HESI RN MENTAL HEALTH EXAM PACK

MEREGED HESI RN MENTAL HEALTH EXAM PACK FROM 2019/2020/2021 EXAMSBEST FOR 2022 ACTUAL EXAM REVIEW MEREGED HESI RN MENTAL HEALTH EXAM PACK FROM 2019/2020/2021 EXAMSBEST FOR 2022 ACTUAL EXAM REVIEW 1- A client with depression remains in bed most of the day, declines activities and re which nursing problem has the greatest priority for this client? A) Loss of interest in diversional activity B) Social isolation C) Refusal to address nutritional needs. D) Low self-esteem 2- The nurse is preparing medications for a client with bipolar disorder and notice antipsychotic medication was discontinued several days ago. Which medication discontinued? A) Lithium (lithotabs) B) Benztropine (cogetin) C) Alprazolam ( Xanax) D) Magnesium (milk of magnesia) 3- A female client requests that her husband be allowed to stay in the room during the admission assessment. While interviewing the client, the nurse notes a discrepancy between the client’s verbal and nonverbal communication. What action should the nurse take? A) Pay close attention and document the nonverbal message. B) Ask the client’s husband to interpret the discrepancy C) Ignore the nonverbal behavior and focus on the client’s verbal message. D) Integrate the verbal and nonverbal message and interpret them as one. 4- A male client approaches the nurse with an angry expression on his face and raises his voice, saying, “My roommate is the most selfish, self-centered, angry person I have ever met. If he loses his temper one more time with me, I am going to punch out! “the nurse recognizes that client is using which defense mechanism? A) Denial B) Projection C) Rationalization D) Splitting 5- A male client with bipolar disorder who began taking lithium carbonate five days ago is complaining of excessive thirst, and the nurse finds him attempting to drink water from the bathroom sink faucet. Which intervention the nurses implement? A) Report the client’s serum lithium level to the healthcare provider. B) Encourage the client to suck on hard candy to relieve the symptoms. C) No action is needed since polydipsia is a common side effect. D) Tell the client that drinking from the faucet is not allowed. 6- The nurse is teaching a client about the initiation of a prescribed abstinence therapy using disulfiram (antabuse). What information should the client acknowledge understanding? A) Completely abstain from heroin or cocaine use. B) Remain alcohol free for 12 hours prior to the first dose. C) Attend monthly meeting of alcoholics anonymous. D) Admit to other that he is a substance abuser. 7- A male client with schizophrenia is admitted to the mental health unit after abruptly stopping his prescription for ziprasidone (Geodon) one month ago. Which question is most important for the nurse to ask the client? A) Have you lost interest in the things that you used to enjoy? B) Is your ability to think or concentrate decreased? C) How many continuous hours do you sleep at night? D) Do you hear sounds or voices that others do not hear? 8- During an annual physical by the occupational nurse working in a corporate clinic, a male employee tells the nurse that his high-stress job is causing trouble in his personal life. He further explains that he often gets so angry while driving to and from work that he has considered “getting even” with other drivers. How should the nurse respond? A) “Anger is contagious and could result in a major confrontation” B) “ Try not to let your anger cause you to act impulsively” C) “Expressing your anger to a stranger could result in an unsafe situation” D) “It sound as if there are many situations that make you feel angry” 9- A client who has agoraphobia (a fear of crowds) is beginning desensitization with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client’s plan of care? A) Encourage substitution of positive thoughts for negative ones. B) Establish trust by providing a calm, safe environment. C) Progressively expose the client to larger crowds. D) Encourage deep breathing when anxiety escalates in a crowd. 10- Which nursing actions are likely to help promote the self-esteem of a male client with moderate depression? ( select all that apply) A) Ask the client what his long- term goals are. B) Discuss the challenges of his medical condition. C) Include the client in determining treatment protocol. D) Encourage the client to engage in recreational therapy. E) Provide opportunities for the client to discuss his concerns. 11- A male client is admitted to the psychiatric unit for recurrent negative symptoms of chronic schizophrenia and medication adjustment of risperidone (Risperdal). When the client walks to the nurse’s station in a literally contracted position, he states that something has made his body confort into a monster. What action should the nurse take? A) Medicate the client with the prescribed antipsychotic thioridazine (mellaril) B) Offer the client a prescribed physical therapy hot pack for muscle spasms. C) Direct client to occupational therapy to distract him from somatic complaints. D) Administer the prescribed anticholinergic benztropine (Cogentin) for dystonia. 12- A mental health worker (MHW) is caring for a client with escalating aggressive behavior. Which action by the MHW warrants immediate intervention by the nurse? A) Is attempting to physically restrain the client. B) Tells the client to go to the quiet area of the unit. C) Is using a loud voice to talk to the client. D) Remains at a distance of 4 feet from the client. 13- A client on the mental health unit is becoming more agitated, shouting at the staff, and pacing in the hallway. When a PRN medication is offered, the client refuses the medication and defiantly sits on the floor in the middle of the unit hallway. What nursing intervention should the nurse implement first? A) Transport of the client to the seclusion room B) Quietly approach the client with additional staff members. C) Take other client in the area to the client lounge. D) Administer medication to chemically restrain the client. 14- A client is admitted to the mental health unit and reports taking extra antianxiety medication because, “I’m so stressed out. I just wanted to go sleep” the nurse should plan one-on- one observation of the client based on which statement? A) What should I do? Nothing seems to help.” B) I have been so tired lately and needed to sleep.” C) I really think that I don’t need to be here.” D) I don’t want to talk. Nothing matters anymore.” 15- A male hospital employee is pushed out of the way by a female employee because of an oncoming gurney. The pushed employee becomes very angry and swings at the female employee. Both employees are referred for counseling with the staff psychiatric nurse. Which factor in the pushed employee’s history is most related to the reaction that occurred? A) Is worried about losing his job to a woman B) Tortured animals as a child. C) Was physically abused by his mother D) Hates to be touched by anyone 16- The nurse documents the mental status of a female client who has been hospitalized for several days by court order. The client state, “I don’t need to be here” and tells the nurse that she believes that the television talks to her. The nurse should document these assessment findings in which section of the mental status exam? A) Level of concentration B) Insight and judgment C) Remote memory D) Mood and affect 17- The nurse on the evening shift receives report that a client is scheduled for electroconvulsive treatment (ECT) in the morning. Which intervention should the nurse implement the evening before the scheduled ECT? A) Hold all bedtime medication. B) Keep the client NPO after midnight. C) Implement elopement precautions. D) Give client an enema at bedtime. 