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A charge nurse is discussing mental status examinations
with a newly licensed nurse. Which of the following
statements by the newly licensed nurse indicates a need
for further teaching?
A."To assess cognitive ability, I should ask the client to
count backward by 7."
B."To assess affect, I should observe the client's facial
expression."
C."To assess language ability, I should instruct the client to
write a sentence."
,D."To assess remote memory, I should have the client
repeat a list of objects." - ANSWER-D.CORRECT: This
statement requires further teaching. Asking the client to
repeat a list of objects is appropriate to assess immediate,
rather than remote, memory.
A.INCORRECT: This statement does not require further
teaching. Counting backward by 7 is an appropriate
technique to assess a client's cognitive ability.
B.INCORRECT: This statement does not require further
teaching. Observing a client's facial expression is
appropriate when assessing affect.
C.INCORRECT: This statement does not require further
teaching. Writing a sentence is an indication of language
ability.
,A nurse is planning care for a client who has a mental
health disorder. Which of the following is appropriate to
include as a psychobiological intervention?
A.Assist the client with systematic desensitization therapy.
B.Teach the client appropriate coping mechanisms.
C.Assess the client for comorbid health conditions.
D.Monitor the client for adverse effects of medications. -
ANSWER-D.CORRECT: Monitoring for adverse effects of
medications is an example of a psychobiological
intervention.
, A.INCORRECT: Assisting with systematic desensitization
therapy is a cognitive and behavioral, rather than a
psychobiological intervention.
B.INCORRECT: Teaching appropriate coping mechanisms
is a counseling or health teaching, rather than a
psychobiological intervention.
C.INCORRECT: Assessing for comorbid health conditions
is health promotion and maintenance, rather than a
psychobiological, intervention.
A nurse in an outpatient mental health clinic is preparing to
conduct an initial client interview. When conducting the
interview, which of the following is the highest priority
action?