. + (ust bought this new

perfume.*

!. *


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1. *,ou loo lovely today.*

2. *,ou$re wearing a new blouse.*

!. *4on$t worryFeveryone gets depressed once in a while.*

%. *,ou will feel better when your medication starts towor.*

2. *,ou$re wearing a new blouse.*

;. The nurse is planning care for a client with bipolar

disorder who is e0periencing psychomotor agitation. Which

activity should the nurse plan for this client?

1. eading letters and boos in a uiet environment

2. "roviding an activity such as checers for the client!. +nvolving the client in a card game with other clients on

the unit

%. +ncluding the client in a clay3molding class that is

scheduled for today

%. +ncluding the client in a clay3molding class that is scheduled for today

;6. The nurse is developing a plan of care for a client withdepression whose food intae is poor. The nurse should

include which interventions in the plan of care? /elect all

that apply.

1. 'ssist the client in selecting foods from the food menu.

2. 5ffer high3calorie fluids throughout the day and evening.

!. 'llow the client to eat alone in the room if the client

reuests to do so.

%. 5ffer small high3calorie) high3protein snacs during the

day and evening.

. /elect the foods for the client to be sure that the client

eats a balanced diet.


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o 1. 'ssist the client in selecting foods from the food menu.

o 2. 5ffer high3calorie fluids throughout the day and evening.

o %. 5ffer small high3calorie) high3protein snacs during the day and evening.

;9. The nurse is monitoring a client with a diagnosis of

schi#ophrenia. The nurse notes that the client$s emotional

responses to situations occurring throughout the day are

incongruent with the tone of the situation. The nurse should

document the findings using which description of the

client$s behavioral response?

1. -lat affect

2. :i#arre affect

!. :lunted affect

%. +nappropriate affect

%. +nappropriate affect

;;. ' mental health nurse notes that a client with

schi#ophrenia is e0hibiting an immobile facial e0pression

and a blan loo. Which should the nurse document in theclient$s record?

1. The client has a flat affect.

2. The client has an inappropriate affect.

!. The client is e0hibiting bi#arre behavior.

%. The client$s emotional responses e0hibit a blunted affect.

1. The client has a flat affect.

;=. The nurse is developing a plan of care for the client

with a diagnosis of paranoia and should include which

interventions in the plan of care? Select all that apply.

1. "rovide a warm approach to the client.

2. 's permission before touching the client.


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!. @liminate physical contact with the client.

%. 4efuse any anger or verbal attacs with a nondefensive

stance.

. se simple and clear language when communicatingwith the client.

o 2. 's permission before touching the client.

o !. @liminate physical contact with the client.

o %. 4efuse any anger or verbal attacs with a nondefensive stance.

o . se simple and clear language when communicating with the client.

=>. The nurse is preparing a client for electroconvulsive

therapy C@BTD) which is scheduled for the ne0t morning.

Which interventions would be included in the

preprocedural plan? Select all that apply.

1. 5btain an informed consent.

2. 8ave the client void before the procedure.

!. emove dentures and contact lenses before the

procedure.%. Withhold food and fluids for 6 hours before the

treatment.

. 'dminister tap water enemas on the evening before the

procedure.

o 1. 5btain an informed consent.

o 2. 8ave the client void before the procedure.

o !. emove dentures and contact lenses before the procedure.

o %. Withhold food and fluids for 6 hours before the treatment.


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=1. ' hospitali#ed client is receiving clo#apine CBlo#arilD

for the treatment of a schi#ophrenic disorder. The nurse

determines that the client may be having an adverse

reaction to the medication if abnormalities are noted onwhich laboratory study?

1. "latelet count

2. Bholesterol level

!. :lood urea nitrogen

%. White blood cell CW:BD count

%. White blood cell CW:BD count

=2. ' client has been prescribed disulfiram C'ntabuseD.:efore giving the client the first dose of this medication)

what should the psychiatric home health nurse determine?

1. +f there is a history of hyperthyroidism

2. When the last full meal was consumed

!. +f there is a history of diabetes insipidus

%. When the last alcoholic drin was consumed

%. When the last alcoholic drin was consumed

=!. ' home care nurse maing an initial home visit notes

that a client is taing donepe#il hydrochloride C'riceptD.

The nurse uestions the client$s spouse about a history of

which disorder that is treated with this medication?

1. 4ementia

2. /chi#ophrenia

!. /ei#ure disorder


1. 4ementia


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=%. The nurse is caring for a client with a diagnosis of

agoraphobia. When communicating with the client about

the disorder) the nurse should e0pect the client to describe

which behavior?1. ' fear of dirt and germs

2. ' fear of leaving the house

!. ' fear of speaing in public

%. ' fear of riding in elevators

2. ' fear of leaving the house

=. ' client recently admitted to the hospital in the manic

phase of bipolar disorder is dehydrated) unempt) taingantipsychotic medications) and complaining of abdominal

fullness and discomfort. The nurse determines that which

intervention is most appropriate for these complaints?

1. Teach self3grooming sills.

2. eward cleanliness with unit privileges.