18- A client who is admitted to the mental health unit report shortness of breath and dizziness. The client tells the nurse, “I feel like I’m going to die” which nursing problem should the nurse include in this client’s plan of care? A) Mood disturbance B) Moderate anxiety C) Altered thoughts D) Social isolation 19- A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confuse. The nurse also determines that the client is homeless and slightly suspicious. This client’s treatment plan should include what priority problem? A) Self-care deficit. B) Disturbed sensory perception. C) Ineffective community coping. D) Acute confuse. 20- A nurse is providing education about strategies for a safety plan for a female client who is a victim of intimate partner violence. Which strategies should be included in the safety plan? (Select all that apply) A) Have a bag ready that has extra clothes for self and children. B) Establish a code with family and friend to signify violence. C) Purchase a gun to use for protection D) Take a self-defense course that retaliate the abuser with injury. E) Plan an escape route to use if the abuser blocks the main exit. 21- A female client, who is wearing dirty clothes and has a foul body odor, comes to the clinic reporting feeling scared because she is being stalked. What A) Offer the client a safe place to relax before interviewing her. B) Ask the client to describe why she is being stalked. C) Recommend that the client talk with a social worked. D) Assure client that the healthcare provider will see her today. 22- The nurse leading a group session of adolescent client gives the members a handout about anger management. One of the male clients is fidgety, interrupts peers when they try to talk, and talks about his pets at home. What nursing action is best for the nurse to take? A) Explore the client’s feelings about his pet and home life. B) Encourage his peers to help involve him in the activity. C) Give the client permission to leave and return in 10 min. D) Redirect him by encouraging him to read from the handout. 23- A male adolescent was admitted to the unit two days ago for depression. When the mental health nurse tries to interview the client to establish rapport, he becomes very irritated and sarcastic. Which action is best for the nurse to take? A) Report the behavior to the next shift. B) Offer to play a game of cards with the client. C) Document the behavior in the chart. D) Plan to talk with the client the next day. 24- A male adult is admitted because of an acetaminophen (Tylenol) overdose. After transfer to mental health unit the client is told he has liver damage. Which information is most important for the nurse to include in the client’s a discharge plan? A) Eat a high carbohydrate, low fat, low protein diet. B) Do not take any over the counter medication. C) Call the crisis hot line if feeling lonely. D) Avoid exposure to large crowds. 25- After receiving treatment for anorexia, a student asks the school nurse for permission to work in the school cafeterias part of the school’s work study program. What action should the nurse take? A) Refer the student to a psychiatrist for further discussion. B) Recommend assignment to the receptionist’s office. C) Suggest that the student work in the athletic department. D) Determine the parents’ opinion of the work assignment. 26- The nurse accepts a transfer to the mental health unit and understands that the client is distractible and is exhibiting a decreased ability to concentrate. The nurse has only 15 min to talk with the client. To develop a treatment plan for this client, wich assessment is most important for the nurse to obtain? A) Motivation for treatment B) History of substance use C) Medication compliance D) Mental status examination 27- A client who is known to abuse drugs is admitted to the psychiatric unit. With medication should the nurse anticipate administering to a client who is exhibiting benzodiazepine withdrawal symptoms? A) Diphenhydramine (Benadryl) B) Perphenazine (trilafon) C) Isocarboxazid (marplan) D) Clordiazepoxide (Librium) 28- A male client who recently lost a loved one arrives at the mental health center and tells the nurse he is no longer interested in his usual activities and has not slept for several days. Which priority nursing problem should the nurse couinclude in this client’s plan of care? A) Risk for suicide B) Sleep deprivation C) Situational low self-esteem. D) Social isolation. 29- A woman brings her 48- years –old husband to the outpatient psychiatric unit and describes his behavior to the admitting nurse. She state that he has been sleepwalking, cannot remember who he is, and exhibits multiple personalities. The nurse knows that these behaviors are often associated with: A) Post-traumatic stress syndrome. B) Panic disorder. C) Dissociative disorder. D) Obsessive-compulsive disorder. 30- A male client with a long history of alcohol dependency arrives in the emergency department describing the feeling of bugs crawling on his body. His BP is 170/102. Pulse rate is 110b/min, and his blood alcohol level (BAL)is 0 mg/dl. Which prescription should the nurse administer? A) Haloperidol (Haldol) B) Thiamine (Vit B1) C) Diphenhydramine (Benadryl) D) Lorazepan (Ativan) 31- The nurse on the day shift receives report about a client with depression who w the weekend. The nurse walks into the client’s room in the morning and finds the what intervention is best for the nurse to implement? A) Assist the client to get out bed and involved in an activity. B) Monitor the client’s appetite and pattern of sleep. C) Assess the client’s feelings about the hospital stay. D) Explain that staff will check on the client every 30 min 32- A client who refuse antipsychotic medications disrupts group activities, talks with nonsensical words wanders into client’s room. The nurse decides that the client needs constant observation based on which of these assessment findings? A) Wanders into client’s rooms. B) Refuse antipsychotic medication. C) Talks with nonsensical words. D) Disrupts group activities. 33- Which client statement suggests to the nurse that the client is using the defense mechanism of projection to deal with anxiety related to admission to a psychiatric unit? A) I am here because the police thought I was doing something wrong” B) I want to be here because I know it is the best psychiatric facility” C) At least I hit the wall instead of hitting the psychiatric aide” D) Don’t believe everything my family tells you, I am not crazy” 34- A client with schizophrenia explains that she has 20 children and then very seriously points to the nurse and explains that she is one of them. What is the most therapeutic response for the nurse to provide? A) Let’s go ask another nurse if this true.” B) My name tag shows that I am a nurse here.” C) I cannot possibly be one of your children” D) I know that you don’t have 9 children” 35- A middle-aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and amotivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning? A) Encourage the client to exercise B) Suggest that the client to develop a list of pleasurable activities C) Teach the client to develop a plan for daily structured activities D) Provide education on methods to enhance sleep 36- A high school girl reveals to the school nurse that she has been engaging in self-induced vomiting as a weight-control measure. Which initial assessment should the nurse focus on with this adolescent? A) National percentile of weight and height. B) Frequency of bingeing and purging behaviors C) Perceptions of family and social relationships D) School grades and extracurricular activities. 