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RN Nursing School · Mental Health · 191 questions

Crisis and Safety practice questions

Every question below is free to read with its full rationale. For timed sets, the rest of the bank and progress tracking on Crisis and Safety, practise in the app.

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  1. 1A nurse is caring for a client who is in physical restraints after demonstrating aggressive behavior. Which of the following criteria must be met before the nurse can remove the restraints?Answer →
  2. 2Which of the following statements provide the best rationale for why the school nurse should have closely monitored this severely depressed client during his therapy? a. Because as depression lifts, physical energy becomes available to carry out suicide. b. Because suicidal clients have difficulty using social supports. c. Because suicide may be precipitated by a variety of internal and external events. d. Because suicide is an impulsive act and a call for attention.Answer →
  3. 3A nurse is conducting a suicide risk assessment for a client who exhibits warning signs such as withdrawing from friends and talking frequently about death. Which approach best demonstrates the nurse's understanding of effective communication about suicide?Answer →
  4. 4A nurse is providing care to a child during a routine wellness check-up. Which of the following client statements should indicate to the nurse that the client is at a higher risk for experiencing abuse and violence?Answer →
  5. 5A nurse is caring for an older adult client who reports their caregiver has been writing checks in their name without their consent. Which of the following types of abuse is the client experiencing?Answer →
  6. 6A co-worker nurse tells you that based on her assessment of a 7-year-old client, she suspects that the client has been physically and sexually abused, she is not sure if she has to report it. Which of the following is the most accurate information to share with her regarding reporting child abuse in Kentucky?Answer →
  7. 7A nurse is conducting a home health visit for an older adult client who lives with family members. The nurse notices that the client has multiple unusual bruises, and, based on several other factors, the nurse suspects that the client has been physically abused. Which of the following actions should the nurse take first?Answer →
  8. 8A client with OCD tells the nurse, "I don't know if I can continue to live this way." Which assessment question shows the nurse understands the client's priority risk?Answer →
  9. 9Terry a 25 years old male consistently avoided thoughts and images related to witnessing the injuries and deaths of others during an earthquake during a recent tourist trip to Syria. After his return to USA, he began spending more time at work and filling his days with hobbies and activities. However, whenever he had free time, he would have unwanted intrusive thoughts about the earthquake. In addition, he was having increasingly distressing nightmares. Which comment by the client requires the nurse to make a close ended question?Answer →
  10. 10A client is admitted for psychiatric observation after being arrested for breaking windows in the home of his former girlfriend, who had refused to see him. His history reveals abuse as a child by a punitive father, torturing family pets, and one arrest for disorderly conduct. What is the priority nursing diagnosis that should be considered in this scenario?Answer →
  11. 11A community health nurse is creating a presentation about mood disorders for a local support group. The nurse should include which of the following as a risk factor for suicide?Answer →
  12. 12A client is seen in the emergency department (ED) with bruises on the arms and a fractured wrist. The nurse suspects intimate partner violence (IPV) but the client denies it. Although the nurse has asked several times, the client's partner refuses to leave the room. Which action should the nurse take?Answer →
  13. 13A bipolar client during a manic episode has been seen responding to auditory hallucinations earlier in the morning approaches the nurse and shakes his fist, saying, 'Back off, bitch!' and then goes into his room. The nurse follows the client into client's room. Which important intervention consideration should has been done?Answer →
  14. 14A newly licensed nurse asks a charge nurse, "What is the difference between a suicide attempt and self-harm?" Which of the following responses should the charge nurse give?Answer →
  15. 15A 20-year-old economics major became severely depressed after failing two examinations in economics. She cried for 2 hours, then called her parents who live in a neighboring state, to know how they were doing. However, her parents were in Europe and did not answer the call. When her roommate went home for the weekend, the client gave her expensive and most precious sweaters for her to keep. Later, the dormitory resident assistant returned a book to the client's room and found her unconscious on the floor, with an empty pill bottle nearby. What client's behavior provided the most definitive clue about a possible suicide attempt?Answer →
  16. 16Why is so important that nurses differentiate aggression from violence?Answer →
  17. 17A charge nurse on a mental health unit is describing assessments for suicide risks to a group of newly licensed nurses. Which of the following tests should the nurse include? (Select All that Apply:)Answer →
  18. 18A nurse is caring for a client whose family has been reported missing. The client is visibly agitated, they are pacing and disregards the nurser's directives. The client loudly tells the nurse. "I want answers NOW". The nurse should identify that this client is in which of the following stages of crisis?Answer →
