Deck 7: Mental Health

Question 1

Which statement made by the nurse during a therapy session demonstrates a need for further instruction regarding effective therapeutic communication techniques?

A)"I don't understand what you mean.  Can you give me an example?"
B)"It is doubtful the president is out to get you."
C)"Tell me more about the day your child died."
D)"Why did you get so angry when she ignored you?"

Answer 1

"Why did you get so angry when she ignored you?"

Question 2

The emergency department nurse cares for a client whose college roommate reports recent changes in the client's behavior.  Which behaviors and clinical data meet the criteria for involuntary admission to the mental health unit?  Select all that apply.

A)Client has been sleeping on the floor in the den rather than the bed
B)Client has refused food and water for 4 days and has poor skin turgor
C)Client repeatedly mumbles, "I must kill them before they get me"
D)Marijuana was found in the client's personal belongings
E)The health care provider makes a diagnosis of schizophrenia

Answer 2

Client has refused food and water for 4 days and has poor skin turgor
Client repeatedly mumbles, "I must kill them before they get me"

Question 3

The nurse is reviewing the records of an adolescent client.  Which findings suggest that the client may need referral for depression screening?  Select all that apply.

A)Client has had school disciplinary issues due to absenteeism and angry outbursts
B)Client has lost approximately 8 lb (3.64 kg) over the last 3 weeks without trying
C)Client is often found sleeping during class or activities
D)Client quit sports despite receiving previous athletic awards and trophies
E)Client voices concern about appearance related to facial acne

Answer 3

Client has had school disciplinary issues due to absenteeism and angry outbursts
Client has lost approximately 8 lb (3.64 kg) over the last 3 weeks without trying
Client is often found sleeping during class or activities
Client quit sports despite receiving previous athletic awards and trophies

Question 4

The nurse is educating a client in preparation for discharge from the hospital when the client breaks down crying, saying that the health care provider thinks she is crazy because he diagnosed her with a functional disorder.  Which statement would be the best reply to this client?

A)"Functional disorder is a general diagnosis for a genuine medical issue that medical science does not yet fully understand."
B)"I am very sorry to hear this, but are you sure that's what he meant?"
C)"The health care provider does not know what he's talking about.  I'll give you the information my health care provider used."
D)"Why do you think he said that?"

Question 5

The nurse is caring for a client with schizophrenia who has been experiencing visual hallucinations.  The client says in a trembling voice, "There's a bad man standing over there in the corner of my room."  What is the bestresponse by the nurse?

A)"I know you are frightened, but I do not see a man in your room."
B)"I'll make the bad man go away."
C)"Let's go into the dayroom and play checkers."
D)"Your illness is making you hallucinate."

Question 6

An adolescent client is brought to the emergency department by the parents after being found making superficial cuts along the side of an arm with a razor blade.  There are several minor cuts in various stages of healing on the client's forearms.  Which statements are appropriate for the nurse to make to the client's parents?  Select all that apply.

A)"Everything is going to be all right."
B)"Tell me about when you started noticing this behavior."
C)"We have the bleeding under control."
D)"Why didn't you bring your child in sooner?"
E)"You must be very upset after seeing this."

Question 7

A nurse performs the initial assessments for 4 assigned clients.  The nurse identifies which client as being at greatest risk for the development of delirium?

A)32-year-old client with gastroenteritis
B)55-year-old client with coronary artery disease, 4 days post coronary bypass surgery
C)60-year-old client with type II diabetes, 2 months post bilateral above-knee amputations
D)80-year-old client with chronic obstructive pulmonary disease, chronic respiratory failure, and urosepsis

Question 8

A client recently diagnosed with schizophrenia is hospitalized.  The client appears distraught and says to the nurse, "The voices are bad today…they are so angry with me."  Which of the following is the best response by the nurse?

A)"Do you need something to help you calm down?"
B)"Don't pay any attention to the voices.  Let's go into the dayroom."
C)"The voices are not real.  Tell them to go away."
D)"What are the voices saying to you?"

Question 9

Yesterday, the client was weaned from the mechanical ventilator and an intravenous infusion of lorazepam.  The client has been alert and oriented for 24 hours but is now experiencing confusion.  The nurse now evaluates new-onset confusion by assessing the client's sense of place and time, difficulty focusing, short-term memory loss, and increasing lethargy.  The nurse suspects which condition in this client?