37- A client is receiving substitution therapy during withdrawal from benzodiazepines. Which expected outcome statement has the highest priority when planning nursing care? A) Excessive CNS stimulation will be reduce B) Co- dependent behaviors will be decreased C) Client’s level of consciousness will increase. D) Client will not demonstrate cross- addiction 38- A female client on a psychiatric unit is sweating profusely while she vigorously does push-ups and then runs the length of the corridor several times before crashing into furniture in the sitting room. Picking herself up, she begins to toss chairs aside , looking for a red one to sit in. when another client objects the disturbance, the client shouts, “I am the boss here. I do what I want” which nursing problem best supports these observation? A) Deficient diversional activity related to excess energy level B) Disturbed personal identity related to grandiosity C) Risk for activity intolerance related to hyperactivity D) Risk for other related violence related to disruptive behaviors 39- Narcan was administered to an adult client following a suicide attempt with an overdose of hydrocodone bitartrate (vicodin). Within 15 min the client is alert and oriented. In planning nursing care which intervention has the highest priority at this time? A) Encourage the client to increase fluid intake. B) Obtain the client’s serum vicodin level C) observe the client for further narcotic effects D) determine the client’s reason for attempting suicide 40- Following surgery, a male client with antisocial personality disorder frequently request that a specific nurse be assigned to his care and is belligerent when another nurse is assigned. What action should the charge nurse implement? A) Reassure the client that his request will be met whenever possible B) Advise the client that assignments are not based on client requests C) Ask the client to explain why he constantly request the nurse D) Encourage the client to verbalize his feelings about the nurse 41- A client postpartum depression receives prescription for sertraline (Zoloft). What information is most important to include in client teaching? A) Avoid processed meats, red, wine, and Swiss cheese B) Contact the healthcare provider immediately if suicidal thoughts occur. C) Increase activity level to include a daily exercise routine D) Contact the healthcare provider immediately if muscle stiffness 42- When preparing to administer a prescribed medication to a homeless male at a community psychiatric clinic the client tells the nurse that he usually takes a different dosage. What action should the nurse take? A) Tell him to take the medication then verify the dosage at the next healthcare team meeting B) Withhold the medication until the dosage can be confirmed C) Inform him that he may refuse the medication and document whether or not he take it D) Explain to the client that the dosage has been changed 43- A client who is being treated with lithium carbonate for bipolar disorder develops diarrhea, vomiting and drowsiness. What action should the nurse take? A) Notify de healthcare provider immediately and prepare for admon of an antidote B) Hold the medication and refuse to admon additional amounts of the drug C) Record the symptoms as normal side effects and continues admon of the prescribed dosage D) Notify the health care provider of the symptoms prior to the next admon of the drug 44- The nurse orients a female client with depression to her new room on the mental unit. The client state, “ It seems strange that I don’t have a tv in my room”. Which statement would be best for the nurse to provider? A) You can watch TV as much as you want ouside of your room B) Sometime client feel like the TV is sending them messages C) It’s important to be out of your room and talking to others D) Watching TV is a passive activity and we want you to be active 45- A client who is admitted with a closed head injury after a fall has a blood alcohol level (BAL) of 0.28 (28%) and is difficult to arouse. Which intervention during the first 6 h following admission should the nurse identify as the priority? A) Give lorazepan ( Ativan) PRN for signs of withdrawal B) Administer disulfiram (antabuse) immediately C) Place in side-lying position with head of bed elevated D) Provide thiamine and folate supplements as prescribed 46- The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking helpbecause his wife said he had a drinking problem. What information should the nurse explore indepth with the client based on this screening tool? A) Cancer screening result angerv gastritis daily alcohol intake. B) Consumptiom, liver enzyme gastrointestinal complaints and bleeding C) Efforts to cut down annoyance with question guilt drinking as an eye opener D) Minimizes drinking frequently misses family event guilt about drinking amount of daily intake 47- A female client engages in repeated checks of door and a window lock behavior that prevents her from arriving on time and interferes with her ability to function effectively. What action should the nurse take? A) Ask the client why she checks the locks B) Discuss checking the time frequently C) Determine the type and size of the locks D) Plan a list of activities to be carried out daily 48- The nurse complete an assessment of a client who is experiencing intimate partner violence (IPV) which finding of the injuries should the nurse include in the documentation? A) The client’s significant other’s statement B) Photographs C) General description D) A summary of the client’s feelings 49- The nurse is completing the admission assessment of and underweight adolescent who is admitted to a psychiatric unit with a diagnosis of depression. Which finding requires notification to the healthcare provider? A) Potassium level 2,9 mEq/dl B) BP of 110/70 mm/hg C) WBC of 10,000 mm3 D) Body mass index of 21 50- The nurse is planning client teaching for a 35 year old client with early alcoholic cirrhosis. Which self-care measure should the nurse emphasize for the client’s recovery? A) Support group meetings B) Vit B and multivitamin supplement C) Diet with adequate calories and protein D) Alcohol abstinence 51- A male client comes to the emergency center he has an erection that will no resolve the client reports that he is taking trazodone (desyrel) for insomnia which information is most important for the nurse to ask this client? A) Have you taken any medication for erectile dysfunction?” B) Are you having any other sexual dysfunctions or problems?” C) When was the last time you drank an alcoholic beverage?” D) Do you have a history of angina or high BP?” 52- A teenager who has lost 20 pounds in the last three months is admitted to the hospital with hypotension and tachycardia. The client reports irregular menses and hair loss. Which intervention is most important for the nurse to include in the client plan of care? A) Implement behaviors modification therapy. B) Indicate caloric and nutritional therapy. C) Evaluate the client for low self- esteem. D) Record daily weights and graft trend. 53- While interviewing a client, the nurse takes notes to assist with accurate documentation later. Which statement is most accurate regarding note-take during an interview? A) The client’s comfort level is increased when the nurse breaks eye contact to take notes. B) The interview process is enhanced with note taking and allows the client’s to speak at a normal pace. C) Taken note during an interview is a legal obligation of the examining nurse. D) The nurse’s ability to directly observe the client’s nonverbal communication is limited with note taking. 54- A male client with bipolar disorder tells the nurse that the needs to “ make some deals so that he can improve his retirement savings “ based on this information, which client outcome should the nurse include in the plan of care? A) Delay business decisions until his mania subsides. B) Identify the feeling associated with his behaviors C) Seek legal counsel when making business decisions D) Describe why he is feeling fearful about his finances. HESI RN MENTAL HEALTH HESI RN MENTAL HEALTH CHRIS JAY FILES 2021 1. A client with paranoia is admitted to the mental health unit and immediately goes to the corner of the room and sits quietly without communicating. In approaching the client, what intervention should the nurse implement first? • Explain the nurse's role to the client. 