  19. 19A nurse is providing teaching to a newly licensed nurse who is caring for a client undergoing cognitive behavioral therapy for the treatment of aggression. Which of the following statements by the newly licensed nurse indicate an understanding of the teaching?Answer →
  20. 20An adult female client becomes combative with the nurse during routine medication administration. What is the nurse's primary responsibility in this situation?Answer →
  21. 21A bipolar client during a manic episode has been seen responding to auditory hallucinations earlier in the morning approaches the nurse and shakes his fist, saying, "Back off, bitch!" and then goes into his room. The nurse follows the client into client's room. Which important intervention consideration should have been done? (Select all that apply)Answer →
  22. 22A 32-year-year-old patient with bipolar I disorder is involuntarily admitted under court order for acute mania. The patient is loud, intrusive, pacing, and making threatening gestures toward peers. Verbal redirection and a PRN antipsychotic were offered but refused. The patient suddenly throws a chair toward another patient. The patient is calm, follows commands, and no longer attempts to harm others. What is the best next nursing action?Answer →
  23. 23A nurse is caring for a client who has a history of being a perpetrator of abuse and violence. Which of the following characteristics should the nurse expect the client to have?Answer →
  24. 24When responding to a call light, the nurse finds a client with aggressive behaviors pacing and restless in the room. The client shouts, 'What took you so long to get in here!' Which action should the nurse implement?Answer →
  25. 25Which is the best approach for the nurse to use when interviewing a client about suicidal ideations?Answer →
  26. 26A nurse is dealing with an agitated client in a lounge with other clients. What is the nurse's priority action in this situation?Answer →
  27. 27A client has been hospitalized several times after self-injurious behavior and suicide attempts. The client has entered cognitive behavior therapy on an outpatient basis. During therapy, the nurse has been counseling her regarding self-harm behavior management. Today the client called the nurse and reported 'feeling empty and anxious'. Which response by the nurse would best help in this situation?Answer →
  28. 28A nurse is caring for a 42-year-old client who was recently diagnosed with type 2 diabetes. The client reports feeling anxious, overwhelmed, and tearful, saying, "I don't know how I will manage this new lifestyle and all the medications." The client states that they have no history of mental illness and were previously coping well with stress. What is the client experiencing?Answer →
  29. 29A nurse is caring for a client diagnosed with major depressive disorder (MDD). Which statement by the client requires the nurse's immediate follow-up?Answer →
  30. 30The unit manager is preparing for an annual state survey. Which unit design features support safety for clients at risk of self-harm/violence? (Select all that apply)Answer →
  31. 31A nurse is discussing adverse childhood experiences (ACES) with another nurse. Which of the following experiences qualify as an ACE? (Select all that apply.)Answer →
  32. 32A 28-year-old woman, recently promoted to a managerial position, visits the mental health clinic because she feels overwhelmed and anxious. She reports difficulty falling sleep, irritability, and frequent headaches. She expresses feelings of self-doubt and inadequacy, saying: "I don't know if I'm ready for this level of responsibility. Everyone seems to expect me to know everything, and I feel like I'm failing." The nurse learns that she was recently married and is trying to balance her career, new marital responsibilities, and social expectations. She has no prior psychiatric history, and there is no history of trauma or recent loss. Her lab work and vital signs are within normal limits. What type of crisis is the woman experiencing?Answer →
  33. 33A community mental health nurse is assigned to investigate the frequent school absentee child. The nurse finds the child home alone, caring for his 1- and 3-year-old siblings. The house is cluttered and dirty, and both parents are at work. The child tells the nurse that whenever his mother is at her part-time job, he must watch the kids because the family cannot afford a babysitter. Based on the data obtained thus far, what preliminary assessment can be made by the nurse?Answer →
  34. 34The nurse is preparing to care for a client with a history of childhood sexual abuse who is being admitted for a routine procedure. Which approach best reflects the principles of trauma-informed care?Answer →
  35. 35A nurse is supervising a group of staff members on a mental health unit. Which of the following actions require the nurse to complete an incident report?Answer →
  36. 36A nurse is caring for a client who begins yelling and pacing around the room. Which of the following actions should the nurse take? (Select all that apply.)Answer →
  37. 37A nurse is speaking about types of aggression to a group of residents at a community outreach center. One of the attendees states, "I keep seeing the same person outside my apartment and they are leaving me items at my door." Which of the following types of aggression should the nurse identify the client is experiencing?Answer →
  38. 38An employee with a history of hypertension visits the employee clinic weekly for blood pressure checks. During the assessment the client reports being upset with coworkers and would like to shoot them. Which action should the nurse take first?Answer →
  39. 39A client with high motor activity runs from chair to chair crying "They're coming!" and cannot follow instructions. Which nursing diagnosis has the highest priority?Answer →
