RN Mental Health Online Practice 2023 B
1. A nurse in an outpatient clinic is reviewing the medical record of a client who has anorexia nervosa.
Click to highlight the information in the client's medical record that indicate the client's condition is
deteriorating. To deselect information, click on the information again.
-QT prolongation
-Exercise regimen
-Hematemesis
-Temperature
-Laxative use
-BMI: QT prolongation is correct. The finding of QT prolongation in the client's ECG during the second visit reveals
cardiac complications of anorexia nervosa. Changes in electrolyte levels can shorten or prolong the QT interval. This is
an indication that the client's condition is deteriorating.
Exercise regimen is correct. The client's purchase of exercise equipment and work- ing out twice a day is a new
manifestation of anorexia nervosa. This is an indication that the client's condition is deteriorating.
Hematemesis is correct. New onset of hematemesis might be caused by esophageal irritation or ulceration due to the
increase in the frequency of induction of vom- iting. Continued induction of vomiting can cause esophageal rupture.
Therefore, hematemesis is an indication that the client's condition is deteriorating.
Temperature is incorrect. The client's temperature has remained within the expected reference range. A decrease in body
temperature with cool skin is an indication that the client's condition is deteriorating.
Laxative use is incorrect. The client's cessation of the use of laxatives is an indication that the client's condition is
improving.
BMI is correct. The client's BMI decreased between visits, which indicates the client is continuing to lose weight. This is
an indication that the client's condition is deteriorating.
2. A nurse is caring for an older adult client who has dementia and has wandered into the day room looking for
their deceased partner. Which of the following actions should the nurse take?
, RN Mental Health Online Practice 2023 B
a. Move the client to a room near the nurses' station.
b. Limit visitors until the client is oriented to the environment.
c. Tell the client that their partner is deceased.
d. Talk with the client about activities they enjoyed with their partner.: d. Talk with the client about activities
they enjoyed with their partner.
Talking about positive experiences can help distract the client from their disorienta- tion
3. A nurse is caring for a client who has alcohol use disorder. Complete the following
sentence by using the list of options.
The client is at greatest risk for as evidenced by the client's .
Dropdown 1:
-Ineffective coping
-Dehydration
-Violent behavior
Dropdown 2:
-Agitation
-Loss of appetite
-Inability to perform simple tasks: Drop down 1:
Ineffective coping is incorrect. The nurse should continue to monitor the client for ineffective coping and encourage the
client to use coping techniques. However, this is not the greatest risk for this client.
Dehydration is incorrect. The nurse should monitor the client's intake and encourage the client to eat and drink.
However, this is not the greatest risk for this client.
Violent behavior is correct. The greatest risk for the client is engaging in violent behavior due to the withdrawal of alcoho
which is causing them increasing agitation. The nurse should closely monitor the client and be prepared to intervene to
protect the client and others from injury.
Dropdown 2: Agitation is correct. The client is at greatest risk of engaging in violent behavior as evidenced by the
client's agitation, which can be indicated by pacing, restlessness, staring, silence, rigid posture, and clenched jaw. The
nurse should closely monitor the client and be prepared to intervene to protect the client and others from injury.
, RN Mental Health Online Practice 2023 B
Loss of appetite is incorrect. The nurse should monitor the client's intake and encourage the client to eat and drink.
However, this is not the greatest risk for the client. Loss of appetite is an expected finding for a client who is
experiencing alcohol withdrawal.
Inability to perform simple tasks is incorrect. The nurse should monitor the client's ability to perform simple tasks and
encourage use of coping strategies. However, this is not the greatest risk for the client.
4. A nurse on a mental health unit is admitting a client who has bipolar disorder.
Complete the following sentence by using the list of options.
The first action the nurse should take is to address the client's due to
the client's .: When prioritizing hypotheses, the nurse should identify the greatest risk to the client
is cardiovascular injury due to constant psychomotor activity. The client is pacing, moving arms and hands around
dramatically, and is unable to sit still. This can increase the client's blood pressure and heart rate, which can indicate
unexpected cardiovascular findings.
5. A nurse is teaching a group of newly licensed nurses about the use of mechanical restraints. Which of the
following information should the nurse include in the teaching?
a. Complete documentation about the client's status every hour while they are in restraints.
b. Maintain the client in restraints for a minimum of 4 hr.
c. Apply restraints when other means of managing the client's behavior have failed.
d. Request that the provider assess the client within 8 hr of the application of restraints.: c. Apply restraints when
other means of managing the client's behavior have failed.
According to the Patient Self-Determination Act, clients have a right to be free from restraints or seclusion unless the
safety of the client or others is at risk. De-escalation methods for controlling behavior should be attempted prior to
initiating restraints.
6. A nurse is preparing to participate in an interdisciplinary conference for a client who has bipolar disorder.
Which of the following behaviors is the priority for the nurse to report to the treatment team?
