A client who has been admitted to the psychiatric unit tells the nurse, "My problems are so bad that noone
can help me." Which response is best for the nurse to make?
How can I help?
A 30-year-old sales manager tells the nurse, "I am thinking about a job change. I don't feel like I amliving up
to my potential." Which of Maslow's developmental stages is the sales manager attempting toachieve?
Self-Actualization
A male client is admitted to a mental health unit on Friday afternoon and is very upset on Sunday because
he has not had the opportunity to talk with the healthcare provider. Which response is best for the nurse to
provide this client?
Let me call and leave a message for your healthcare provider
An 86-year-old female client with Alzheimer's disease is wandering the busy halls of the extended care
facility and asks the nurse, "Where should I stand for the parade?" Which response is best for the nurse to
provide?
Let us go back to the activity room and see what is going on in there
A client is admitted with a diagnosis of depression. The nurse knows that which characteristic is most
indicative of depression?
A negative view of self and the future
A 40-year-old male client diagnosed with schizophrenia and alcohol dependence has not had any visitors
or phone calls since admission. He reports he has no family that cares about him and was living on the
streets prior to this admission. According to Erikson's theory of psychosocial development, which stage is
the client in at this time?
Stagnation
An elderly female client with advanced dementia is admitted to the hospital with a fractured hip. The client
repeatedly tells the staff, "Take me home. I want my Mommy." Which response is best for the nurse to
provide?
Tell the client that the nurse is there and will help her
A 45-year-old male client tells the nurse that he used to believe that he was Jesus Christ, but now heknows
he is not. Which response is best for the nurse to make?
Others have had similar thoughts when under stress
, A male client is admitted to the psychiatric unit with a medical diagnosis of paranoid schizophrenia.During
the admission procedure, the client looks up and states, "No, it's not MY fault. You can't blame me. I didn't
kill him, you did." What action is best for the nurse to take?
Assess the content of the hallucinations by asking the client what he is hearing
A woman arrives in the Emergency Center and tells the nurse she thinks she has been raped. The client is
sobbing and expresses disbelief that a rape could happen because the man is her best friend.After
acknowledging the client's fear and anxiety, how should the nurse respond?
"Rape is no limited to strangers and frequently occurs by someone who is known to the victim"
A 72-year-old female client is admitted to the psychiatric unit with a medical diagnosis of major depression.
Which statement by the client should concern the nurse and require further assessment?
I think my cat is going to die
A 52-year-old male client in the intensive care unit who has been oriented suddenly becomes disoriented
and fearful. Assessment of vital signs and other physical parameters reveal no significant change and the
nurse formulates the diagnosis, "Confusion related to ICU psychosis." Which intervention is best to
implement?
Cluster care so that brief periods of rest can be scheduled during the day
A 27-year-old female client is admitted to the psychiatric hospital with a diagnosis of bipolar
disorder,manic phase. She is demanding and active. Which intervention should the nurse include in this
client's plan of care?
Provide a structured environment with little stimuli
A male client with mental illness and substance dependency tells the mental health nurse that he has
started using illegal drugs again and wants to seek treatment. Since he has a dual diagnosis, which person
is best for the nurse to refer this client to first
His case manager
The parents of a 14-year-old boy bring their son to the hospital. He is lethargic, but responsive. The mother
states, "I think he took some of my pain pills." During initial assessment of the teenager, what information
is most important for the nurse to obtain from the parents?
If he might have taken any other drugs
A 38-year-old female client is admitted with a diagnosis of paranoid schizophrenia. When her tray is
brought to her, she refuses to eat and tells the nurse, "I know you are trying to poison me with that food."
Which response is most appropriate for the nurse to make?
I'll leave your tray here. I am available if you need anything else.