N3381 MENTAL HEALTH EXAMS SCRIPT LATEST
QUESTIONS AND ANSWERS SURE A+
✔✔A manic client begins to make sexual advances toward 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. Based on the
analysis of this situation, which intervention should the nurse implement?
1.Place the client in seclusion for 30 minutes.
2.Tell the client that the behavior is inappropriate.
3.Escort the client to his or her room, with the assistance of other staff.
4.Tell the client that his or her telephone privileges are revoked for 24 hours. -
✔✔Escort the client to his or her room, with the assistance of other staff.
Rationale:The client is at risk for injury to self and others and should be escorted out of
the dayroom. Seclusion is premature in this situation. Telling the client that the behavior
is inappropriate has already been attempted by the nurse. Denying privileges may
increase the agitation that already exists in this client.
✔✔The nurse is caring for a client diagnosed with paranoid personality disorder who is
experiencing disturbed thought processes. In formulating a nursing plan of care, which
best intervention should the nurse include?
, 1.Increase socialization of the client with peers.
2.Avoid using a whisper voice in front of the client.
3.Begin to educate the client about social supports in the community. 4.Have the client
sign a release of information to appropriate parties for assessment purposes. -
✔✔Avoid using a whisper voice in front of the client.
Rationale:Disturbed thought processes related to paranoid personality disorder are the
client's problem, and the plan of care must address this problem. The client is distrustful
and suspicious of others. The members of the health care team need to establish a
rapport and trust with the client. Laughing or whispering in front of the client would be
counterproductive. The remaining options ask the client to trust on a multitude of levels.
These options are actions that are too intrusive for a client with this disorder.
✔✔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.Chess
2.Writing
3.Ping pong
4.Basketball - ✔✔Writing
Rationale:Solitary activities that require a short attention span with mild physical
exertion are the most appropriate activities for a client who is exhibiting aggressive
behavior. Writing (journaling), walks with staff, and finger painting are activities that
minimize stimuli and provide a constructive release for tension. The remaining options
have a competitive element to them and should be avoided because they can stimulate
aggression and increase psychomotor activity.
✔✔The home health nurse visits a client at home and determines that the client is
dependent on drugs. During the assessment, which action should the nurse take to plan
appropriate nursing care?
1.Ask the client why he started taking illegal drugs.
2.Ask the client about the amount of drug use and its effect.
3.Ask the client how long he thought that he could take drugs without someone finding
out.
4.Not ask any questions for fear that the client is in denial and will throw the nurse out of
the home. - ✔✔Ask the client about the amount of drug use and its effect.
Rationale:Whenever the nurse carries out an assessment for a client who is dependent
on drugs, it is best for the nurse to attempt to elicit information by being nonjudgmental
and direct. Option 1 is incorrect because it is judgmental and off-focus, and reflects the
nurse's bias. Option 3 is incorrect because it is judgmental, insensitive, and aggressive,
which is nontherapeutic. Option 4 is incorrect because it indicates passivity on the
nurse's part and uses rationalization to avoid the therapeutic nursing intervention.
,✔✔Which interventions are most appropriate for caring for a client in alcohol
withdrawal? Select all that apply.
1.Monitor vital signs.
2.Provide a safe environment.
3.Address hallucinations therapeutically.
4.Provide stimulation in the environment.
5.Provide reality orientation as appropriate.
6.Maintain NPO (nothing by mouth) status. - ✔✔1. Monitor vital signs.
2. Provide a safe environment.
3. Address hallucinations therapeutically.
4. Provide reality orientation as appropriate.
Rationale:When the client is experiencing withdrawal from alcohol, the priority for care is
to prevent the client from harming self or others. The nurse would monitor the vital signs
closely and report abnormal findings. The nurse would provide a low-stimulation
environment to maintain the client in as calm a state as possible. The nurse would
reorient the client to reality frequently and would address hallucinations therapeutically.
Adequate nutritional and fluid intake need to be maintained.
✔✔The nurse in the emergency department is caring for a young female victim of
sexual assault. The client's physical assessment is complete, and physical evidence
has been collected. The nurse notes that the client is withdrawn, confused, and at times
physically immobile. How should the nurse interpret these behaviors?
1. Signs of depression
2. Reactions to a devastating event
3. Evidence that the client is a high suicide risk
4. Indicative of the need for hospital admission - ✔✔Reactions to a devastating event
Rationale:During the acute phase of the rape crisis, the client can display a wide range
of emotional and somatic responses. The symptoms noted indicate an expected
reaction. Options 1, 3, and 4 are incorrect interpretations.