2. Client treated with lithium for bipolar develops diarrhea, vomiting and drowsiness, what action should the nurse do • Notify HCP of the symptoms prior to the next admin of the drug 3. A mental health worker (MHW) is caring for a client with escalating aggressive behavior, which action by the MHW warrants immediate intervention by the nurse? • Is attempting to physically restrain the client. 4. A woman who is bipolar is wearing low cut blouse, and skirt with no underwear, what does nurse do? • Walk her to room and help her pick out something more appropriate 5. An older man who recently got divorced and is 2 years sober, and an alcoholic loves God. He loves kids also. What should nurse ask at his initial interaction? • What is your biggest concern? 6. A woman who is diagnosed with breast cancer becomes dependent and asks family members if they can do ADL's that she is fully capable of doing. What is the reason for this behavior? • Its expected; regression is a naturalstart for recovery 7. Patient having to get treated for benzo diazepam and methadone overdose. What do you use? • Narcan 8. Patient watching TV starts talking loud to himself. The nurse comes in and can't distract him so turns down the TV. What should the nurse do then? • Move client to quieter room 9. In group therapy the charge nurse notices a client increasing to severe levels of anxiety. What should the nurse do? • Talk in a calm, approaching manner 10. A chronic depressed older man refuses to leave his room. His family moved away to a further location so they're not able to visit him as much. What approach should the nurse take with this man? • May I lay with you for a little? 11. Patient who isreally depressed and won't talk or communicate, later is energetic and talkative. What should the nurse do? • Closely monitor the patient (could be suicidal) 12. Patient who had generalized anxiety disorder on Xanax long-term. What is the outcome? • Importance of not quickly stopping the drug 13. A mother has a 9-month-old baby with mental issues and growth issues. The mother comes in and says she's depressed because she’ll never have a normal baby. What should the nurse say? • Have you had any thoughts of harming your baby or yourself? 14. Lithium level 1.5. What do you tell the client who had a recent suicide attempt afterseeing him become very anxious after hearing his Lithium levels? • drink 2-3L of water in 24 hours 15. Woman comes into ED having been raped by her date. What should the nurse document? • document she stated "I was raped by my date" 16. Which patient would require CAGE assessment? • Alcohol patient, cut down, annoyed, guilty, eye opener 17. A nurse is changing a dressing on a bipolar patient's stomach from selfinflicting knife wound. What is the nurse's best approach? • showing no signs of being judgmental 18. Woman is at a meeting with you, what isimportant for the nurse to document after hearing her issues in the relationship • getspouses statement as well 19. A patient in a corner with paranoid symptoms, staring and watching you. They refused to communicate with you. What do you do? • ask simple questions 20. A patientstates "I can't get my thoughts together Ishould really sell my car. It’s not in here. Let's buy a car. What is the patient experiencing? • Tangential thinking 21. A depressed adolescent becomes sarcastic and irritate when you start to ask him questions. What does the nurse do? • Ask him to play cards 22. A patient who has been on an antidepressant for 2 weeks. What should you watch for? • suicidal attempts 23. A patient won't take oral meds that is going through alcohol withdrawal. The nurse starts giving saline lock per alcohol protocol and thiamine. What do you tell them that it will help with recovery? • Thiamine will replenish alcohol effects on the body (something to do with iron) 24. A male patient got divorced a year ago, lost his job, and recently suffered from a break up. What is his reason for his recent depression? • feelings of loss 25. A patient is being admitted for drug overdose. She says the reason she is using drugs is because of a recent breakup of an intimate relationship? what does the nurse do first • ask the patient if they feel as if they have a plan of suicide 26. A bipolar patient hasstopped taking an antipsychotic. What other medication should the nurse expect to be D/C • benztropine (Congentin) 27. What should you recommend to a patient saying she can't get any sleep recently after receiving newsshe has breast cancer. What medication should you recommend? • Ativan 28. A patient has possessions she doesn't trust anyone to hold because she thinks they will steal them. How does the nurse establish trust? • make sure to talk short comments every now and then to her 29. A male adult comes to the mental health clinic and walks back and forth in front of the office door but does not enter the office. He then walks around a chair that isin the hallway several times before sitting down in the chair. What action should the nurse take? • first observe the client in the chair 30. A female client engages in repeated checks of door and window locks. Behavior that prevents her from arriving on time and interferes with her ability to function efectively. What action should the nurse take? • plan a list of activities to be carried out daily. 31. A male client with schizophrenia is admitted to the mental health unit after abruptly stopping his prescription for ziprasidone (Geodon) one month ago. Which question is most important for the nurse to ask the client? • Do you hear voices. 32. Which client statement suggests to the nurse that the client is using the defense mechanism of projection to deal with anxiety related to admission to a psychiatric unit? • I am here because the police thought I was doing something wrong 33. A female client on a psychiatric unit is sweating profusely while she vigorously does push-ups and then runs the length of the corridorseveral times before crashing into the furniture in the sitting room. Picking herself up, she begins to toss chairs aside, looking for a red one to sit in. When another client objects to the disturbances, the client shouts," I am the boss here. I do what I want." Which nursing problem best supports these observations? • Risk for other related violence related to disruptive 34. What isthe most important goal for a client diagnosed with major depression who has been receiving an antidepressant medication for two weeks? • not attempt to commit suicide 35. Alcohol-Pancreatitis health assessment of history of alcohol dependency WHAT ELSE WOULD BE A CONCERN? • pancreatitis 36. Anorexia Nervosa-syncope Syncope is a clinical feature of? • Abuse-BAL37. Admission A female client with a history of drinking who was admitted 8 hours ago after receiving treatment for minor abrasions occurred from a fall at home. The nurse determines the client's blood alcohol level (BAL) was not analyzed on administration, What action should the nurse take? • Blood alcohol level- ask the client about alcohol quantity, frequency, and time of the last drink. 38. IPV- difficulty leaving victim of intimate partner violence what 3 things should you do? • establish a code with family and friends to signify violence • plan an escape route to use if the abuser blocks main exit • have a bag ready that has extra clothes for self and children 39. Anger Management • Give the client permission to be angry 40. Antisocial- interrupting A female client with bipolar disorder, manic phase, is planning weekend activities with the other clients on the unit. The client interrupts the group, insists that they change their plans to a disco party, and begins to curse loudly when the group refuses to change the plans. Which intervention should the nurse implement? • Escort the client to a quieter place. 