!.


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confidentiality.

%. The nurse must override the duty to observe

confidentiality and notify the client$s health care provider

C8B"D about the suicidal ideation.%. The nurse must override the duty to observe confidentiality and notify the client$shealth care provider C8B"D about the suicidal ideation.

=9. The mental health nurse is reviewing the discharge

plan for a hospitali#ed client. +n reviewing the plan) the

nurse recogni#es that which is the most prominent problem

in the management of a client with a mental health problem

in the community?1. The community$s opposition

2. The client$s noncompliance with medication therapy

!. The associated increased incidence of social problems

%. The family$s reaction to eeping the client in the

community

2. The client$s noncompliance with medication therapy

=;. 4uring a home visit) the nurse suspects that a young

daughter of the client is bulimic. The nurse bases this

suspicion on which primary characteristic of bulimia?

1. efusing to eat and e0cessive e0ercising

2. @ating only vegetables and fruits and fasting

!. 8oarding of food and difficulty controlling food intae

%. @ating a lot of food in a short period of time and misuse

of la0atives

%. @ating a lot of food in a short period of time and misuse of la0atives

==. The mental health nurse is taling to a client who has

been diagnosed with posttraumatic stress disorder. 4uring


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the conversation) the nurse notes that the client is e0hibiting

a paranoid stare and that he begins to pace and fidget. What

is the appropriate nursing intervention?

1. 'llow the client to pace.2. @scort the client to a uiet room.

!. Bhange the conversation to a less threatening sub(ect.

%. /hare the observation with the client and help the client

to recogni#e his feelings.

%. /hare the observation with the client and help the client to recogni#e his feelings.

1>>. The nurse is reviewing the record of a client admitted

to the mental health unit. The nurse notes documentationthat the client e0periences flashbacs. What diagnosis

should the nurse e0pect to be documented for this client?

1. 'n0iety

2. 'goraphobia

!. /chi#ophrenia

%. "osttraumatic stress disorder C"T/4D

%. "osttraumatic stress disorder C"T/4D

1>1. The nurse is admitting a client with a diagnosis of

posttraumatic stress disorder to the mental health unit. The

client is confused and disoriented. 4uring the assessment)

what is the nurse$s primary goal for this client?

1. @0plain the unit rules.

2. 5rient the client to the unit.

!. /tabili#e the client$s psychiatric needs.

%. 'ccept the client and mae the client feel safe.

%. 'ccept the client and mae the client feel safe.


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1>2. The nurse in the mental health unit is having a

conversation with a client diagnosed with posttraumatic

stress disorder. The client seems upset and loos an0ious.

What is the appropriate nursing statement the nurse shouldmae to the client?

1. *4on$t worry so much.*

2. *+ can see that you are upset.*

!. *@verything is going to be all right.*

%. *Why are you having so much trouble controlling your

an0iety?*

2. *+ can see that you are upset.*

1>!. ' client with depression is scheduled to receive three

sessions of electroconvulsive therapy C@BTD. The client

ass the nurse about the length of time it will tae for

improvement in the condition. The nurse should tell the

client he or she will see improvement appro0imately how

long after the three treatments?

1. 1 wee 2. ! wees

!. % wees

%. ; wees

1. 1 wee

1>%. ' client has been diagnosed with ma(or depression.

The nurse notes that the client is not eating adeuately and

at times refuses to eat. What should the nurse plan to do to

meet the client$s nutritional needs?

1. -orce foods and fluids.

2. "rovide small) freuent meals.

!. "rovide snacs and meals as reuested.


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%. Tell the client that social activities will be restricted

unless food intae is increased.

2. "rovide small) freuent meals.

1>. The health care provider has prescribed medication

therapy for a client with an alcohol abuse problem to assist

in the maintenance of sobriety. The nurse reviews the

client$s record and e0pects to note that which medication

has been prescribed?

1. Blonidine CBatapresD

2. 4isulfiram C'ntabuseD

!. "yrido0ine hydrochloride Cvitamin :6D%. Bhlordia#epo0ide hydrochloride CLibriumD

2. 4isulfiram C'ntabuseD

1>6. The mental health nurse is caring for a client with a

social phobia. The nurse tells the client that a music therapy

session has been scheduled as part of the treatment plan.

The client tells the nurse that she cannot sing and refuses toattend. What is the appropriate nursing response?

1. *,ou must go. ,ou have no choice.*

2. *Why don$t you want to attend? What is the real reason?*

!. *The health care provider has prescribed this therapy for

you.*

%. *,ou don$t have to sing at the session. ,ou can listen and

en(oy the music.*

%. *,ou don$t have to sing at the session. ,ou can listen and en(oy the music.*

1>9. The nurse is monitoring a client who has been placed

in restraints because of violent behavior. When should the

nurse determine that it will be safe to remove the restraints?


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%. This treatment is a permanent cure to the condition.

. This treatment is tried before the use of medications.

o 1. The average series involves 6 to 12 treatments.

o 2. /ome confusion may be noted after the procedure.

o !. . The nurse is planning a stress management seminar for

clients in an ambulatory care setting. Which concept should

the nurse plan to include in the content of the seminar?