A)Amnesia
B)Delirium
C)Dementia
D)Psychosis

Question 10

The nurse is caring for a client who entered the psychiatric emergency department in a state of acute psychosis after ingesting illicit substances.  The parents ask the nurse if the client will develop schizophrenia.  What is the most appropriate response by the nurse?

A)"I know it must be terrible to see your son like this, but he will be fine."
B)"Most people have permanent side effects after an episode like this."
C)"Your son will have to remain here for observation until we know more."
D)"Your son would be fine right now if he had not taken these drugs."

Question 11

A client with schizophrenia says to the nurse, "The world turns as the world turns on a ball at the beach.  But all the world's a stagecoach and I took the bus home."  The nurse recognizes this statement as an example of which of the following?

A)Concrete thinking
B)Loose associations
C)Tangentiality
D)Word salad

Question 12

An elderly client at the end of life is visited by family members.  One begins to cry and asks the nurse, "Will you please stay for a few minutes?"  The nurse has other clients to care for as well.  Which statement by the nurse is the mosthelpful?

A)"I am busy right now but can stay for a few minutes."
B)"I can call the clergy to come sit with you."
C)"I can stay and sit with you if you would like."
D)"I don't think I should interrupt your family time."

Question 13

A newly admitted client with schizophrenia has been exhibiting severe social withdrawal, odd mannerisms, and regressive behavior.  The client is sitting alone in the room when the nurse enters, says "good morning," and proceeds to sit down next to the client.  Without responding, the client stands up and starts to leave.  Which of the following actions is bestfor the nurse to take?

A)Ask where the client is going
B)Immediately follow the client out the door
C)In a loud voice, direct the client to come back to the room
D)Remain silent and allow the client to leave

Question 14

The nurse is managing the care of a client diagnosed with chronic anxiety.  Which behavior demonstrates to the nurse that the client possesses resilience?

A)Avoids anxiety-producing situations
B)Is able to identify anxiety-inducing triggers
C)Practices stress reduction techniques daily
D)Relies on anxiolytic medication to manage symptoms

Question 15

A client with schizophrenia is started on clozapine.  Which periodic measurements take priority in this client?

A)Complete blood count and absolute neutrophil count
B)ECG and blood pressure
C)Fasting blood glucose and fasting lipid panel
D)Height, weight, and waist circumference

Question 16

A client recently diagnosed with schizophrenia is brought to the mental health clinic by the identical twin sibling for the first follow-up visit after hospitalization.  The client's sibling says to the nurse, "I read that schizophrenia runs in families.  I guess I'm doomed."  Which is the bestresponse by the nurse?

A)"At the moment, I would worry more about how your sibling is doing."
B)"The odds are about 50-50 that you will come down with the disease as well."
C)"Would you like to talk to a health care provider about this?"
D)"You are at risk for the disease.  However, there are other factors that contribute to the development of schizophrenia."

Question 17

A client with a 20-year history of schizophrenia is hospitalized.  The client appears visibly upset, approaches the nurse, and says in a shaky voice, "I can't find my headband.  I can't find my headband.  The oil is going to leak out of the crack in my head."  What is the best response by the nurse?

A)"How long has the oil been leaking from your head?"
B)"Let's go back to your room and look for your headband together."
C)"There is no oil coming out of your head."
D)"You are going to miss breakfast if you do not go into the dining room."

Question 18

The nurse is preparing discharge instructions for a client with a history of alcohol abuse on the third day after an emergency appendectomy.  The nurse suspects delirium tremens based on which assessment data?  Select all that apply.

A)Bradypnea
B)Diaphoresis
C)Hallucinations
D)Lethargy
E)Tachycardia

Question 19

A client with schizophrenia has been hospitalized for a week and placed on an antipsychotic medication.  The client tells the nurse of hearing multiple voices all day long arguing about whether the client is a good or bad person.  The client says, "Everyone tells me that the voices are not real, but they are driving me crazy."  What is the best action by the nurse?

A)Give the client a book to read
B)Provide earphones and a DVD player and have the client sing along with the music
C)Tell the client that the voices will go away when the medication starts to work
D)Tell the client to ignore the voices

Question 20

A client with a diagnosis of schizophrenia with catatonia has recently been admitted to the psychiatric unit.  Which of the following is the priority nursing diagnosis?