1. A nurse in an outpatient clinic is reviewing the medical record of a client who has anorexia nervosa.
Click to highlight the information in the client's medical record that indicate the client's condition is
deteriorating. To deselect information, click on the information again.
-QT prolongation
-Exercise regimen
-Hematemesis
-Temperature
-Laxative use
-BMI: QT prolongation is correct. The finding of QT prolongation in the client's ECG during the second visit reveals
cardiac complications of anorexia nervosa. Changes in electrolyte levels can shorten or prolong the QT interval. This is
an indication that the client's condition is deteriorating.
Exercise regimen is correct. The client's purchase of exercise equipment and work- ing out twice a day is a new
manifestation of anorexia nervosa. This is an indication that the client's condition is deteriorating.
Hematemesis is correct. New onset of hematemesis might be caused by esophageal irritation or ulceration due to the
increase in the frequency of induction of vom- iting. Continued induction of vomiting can cause esophageal rupture.
Therefore, hematemesis is an indication that the client's condition is deteriorating.
Temperature is incorrect. The client's temperature has remained within the expected reference range. A decrease in body
temperature with cool skin is an indication that the client's condition is deteriorating.
Laxative use is incorrect. The client's cessation of the use of laxatives is an indication that the client's condition is
improving.
BMI is correct. The client's BMI decreased between visits, which indicates the client is continuing to lose weight. This is
an indication that the client's condition is deteriorating.
2. A nurse is caring for an older adult client who has dementia and has wandered into the day room looking for
their deceased partner. Which of the following actions should the nurse take?
, RN Mental Health Online Practice 2023 B
a. Move the client to a room near the nurses' station.
b. Limit visitors until the client is oriented to the environment.
c. Tell the client that their partner is deceased.
d. Talk with the client about activities they enjoyed with their partner.: d. Talk with the client about activities
they enjoyed with their partner.
Talking about positive experiences can help distract the client from their disorienta- tion
3. A nurse is caring for a client who has alcohol use disorder. Complete the following
sentence by using the list of options.
The client is at greatest risk for as evidenced by the client's .
Dropdown 1:
-Ineffective coping
-Dehydration
-Violent behavior
Dropdown 2:
-Agitation
-Loss of appetite
-Inability to perform simple tasks: Drop down 1:
Ineffective coping is incorrect. The nurse should continue to monitor the client for ineffective coping and encourage the
client to use coping techniques. However, this is not the greatest risk for this client.
Dehydration is incorrect. The nurse should monitor the client's intake and encourage the client to eat and drink.
However, this is not the greatest risk for this client.
Violent behavior is correct. The greatest risk for the client is engaging in violent behavior due to the withdrawal of alcoho
which is causing them increasing agitation. The nurse should closely monitor the client and be prepared to intervene to
protect the client and others from injury.
Dropdown 2: Agitation is correct. The client is at greatest risk of engaging in violent behavior as evidenced by the
client's agitation, which can be indicated by pacing, restlessness, staring, silence, rigid posture, and clenched jaw. The
nurse should closely monitor the client and be prepared to intervene to protect the client and others from injury.
, RN Mental Health Online Practice 2023 B
Loss of appetite is incorrect. The nurse should monitor the client's intake and encourage the client to eat and drink.
However, this is not the greatest risk for the client. Loss of appetite is an expected finding for a client who is
experiencing alcohol withdrawal.
Inability to perform simple tasks is incorrect. The nurse should monitor the client's ability to perform simple tasks and
encourage use of coping strategies. However, this is not the greatest risk for the client.
4. A nurse on a mental health unit is admitting a client who has bipolar disorder.
Complete the following sentence by using the list of options.
The first action the nurse should take is to address the client's due to
the client's .: When prioritizing hypotheses, the nurse should identify the greatest risk to the client
is cardiovascular injury due to constant psychomotor activity. The client is pacing, moving arms and hands around
dramatically, and is unable to sit still. This can increase the client's blood pressure and heart rate, which can indicate
unexpected cardiovascular findings.
5. A nurse is teaching a group of newly licensed nurses about the use of mechanical restraints. Which of the
following information should the nurse include in the teaching?
a. Complete documentation about the client's status every hour while they are in restraints.
b. Maintain the client in restraints for a minimum of 4 hr.
c. Apply restraints when other means of managing the client's behavior have failed.
d. Request that the provider assess the client within 8 hr of the application of restraints.: c. Apply restraints when
other means of managing the client's behavior have failed.
According to the Patient Self-Determination Act, clients have a right to be free from restraints or seclusion unless the
safety of the client or others is at risk. De-escalation methods for controlling behavior should be attempted prior to
initiating restraints.
6. A nurse is preparing to participate in an interdisciplinary conference for a client who has bipolar disorder.
Which of the following behaviors is the priority for the nurse to report to the treatment team?