✔✔The nurse has been closely observing a client who has been displaying aggressive
behaviors. The nurse observes that the behavior displayed by the client is escalating.
Which nursing intervention is most helpful to this client at this time? Select all that apply.
1.Initiate confinement measures.
2.Acknowledge the client's behavior.
3.Assist the client to an area that is quiet.
4.Maintain a safe distance from the client.
5.Allow the client to take control of the situation. - ✔✔Acknowledge the client's behavior.
Assist the client to an area that is quiet.
Maintain a safe distance from the client.
, Rationale:During the escalation period, the client's behavior is moving toward loss of
control. Nursing actions include taking control, maintaining a safe distance,
acknowledging behavior, moving the client to a quiet area, and medicating the client if
appropriate. To initiate confinement measures during this period is inappropriate.
Initiation of confinement measures, if needed, is most appropriate during the crisis
period.
✔✔Which behavior observed by the nurse indicates a suspicion that a depressed
adolescent client may be suicidal?
1.The adolescent gives away a DVD and a cherished autographed picture of a
performer.
2.The adolescent runs out of the therapy group, swearing at the group leader, and to
her room.
3.The adolescent becomes angry while speaking on the telephone and slams down the
receiver.
4.The adolescent gets angry with her roommate when the roommate borrows the
client's clothes without asking. - ✔✔The adolescent gives away a DVD and a cherished
autographed picture of a performer.
Rationale:A depressed suicidal client often gives away that which is of value as a way of
saying goodbye and wanting to be remembered. Options 2, 3, and 4 deal with anger
and acting-out behaviors that are often typical of an adolescent.
✔✔A moderately depressed client who was hospitalized 2 days ago suddenly begins
smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally
cured." How should the nurse interpret this behavior as a cue to modify the treatment
plan?
1.Suggesting a reduction of medication
2.Allowing increased "in-room" activities
3.Increasing the level of suicide precautions
4.Allowing the client off-unit privileges as needed - ✔✔Increasing the level of suicide
precautions
Rationale:A client who is moderately depressed and has only been in the hospital 2
days is unlikely to have such a dramatic cure. When a depression suddenly lifts, it is
likely that the client may have made the decision to harm himself or herself. Suicide
precautions are necessary to keep the client safe. The remaining options are therefore
incorrect interpretations.
✔✔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.Information regarding shelters
QUESTIONS AND ANSWERS SURE A+
✔✔A manic client begins to make sexual advances toward 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. Based on the
analysis of this situation, which intervention should the nurse implement?
1.Place the client in seclusion for 30 minutes.
2.Tell the client that the behavior is inappropriate.
3.Escort the client to his or her room, with the assistance of other staff.
4.Tell the client that his or her telephone privileges are revoked for 24 hours. -
✔✔Escort the client to his or her room, with the assistance of other staff.
Rationale:The client is at risk for injury to self and others and should be escorted out of
the dayroom. Seclusion is premature in this situation. Telling the client that the behavior
is inappropriate has already been attempted by the nurse. Denying privileges may
increase the agitation that already exists in this client.
✔✔The nurse is caring for a client diagnosed with paranoid personality disorder who is
experiencing disturbed thought processes. In formulating a nursing plan of care, which
best intervention should the nurse include?
, 1.Increase socialization of the client with peers.
2.Avoid using a whisper voice in front of the client.
3.Begin to educate the client about social supports in the community. 4.Have the client
sign a release of information to appropriate parties for assessment purposes. -
✔✔Avoid using a whisper voice in front of the client.
Rationale:Disturbed thought processes related to paranoid personality disorder are the
client's problem, and the plan of care must address this problem. The client is distrustful
and suspicious of others. The members of the health care team need to establish a
rapport and trust with the client. Laughing or whispering in front of the client would be
counterproductive. The remaining options ask the client to trust on a multitude of levels.
These options are actions that are too intrusive for a client with this disorder.
✔✔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.Chess
2.Writing
3.Ping pong
4.Basketball - ✔✔Writing
Rationale:Solitary activities that require a short attention span with mild physical
exertion are the most appropriate activities for a client who is exhibiting aggressive
behavior. Writing (journaling), walks with staff, and finger painting are activities that
minimize stimuli and provide a constructive release for tension. The remaining options
have a competitive element to them and should be avoided because they can stimulate
aggression and increase psychomotor activity.
✔✔The home health nurse visits a client at home and determines that the client is
dependent on drugs. During the assessment, which action should the nurse take to plan
appropriate nursing care?
1.Ask the client why he started taking illegal drugs.
2.Ask the client about the amount of drug use and its effect.