A)Impaired social interaction
B)Impaired verbal communication
C)Risk for deficient fluid volume
D)Risk for impaired skin integrity

Question 21

A client with obsessive-compulsive disorder (OCD) has been cleaning a bathroom for most of the morning.  When the roommate demands that the client leave the bathroom so that the roommate can shower, the client becomes angry and says, "You can't make me leave, everything is still dirty."  What is the best nursing action?

A)Engage other staff members to remove the client from the bathroom
B)Give a reminder that the client has been cleaning the bathroom for 1½ hours and it is time to take a break
C)Tell the client that the bathroom is very clean and that this behavior is unreasonable
D)Tell the roommate to use the shower in another room

Question 22

The health care provider has just informed a client who has diabetes and chronic kidney disease of the need to start dialysis.  The client tearfully says to the nurse, "I don't know what I'm going to do; everything was so overwhelming before, and now there is this."  How should the nurse respond?

A)"You can cry and get it all out; I will stay with you."
B)"You have dealt with diabetes; you can conquer dialysis."
C)"You sound very discouraged and frightened."
D)"You still have a lot to live for; think about your family."

Question 23

A client recently admitted to an inpatient unit for treatment of alcoholism says to the nurse, "I only came here to get away from my nagging spouse.  Sometimes I think my spouse is the one who should be here.  I can stop drinking any time I want."  The nurse recognizes that the client is exhibiting which of the following defense mechanisms?

A)Denial and projection
B)Rationalization and depression
C)Regression and displacement
D)Sublimation and reaction formation

Question 24

A young client is diagnosed with major depressive disorder.  Three weeks prior, the client's fiancé broke off their engagement, claiming the client was "too fat and ugly."  During a one-on-one interaction with the nurse, the client says, "My fiancé is really wonderful and is not to blame for calling off the engagement.  I look awful and I'm not much good for anything."  What is the best response by the nurse?

A)"How could your fiancé be wonderful after saying those things to you?"
B)"I think you are better off without your fiancé."
C)"Maybe the breakup was for the best."
D)"Tell me how you felt when your fiancé broke up with you."

Question 25

The nurse is conducting a follow-up interview with a client who is being treated for depression and suicidal ideation.  Which factor best indicates the client is not currently at risk for suicide?

A)Client claims to have more energy and vigor since starting therapy
B)Client has clear future plans involving personal goals and family milestones
C)Client has signed a contract promising not to commit suicide
D)Client reports losing amitriptyline and requests a refill

Question 26

The nurse is conducting a seminar for parents of adolescents about health issues common to this age group.  Which parent's statement indicates that the adolescent may have bulimia nervosa?

A)"I found several empty boxes of laxatives in my child's wastebasket."
B)"I have noticed my child has started wearing bulky, oversized clothing."
C)"My child has lost 20 lb (9.1 kg) in the past 2 months."
D)"My child has stopped going to the gym."

Question 27

A client on a medical unit recently received a diagnosis of end-stage renal disease and was told of the need to go on dialysis.  This morning the client was found in the bathroom trying to commit suicide by hanging using hospital gown ties.  The client was stabilized and transferred to the psychiatric unit.  Which of the following is the highest priority nursing action for this client?

A)Assess the client's risk for another suicide attempt
B)Encourage the client to express current feelings about the medical diagnosis
C)Place the client in a private room near the nurses' station
D)Provide continuous one-to-one observation with the client

Question 28

The emergency department registered nurse is triaging a client for the risk of suicide.  The client had thoughts of self-injury yesterday but is not sure today.  Which of the following would be considered a known risk factor for suicide in this client?  Select all that apply.

A)Constantly hearing voices saying client is worthless
B)Deliberately took an overdose 1 year ago
C)Has a gun at home
D)Married with 3 children
E)Participation in religious activities
F)Unemployed and unable to find a job

Question 29

A client with a history of major depressive disorder with psychotic features was rescued before jumping off a dam.  The client is pacing, picking at the arms, and repeatedly mumbling, "I have to die.  You cannot stop me."  When the health care provider recommends electroconvulsive therapy (ECT) as the initial treatment, the client's spouse says to the nurse, "I can't allow such a cruel treatment.  Why can't they just give my spouse medication?"  Which is the best response by the nurse?

