PN Mental Health Online Practice (B)
Study online at https://quizlet.com/_a1vun5
1. A nurse on a mental health unit is assisting with the plan of care for a
newly admitted client who has anorexia nervosa. Which of the following actions
should the nurse include in the plan of care?
a. weigh the client at night prior to bedtime
b. offer liquid supplements to the client
c. encourage the client to gain 2.3 kg (5 lb) per week
d. observe the client for up to 30 min after meals: b. offer liquid supplements to the client
-the nurse should offer liquid supplements to the client because the client might be unable to eat solid foods when he
is first admitted.
2. A nurse in a mental health facility is caring for a client who has schizophrenia.
The client becomes violent in the dayroom and begins throwing objects at staff
and other clients. After calling for assistance, which of the following actions
should the nurse take next?
a. obtain a prescription for mechanical restraints
b. place the client in a monitored seclusion room
c. tell the client calmy to sit down
d. administer diazepam intramuscularly: c. tell the client calmly to sit down.
-when providing client care, the nurse should first use the least restrictive intervention. Therefore, the nurse should use
verbal de-escalation techniques after calling for assistance for a client who is aggressive.
3. A nurse is caring for a group of clients on a mental health unit. Which of the
following client behaviors should the nurse report to the charge nurse?
a. a client who has schizophrenia is communicating using echolalia
b. a client who has depression is exhibiting anergia
c. a client who is manic has been pacing the unit for several hours
d. a client who has a phobia is using thought stopping: c. a client who is manic has been
pacing the unit for several hours
-the nurse should identify that excessive physical activity in a client who is experiencing a manic episode places the
client at risk for physical exhausting and possible death. The nurse should report this client's behavior to the charge
nurse.
4. A nurse is collecting data from a client who is taking valproic acid for treat-
ment of bipolar disorder. The nurse should identify that which of the following
findings is priority to report to the provider?
, PN Mental Health Online Practice (B)
Study online at https://quizlet.com/_a1vun5
a. drowsiness
b. nausea and vomiting
c. constipation
d. bleeding gums: d. bleeding gums
-when using the urgent vs non urgent approach to the client care, the nurse should determine that the priority finding
is bleeding gums because of the risk of thrombocytopenia.
OR---------
Yellow sclera
Rationale: priority finding is yellow sclera because of risk for hepatotoxicity.
5. A nurse is attempting to resolve an ethical dilemma that involves a client's
medical decisions and his own personal values. After collecting data and iden-
tifying the problem, which of the following actions should the nurse take next?
a. discuss information about the dilemma with the client's provider
b. determine the benefits and consequences of respecting the client's medical
decisions
c. reflect on the effect of ethical theories on the nurse's personal values
d. develop a plan that balances both the nurse's values and the client's medical
decisions: b. determine the benefits and consequences of respecting the client's medical decisions
-The first action the nurse should take using the nursing process is to collect data from the client. After the nurse collects
the data and identifies the problem, the nurse should determine the benefits and consequences of respecting the
client's medical decisions as the next step in the ethical decision-making model.
6. A nurse is reinforcing teaching with a client who has obsessive-compulsive
disorder and performs hand hygiene to decrease anxiety. Which of the follow-
ing actions should the nurse take to demonstrate modeling as a behavioral
intervention strategy?
a. setting a time limit between episodes of hand hygiene
b. reminding the client to shout "stop" each time she has an urge to perform
hand hygiene
c. demonstrating performing hand hygiene at appropriate times
, PN Mental Health Online Practice (B)
Study online at https://quizlet.com/_a1vun5
d. instructing the client to practice muscle relaxation when she has the urge to
perform hand hygiene: c. demonstrating performing hand hygiene at appropriate times
-This action is an example of modeling, which is a strategy that allows the client to see another person perform the
expected behavior.
7. A nurse is caring for a client who has antisocial personality disorder. Which of
the following actions should the nurse take when caring for this client?
a. persuade the client to demonstrate acceptable behavior
b. avoid talking about the client's past display of unacceptable behavior
c. use countertransference to develop the therapeutic relationship
d. remind the client of consequences for unacceptable behavior: d. remind the client
of consequences for unacceptable behavior
-Clients who have an antisocial personality disorder do not respect the rights of others. Therefore, the nurse should
remind the client about which behaviors are acceptable and unacceptable and be prepared to administer consequences
for unacceptable behavior.
8. A nurse is assisting with the plan of care for a client who is malnourished due
to alcohol use disorder. Which of the following interventions should the nurse
include in the plan?
a. restrict the client's sodium intake
b. encourage the client to eat three large meals per day
c. weigh the client weekly
d. observe the client for 1 hr after he eats: a. restrict the client's sodium intake
-A client who is malnourished due to alcohol use disorder is at risk for ascites. Therefore, the nurse should restrict the
client's sodium intake to decrease the risk of fluid retention.
9. A nurse is collecting data from a client whose home was destroyed by a fire.
Which of the following responses should the nurse make first?
a. "Are you experiencing feeling of hopelessness?"
b. "Is there someone I can call for you?"
c. "It might be helpful for you to attend a support group?"
d. "Now is a good time for you to use relaxation breathing.": a. "Are you experiencing
feeling of hopelessness?"
-When using Maslow's hierarchy of needs, the priority action for the nurse to take is to determine if the client is safe.