41. Borderline personality disorderself-inflicted lacerations on abdomen • perform the dressing change in a non-judgmental manner 42. Conversion disorder patient complains of blindness • Conversion disorder characterized by transferring a mental conflict into a physical symptom for which there is no organic cause. Ex: blindness, paralysis, seizures, deafness, and pseudocyesis(false pregnancy). 43. Countertransference occurs • when a mental health care professional redirects his or her feelings toward a client or becomes emotionally entangled with a client counter transference. 44. After returning to work after a weekend off the nurse gets report that a depressed client has been in bed all weekend. What should the nurse to first? • Assist the client out of bed and involve in activity. 45. A client with dementia usesthe defense mechanism of confabulation. What is the reasoning? • To decrease anxiety. 46. A husband states to the nurse that his wife is not sleeping, buying impulsively, taking last minute trips, and has lost 22 pounds one month. What is an appropriate nursing dx? • Disturbed thought process. 47. The nurse is assessing a client who is believed to have a borderline personality disorder. Which question is most important to include in this assessment? can be • ask to summarize-others need time also Borderline-interaction • Self-critical demanding, whiney, manipulative, argumentative and verbally abusive suicidal gestures. HESI RN MENTAL HEALTH Middle age female with no previous mental illness and the family states that she is having paranoid thoughts, pt states: "I want to find out why people are stalking me". Therapeutic response: "it sounds like this experience is frightening for you" Pt is mad at mom for turning him in and wants mom to bring belongings and does not want to talk to her. What action does the nurse need to take before the visit? Discuss methods of clear communication Duty to warn question: Pt tells the nurse that he wants to kill his boss, nurse tells healthcare provider, healthcare provider tells his boss. What disciplinary action is needed? None. The action was appropriate Defense mechanism question: for projection "I am here because the police said I did something wrong" pt with stress admits to taking care of the ex-husband 's parents. Which defense mechanism is this? Regression therapeutic Milieu: Pt had a recent suicide attempt after his wife offered divorce, lost his job, and his best friend moved away. What is the best nursing intervention to support therapeutic Milieu ? Encourage activities that will allow him to take control over his environment Interview noting taking question arrange the setting and decrease any stimuli Prep from D/C from the psychic unit, what should the nurse include ? Explore that pt's feelings regarding the discharge People in a group home and they are wiping feces on the wall. What is the nurse's highest priority? Infection control Pt refuses to take medications and in defiance sits in the middle of the hallway floor. Best nursing action? To move other clients to another room Nurse and client trade roles: nurse demonstrates bad behavior of the client. Why is this important? Role play assists the client to recognize their own behavior Pt states, "I don't know, I just can't think". What is the best activity by the nurse? Set daily goals Adolescent interrupts group to talk about pets during group therapy. Best nursing action? Redirect him with a handout Crisis intervention: male client feeling stressed, increased anger over the last month. What is an appropriate nursing action? Ask to identify problems that have occurred during the last month Pt discharged after diening suicide thoughts to the healthcare provider. Pt mutters as walking towards the door, " Now I can kill myself". What is the best nursing action? Notify the HCP and stop the patient from leaving Long term care client who is anxious and agitated. What is the best nursing action? decrease stimuli by lowering the TV volume Elderly pt anxious about procedure. What is the best nursing action? Encourage the pt to express their feelings about the procedure Agoraphobia question: Highest priority question: To establish trust by providing a calm, safe environment Agoraphobia question: client afraid to leave house due to fear of open places. What is the nursing diagnosis? Anxiety related to real or perceived fear OCD: a client that continues to wash hands for 2 hours. What is the priority nursing intervention? To set limits OCD: a client that keeps cleaning windows. What should you do? Give a list of activities A pt with PTSD after rape who displays a detached effect. Best action from nurse? To ask if they are thinking about harming themselves PTSD: what should you include in the plan of care? to provide a quiet room away from a recreational area conversion disorder: Pt with new onset of blindness, what would suggest a conversion reaction? No organic correlation to symptoms Borderline personality disorder: Splitting question Client's view people as all good or all bad Bulimia pt who has eroded tooth enamel, complains of severe chest and abdominal pain. Mentions heartburn for two weeks. What should the nurse address first? Chest and abdominal pain Pt with eating disorder. What should be included in the plan of care? To weigh in everyday Teenager with self inducing vomiting. Nursing priority? Assess frequency of binging and purging behaviors Depression: Pt with major depressive disorder is not motivated and has insomnia. Best nursing action? Design a teaching plan with structured activities The male client admitted after attempted suicide due to a recent divorce. What is the source of the current depression? A sense of loss Client with history of major depressive disorder is exhibiting increased energy, to assess for suicide what would you ask? Do you still feel sad? Client very depressed and slow to respond to questions and when asked how to explain how he feels, he looks down at the table. What is the best nursing intervention? Return at a later time to talk A depressed client has only had four hours of sleep. Would you wake the client for vital signs ? NO ! Let them sleep. A depressed client sleeps all day. What would be the best nursing action? Encourage the client to get out of bed Postpartum depression: Parent of a 8 month old states that the child is not growing normally, that something is wrong with him and not right. What is the priority action? To ask if the parent wants to harm the infant A client has just given birth and is now displaying sadness, poor concentration, sleep disturbance, and tiredness. What is the priority nursing action? Suicide assessment Grief/loss/depression: Husband died and the spouse is not sleeping. Best action? Assess for depression related to grief Bipolar: Wife states that patient is spending large sums of money, not sleeping, has weight loss. Pt has a bipolar diagnosis. What would be an appropriate nursing diagnosis? Risk for violence related to impulsivity Bipolar patient tells the nurse that he needs to make some business deals. What should the nurse include in his plan of care? Delay business decisions until the mania subsides Bipolar patient who superficially cuts himself. How should you communicate? Be non-judgmental Client visits clinic and asks nurse for more lithium and Elavil to help sleep. A serum creatinine was obtained. What is the reason for the lab test? Lithium is excreted by the kidneys and creatinine is related to kidney function Schizophrenia- client isolates himself to his room, vaguely answers questions, and peeks down hallway occasionally. Which problem can the nurse anticipate? Delusions of persecution Schizophrenic patient using echolalia and is becoming more annoying. What is the best nursing intervention? Escort them to their room Schizophrenic patient refuses to eat because the food is poisoned. What is the best intrevention? Get food that is in an unopened container Substance abuse- Client with tremors, auditory