A)"ECT is safe and your spouse will not feel anything."
B)"It could take up to 3 weeks for medication to become effective."
C)"Your spouse could die by not receiving this treatment."
D)"Your spouse is very ill and ECT might be the best treatment at this time.  What are your concerns about ECT?"

Question 30

A client with schizophrenia is hospitalized.  After 2 weeks of treatment, the frequency of the client's hallucinations seems to be diminishing.  When first hospitalized, the client refused to leave the room.  Now the client spends time in the dayroom, sitting in a corner watching television, but does not initiate conversation or social interaction with other clients or staff.  What is the most appropriate activity for the client?

A)A board game with a staff member
B)Participation in a group songfest
C)Planning a unit picnic
D)Playing Bingo with other clients

Question 31

The nurse is admitting a client with malnutrition related to anorexia nervosa.  Which of the following actions are appropriate to include in the care of this client?  Select all that apply.

A)Allow the client to continue to exercise per usual routine
B)Assist the client in reflecting on triggers of disordered eating
C)Maintain strict record of protein and calorie intake
D)Remain with the client for the duration of each meal
E)Weigh the client each morning prior to any oral intake

Question 32

The home health aide reports to the nurse care manager that the client has been trying to give away possessions.  When the nurse asks the client about this behavior, the client says, "With my spouse dead, there's no reason for me to go on."  What is the best priority response by the nurse?

A)"Do you have any friends in the building?"
B)"Have you had any thoughts of hurting yourself?"
C)"Tell me more about how you're feeling."
D)"You're not thinking of killing yourself, are you?"

Question 33

A nursing home client with major depressive disorder reports difficulty going to sleep until late at night.  The client gets up, paces the hallway, wrings the hands, and appears teary.  What interventions should be included in the client's nursing care plan?  Select all that apply.

A)Allow the client to receive at least 20 minutes of natural sunlight each day
B)Encourage the client to take naps during the day to make up for lost sleep
C)Have the client engage in strenuous physical exercise just before bedtime
D)Spend time with the client in a quiet environment just before bedtime
E)Suggest that the client take a warm bath before going to bed

Question 34

A client is receiving nasogastric tube feedings as nutritional rehabilitation for anorexia nervosa.  After a weigh-in, the client learns of gaining 2 lb (0.9 kg) and says to the nurse, "See what your force feeding has done to me?  I'm fatter and uglier than ever."  What is the best action by the nurse?

A)Have the client keep a journal and write about feelings
B)Initiate one-on-one supervision of the client during feedings
C)Remind the client that gaining weight means being able to go home
D)Say that the client is not fat and ugly

Question 35

A client, who has been hospitalized for 3 days with major depressive disorder, has stayed in the room and not gotten out of bed except for toileting.  The nurse enters the room to remind the client that breakfast will be served in the dining room in 20 minutes.  The client says, "I'm not hungry and I don't feel like doing anything."  What is the best response by the nurse?

A)"I will help you get ready; then we can walk to the dining room together."
B)"I'll have breakfast brought to your room."
C)"It's okay.  You can join us when you are ready."
D)"You'll feel better when you get up."

Question 36

The nurse is caring for a client with bulimia nervosa.  Which is the most important time for the nurse to monitor the client's behavior?

A)During 1-2 hours after each meal
B)During every meal
C)During the evening meal
D)During the overnight hours

Question 37

Which of the following actions would the nurse include in planning care for a client hospitalized for bipolar disorder, acute manic episode?  Select all that apply.

A)Assign the client to a private room
B)Choose clothing for the client
C)Have the client be in charge of planning an outing for the unit
D)Have the client join other clients in the dining room for meals
E)Have the client participate in physical exercise with a staff member
F)Include the client in group therapy sessions

Question 38

An elderly client with dementia frequently exhibits sundowning behavior while living in a community-based residential facility.  When the nurse finds the client wandering at night, which of the following statements is most appropriate?

A)"Don't you know it's not morning yet?"
B)"It's time to get back to bed now."
C)"You might fall if you wander in the dark."
D)"You should not leave your room without assistance."

