Questions and Revised Answers & Rationales, 100%
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A nurse is planning care for a group of clients in an inpatient mental health facility.
Which of the following tasks should the nurse delegate to an assistive personnel
(AP)?
- Update the plan of care for a client who has bipolar disorder
- Weigh a newly admitted client who has anorexia nervosa
- Lead a medication education group
- Conduct a mental status exam on a client who is new to the unit - ANSWER
Weigh a newly admitted client who has anorexia nervosa
A nurse is caring for a client who is scheduled to undergo electroconvulsive therapy
in 1 hr. The client tells the nurse that they have changed their mind and does not
want the therapy. Which of the following responses should the nurse make?
- "Your doctor would not have ordered the treatment if it wasn't necessary."
- "How could you agree to it and then change your mind?"
- "You will feel much better after the therapy, you'll see."
- "You have the right to change your mind at any time." - ANSWER "You have the
right to change your mind at any time."
A nurse in an acute care facility is planning discharge for a client who has alcohol
use disorder and recently experienced alcohol withdrawal with several serious
complications. The client requires continued nursing care and supervised medication
monitoring. Which of the following resources should the nurse recommend?
- An intensive outpatient program
- Standard outpatient treatment
- A residential halfway house facility
- A residential rehabilitation facility - ANSWER A residential rehabilitation facility
,A nurse in an outpatient facility is delegating tasks to an assistive personnel (AP).
Which of the following tasks should the nurse delegate to the AP based on client
needs?
- Providing telephone advice about rehabilitation facilities
- Performing basic life support for a client who has depressive disorder and no
pulse?
- Instructing a client how to collect a urine sample for drug screening
- Giving two acetaminophen to a client who reports a headache because of
antipsychotic medication - ANSWER Performing basic life support for a client who
has depressive disorder and no pulse?
A nurse on an acute mental health unit is delegating tasks to an assistive personnel
(AP). Which of the following tasks should the nurse delegate?
- Assisting with oral care for a client who reports having a dry mouth because of a
prescribed antipsychotic
- Providing instructions about photosensitivity to a client who has a prescription for
an antipsychotic medication
- Evaluation the change in blood glucose levels for a client who is taking an
antipsychotic
- Obtaining an Abnormal Involuntary Movement Scale (AIMS) rating for a client who
is taking an antipsychotic - ANSWER Assisting with oral care for a client who
reports having a dry mouth because of a prescribed antipsychotic
A charge nurse on a mental health unit is making shift assignments to best utilize the
team and implement effective care. The staffing for the shift includes a practical
nurse (PN) and an assistive personnel (AP). Which of the following tasks should the
nurse delegate to the PN?
- Creating a care plan for a client who has schizophrenia
- Weight a client who has bulimia nervosa
- Reinforcing teaching about medications for a client who has depression
- Record the intake of a client who is experiencing mania - ANSWER Reinforcing
teaching about medications for a client who has depression
A nurse if planning care for a client who has borderline personality disorder with self-
harming behavior. Which of the following actions is the nurse's priority?
- Observe the client's behavior
, - Have the client agree to a verbal no-harm contract
- Encourage verbalization of feelings
- Act as a role model for expression of anger - ANSWER Observe the client's
behavior
A community health nurse is assessing older adult client who need daily physical
care of determine additional risk factors for maltreatment. Which of the following
client's should the nurse recognize as having an additional risk factor for
maltreatment?
- A client who needs to be repositioned frequently and lived in a foster can facility
- A client who needs assistance with ambulation and is care for by her adult child
- A client who is incontinent and lived in an assisted living facility
- A client who lives alone and received a daily dressing change from a home health
nurse - ANSWER A client who needs assistance with ambulation and is care for by
her adult child
A nurse is caring for a client who has become homeless following a recent tornado.
Which of the following actions is the nurse's priority?
- Contact the client's family members
- Determine the client's level of anxiety
- Arrange for a change of clothing for the client
- Notify the social worker of the client's needs - ANSWER Determine the client's
level of anxiety
A nurse is caring for a client who has schizophrenia. The client begins dressing in a
similar manner to the nurse and asks the staff for a name badge to wear. Which of
the following defense mechanisms is the client using?
- Displacement
- Identification
- Suppression
- Projection - ANSWER Identification
A nurse is performing a mental status examination for a newly admitted client. Which
of the following client behaviors indicates impaired reality testing?
- Delusions