hallucinations, confused, and dehydrated. What is the priority? To assess vital signs Chronic drinker with alcohol withdrawal risk. What is the best action? Seizure precautions Patient admitted with chronic alcohol abuse. What should be included in the plan of care? IV assess Patient with history of alcohol abuse, admitted for detox, and getting Ativan. What else should be administered? Vitamin B1 (Thiamine) Which statement made by a spouse of an alcoholic indicates codependency? A statement that basically makes excuses for their behavior- couldn't remember exact answer, so general idea (example:wife is making excuses) Client admitted for aspiration of material related to a suicide attempt. Highest priority? Risk for ineffective breathing 18 year old admitted with suspected drug overdose. What is the most important information to obtain from family/friends? What drug was ingested Patient with schizophrenia in a hospital with drug and alcohol abuse, is admitted for hepatitis. The nurse should consult the HCP prior to giving which medication? Acetaminophen (Tylenol) The client falls downstairs with signs and symptoms of early narcotic withdrawal. What other signs and symptoms would the nurse suspect? Agitation, sweating, and abdominal cramps Amphetamines Puts a person at high risk for myocardial infarction Intimate partner violence: which findings of the injury should the nurse include in documentation? Photographs Rape and sexual assault: A client who was raped. What is an appropriate nursing diagnosis? Decreased self-esteem due to blaming themselves for the rape Attention deficit disorder: A child has impulsiveness, hyperactivity, inappropriate attention span. What is the best nursing intervention? Administer the prescribed medications Antidepressant medication side effects (example drug: Cymbalta) Anticholinergic effects: dry mouth, blurred vision, constipation Patient is taking chlorpromazine for schizophrenia, starts to exhibit signs of tardive dyskinesia. What is the best action? Administer Benztropine (Cogentin) A patient is being administered Xanax (Alprazolam) and reports dizziness, lightheadedness, low blood pressure. What is the highest priority? Monitor vital signs Patient is prescribed buspar. Patient is concerned how long it will take for the medication to work? Normally takes 2 to 3 weeks to start working For trazodone or lidisoril: if the patient develops priapism what do you ask them about? Ask about other erectile dysfunction medications Patient is getting Depakote for mania, how do you know if this medication is working? Decrease hyperexcitable behaviors Schizophrenic patient on Haldol times two weeks. What should the nurse obtain during the initial visit? Vital signs Patient on Haldol develops tremors. Best nursing action? Call the HCP to decrease the dose Schizophrenic patient on Risperdal, exhibiting negative symptoms. Best nursing action? Give Benztropine (Cogentin) for dystonia Patient with schizophrenia getting Geodon, spouse concerned as to why this medication would be administered? Will help the patient think more clearly Patient taking Clozaril and Benztropine, and Clozaril is discontinued. What should the next nurse's action be? Call the HCP to get the Benztropine discontinued Teaching for the client about the initial of Antabuse. What info to include Should remain alcohol free 12 hours prior to the first dose Alzheimer's medications: What type of medication is Namenda (Memantine) NMDA Antagonist HESI RN MENTAL HEALTH While in group therapy, a client who is diagnosed with posttraumatic stress disorder (PTSD) is processing an experience from the war in Iraq when another client tips over a chair. What action should the nurse take when the client with PTSD falls to the floor in a fetal position? A. Confront the client who tipped over the chair about the inconsiderate behavior. B. Dismiss the other clients from the group therapy session for a 10-minute break. C. Reinforce reality to the client on the floor and remove him to a quiet space. D. Call a security code and medicate both clients with an antianxiety drug. Correct Answer: C Rationale: The client who is diagnosed with PTSD is reexperiencing the traumatic experience and needs reality reassurance (confirmation that there is no danger at this time) and reduced stimuli (C). (A, B, and D) do not consider the needs of these two clients at this time. The nurse notes multiple burns on the arms and chest of a 2-year-old Vietnamese child who is being treated for dehydration. When questioned, the child's father states that he treated the child's vomiting with the cultural practice termed coining, which resulted in burned areas. Which expected outcome statement has the highest priority? A. The child will be protected from further harm. B. The family's cultural values will be respected. C. The parents will express regret at harming their child. D. The parents will demonstrate an ability to care for burn wounds. Correct Answer: A Rationale: The nurse's highest priority is to ensure that no further harm befalls the child (A). (B, C, and D) are also important objectives but are secondary to (A). A client in an acute care facility has been taking antipsychotic medications for the past 3 days with a decrease in psychotic behaviors and no adverse reactions. On the fourth day, the client experiences an increase in blood pressure and temperature and demonstrates muscular rigidity. Which action should the nurse initiate? A. Place the client on seizure precautions and monitor frequently. B. Take the client's vital signs and notify the health care provider immediately. C. Describe the symptoms to the charge nurse and document them in the client's record. D. No action is required at this time because these are known side effects of her medications. Correct Answer: B Rationale: This is an emergency situation, and the client requires immediate management in a critical care setting (B). These symptoms are descriptive of neuroleptic malignant syndrome (NMS), an extremely serious and life-threatening reaction to neuroleptic drugs. The major symptoms of this syndrome are fever, rigidity, autonomic instability, and encephalopathy. Respiratory failure, cardiovascular collapse, arrhythmias, and/or renal failure can result in death. (A) is not indicated in this situation. (C) does not consider the seriousness of the situation. (D) is an incorrect statement. A client who recently retired is admitted to the psychiatric inpatient unit with a diagnosis of major depression. The initial nursing care plan includes the goal, "Assist client to express feelings of guilt." What is true about the goal statement referring to the client's depression? A. Implementation of the goal should be deferred until further data can be gathered. B. The depression will dissipate once the client becomes accustomed to retirement. C. Depressed clients may be unaware of guilt feelings and should be encouraged to increase selfawareness. D. Nursing goals should be approved by the treatment team before they are initiated. Correct Answer: C Rationale: Depression is associated with feelings of guilt, and clients are often not aware of these feelings (C). Awareness is the first step in dealing with guilt (or any other feeling), so the nurse's efforts should be directed toward increasing the client's awareness of feelings. Although a goal may be changed based on an evaluation of interventions to meet the goal, a goal should never be ignored (A). (B) dismisses the client's symptoms as age-related. Setting goals for the nursing care plan is a function of the nurse (D), although the nurse can collaborate with the treatment team. An individual with a known history of alcohol abuse is admitted for emergency surgery following a motor vehicle collision. The nurse includes in the client's plan of care, "Observe for signs of delirium tremens." Which early signs indicate that the client is beginning to have delirium tremens? A. Abdominal