Question 39

A client with severe major depressive disorder is lying in bed and has not moved for 3 hours.  The client will respond slowly to "yes" and "no" questions; otherwise, the client does not respond when spoken to.  The clinical manifestations exhibited by the client are known as:

A)Psychogenic dystonia
B)Psychogenic gait
C)Psychomotor retardation
D)Somatization

Question 40

A client has been admitted to the acute inpatient psychiatric unit with a diagnosis of major depressive disorder (unipolar depression).  The nurse understands that this diagnosis was made because the client has been exhibiting at least 1 of which of the 2 key clinical findings daily for at least 2 weeks?

A)Daily sleep disturbance or significant weight loss
B)Decreased ability to think or low energy
C)Depressed mood or loss of interest or pleasure
D)Thoughts of worthlessness or recurrent thoughts of death

Question 41

The registered nurse is counseling the parent of a child recently diagnosed with attention-deficit hyperactivity disorder (ADHD), combined type.  Which statement by the parent requires an intervention?

A)"I should offer a choice between 2 things for my child's clothes or meals."
B)"I will need to advocate for an individualized educational plan for my child."
C)"My child will outgrow this disorder around age 20."
D)"When talking with my child, I should not be multi-tasking."

Question 42

The nurse is developing a plan of care for a 16-year-old client with bulimia nervosa.  Which interventions would be included in the plan of care?  Select all that apply.

A)Allow client to remain on current laxatives
B)Assess client for electrolyte imbalances
C)Be alert to hidden or discarded food wrappers
D)Do not allow client to keep a food diary during hospitalization
E)Monitor client for 1-2 hours after each meal in a central area

Question 43

A client is newly admitted to the mental health unit with a diagnosis of schizophrenia with persecutory delusions.  Which nursing interventions should the nurse include in the client's plan of care with regard to the delusional thinking?  Select all that apply.

A)Explore the meaning behind the client's delusions
B)Focus on reality and verbally reinforce it
C)Focus on the client's feelings secondary to the delusions
D)Gently confront the client about the false beliefs
E)Present logical explanations to discredit the delusions

Question 44

The nurse on the mental health unit receives report about a client diagnosed with schizophrenia who is experiencing a delusion of reference.  Which client statement supports this symptom?

A)"I need for you to get rid of these bugs that are crawling under my skin."
B)"Hear that?  She told me to kill my father."
C)"That song is a message sent to me in secret code."
D)"Those Martians are trying to poison me with the tap water."

Question 45

A client with social anxiety disorder is receiving treatment at the local community mental health center.  Which situation most likely caused the client to seek therapy?

A)The client and spouse are soon moving into a new neighborhood
B)The client's boss has asked the client to represent the company at an upcoming convention
C)The client's primary health care provider (HCP) of 30 years is retiring and the client will be seeing a new HCP
D)The client's son is getting married in a few months

Question 46

A client states, "I just don't know what to do about this situation with my parents," and the nurse replies, "I'm sure you will do the right thing."  Which summary is true regarding the nurse's response?

A)The nurse has encouraged exploration of the client's situation
B)The nurse has shown interest in the client's concerns
C)The response conveys empathy toward the client and promotes self-confidence
D)The response devalues the client's feelings and gives false reassurance

Question 47

A nurse is admitting a child and observes multiple irregular bruises.  Which action should the nurse take next?

A)Ask parents to leave the room during the admission process
B)Continue with a detailed interview and physical examination
C)Notify the charge nurse and the social worker
D)Promise not to tell anyone if the child reveals abuse

Question 48

After a daily weigh-in, a client with anorexia nervosa realizes a 2-lb weight gain.  The client says to the nurse in a distressed voice, "This is terrible.  I'm so fat."  What is the best response by the nurse?

A)"But you look so thin."
B)"I don't see you that way; you are making progress toward a healthy weight."
C)"If you continue to gain weight at this rate, you will be able to go home soon."
D)"You are not fat; it's all in your imagination."

Question 49

A client with generalized anxiety disorder is referred to outpatient mental health department for cognitive behavioral therapy (CBT).  The CBT includes which interventions and strategies?  Select all that apply.