1. :iofeedbac has the advantage of using no euipment at

all.2. uided imagery is a helpful techniue but reuires video

euipment for its use.

!. Bonfrontation is a useful method for solving potentially

stressful conflicts with others.

%. "rogressive muscle rela0ation techniues are useful for

easing tension from many causes.

%. "rogressive muscle rela0ation techniues are useful for easing tension from manycauses.

111. ' 13year3old client who is pregnant and unwed tells

the nurse) *


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%. *+t seems that you needed help to separate from your

family. 4o you feel you are ready to have a baby with

Gohnny?*

%. *+t seems that you needed help to separate from your family. 4o you feel you are readyto have a baby with Gohnny?*

112. ' 1>3year3old girl who has been referred for

evaluation for drawing se0ually e0plicit scenes in her

te0tboos says to the psychiatric nurse) *+ (ust felt lie it.*

Which response is therapeutic for the nurse to mae in

order to assess abuse3related symptoms?

1. *Well) a picture paints a thousand words.*2. *,ou (ust felt lie destroying your te0tboos?*

!. *,our parents and teachers are very concerned about

your drawings.*

%. *+ am concerned about you. 're you now or have you

ever been abused?*

%. *+ am concerned about you. 're you now or have you ever been abused?*

11!. 4uring a nursing interview) a client says) *


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2. *8ave you shared your concerns with the police?*

11%. The nurse is assessing a client in the coronary care

unit CBBD who seems to fluctuate in his ability to focus

during the day. 5n the basis of this assessment) whichclient problem should the nurse suspect?

1. 4ementia as a result of isolation

2. 'cute confusion as a result of BB psychosis

!. 4ementia as a result of substance into0ication

%. +nterruption in the family as a result of alcohol

withdrawal

2. 'cute confusion as a result of BB psychosis

11. ' client with diabetes mellitus is told that amputation

of the leg is necessary to sustain life. The client is very

upset and tells the nurse) *This is all the health care

provider$s fault. + have done everything that he has ased

me to do7* 8ow should the nurse interpret the client$s

statement?

1. 'n e0pected coping mechanism2. 'n ineffective coping mechanism

!. ' need to notify the hospital lawyer

%. 'n e0pression of guilt on the part of the client


116. The nurse is planning to formulate a psychotherapy

group. /everal clients are interested in attending thesession. The nurse plans the group) nowing that which is

the ma0imum number of group members that can be

included?

1. !


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2. ;

!. 1%

%. 16

2. ;

119. ' nurse assists a client with a diagnosis of obsessive3

compulsive disorder C5B4D in his preparations for bedtime.

5ne hour later the client calls the nurse and says that he is

feeling an0iousE he ass the nurse to sit and tal for a while.

Which is the appropriate initial nursing action?

1. /it and tal with the client.

2. 's the unlicensed assistive personnel to sit with theclient.

!. 'dminister the prescribed as3needed antian0iety

medication.

%. Tell the client that it is time for sleep and that you will

tal with him tomorrow.

1. /it and tal with the client.

11;. ' nurse is planning care for a group of clients on a

mental health unit. The nurse notes that most of the

assigned clients reuire interventions commonly used to

treat an0iety disorders. /uch antian0iety interventions

would be appropriate for which clients? Select all that

apply.

1. ' client with panic disorder

2. enerali#ed an0iety disorder

!. ' client with multiple personality disorder

%. ' client with posttraumatic stress disorder C"T/4D

. ' client with obsessive3compulsive disorder C5B4D


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o 1. ' client with panic disorder

o 2. enerali#ed an0iety disorder

o %. ' client with posttraumatic stress disorder C"T/4D

o . ' client with obsessive3compulsive disorder C5B4D

11=. ' nurse is preparing to admit a client with a diagnosis

of obsessive3compulsive disorder C5B4D to the mental

health unit. The nurse would e0pect to note which

behaviors in the client?

1. /uspicious and hostile

2. -le0ible and adaptable!. -rightened and delusional

%. igidness in thought and infle0ibility

%. igidness in thought and infle0ibility

12>. ' nurse is performing an assessment on a client

admitted to the mental health unit. The client tells the nurse

that she cannot leave home without checing numerous

times that the iron and coffee pot have been shut off. The

client states that this activity maes her late for many

functions and that she misses engagements on occasion

because of it. The nurse would e0pect to note which

an0iety disorder documented in the client$s record?

1. ' phobia

2. enerali#ed an0iety disorder

!. "osttraumatic stress disorder C"T/4D%. 5bsessive3compulsive disorder C5B4D

%. 5bsessive3compulsive disorder C5B4D


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121. ' nurse is performing an assessment on a client

admitted to the mental health unit. The nurse notes that the

client$s diagnosis is documented as obsessive3compulsive

disorder. The nurse plans care nowing that the clientis most likely to e0perience which type of compulsive

behavior?