cramping and watery eyes B. Depression and fatigue C. Restlessness and confusion D. Hostility and anger Correct Answer: C Rationale: A client experiencing alcohol withdrawal often has delirium tremens (DTs), which are characterized by progressive disorientation. Initially, the client will appear restless and confused (C) and develop tachycardia, tachypnea, and diaphoresis. Hallucinations, paranoia, and seizures can also occur later in the development of DTs. (A) is indicative of withdrawal from opiates such as heroin or morphine. (B) is often seen in cocaine withdrawal. (D) is most characteristic of the paranoid client. A woman brings her 48-year-old husband to the outpatient psychiatric unit and tells the nurse that he has been sleepwalking, cannot remember who he is, and exhibits multiple personalities. These behaviors are often associated with which condition? A. Dissociative disorder B. Obsessive-compulsive disorder C. Panic disorder D. Posttraumatic stress syndrome Correct Answer: A Rationale: Sleepwalking, amnesia, and multiple personalities are examples of detaching emotional conflict from one's consciousness (A). (B) is characterized by persistent, recurrent intrusive thoughts or urges (obsessions) that are unwilled and cannot be ignored and provoke impulsive acts (compulsions), such as constant and repeated hand washing. (C) is an acute attack of anxiety characterized by personality disorganization. (D) is reexperiencing a psychologically terrifying or distressing event that is outside the usual range of human experience such as war or rape. client in the critical care unit who has been oriented suddenly becomes disoriented and fearful. Assessment of vital signs and other physical parameters reveals no significant changes, and the nurse formulates the diagnosis of Confusion related to ICU psychosis. Which intervention is best to implement based on this client's behavior? A. Move all medical equipment away from the client's bedside. B. Allay fears by teaching the client about the causes of the disease. C. Cluster care to allow for brief rest periods during the day. D. Encourage visitation by the client's family members, including the client's young children. Correct Answer: C Rationale: The best intervention is to organize care so that the client can experience rest periods (C). The critical care unit contains many lifesaving treatment modalities that offer clients an array of auditory, visual, and even painful stimuli. These stressors can result in isolation and confusion. (A) is not practical because the client may need assistance from medical equipment to survive. The client is too ill to receive teaching (B). Although (D) may be supportive, young children are routinely prohibited from critical care units because of increased risk of infectious disease transmission. At the first meeting of a group at a daycare center for older adults, the nurse asks one of the members what kinds of things the client would like to do with the group. The older adult shrugs and says, "You tell me. You're the leader." What would be the best response for the nurse to make? A. "Yes, I am the leader today. Would you like to be the leader tomorrow?" B. "Yes, I will be leading this group. What would you like to accomplish?" C. "Yes, I have been assigned to lead this group. I will be here for the next 6 weeks." D. "Yes, I am the leader. You seem angry about not being the leader yourself." Correct Answer: B Rationale: Anxiety over participation in a group and testing of the leader characteristically occur in the initial phase of group dynamics. (B) provides information and refocuses the group to defining its function. (A) is manipulative bargaining. (C) does not focus the group on its purpose or task. (D) is interpreting the client's feelings and is almost challenging. The nurse is assessing a young client admitted to the psychiatric unit for acute depression related to a recent divorce. Which statement is most indicative of a client suffering from depression? A. "I'm not very pretty or likeable." B. "I've lost 20 pounds in the past month." C. "I like to keep things to myself." D. "I think everyone is out to get me." Correct Answer: A Rationale: Feelings of hopelessness (A) are characteristic of one who is depressed. Although (B) might be indicative of depression, further assessment would be required to rule out an organic cause before attributing the statement to depression. (C and D) are indicative of a paranoid personality. The nurse develops a plan of care for a client with symptoms of paranoia and psychosis. The priority nursing diagnosis is Impaired social interactions related to inability to trust. Which intervention is most important for the nurse to implement? A. Greet the client by first name during each social interaction. B. Determine if the client is experiencing auditory hallucinations. C. Introduce the client to peers on the unit as soon as possible. D. Assign the client to a group about developing social skills. Correct Answer: A Rationale: The most important nursing intervention is to greet the client by name (A) and provide short frequent contact to establish trust. The presence of auditory hallucinations can affect social interactions (B), but is not a priority intervention. (C and D) are effective interventions after individual rapport has been established with the client. On admission, a highly anxious client is described as delusional. Delusions are most likely to occur with which disorder? A. Dissociative disorders B. Personality disorders C. Anxiety disorders D. Psychotic disorders Correct Answer: D Rationale: Delusions are false beliefs characteristic of psychosis (D). Delusions are generally not characteristic of (A, B, and C). On admission, a depressed client tells the nurse, "I can't eat because my tongue is rubber." Which is the best action for the nurse to implement? A. Provide packaged foods for the client to eat. B. Begin the client on total parenteral nutritional (TPN) therapy. C. Provide a well-balanced liquid diet for the client. D. No action is necessary because the client will eat when hungry. Correct Answer: C Rationale: The nurse should strive to provide a safe environment (adequate nutrition is part of a safe environment) and should not argue with the client's delusions. (C) is the least invasive while providing nutrition that does not argue with the client's delusion. (A) is given to those with paranoid delusions. (B) is invasive and would be used as a last resort. (C) should be tried first. This client's delusion could be life threatening and should not be ignored (D). A 38-year-old client is admitted with a diagnosis of paranoid schizophrenia. When the lunch tray is brought to the room, the client refuses to eat and tells the nurse, "I know you are trying to poison me with that food." Which response by the nurse is the most therapeutic? A. "I'll leave your tray here. I am available if you need anything else." B. "You're not being poisoned. Why do you think someone is trying to poison you?" C. "No one on this unit has ever died from poisoning. You're safe here." D. "I will talk to your health care provider about the possibility of changing your diet." Correct Answer: A Rationale: (A) is the best choice because the nurse does not argue with the client or demand that that the client eat but offers support by agreeing to be there if needed, which provides an open, rather than closed, response to the client's statement. (B and C) are challenging the client's delusions, and (B) asks "why." Probing questions, which start with "why," are usually not therapeutic communication for a psychotic client. (D) has not addressed the actual problem—that is, the client's delusions. During a home visit, a client with schizophrenia reports hearing voices that tell the client to walk in the middle of the street. The nurse records several statements made by the client. Based on which statement should the nurse