A)Desensitization to a specific stimulus or situation
B)Discussing the interpersonal difficulties that have led to the client's psychological problems
C)Helping the client develop insight into the psychological causes of the disorder
D)Relaxation techniques
E)Self-observation and monitoring
F)Teaching new coping skills and techniques to reframe thinking

Question 50

The nurse cares for a client who just had surgical excision and biopsy of a tumor.  The biopsy results show that the tumor is malignant, but the client has not yet been informed by the health care provider.  The client asks the nurse, "Am I going to die?"  Which statement by the nurse is appropriate?

A)"I know how anxious you must be.  Watching some television might help you relax."
B)"Tell me more about your thoughts and feelings regarding the situation."
C)"The biopsy result shows that you have cancer, but many cancers are treatable."
D)"Waiting for test results can be stressful.  I am sorry I cannot tell you more."

Question 51

A 60-year-old client wanders away during halftime at a football game and is found 48 hours later sleeping on a park bench, 100 miles from home.  The client is brought to the emergency department by the police.  The client can state the name and address but has no recollection of the past 2 days.  What is the priority nursing action?

A)Assess vital signs
B)Contact family members
C)Encourage the client to recall recent events
D)Perform a mental status assessment

Question 52

A young adult with obesity comes to the free clinic for a 2-week post-antibiotic follow-up visit for a superficial abdominal skin abscess.  The client has a history of major depressive disorder and was hospitalized twice in the past 6 months for attempted suicide.  The client now reports feeling "emotionally upset, alone, and at the end of my rope," due to difficulty finding a job and inability to qualify for medical insurance.  The client is currently prescribed fluoxetine but has not been able to follow up with the prescribing health care provider (HCP).  What is the priority nursing diagnosis (ND) at this time?

A)Hopelessness
B)Ineffective coping
C)Risk for infection
D)Risk for suicide

Question 53

A client who was suddenly overwhelmed with an intense fear that something terrible was going to happen is brought to the emergency department by the spouse after they were out at dinner.  The client is now shaking, hyperventilating, and having heart palpitations.  What is the priority nursing action?

A)Encourage the client to perform deep breathing exercises
B)Explore possible reasons for the episode
C)Place the client in a private room and tell the client to relax
D)Remain in the room with the client

Question 54

The nurse is caring for a hospitalized elderly client who is admitted with pneumonia.  Which assessment finding is most consistent with the diagnosis of delirium?

A)Client is alert but disoriented to time
B)Client is inattentive and hallucinating
C)Client reports decreased enjoyment in previously pleasurable activities
D)Family reports a gradual progressive inability to remember recent events

Question 55

The nurse is presenting an in-service educational session on child abuse and neglect to a class of certified home health aides.  Which of the following statements should the nurse include when discussing the characteristics of the typical perpetrator of child abuse?  Select all that apply.

A)"Abusers often have a history of growing up in an environment of domestic violence."
B)"Abusers often have a history of substance abuse."
C)"Child abusers always present as being agitated or out of control."
D)"Most child abusers have a sense of low self-esteem."
E)"Teenage parents are particularly vulnerable to abusing their children."

Question 56

Which clinical manifestations would the nurse identify with severe anorexia nervosa?  Select all that apply.

A)Amenorrhea
B)Fluid and electrolyte imbalances
C)Heat intolerance
D)Presence of lanugo
E)Refusal to exercise
F)Weight loss of 25% below normal weight

Question 57

A client on the locked unit of an inpatient psychiatric hospital says to a nurse on the evening shift, "During the day they let me out to go to the gift shop.  You're my favorite nurse; I know you'll be a good sport and give me a pass."  What is the best response by the nurse?

A)"The gift shop is not even open right now."
B)"I guess the day shift staff needs to be reminded of the rules."
C)"What do you want to get from the gift shop?"
D)"You do not have privileges for leaving the unit.  I cannot give you a pass."

Question 58

The spouse brings a client to the emergency department due to erratic behavior and expressions of despair.  The emergency department is extremely busy with many clients.  When the triage nurse asks if the client feels suicidal now, the client shrugs the shoulders.  What initial action should the triage nurse take?

A)Ask the client to make a verbal contract to not harm self
B)Document that the client is not currently suicidal
C)Place the client in an inside hallway with one-on-one observation
D)Return the client to the waiting room with the spouse

Question 59

A client is brought to the emergency department after the spouse finds the client locked in the car inside their garage with the motor running.  The spouse says to the nurse, "If I hadn't come home early from work, my spouse would be dead.  I can't believe this is happening."  What is the bestresponse by the nurse?