1. -ears

2. 'ctions

!. +llusions

%. Thoughts

2. 'ctions

122. ' mental health nurse ass a nurse orientee to describe

the underlying pathophysiology associated with acts of

compulsion) such as repeated hand washing) performed by

clients with obsessive3compulsive disorder C5B4D. The

nurse determines that the orientee understands this disorder

if the orientee identifies which characteristic of the client?

1. naware that the client is performing the ritual2. Bonsciously attempting to punish the self or others

!. nconsciously controlling unpleasant thoughts or

feelings

%. esponding to *the voices* telling the client to perform

rituals

!. nconsciously controlling unpleasant thoughts or feelings

12!. ' nurse is performing an assessment on a client being

admitted to the mental health unit. 4uring the interview) the

nurse discovers that the client suffered a severe emotional

trauma 1 month earlier and is now e0periencing paralysis

of the right arm. Which is the initial nursing action?


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1. efer the client to a psychiatrist.

2. @ncourage the client to move and use the arm.

!. 'ssess the client for organic causes of the paralysis.

%. @ncourage the client to tal about his or her feelings.!. 'ssess the client for organic causes of the paralysis.

12%. ' nurse is developing a plan of care for a client

admitted to the mental health unit with a diagnosis of

obsessive3compulsive disorder C5B4D. What is the

nurse$s first priority in the plan of care?

1.


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symptoms that usually result from a loss of physical

functioning) although no such loss can be confirmed

medically. The nurse interprets these findings as indicating

which condition?1. 4epression

2. /omati#ation disorder

!. "osttraumatic stress disorder


2. /omati#ation disorder

129. The home health nurse visits an older adult client who

has recently lost her husband. The client says) *No onecares about me anymore. 'll the people + loved are dead.*

Which is the appropriate response?

1. *ight7 Why not (ust Hpac it in$?*

2. *That seems rather unliely to me.*

!. *+ don$t believe that) and neither do you.*

%. *,ou must be feeling all alone at this point.*

%. *,ou must be feeling all alone at this point.*

12;. ' depressed client who appeared sullen) distraught)

and hopeless a few days ago now suddenly appears calm)

rela0ed) and more energetic. Which is the

nurse$s best initialaction with regard to the client$s altered

demeanor?

1. Bontinue to assess the client$s behaviors and document

clearly in the chart.

2. eport to the health care provider that the client is

adapting to the unit and is feeling safe.

!. Notify the health team of these observations and alert

them to the suspicion that the client is contemplating


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suicide.

%. @ngage the client in one3to3one supervision) share with

the client the observations that have been assessed) and as

whether the client is thining about suicide.%. @ngage the client in one3to3one supervision) share with the client the observations thathave been assessed) and as whether the client is thining about suicide.

12=. The nurse is performing an assessment on a 163year3

old female client who has been diagnosed with anore0ia

nervosa. Which statement) if made by the client) would the

nurse identify as necessitating further assessment on

a priority basis?1. *+ chec my weight every day without fail.*

2. *+$ve been told that + am 1>I below ideal body weight.*

!. *+ e0ercise ! to % hours every day to eep my slim

figure.*

%. *. ' nurse is assessing a client in crisis and is

determining the potential for self3harm. Which assessment

data would indicate that the client is at very high ris for

suicide?

1. The client is impulsive.

2. The client is disorgani#ed.

!. The client has a history of suicide attempts.%. The client has an immediate plan for a suicide attempt.

%. The client has an immediate plan for a suicide attempt.


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1!1. The nurse is planning to instruct a mental health client

and his or her family about the importance of medication

compliance. The nurse should plan for which interventions

that are associated with increased compliance? Select allthat apply.

1. iving all medications (ust once per day

2. +ncluding the family in the medication planning process

!. Woring with the psychiatrist to find the right

medication at the right dose

%. "roviding the client with the in(ectable) long3acting form

of the medication if available

. Woring with the psychiatrist to find the medication that provides the least side effects for the client

o 2. +ncluding the family in the medication planning process

o !. Woring with the psychiatrist to find the right medication at the right dose

o %. "roviding the client with the in(ectable) long3acting form of the medication if

available

o . Woring with the psychiatrist to find the medication that provides the least side

effects for the client

1!2. The nurse is planning care for a client who has been

hospitali#ed for violent behavior and is at ris for harming

others. Which intervention could potentially present a

danger to the client) health care providers) and others on the

nursing unit?

1. -acing the client when providing care2. 'ssigning the client to a room at the end of the hall

!. @nsuring that a security officer is within the immediate

area


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%. Aeeping the door to the client$s room open when

providing care to the client

2. 'ssigning the client to a room at the end of the hall

1!!. ' nurse who is caring for a client with severe

depression is planning activities for the client. The nurse

goes to the activity room and finds a pu##leE a

checerboard gameE a paint3by3number pictureE and

crayons) colored pencils) and paper for drawing. Which

activity would be most appropriate for this client?

1. 4rawing

2. "laying checers!. "ainting by numbers

%. "utting a pu##le together

1. 4rawing

1!%. The nurse is developing a plan of care for a client who

is scheduled to have electroconvulsive therapy C@BTD.

