Question 1

A nurse is working with a client who is delusional. The client says to the nurse, "The leaders of a religious cult are being sent to assassinate me." Which of the following is the best response by the nurse?

Accepted Answer

The best response by the nurse is to acknowledge the client's feelings without confirming or denying the delusion. This approach helps to build trust and open communication without reinforcing the delusion.

Question 2

A woman is seen in the emergency department in a severe state of anxiety following assault and battery. The nurse places highest priority on taking which of the following nursing actions at this time?

Accepted Answer

Remaining with the client provides immediate emotional support and a sense of safety, which is crucial following a traumatic event such as assault and battery.

Question 3

An older female client with delirium becomes agitated and confused at night. The nurse's most important strategy for this is to do which of the following?

Accepted Answer

Reducing sensory overload by turning off the television and radio while using a nightlight can help minimize confusion and agitation in a client with delirium.

Question 4

A mental health nurse is assigned to care for a client with a diagnosis of undifferentiated schizophrenia. The nurse uses which of the following approaches when planning care for this client?

Accepted Answer

Providing assistance with grooming and nutrition is important as clients with undifferentiated schizophrenia may have impaired ability to care for themselves due to disorganized thinking.

Question 5

The nurse is talking with a male client who is actively hallucinating. The client is fearful that the voices he hears will direct him to kill himself or will hurt him directly. Which of the following nursing statements would be therapeutic at this time?

Accepted Answer

Option D is therapeutic because it acknowledges the client's experience without validating the hallucination as real, showing empathy and understanding towards the client's situation.

Question 6

The client tentatively diagnosed with a borderline personality is admitted to the psychiatric unit for control of symptoms. Based on a thorough understanding of personality disorders, the nurse would select which nursing diagnosis as the priority?

Accepted Answer

Risk for self-mutilation is a priority nursing diagnosis for a client with borderline personality disorder due to the high risk of self-harm behaviors associated with this condition.

Question 7

A client admitted to the inpatient unit is being considered for electroconvulsive therapy (ECT). The client is calm, but the client's daughter is hypervigilant and anxious. The daughter says to the nurse, "My mother's brain will be shocked with electricity. How can the doctor even think about doing this to her?" Which of the following responses by the nurse would be therapeutic?

Accepted Answer

This response acknowledges the daughter's feelings and opens the door for further discussion and education about ECT, which can help alleviate her concerns.

Question 8

The nurse is assigned to a client who is psychotic, pacing, agitated, and using aggressive gestures and rapid speech. The nurse determines that the priority of care at this time is which of the following?

Accepted Answer

The priority in managing a client who is psychotic, pacing, agitated, and using aggressive gestures and rapid speech is ensuring safety for both the client and others on the unit. This is in line with the principle of providing a safe environment, which is a fundamental aspect of nursing care.

Question 9

A female client diagnosed with catatonic stupor is lying on the bed, hidden under the sheets, with her body pulled into a fetal position. The nurse should take which appropriate action?

Accepted Answer

Sitting beside the client in silence while occasionally asking open-ended questions is a supportive approach that respects the client's current state and can help in establishing trust and a therapeutic relationship. It provides presence without forcing interaction, which can be beneficial for someone in a catatonic stupor.

Question 10

A client who has sustained severe injuries in a motorcycle accident was diagnosed with intensive care unit (ICU) psychosis. The nurse would be most likely to conclude that the client's status is improving if the client:

Accepted Answer

Increased hours of sleep and improved alertness are signs of recovery from ICU psychosis, indicating the client's mental status is improving towards normalcy.

Question 11

A nurse caring for a client recently admitted to the hospital for anorexia nervosa enters the client' s room and finds her in the middle of performing rapid exercises. Which action would be the priority?

Accepted Answer

Interrupting the client's rapid exercises and offering a more controlled and supervised activity like walking helps address the immediate safety concern of overexertion and aligns with therapeutic management of anorexia nervosa.

Question 12

The postsurgical client with a history of heavy alcohol intake is at risk for delirium tremens (DTs), which would be manifested by:

Accepted Answer

Delirium tremens (DTs) is a severe form of alcohol withdrawal that can occur in individuals with a history of heavy alcohol intake when they suddenly decrease or stop their alcohol consumption. It is characterized by fever, hypertension, changes in the level of consciousness (such as confusion or stupor), and hallucinations (which can be visual, auditory, or tactile). These symptoms reflect the body's hyperarousal state as it reacts to the absence of alcohol.

Question 13

A nurse working in a detoxification unit is admitting a client for alcohol withdrawal. The client's spouse states, "I don't know why I don't get out of this rotten situation." Which of the following would be the therapeutic response by the nurse?

Accepted Answer

Option C, "What aspects of this situation are the most difficult for you?" is therapeutic because it encourages the spouse to express feelings and identify specific stressors, facilitating open communication and reflection.

Question 14

The nurse monitors this client with a history of opioid abuse for which of the following signs and symptoms associated with opioid withdrawal?

Accepted Answer

Opioid withdrawal symptoms include increased pulse and blood pressure, low-grade fever, yawning, restlessness, anxiety, craving, diarrhea, and mydriasis (dilated pupils), which are all mentioned in option D. These symptoms are part of the body's response to the absence of the opioid, reflecting the physiological dependence that has developed.

Question 15

The nurse is working with a client who shows signs of benzodiazepine withdrawal. The nurse suspects that the client has suddenly discontinued taking which of the following prescribed medications?

Accepted Answer

Diazepam (Valium) is a benzodiazepine, and sudden discontinuation can lead to withdrawal symptoms. The other medications listed are not benzodiazepines; Sertraline and Fluoxetine are SSRIs, and Haloperidol is an antipsychotic.

Question 16

A nurse is admitting a client who is in a state of starvation because of anorexia nervosa. Which of the following roommate choices would indicate a lack of understanding by the nurse regarding theadmitting client's health needs?

Accepted Answer

Placing a client with anorexia nervosa, who is in a state of starvation, with a client who has pneumonia could increase the risk of infection for the anorexic client due to their likely compromised immune system. This choice indicates a lack of understanding of the admitting client's health needs, as it does not consider the increased vulnerability of a malnourished individual to infections.

Question 17

A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I don't want help. I have other things to attend to that are more important." The nurse attempts to discuss the client's concerns, but the client dresses and begins to walk out of the hospital room. The nurse should take which of the following actions at this time?

Accepted Answer

Calling the nursing supervisor is the appropriate action because it involves seeking guidance on how to handle the situation within the hospital's policies and ensures that the client's decision is managed appropriately.

Question 18

The nurse will monitor the client with a history of heroin addiction for which of the following signs of heroin withdrawal?

Accepted Answer

Heroin withdrawal symptoms include nausea, vomiting, diarrhea, muscle aches, and diaphoresis, reflecting the body's reaction to the absence of the drug after dependence has developed.

Question 19

The nurse is interviewing a client in crisis to assess the risk for self-harm. The nurse interprets that the client is most at risk for suicide if the client:

Accepted Answer

Having an immediate plan for a suicide attempt indicates a high level of risk as it shows the client has thought through the process and is prepared to act on their suicidal thoughts.

Question 20

A client with a potential for violence is exhibiting aggressive gestures, making belligerent comments to the other clients, and is continuously pacing in the hallway. Which of the following comments by the nurse would be therapeutic at this time?

Accepted Answer

Asking the client what is causing them to become agitated is a therapeutic approach because it acknowledges the client's feelings and attempts to understand the underlying cause of their behavior without making assumptions or threats. This can help de-escalate the situation by showing empathy and concern for the client's well-being.

Quiz 5: Mental Health