A)"Do you have any relatives or close friends who can help you through this?"
B)"Has your spouse seemed depressed lately?"
C)"This has been very overwhelming for you.  What are you feeling right now?"
D)"Well, you did find your spouse.  You need to focus on helping your spouse get better."

Question 60

A client comes to the community mental health clinic seeking treatment for severe anxiety associated with a recent job promotion that requires a 30-minute commute via train.  The nurse recognizes that this client most likely suffers from which psychological disorder?

A)Agoraphobia
B)Generalized anxiety disorder
C)Social anxiety disorder
D)Zoophobia

Question 61

A client with Alzheimer disease is admitted to the hospital for a urinary tract infection.  The daughter says to the nurse, "I really want to take my mother home and continue care there.  However, lately, my mother has become agitated and restless at night.  I'm awake most of the night, feel exhausted, and do not know what to do."  What is the best response by the nurse?

A)"Do not let your mother take naps in the afternoon."
B)"Our social worker can discuss long-term care options with you."
C)"We can ask the health care provider for medication that will help your mother sleep."
D)"Your mother can be cared for in a nursing home."

Question 62

The registered nurse is leading a support group for partners of military veterans suffering from posttraumatic stress disorder (PTSD).  A participant asks the nurse how to identify the typical symptoms of PTSD.  The nurse responds that most individuals with PTSD report which symptoms?

A)Auditory hallucinations, feelings of paranoia, isolation from others
B)Increased anxiety, reliving the event, feeling detached from others
C)Rapidly changing emotions, delusions, lethargy
D)Recurring nightmares, uncontrollable anger, daytime sleepiness

Question 63

The nurse is caring for a new mother whose infant has been diagnosed with Down syndrome.  The client says to the nurse, "I'm so worried.  My husband is so devastated that he won't even look at the baby."  What is the best response by the nurse?

A)"Both of you will benefit from supportive counseling."
B)"How are you feeling about your baby?"
C)"I will have the doctor speak to your husband."
D)"Why do you think your husband feels this way?"

Question 64

The student nurse is performing an assessment of a 10-year-old diagnosed with attention-deficit hyperactivity disorder (ADHD).  In addition to the 3 core symptoms of ADHD (hyperactivity, impulsiveness, and inattention), which of the following would the student nurse expect to find during the assessment?

A)Confusion and a learning disability
B)Delayed physical and emotional development
C)Disorientation and cognitive impairment
D)Low self-esteem and impaired social skills

Question 65

After a client with Alzheimer disease is found wandering in the middle of the street at 3:00 AM and returned by police, the community health nurse teaches family members about measures to keep the client safe at home.  What is the most important strategy for the nurse to include in the instruction?

A)Ensure that the client is never left alone
B)Notify neighbors of the client's tendency to wander
C)Place a chain lock on the door above or below the client's eye level
D)Place a safe return bracelet on the client's non-dominant hand

Question 66

The nurse on the mental health unit received report on 4 clients.  Which client should the nurse see first?

A)Client diagnosed with major depressive disorder who has consumed no food from the past 3 meal trays
B)Client diagnosed with post-traumatic stress disorder who reports an anxiety level of 8/10 and is pacing in the room
C)Client newly admitted with bipolar mania who reports sleeping only 4 hours last night
D)Client newly admitted with obsessive-compulsive disorder who has spent the last hour counting socks

Question 67

The nurse on the mental health unit recognizes the use of which defense mechanism when a client leaves a stressful family meeting and immediately begins to verbally abuse a roommate?

A)Compensation
B)Displacement
C)Projection
D)Reaction formation

Question 68

A female client who was the victim of acquaintance rape 2 months ago is receiving therapy for posttraumatic stress disorder (PTSD).  She says to the nurse, "It's all my fault.  I should have known not to accept a drink from someone I just met in a bar."  What is the best response by the nurse?

A)"It may take time to overcome those thoughts and feelings."
B)"Those kinds of thoughts are self-destructive.  You should stop thinking about it."
C)"You could not have anticipated the rape.  You did not deserve or ask for it."
D)"You have to stop blaming yourself so you can move on with your life."