3.Ask the client how long he thought that he could take drugs without someone finding
out.
4.Not ask any questions for fear that the client is in denial and will throw the nurse out of
the home. - ✔✔Ask the client about the amount of drug use and its effect.
Rationale:Whenever the nurse carries out an assessment for a client who is dependent
on drugs, it is best for the nurse to attempt to elicit information by being nonjudgmental
and direct. Option 1 is incorrect because it is judgmental and off-focus, and reflects the
nurse's bias. Option 3 is incorrect because it is judgmental, insensitive, and aggressive,
which is nontherapeutic. Option 4 is incorrect because it indicates passivity on the
nurse's part and uses rationalization to avoid the therapeutic nursing intervention.
,✔✔Which interventions are most appropriate for caring for a client in alcohol
withdrawal? Select all that apply.
1.Monitor vital signs.
2.Provide a safe environment.
3.Address hallucinations therapeutically.
4.Provide stimulation in the environment.
5.Provide reality orientation as appropriate.
6.Maintain NPO (nothing by mouth) status. - ✔✔1. Monitor vital signs.
2. Provide a safe environment.
3. Address hallucinations therapeutically.
4. Provide reality orientation as appropriate.
Rationale:When the client is experiencing withdrawal from alcohol, the priority for care is
to prevent the client from harming self or others. The nurse would monitor the vital signs
closely and report abnormal findings. The nurse would provide a low-stimulation
environment to maintain the client in as calm a state as possible. The nurse would
reorient the client to reality frequently and would address hallucinations therapeutically.
Adequate nutritional and fluid intake need to be maintained.
✔✔The nurse in the emergency department is caring for a young female victim of
sexual assault. The client's physical assessment is complete, and physical evidence
has been collected. The nurse notes that the client is withdrawn, confused, and at times
physically immobile. How should the nurse interpret these behaviors?
1. Signs of depression
2. Reactions to a devastating event
3. Evidence that the client is a high suicide risk
4. Indicative of the need for hospital admission - ✔✔Reactions to a devastating event
Rationale:During the acute phase of the rape crisis, the client can display a wide range
of emotional and somatic responses. The symptoms noted indicate an expected
reaction. Options 1, 3, and 4 are incorrect interpretations.
✔✔The nurse has been closely observing a client who has been displaying aggressive
behaviors. The nurse observes that the behavior displayed by the client is escalating.
Which nursing intervention is most helpful to this client at this time? Select all that apply.
1.Initiate confinement measures.
2.Acknowledge the client's behavior.
3.Assist the client to an area that is quiet.
4.Maintain a safe distance from the client.
5.Allow the client to take control of the situation. - ✔✔Acknowledge the client's behavior.
Assist the client to an area that is quiet.
Maintain a safe distance from the client.
, Rationale:During the escalation period, the client's behavior is moving toward loss of
control. Nursing actions include taking control, maintaining a safe distance,
acknowledging behavior, moving the client to a quiet area, and medicating the client if
appropriate. To initiate confinement measures during this period is inappropriate.
Initiation of confinement measures, if needed, is most appropriate during the crisis
period.
✔✔Which behavior observed by the nurse indicates a suspicion that a depressed
adolescent client may be suicidal?
1.The adolescent gives away a DVD and a cherished autographed picture of a
performer.
2.The adolescent runs out of the therapy group, swearing at the group leader, and to
her room.
3.The adolescent becomes angry while speaking on the telephone and slams down the
receiver.
4.The adolescent gets angry with her roommate when the roommate borrows the
client's clothes without asking. - ✔✔The adolescent gives away a DVD and a cherished
autographed picture of a performer.
Rationale:A depressed suicidal client often gives away that which is of value as a way of
saying goodbye and wanting to be remembered. Options 2, 3, and 4 deal with anger
and acting-out behaviors that are often typical of an adolescent.
✔✔A moderately depressed client who was hospitalized 2 days ago suddenly begins
smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally
cured." How should the nurse interpret this behavior as a cue to modify the treatment
plan?
1.Suggesting a reduction of medication
2.Allowing increased "in-room" activities
3.Increasing the level of suicide precautions
4.Allowing the client off-unit privileges as needed - ✔✔Increasing the level of suicide
precautions
Rationale:A client who is moderately depressed and has only been in the hospital 2
days is unlikely to have such a dramatic cure. When a depression suddenly lifts, it is
likely that the client may have made the decision to harm himself or herself. Suicide
precautions are necessary to keep the client safe. The remaining options are therefore
incorrect interpretations.
✔✔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.Information regarding shelters