Which problem is a priority for this client?1. -ear

2. 'n0iety

!. is for aspiration

%. Worry about body image

!. is for aspiration

1!. ' female client in a manic state emerges from herhospital room. /he is topless and is maing se0ual remars

and gestures toward the staff and other clients. Which is

the best initial nursing action?

1. +gnore the client.

2. Tell the client to go bac to her room.


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!. @scort the client to her room and assist her in getting

dressed.

%. Tell the other clients to go into the nursing unit day room

immediately.!. @scort the client to her room and assist her in getting dressed.

1!6. ' nurse is monitoring a group therapy session. 4uring

this session the members are identifying tass and

boundaries. The nurse determines that these activities are

characteristic of which stage of group development?

1. -orming

2. /torming!. Norming

%. "erforming

1. -orming

1!9. When planning discharge care for a client with bipolar

disorder) the nurse determines theneed for further

teaching when the client maes which statement?1. *+ hope + am going to lie my new counselor.*

2. *+ sure hope + will still be productive at wor.*

!. *+ am going to eep a close chec on any stress in my

life.*

%. *+ will tae the medicine until + am sure + am feeling well

enough to handle my problems again.*

%. *+ will tae the medicine until + am sure + am feeling well enough to handle my problems again.*

1!;. ' client has consented to participate in 'lcoholics

'nonymous C''D community groups after discharge from

the hospital. The nurse is monitoring the client$s response to


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the substance abuse sessions. Which statement by the

client best reflects the development of an effective coping

response style and effective processing of information for

self3use?1. *+ now +$m ready to be discharged. + feel lie + can say

Hno$ and leave a group of friends if they are drining. No

problem.*

2. *+$ll eep all my appointments and go to all my ''

groupsE +$ll do everything +$m supposed to. Nothing will go

wrong that way.*

!. *+$m looing forward to leaving here. + will miss all of

you. /o) +$m happy and +$m sad) +$m e0cited) and +$m scared.+ now that + have to wor hard to be strong and that

everyone isn$t going to be as helpful as you people.*

%. *This group has really helped a lot. + now it will be

different when + go home. :ut +$m sure that my family and

friends will all help me lie the people in this group have....

They$ll all help me.... + now they will.... They won$t let me

go bac to old ways.*!. *+$m looing forward to leaving here. + will miss all of you. /o) +$m happy and +$m sad)+$m e0cited) and +$m scared. + now that + have to wor hard to be strong and that

everyone isn$t going to be as helpful as you people.*

1!=. ' client who is on lithium carbonate will be

discharged at the end of the wee. +n formulating a

discharge teaching plan) the nurse should include which

precaution?1. 'void soy sauce) wine) and aged cheese.

2. 8ave the blood lithium level checed every 2 wees.

!. Tae the medication only as prescribed because it can

become addicting.


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%. Bhec with the psychiatrist before using any over3the3

counter medications.

%. Bhec with the psychiatrist before using any over3the3counter medications.

1%>. The home health nurse visits an agoraphobic client

who e0periences panic attacs. Which statement by the

client would indicate a therapeutic response to behavioral

and pharmacological treatment?

1. *+ too an e0tra pill for an0iety and got through the

funeral fairly well.*

2. *Taing my an0iety pills before + leave has helped me to

cross the bridge and go to wor every morning.*!. *+ went to the movies with my family and stayed through

the whole film by sitting in a seat along the aisle.*

%. *+ have noticed that +$m becoming an0ious) and + worry

that if + don$t tae my an0iety pill (ust before it$s due) +$ll go

cra#y) so + get it ready to tae to calm down.*

!. *+ went to the movies with my family and stayed through the whole film by sitting in a

seat along the aisle.*

1%1. The psychiatric home care nurse visits a client with a

phobia who e0periences panic attacs. The nurse teaches

the client to use parado0ical intention and employs which

method to teach the client this form of therapy?

1. 8aving the client confront the an0iety3provoing

stimulus and providing support during the episode

2. +nstructing the client to do what the client fears and) if possible) to e0aggerate the outcome of this e0posure to the

point of humor

!. "resenting the an0iety3provoing stimulus without any

preparation of the client and having him or her remain


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e0posed until the an0iety subsides

%. sing progressive rela0ation toward the client$s

individual an0iety hierarchy) increasing the level of

difficulty) and pairing rela0ation with the gradual e0posureto reduce his or her an0iety

2. +nstructing the client to do what the client fears and) if possible) to e0aggerate the

outcome of this e0posure to the point of humor

1%2. ' client tentatively diagnosed with a borderline

personality disorder says to the nurse) *+ don$t now why +

got my tattooE it was for me. 5A? /ometimes + do these

things to get my parents mad) and sometimes + do them because +$m bored. That$s what happened the night +

crashed the family car. + wasn$t drun or suicidal or

anything lie the police thought. +t was (ust for ics7*

Which is the appropriate nursing response?