Question 69

A 12-year-old with moderate intellectual disability and an intelligent quotient of 45 is hospitalized.  What will the nurse recommend as the best recreational activity for this child?

A)Child's favorite stuffed animal
B)Connect-the-dots puzzle book
C)Putting together a 300-piece jigsaw puzzle
D)Writing in a journal about the hospital stay

Question 70

The nurse is planning care for an 11-year-old admitted for surgical treatment of a fractured femur.  The child also has attention-deficit hyperactivity disorder, predominantly inattentive type.  What is the priority nursing action?

A)Encourage the child to keep up with school work
B)Give the child a written schedule of daily activities
C)Limit the number of visitors
D)Provide verbal explanations of what to expect during hospitalization

Question 71

A child with a high level of school absenteeism has been determined to have school phobia.  The school nurse should counsel the child's parent/caregiver to take which action?

A)Allow the child to stay home when the child seems particularly anxious
B)Encourage the parent/caregiver to sit in the classroom with the child
C)Insist on school attendance immediately, starting with a few hours a day
D)Return the child to school when the cause of the school phobia has been identified

Question 72

An 87-year-old client has been admitted to the hospital with signs and symptoms of a urinary tract infection along with agitation, confusion, and disorientation to time and place.  What is the most important nursing action?

A)Encouraging frequent fluid intake
B)Keeping the bed elevated with the side rails raised
C)Providing one-on-one supervision
D)Turning lights off in client's room to reduce stimulation

Question 73

The school nurse is called to the classroom to assist with a 7-year-old with attention-deficit hyperactivity disorder who is throwing books and hitting the other children.  What is the best initial action for the nurse to take?

A)Administer a PRN dose of methylphenidate
B)Ask the child to blow up a balloon
C)Give the child a "time out" in a quiet place
D)Reinforce the consequences of disruptive behaviors

Question 74

The nurse is providing care to a client experiencing posttraumatic stress disorder following a terrorist attack at the client's place of worship.  What is the priority nursing action?

A)Acknowledge the client's feelings of anger
B)Assess the client's support system
C)Encourage the client to talk about the trauma
D)Offer the client a PRN sleep medication

Question 75

The nurse performs an initial assessment on a client with suspected post-traumatic stress disorder.  Which assessments would support this diagnosis?  Select all that apply.

A)Difficulty concentrating
B)Feeling detached from others
C)Feeling lethargic and apathetic
D)Flashbacks of the traumatic event
E)Persistent angry, fearful mood

Question 76

A client who is diagnosed with breast cancer asks the nurse, "Am I going to die?"  Which statement by the nurse promotes a therapeutic relationship?

A)"Cancer is no longer a death sentence; you may live for many years."
B)"I will ask the chaplain to talk to you sometime today."
C)"People with cancer experience fear of dying; tell me about your concerns."
D)"Tell me about your life and hopes for the future."

Question 77

A 10-year-old client with autism spectrum disorder is hospitalized for a diagnostic workup.  Which is the most appropriate nursing action?

A)Encouraging visits by friends to decrease social isolation
B)Giving the client a schedule of daily activities
C)Placing the client in restraints during invasive procedures
D)Providing the client with a variety of toys

Question 78

A client with moderate Alzheimer disease is started on memantine.  In evaluating the effectiveness of this medication, the registered nurse should assess the client for which of the following?

A)Improved ability to perform activities of daily living
B)Indications that disease progression has stopped
C)Rapid improvement in cognitive functioning
D)Reversal of the disease

Question 79

The nurse plans care for a client diagnosed with anorexia nervosa who is being admitted after failure of outpatient treatment.  Which client outcome will the nurse prioritize?

A)Acknowledges poor interpersonal skills
B)Identifies new coping mechanisms
C)Increases caloric intake to gain weight
D)Verbalizes sources of conflict and anger

Question 80

A client presents to the emergency department with alcohol intoxication.  Assessment shows nystagmus, ataxia, and confusion.  The client's breath smells of alcohol.  Which prescription from the health care provider should the nurse implement first?

A)Blood draw for liver function tests
B)D5 1/2 normal saline
C)Folic acid, IV
D)Thiamine, IV