Study online at https://quizlet.com/_a1vun5
1. A nurse on a mental health unit is assisting with the plan of care for a
newly admitted client who has anorexia nervosa. Which of the following actions
should the nurse include in the plan of care?
a. weigh the client at night prior to bedtime
b. offer liquid supplements to the client
c. encourage the client to gain 2.3 kg (5 lb) per week
d. observe the client for up to 30 min after meals: b. offer liquid supplements to the client
-the nurse should offer liquid supplements to the client because the client might be unable to eat solid foods when he
is first admitted.
2. A nurse in a mental health facility is caring for a client who has schizophrenia.
The client becomes violent in the dayroom and begins throwing objects at staff
and other clients. After calling for assistance, which of the following actions
should the nurse take next?
a. obtain a prescription for mechanical restraints
b. place the client in a monitored seclusion room
c. tell the client calmy to sit down
d. administer diazepam intramuscularly: c. tell the client calmly to sit down.
-when providing client care, the nurse should first use the least restrictive intervention. Therefore, the nurse should use
verbal de-escalation techniques after calling for assistance for a client who is aggressive.
3. A nurse is caring for a group of clients on a mental health unit. Which of the
following client behaviors should the nurse report to the charge nurse?
a. a client who has schizophrenia is communicating using echolalia
b. a client who has depression is exhibiting anergia
c. a client who is manic has been pacing the unit for several hours
d. a client who has a phobia is using thought stopping: c. a client who is manic has been
pacing the unit for several hours
-the nurse should identify that excessive physical activity in a client who is experiencing a manic episode places the
client at risk for physical exhausting and possible death. The nurse should report this client's behavior to the charge
nurse.
4. A nurse is collecting data from a client who is taking valproic acid for treat-
ment of bipolar disorder. The nurse should identify that which of the following
findings is priority to report to the provider?
, PN Mental Health Online Practice (B)
Study online at https://quizlet.com/_a1vun5
a. drowsiness
b. nausea and vomiting
c. constipation
d. bleeding gums: d. bleeding gums
-when using the urgent vs non urgent approach to the client care, the nurse should determine that the priority finding
is bleeding gums because of the risk of thrombocytopenia.
OR---------
Yellow sclera
Rationale: priority finding is yellow sclera because of risk for hepatotoxicity.
5. A nurse is attempting to resolve an ethical dilemma that involves a client's
medical decisions and his own personal values. After collecting data and iden-
tifying the problem, which of the following actions should the nurse take next?
a. discuss information about the dilemma with the client's provider
b. determine the benefits and consequences of respecting the client's medical
decisions
c. reflect on the effect of ethical theories on the nurse's personal values
d. develop a plan that balances both the nurse's values and the client's medical
decisions: b. determine the benefits and consequences of respecting the client's medical decisions
-The first action the nurse should take using the nursing process is to collect data from the client. After the nurse collects
the data and identifies the problem, the nurse should determine the benefits and consequences of respecting the
client's medical decisions as the next step in the ethical decision-making model.
6. A nurse is reinforcing teaching with a client who has obsessive-compulsive
disorder and performs hand hygiene to decrease anxiety. Which of the follow-
ing actions should the nurse take to demonstrate modeling as a behavioral
intervention strategy?
a. setting a time limit between episodes of hand hygiene
b. reminding the client to shout "stop" each time she has an urge to perform
hand hygiene
c. demonstrating performing hand hygiene at appropriate times
, PN Mental Health Online Practice (B)
Study online at https://quizlet.com/_a1vun5
d. instructing the client to practice muscle relaxation when she has the urge to
perform hand hygiene: c. demonstrating performing hand hygiene at appropriate times
-This action is an example of modeling, which is a strategy that allows the client to see another person perform the
expected behavior.
7. A nurse is caring for a client who has antisocial personality disorder. Which of
the following actions should the nurse take when caring for this client?
a. persuade the client to demonstrate acceptable behavior
b. avoid talking about the client's past display of unacceptable behavior
c. use countertransference to develop the therapeutic relationship
d. remind the client of consequences for unacceptable behavior: d. remind the client
of consequences for unacceptable behavior
-Clients who have an antisocial personality disorder do not respect the rights of others. Therefore, the nurse should
remind the client about which behaviors are acceptable and unacceptable and be prepared to administer consequences
for unacceptable behavior.
8. A nurse is assisting with the plan of care for a client who is malnourished due
to alcohol use disorder. Which of the following interventions should the nurse
include in the plan?
a. restrict the client's sodium intake
b. encourage the client to eat three large meals per day
c. weigh the client weekly
d. observe the client for 1 hr after he eats: a. restrict the client's sodium intake
-A client who is malnourished due to alcohol use disorder is at risk for ascites. Therefore, the nurse should restrict the
client's sodium intake to decrease the risk of fluid retention.
9. A nurse is collecting data from a client whose home was destroyed by a fire.
Which of the following responses should the nurse make first?
a. "Are you experiencing feeling of hopelessness?"
b. "Is there someone I can call for you?"
c. "It might be helpful for you to attend a support group?"
d. "Now is a good time for you to use relaxation breathing.": a. "Are you experiencing
feeling of hopelessness?"
-When using Maslow's hierarchy of needs, the priority action for the nurse to take is to determine if the client is safe.