determine that the client needs hospitalization? A. "Sometimes I take an extra one of my pills when I hear the voices." B. "The voices are louder when I forget to take my medication. " C. "No matter what I do, I cannot make the voices go away. " D. "I just try to tell the voices to stop when they bother me. " Correct Answer: C Rationale: Hospitalization is needed if the client continues to hear voices telling the client to do things that can cause self-harm (C). (A or B) do not require hospitalization unless symptoms become severe. The client should continue symptom management strategies (D) to prevent hospitalization. Which behavior indicates to the nurse that a client with paranoid ideas is improving? A. Arrives on time for all activities B. Talks more openly about plans to protect his possessions C. Aggressively uses the punching bag in the gym D. Discusses his feelings of anxiety with the nurse Correct Answer: D Rationale: Anxious feelings increase paranoid ideation. If the client is able to discuss these feelings (D), then the client is improving because of fewer paranoid ideas. (A) would indicate that a client with depression or one who is passive-aggressive is improving. (B) indicates feelings of paranoia. (C) indicates the release of anger, and "anger turned inward" is sometimes used as a definition for depression. A 25-year-old client has been particularly restless and the nurse finds the client trying to leave the psychiatric unit. The client tells the nurse, "Please let me go! I must leave because the secret police are after me." Which response is best for the nurse to make? A. "No one is after you. You're safe here." B. "You'll feel better after you have rested." C. "I know you must feel lonely and frightened." D. "Come with me to your room, and I will sit with you." Rationale: (D) is the best response because it offers support without judgment or demands. (A) is challenging the client's delusion. (B) is offering false reassurance. (C) is a violation of therapeutic communication because the nurse is telling the client how she or he feels (frightened and lonely), rather than allowing the client to describe his or her own feelings. Hallucinating and delusional clients are not capable of discussing their feelings, particularly when they perceive a crisis. A 35-year-old client admitted to the psychiatric unit of an acute care hospital tells the nurse that someone is trying to poison her. The client's delusions are most likely related to which factor? A. Authority issues in childhood B. Anger about being hospitalized C. Low self-esteem D. Phobia of food Rationale: Delusional clients have difficulty with trust and have low self-esteem (C). Nursing care should be directed at building trust and promoting positive self-esteem. Activities with limited concentration and no competition should be encouraged to build self-esteem. (A, B, and D) are not specifically related to the development of delusions. The nurse admits a client with depression to the mental health unit. The client reports difficulty concentrating, has lost 10 pounds in 2 weeks, and is sleeping 12 hours a day. Which outcome is most important for the client to meet by discharge? A. Tries to interact with a few peers and staff B. Reports feeling better and less depressed C. Sits attentively with peers in group therapy D. Easily awakens for morning medications Rationale: The client is experiencing symptoms of depression, and the outcome by discharge for this client would be that the client reports feeling better and less depressed (B). The client may interact with peers and staff (A) and sit attentively in groups (C) without any improvement in depression. Difficulty awakening is usually caused by the medication regimen for depression, so awakening (D) is not an indication of improvement. A client begins taking an atypical antipsychotic medication. The nurse must provide informed consent and education about common medication side effects. Which client education will be most important? A. Maintain a balanced diet and adequate exercise. B. Be sure that the diet is adequate in salt intake. C. Monitor for any changes in sleep pattern. D. Report any unusual facial movements. Rationale: Several atypical antipsychotic medications can cause significant weight gain, so the client should be advised to maintain a balanced diet and adequate exercise (A). (B) is important with lithium, a mood stabilizer. (C and D) are less common than weight gain. The nurse is caring for a client who is taking the mood stabilizer divalproex sodium (Depakote). Which laboratory finding is most important to include in this client's record? A. Liver function test results B. Creatinine clearance C. Complete blood count D. Chemistry panel Rationale: Depakote is metabolized by the liver and can cause hepatotoxicity, so laboratory findings of liver function tests (A) should be included in the client's record. (B) should be in the client record of those who are receiving lithium because it is excreted by the kidneys. (C and D) are routine laboratory tests and are not specifically related to administration of Depakote. An adult client who lives in a residential facility is mentally retarded and has a history of bipolar disorder. During the past week, the client has refused to wear clothes and frequently exposes their body to other residents. Which intervention should the nurse implement? A. Establish a one-to-one relationship to discuss the behavior. B. Redirect the client to physically demanding activities. C. Encourage the client to verbalize thoughts when acting out. D. Restrict social interactions with other residents in the facility. Rationale: The client is exhibiting manic behavior related to bipolar disorder, and the nurse should redirect the client to activities that are physically demanding (B) so that energy can be expended in a socially acceptable manner. Psychotic clients are not capable of (A). When exhibiting acting-out behavior, the client is distracted and (C) is difficult. (D) is likely to increase manic behaviors, such as mood swings and acting-out behaviors. A client on the psychiatric unit seeks out a particular nurse and imitates her mannerisms. Which defense mechanism does the nurse recognize in this client? A. Sublimation B. Identification C. Introjection D. Repression Rationale: Identification (B) is an attempt to be like someone or emulate the personality traits of another. (A) is substituting an unacceptable feeling for one that is more socially acceptable. (C) is incorporating the values or qualities of an admired person or group into one's own ego structure. (D) is the involuntary exclusion of painful thoughts or memories from one's awareness. A nurse working in the emergency department of a children's hospital admits a child whose injuries could have been the result of abuse. Which statement most accurately describes the nurse's responsibility in cases of suspected child abuse? A. Obtain objective data such as radiographs before reporting suspicions. B. Confirm suspicions of abuse with the health care provider. C. Report any case of suspected child abuse. D. Document injuries to confirm suspected abuse. Rationale: It is the nurse's legal responsibility to report all suspected cases of child abuse (C), and notifying the nurse manager or charge nurse starts the legal reporting process. (A, B, and D) delay the first step in reporting the abuse. Physical examination of a 6-year-old boy reveals several bite marks in various locations on his body. Xray examination reveals healed fractures of the ribs. The mother tells the nurse that her child is always having accidents. Which initial response by the nurse would be most appropriate? A. "I need to tell the health care provider about your child's tendency to be accident-prone." B. "Tell me more about these accidents that your child has been having." C. "I need to report these injuries to the authorities because they do not seem a