QUESTIONS AND ANSWERS 100% VERIFIED GET IT CORRECT!!
A charge nurse is discussing mental status examinations with a newly licensed nurse.
Which of the following statements by the newly licensed nurse indicates an understanding
of the teaching? (SATA)
A. "To assess cognitive ability; I should ask the client to count backwards by sevens."
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."
E. "To assess abstract thinking, I should ask the pt to identify our most recent presidents"
A, B, C
A nurse is planning care for a client who has a mental health disorder. Which of the
following actions should the nurse 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
D. Monitor the client for adverse effects of medications
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?
A. Coordinate holistic care with social services
B. Identify the client's perception of her of her own mental health status
C. Include the client's family in the interview
D. Teach the client about her current mental health disorder
B. Identify the client's perception of her of her own mental health status
A nurse is planning a peer group discussion about the DSM-5. Which of the following is
appropriate to include in the discussion? (select all that apply)
A. The DSM-5 includes client education handouts for mental health disorders
B. The DSM-5 establishes diagnostic criteria for individual mental health disorders
C. The DSM-5 indicates recommended pharmacological treatment for mental health
disorders
,[Type here]
D. The DSM-5 assists nurses in planning care for clients with mental health disorders
E. The DSM-5 indicates expected assessment findings of mental health disorders
B, D, E
establishes diagnostic criteria
assists nurses in planning care
indicates expected assessment findings
A nurse in an emergency mental health facility is caring for a group of clients. The nurse
should identify that which of the following clients requires a temporary emergency
admission?
A. A client who has schizophrenia with delusions of grandeur
B. A client who has manifestations of depression and attempted suicide a year ago
C. A client who has borderline personality disorder and assaulted a homeless man with a
metal rod
D. A client who has bipolar disorder and paces quickly around the room while talking to
himself
C. CORRECT: A client who is a current danger to self or others is a candidate for a
temporary emergency admission.
A. The presence of delusions does not constitute a clear reason for a temporary emergency
admission unless they present a danger for the client or others.
B. Clinical findings of depression do not constitute a clear reason for a temporary emergency
admission unless the client is currently at risk for suicide.
D. A client who is pacing does not constitute a clear reason for a temporary emergency
admission.
A nurse decides to put a client who has a psychotic disorder in seclusion overnight because
the unit is very short-staffed, and the client frequently fights with other clients. The nurse's
actions are an example of which of the following torts?
A. Invasion of privacy
B. False imprisonment
C. Assault
D. Battery
,[Type here]
B. CORRECT: A civil wrong that violates a client's civil rights is a tort. In this case, it is
false imprisonment, which is the confining of a client to a specific area, such as a seclusion
room, if the reason for such confinement is for the convenience of staff.
A. Invasion of privacy is the sharing or obtaining of the client's confidential information without
the client's consent.
C. Assault is making a threat to the client's person.
D. Justice involves the fair and equal treatment of clients
A client tells a nurse, "Don't tell anyone, but I hid a sharp knife under my mattress in
order to protect myself from my roommate, who is always yelling at me and threatening
me." Which of the following actions should the nurse take?
A. Keep the client's communication confidential, but talk to the client daily, using
therapeutic communication to convince him to admit to hiding the knife.
B. Keep the client's communication confidential, but watch the client and his roommate
closely.
C. Tell the client that this must be reported to the health care team because it concerns the
health and safety of the client and others.
D. Report the incident to the health care team, but do not inform the client of the intention
to do so.
.C. CORRECT: The information presented by the client is a serious safety issue that the
nurse must report to the health care team. Using the ethical principle of veracity, the
student tells the client truthfully what must be done regarding the issue.
A. The nurse should use therapeutic communication with the client. However, based on the
nature of the information, the nurse cannot keep the information confidential from everyone
despite the client's request.
B. Based on the nature of the information, the nurse cannot keep the information confidential
from everyone despite the client's request
D. The nurse should inform the if the information will be reported to the health care team
A nurse is caring for a client who is in mechanical restraints. Which of the following
statements should the nurse include in the documentation? (Select all that apply.)
A. "Client ate most of his breakfast."
B. "Client was offered 8 oz of water every hr."
C. "Client shouted obscenities at assistive personnel."
D. "Client received chlorpromazine 15 mg by mouth at 1000."
, [Type here]
E. "Client acted out after lunch."
B. CORRECT: How much water was offered and how often it was offered is objective data
that the nurse should document when caring for a client in mechanical restraints.
C. CORRECT: A description of the client's verbal communication is objective data that the
nurse should document when caring for a client in mechanical restraints.
D. CORRECT: The dosage and time of medication administration is objective data that the
nurse should document when caring for a client in mechanical restraints
A. The nurse should document objective information regarding intake in the client's medical
record.
E. The nurse should document objective information regarding the client's behavior in the client's
medical record.
A nurse hears a newly licensed nurse discussing a client's hallucinations in the hallway with
another nurse. Which of the following actions should the nurse take first?
A. Notify the nurse manager.
B. Tell the nurse to stop discussing the behavior.
C. Provide an in-service program about confidentiality.
D. Complete an incident report.
B. CORRECT: The greatest risk to this client is an invasion of privacy through the sharing
of confidential information in a public place. The first action the nurse should take is to tell
the newly licensed nurse to stop discussing the client's hallucinations in a public location.
A. T he nurse should notify the nurse manager if the client's right to privacy is violated.
However, there is another action that the nurse should take first.
C. The nurse should provide an in-service program for staff about confidentiality. However, there
is another action that the nurse should take first.
D. The nurse should complete an incident report about the violation of the client's right to
privacy. However, there is another action that the nurse should take first.
A charge nurse is conducting a class on therapeutic communication to a group of newly
licensed nurses. Which of the following aspects of communication should the nurse identify
as a component of verbal communication?
A. Personal space
B. Posture
C. Eye contact
D. Intonation