1. *Ne0t time) pic less dangerous and e0pensive ways to

e0plode.*

2. *What can you do to stop your behavior when it gets tothat point the ne0t time?*

!. *+t$s a good thing that you don$t abuse substances or you

might be dead because of your recless disregard.*

%. *+t is scary when you feel out of control with such

feelings of emptiness and anger that you can$t stop

yourself.*

%. *+t is scary when you feel out of control with such feelings of emptiness and anger that

you can$t stop yourself.*

1%!. The nurse is reviewing the medical record of a client

who received electroconvulsive therapy C@BTD in the past.

Which assessment data would indicate to the nurse the


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presence of long3term retrograde amnesia in the client?

1. The client has memory loss for 2 days after the

procedure.

2. 'fter the procedure) the client has difficulty recallingnewly learned information.

!. The client had difficulty remembering information

learned for % months before @BT.

%. The client has difficulty recalling newly learned

information for 2 wees following the procedure.

!. The client had difficulty remembering information learned for % months before @BT.

1%%. The mother of a teenage client with an an0ietydisorder is concerned about her daughter$s progress on

discharge. /he states that her daughter stashes food) eats all

the foods that mae her hyperactive) and hangs out with the

*wrong crowd.* +n helping the mother prepare for her

daughter$s discharge) what instruction should the nurse

provide?

1. estrict the daughter$s sociali#ing time with her friends.2. estrict the amount of chocolate and caffeine products in

the home.

!. Aeep her daughter out of school until she can ad(ust to

the school environment.

%. Bonsider taing time off from wor to help her daughter

read(ust to the home environment.

2. estrict the amount of chocolate and caffeine products in the home.

1%. The nurse is reviewing the record of a client scheduled

for electroconvulsive therapy C@BTD. Which medical

diagnosis) if noted on the client$s record) would indicate a

need to contact the health care provider scheduled to


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perform the @BT?

1. 4iabetes mellitus

2. 8yperthyroidism

!. "eripheral vascular disease%. ecent myocardial infarction

%. ecent myocardial infarction

1%6. ' woman who is a victim of family violence is now

engaged in group therapy sessions. /he begins yelling at

another client during the therapy session and screams) *+

can$t listen to this. ,ou people are no different from the

ones at home.* The client stands up and tips the chair over bacward. What is the nurse$s immediate action?

1. +nform the yelling client that she must leave the group.

2. Ball security personnel to come to the group therapy

session.

!. @0plore the other client$s responses to the woman$s

yelling behavior.

%. -irmly reinforce group rules to the woman) stating thataggressive yelling is not acceptable in the group.

%. -irmly reinforce group rules to the woman) stating that aggressive yelling is not

acceptable in the group.

1%9. ' client hospitali#ed in the mental health unit with

depression is preparing to be discharged to outpatient

status. The nurse is discussing termination and follow3up

plans with the client. Which client statementwould most concern the nurse about the client$s discharge

and indicate the need for follow-up treatment?

1. *+ want to say than you. + thin +$ve wored hard and

you) too. + now +$m not finished yet. + need to come bac


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for appointments. +$m glad. + don$t thin + could leave

totally on my own.*

2. *This has been the hardest trip here for me) but + have

made progress in learning how to communicate) especiallywith my family. +$m ready to go. + feel +$m ready this

time...more than the last7*

!. *+ really tried to listen to what people said in the group

this time. /ometimes it was hard) but + tried to listen. +

thin we really helped each other. + thin +$ve learned to

listen better rather than my (umping too uicly into

something.*

%. *+ thin + really couldn$t have wored that (ob even if theman had given me the time he should have during the

interview. +t$s (ust as well. + really didn$t want a (ob where +

had to wor such long hours. :ut + had good reason to get

depressed and end up here. :ut it all wored out. + really

didn$t want that (ob anyway.*

%. *+ thin + really couldn$t have wored that (ob even if the man had given me the time

he should have during the interview. +t$s (ust as well. + really didn$t want a (ob where + hadto wor such long hours. :ut + had good reason to get depressed and end up here. :ut it

all wored out. + really didn$t want that (ob anyway.*

1%;. 4uring a support group session for battered women) a

client says) *+ was abused by my father and then my

husband) so + finally stabbed my husband when he came

after me) but no one on the (ury believed me *cause my

husband) the Hbig shot)$ can lie to anyone and be believed.*

+f no one in the group responds) which statement is the

therapeutic response by the nurse?

1. *' pretty horrible e0perience for you to undergo. 4oes

anyone in the group want to respond?*

2. *,es. @veryone here was ill3used and abused) but what


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maes you thin that this is a reason to stab someone?*

!. *,our story is very much lie every woman$s here. +

thin you had other options besides violence) don$t you?*

%. */eems as if you went from one abusing man to another.4o you really thin you$re here because your husband is a

good liar and a Hbig shot$?*

1. *' pretty horrible e0perience for you to undergo. 4oes anyone in the group want torespond?*

1%=. The nurse is caring for a client with 'l#heimer$s

disease who is having difficulty recogni#ing ob(ects that are

well nown) including people. The nurse determines thatthe client is e0periencing which problem?

