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1. A charge nurse is discussing mental status -To assess cognitive ability, I should ask the
exams with a newly licensed nurse. Which client to count backward by sevens."
of the following statements by the newly -To assess affect, I should observe the
licensed nurse indicates an understanding client's facial expression.
of the teaching? (Select all that apply). -To assess language ability, I should instruct
the client to write a sentence."
2. A nurse is planning care for a client who Monitor the client for adverse effects of the
has a mental health disorder. Which of the medications.
following actions should the nurse include
as a psychobiological intervention?
3. A nurse in an outpatient mental health Identify the client's perception of her mental
clinic is preparing to conduct an initial health status.
client interview. When conducting the in-
terview, which of the following actions
should the nurse identify as the priority?
4. A nurse is told during change of shift re- The client arouses briefly in response to a
port that a client is stuporous. When as- sternal rub.
sessing the client, which of the following
findings should the nurse expect?
5. A nurse is planning a peer group discus- The DSM-5 establishes diagnostic criteria
sion about the DSM-5. Which of the follow- for individual mental health disorders.
ing information is appropriate to include -The DSM-5 assists nurses in planning care
in the discussion? (Select all that apply) for client's who have mental health disor-
ders.
-The DSM-5 indicates expected assessment
findings of mental health disorders.
6. A nurse in an emergency mental health
facility is caring for a group of clients. The
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nurse should identify that which of the fol- A client who has borderline personality dis-
lowing clients requires a temporary emer- order and assaulted a homeless man with a
gency admission? metal rod
7. A nurse decides to put a client who has a False imprisonment
psychotic disorder in seclusion overnight
because the unit is very short-staffed,
and the client frequently fights with other
clients. The nurse's actions are an example
of which of the following torts?
8. A client tells a nurse, "Don't tell anyone but Report the incident to the health care team,
I hid a sharp knife under my mattress in or- but do not inform the client of the intention
der to protect myself from my roommate, to do so.
who is always yelling at me and threat-
ening me." Which of the following actions
should the nurse take?
9. A nurse is caring for a client who is in -Client was offered 8 oz of water every hr."
mechanical restraints. Which of the follow- -Client shouted obscenities at assistive per-
ing statements should the nurse include in sonnel."
the documentation? (Select all that apply) -Client received chlorpromazine 15 mg by
mouth at 1000.
10. A nurse hears a newly licensed nurse dis- Tell the nurse to stop discussing the behav-
cussing a client's hallucinations in the hall- ior
way with another nurse. Which of the fol-
lowing actions should the nurse take first?
11. A nurse is caring for the parents of a child I understand you're concerned. Let's discuss
who has demonstrated changes in behav- what concerns you specifically."
ior and mood. When the mother of the
child asks the nurse for reassurance about
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her son's condition, which of the following
responses should the nurse make?
12. A nurse is caring for a client who smokes Denial
and has lung cancer. The client reports,
"I'm coughing because I have that cold
that everyone has been getting." The
nurse should identify that the client is us-
ing which of the following defense mech-
anisms?
13. A nurse is providing preoperative teach- Moderate
ing for a client who was just informed
that she requires emergency surgery. The
client has a respiratory rate 30/min and
says, "This is difficult to comprehend. I
feel shaky and nervous." The nurse should
identify that the client is experiencing
which of the following levels of anxiety?
14. A nurse is caring for a client who is expe- -Discuss prior use of coping mechanisms
riencing moderate anxiety. Which of the with the client.
following actions should the nurse take -Demonstrate a calm manner while using
when trying to give necessary information simple and clear directions.
to the client? (Select all that apply.)
15. A nurse is talking with a client who is at -Losing someone close to you must be very
risk for suicide following the death of his upsetting."
spouse. Which of the following statements
should the nurse make?
16. A charge nurse is discussing the charac-
teristics of a nurse-client relationship with
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a newly licensed nurse. Which of the fol- -It is goal-directed.
lowing characteristics should the nurse in- -Behavioral change is encouraged.
clude in the discussion? (Select all that ap- -A termination date is established.
ply)
17. A nurse is in the working phase of a ther- The client accuses the nurses of telling him
apeutic relationship with a client who has what to do just like his ex-girlfriend.
methamphetamine use disorder. Which of
the following actions indicates transfer-
ence behavior?
18. A nurse is planning care for the termina- Discussing ways to use new behaviors
tion phase of a nurse-client relationship.
Which of the following actions should the
nurse include in the plan of care?
19. A nurse is orienting a new client to a men- You and the other clients will meet with staff
tal health unit. When explaining the unit's to discuss common problems.
community meetings, which of the follow-
ing statements should the nurse make?
20. A nurse is caring several clients who are at- A client who says he is hearing a voice that
tending community-based mental health tells him he is not worth living anymore.
programs. Which of the following clients
should the nurse plan to visit first?
21. A community mental health nurse is plan- Establishing rehabilitation programs to de-
ning care to address the issue of depres- crease the effects of depression
sion among older adult clients in the com-
munity. Which of the following interven-
tions should the nurse plan as a method
of tertiary prevention?