1. 'ta0ia

2. 'gnosia

!. 'pra0ia

%. 'phasia

2. 'gnosia

1>. ' client with schi#ophrenia says to the nurse) *Will

you protect me from the rand 4uchess?* and points to an

older client who is sitting reading a boo. Which statement

is the therapeutic response by the nurse?

1. *Where is she? +$ll tal to her.*

2. *+ can see no rand 4uchess. ,ou will need to trust me

on that.*

!. *,ou will be safe here. ,our thining will be clearer after your medication starts to wor.*

%. *The rand 4uchess) huh? Well) +$m the Jueen) and +

will order her to stay away from you.*


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!. *,ou will be safe here. ,our thining will be clearer after your medication starts to

wor.*

11. The night nurse reported to the nurse manager that a

client was admitted to the mental health unit after attacinghis father with an iron for interrupting him at his computer.

4uring nursing rounds) this client interrupts the nurse

manager and says) *+ need to get out of here) so + can wor

on my computer pro(ect to save the world7* Which

statement is a therapeutic response by the nurse manager?

1. *+ will be able to tal with you in 1 minutes after +

complete nursing rounds.*

2. *,ou have a pro(ect to save the world? +$d really lie tohear about that after + finish rounds.*

!. *Well) sit right down and eat your breafast. ,ou$re not

going to save the world on an empty stomach.*

%. *,ou hurt your father because of these thoughts) and you

won$t leave here until you can control yourself better.*

1. *+ will be able to tal with you in 1 minutes after + complete nursing rounds.*

12. The nurse is performing a mental status e0amination

on a client) and the client states) *lass breas if you throw

stones or shoot at it with a gun.


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1!. The nurse is caring for a client with schi#ophrenia

who states) *+ decided not to tae my medication because +

reali#e that it really can$t help me. 5nly + can help me.*

Which nursing response would be therapeutic?1. *5nly you can help?*

2. *,ou decided not to tae your medication?*

!. *+f you can mae this wise observation) you probably

don$t need your medication any longer.*

%. *,our health care provider wants you to continue with

this medication because it is helping you. 4o you recall

needing to be hospitali#ed because you stopped your

medication?*

%. *,our health care provider wants you to continue with this medication because it is

helping you. 4o you recall needing to be hospitali#ed because you stopped yourmedication?*

1%. ' nursing student is ased to identify suicide methods

that are referred to as soft methods. The nursing instructor

determines that the student understands the sub(ect if he or

she states that which is a soft method?1. 8anging

2. sing a gun

!. +nhaling natural gas

%. Gumping off a bridge

!. +nhaling natural gas

1. The nurse in a mental health clinic is reviewing therecords of the clients to be seen that day. The nurse

determines that which client is at highest ris for suicide?

1. 'n 'frican3'merican male lawyer who is %9 years old

and recently divorced


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2. ' 23year3old housewife who is married to a widower

and has one 23year3old son and a !3year3old stepdaughter

!. ' single parent who failed the general euivalency

diploma e0amination and whose si0 children are onscholarship in graduate and medical schools

%. 'n 1;3year3old alcohol3 and drug3abusing youth who

must tell his parents that he failed to pass an e0amination

reuired for graduation from high school

%. 'n 1;3year3old alcohol3 and drug3abusing youth who must tell his parents that hefailed to pass an e0amination reuired for graduation from high school

16. The spouse of an alcoholic client is attending asupport group and says to the group members) *+t$s all very

well for everyone to label me an enabler) but if + didn$t call

him in sic at wor) he$d lose his (ob. Where would we be

then?* Which statement by the nurse co3leader would be

therapeutic?

1. *4oes anyone in the group want to respond to that?*

2. */o you only call him in sic because you are worriedabout money?*

!. *4o you now that enabling creates codependency? +sn$t

viewing his failure as yours significant?*

%. *4o you need a house to fall on you to understand this

disease? Ban someone else deal with this client$s

statements?*

!. *4o you now that enabling creates codependency? +sn$t viewing his failure as yours

significant?*

19. ' heroin3addicted client who is taing methadone

hydrochloride C4olophineD discontinues the methadone

without consulting the health care provider. The client says


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to the nurse) *+ thought + didn$t need the methadone after 1

year. + had a (ob and was even saving money. + can$t believe

+ ruined everything.* Which statement by the nurse is

therapeutic?1. *+t sounds as if everything you do is either all3or3none.*

2. *,our counselor called and ased for you) so it would

seem that everything isn$t ruined yet.*

!. *The methadone program is now refusing you) and your

boss fired you) so you$re at suare one) so to spea.*

%. *+t does sound as if you need to wor on repair) but now

you will need to be more alert to your signs of being

vulnerable to slipping off your treatment program.*

%. *+t does sound as if you need to wor on repair) but now you will need to be more alert

to your signs of being vulnerable to slipping off your treatment program.*

1;. 'n alcohol3troubled client says) *The 12 /teps of

'lcoholics 'nonymous C''D frea me out. + had to go for a

drin after 1 hour with those peopleE they$re fanatics7*

Which statement by the nurse would be therapeutic?1. *+t sounds as if you loo for any reason to drin7*

2. *+ agree. '' is definitely not for you if you find it is a

trigger to restart drining.*

!. *,ou thin '' is for fanatics? ,ou now) + (ust don$t

understand how you can (udge individuals who are sober.*

%. *Not all strategies for remaining sober are the best for

everyone. +t seems that you don$t view yourself as having

the same problem as others in the group.*

%. *Not all strategies for remaining sober are the best for everyone. +t seems that you don$t

view yourself as having the same problem as others in the group.*


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1=. ' !93year3old client who is recovering from

ben#odia#epine dependence says) *+ thin +$ve waled

under a blac cloud. +$ve lost so many people. -irst) my

brother dies of the big BE then my husband leaves me for a2>3year3old bimbo. + wish + had a Kana0 right now.* Which

statement by the nurse would be therapeutic?

1. *The big Bit must have been a terrible loss for you

when your brother died.*

2. *4id you ever stop to thin that your spouse might have

gotten fed up with your using Kana0 so much?*

!. *+t sounds as if you feel that all of this has (ust happened

to you. + wonder what part you played in events?*%. *Ban you tell me what you thin the Kana0 can do for

you? 're there other things you used to do that might help

you (ust as well?*

%. *Ban you tell me what you thin the Kana0 can do for you? 're there other things youused to do that might help you (ust as well?*

16>. The husband of an alcohol3troubled wife says) *+fanyone had said +$d be henpeced) +$d have called them a

liar) but now + reali#e that +$m codependent.* Which

statement by the nurse would be therapeutic?

1. *4id you now that more people identify with (ust what

you are saying?*

2. *Which of the features that describe codependence

caused you to sit up and tae notice?*

!. *Ban you tell me more about that? ,ou see yourself as being codependent with your wife?*

%. *8ave you discussed your feelings with your wife? What

does your wife thin about what you$ve said?*


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!. *Ban you tell me more about that? ,ou see yourself as being codependent with your

wife?*

161. ' %3year3old client states that he used to drin a

coctail nightly after wor and also had a drin with hismeal. Now he has two drins before dinner and two or

three more drins during his meal. 's the client continues

to describe his alcohol intae) the nurse discovers that he

also has added a couple of drins at night to help him sleep.

Which is the most accurate assessment of his alcohol

consumption?

1. Tolerance

2. 'ddiction!. 'd(ustment

%. 8eavy social drining

1. Tolerance

162. ' battered wife says) *


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share with me some ways that you feel you can cope with

this abuse?*

%. */o you reali#e that there are many ways to erode someone$s self3confidence and

independence? Ban you share with me some ways that you feel you can cope with thisabuse?*

16!. 'n ;>3year3old resident in a long3term care facility

prepares to wal out into a rainstorm after saying) *


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1. "lan nothing until the client ass to participate in milieu.

2. @ncourage the client to play solitaire while providing a

dec of cards.

!. "rovide a structured daily program of activities andencourage the client to participate.

%. 5ffer the client a menu of daily activities and insist that

the client participate in all of them.

!. "rovide a structured daily program of activities and encourage the client to participate.

166. ' client with a history of panic disorder comes to the

emergency department and states to the nurseM *"lease help

me+ thin +$m having a heart attac.* What isthe priority nursing action?

1. 'ssess the client$s vital signs.

2. +dentify the client$s activity during the pain.

!. 'ssess for signs related to a panic disorder.

%. 4etermine the client$s use of rela0ation techniues.

1. 'ssess the client$s vital signs.

169. The nurse reviews the assessment data of a client

admitted to the hospital with a diagnosis of an0iety. The

nurse should assign priority to which assessment finding?

1. Tearful) self3isolated

2. 'ffect bland) withdrawn

!. -ist clenched) pounding table) fearful

%. Temperature =;.% -E respirations 1; breathsOmin

!. -ist clenched) pounding table) fearful

16;. ' home care nurse suspects that a client$s spouse is

e0periencing caregiver strain. Which nursing action will

assist in supporting the nurse$s suspicion?


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1. 5btaining feedbac from the client about the coping

abilities of the caregiver

2. athering sub(ective and ob(ective assessment from the

caregiver and the client!.


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191. The client with a diagnosis of dependent personality

disorder is most likely to have problems coping with which

issue?

1. Trust2. /ociali#ation

!.


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have been using alcohol to prevent or decrease the ris of

which complication?

1. Birrhosis

2. 4elirium tremens!. @sophageal varices

%. Wernice3Aorsaoff syndrome

%. Wernice3Aorsaoff syndrome

19. Which mental health professional is responsible for

the milieu in an inpatient psychiatric setting?

1. Nurse

2. "sychiatrist!. "sychologist

%. /ocial worer

1. Nurse

196. Which best describes the purpose of behavioral

therapy?

1. -osters positive behavioral change2. 4evelops structure and organi#es time

!. Breates insight i

nclex mental health

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