  40. 40Scenario: Anna tells the school nurse, "My friend John threatened to take an overdose of Ativan pills." The nurse talks to John, who confirms the comment and provides steps on how he wants to do it. What is the next most critical question for the nurse to ask at this moment?Answer →
  41. 41A nurse in an emergency mental health facility is caring for a group of clients. The nurse should identify which of the following clients requires a temporary emergency admission?Answer →
  42. 42A nurse is assigned to investigate the frequent school absences of an 11-year-old child. The nurse finds the child home alone, caring for his 1- and 3-year-old siblings. The house is cluttered and dirty, and both parents are at work. The child tells the nurse that whenever his mother is called to work at her part-time job, he must watch the kids because the family cannot afford a babysitter. Based on the information obtained thus far, what preliminary assessment can be made by the nurse?Answer →
  43. 43A nurse is collecting data from a client at a community mental health facility using the SAFE-T tool. The nurse knows that this tool provides which of the following data related to a client?Answer →
  44. 44The nurse is asked by the spouse of a client seeking crisis intervention to give an example of an adventitious crisis. What should the nurse mention as an example of an adventitious crisis?Answer →
  45. 45A nurse is providing crisis intervention after a community disaster. Which actions are appropriate? (Select All That Apply)Answer →
  46. 46A nurse is providing care to a child during a routine wellness check-up. Which of the following client statements should indicate to the nurse that the client is at a higher risk for experiencing abuse and violence?Answer →
  47. 47A nurse is caring for a group of clients at a mental health facility. The nurse should identify that which of the following clients is exhibiting a warning sign of suicide?Answer →
  48. 48A nurse is caring for a client who has depressive disorder, is in alcohol withdrawal, and reports a recent job loss. Which of the following should be the priority nursing intervention?Answer →
  49. 49A client with schizophrenia becomes violent on the unit. What is the first nursing action?Answer →
  50. 50A nurse is caring for a client who stands up, clenches their fists, shouts, and throws a book during a group therapy session. Which of the following actions should the nurse take?Answer →
  51. 51A nurse is caring for a client who is threatening to commit suicide. Which of the following questions should the nurse ask?Answer →
  52. 52A nurse is caring for a client who is agitated and threatening to leave against medical advice. The client is pacing the unit and yelling. Which of the following actions should the nurse take?Answer →
  53. 53A woman states, 'My husband had an affair, and we do not communicate anymore. Three months ago I found a lump in my breast that the doctor is watching closely, and yesterday my 20-year-old daughter told me she is quitting college and moving to another state with her boyfriend.' Which comment or concern should be the priority for further assessment?Answer →
  54. 54A 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.)Answer →
  55. 55When a nurse listens to a patient explain their crisis, how should the nurse primarily try to view the situation to provide the most effective and empathetic care?Answer →
  56. 56A nurse uses Maslow's hierarchy to plan care. Which client's problem will receive priority?Answer →
  57. 57A friend brings a teenager to the emergency department. The friend found the client unconscious in a bedroom at a party after been drinking alcohol all night. Semen is observed on the client's underclothes. What priority actions by the nurse should focus on?Answer →
  58. 58A nurse is collaborating with psychiatric technicians (psych techs) on an inpatient psychiatric unit caring for a client exhibiting escalating aggressive behavior. Which action by the psych tech best supports the nurse in managing this situation effectively?Answer →
  59. 59A client, aged 42 years, seeks crisis intervention. She tells the nurse, "I cannot take it anymore, I will ended it all! Last year my husband had an affair, and we do not communicate anymore. Three months ago I found a lump in my breast that the doctor is watching closely, and yesterday my 20-year-old daughter told me she is quitting college and moving to another state with her boyfriend." Which comment or concern should be the priority for further assessment?Answer →
  60. 60A nurse in a mental health clinic is caring for a client who is experiencing acute psychosis. Which of the following interventions should the nurse include in the client's plan of care to decrease the risk of other-directed violence?Answer →
  61. 61An adult is been hospital admitted with depression after declaring bankruptcy. The client takes an antidepressant medication for five days. The client is now more talkative and shows increased energy. Select the highest priority nursing intervention.Answer →
  62. 62A college student who attempted suicide by overdose is hospitalized. When the parents are contacted, they respond, "There must be a mistake. This could not have happened. We've given our child everything." Select the correct answer.Answer →
  63. 63Select the highest priority nursing diagnosis.Answer →
  64. 64A nurse is caring for a client who is having trouble managing anger and is upset because they feel their personal property is being disrespected. Which of the following client statements should the nurse recognize as being the cause of the client's anger and frustration?Answer →
  65. 65An older adult man with a history of multiple falls at home tells the clinic nurse that his son, who was incarcerated last year for assault and battery, has become increasingly abusive since his release from prison six weeks ago. Which intervention is most important for the nurse to implement?Answer →
  66. 66A nurse is discussing restraints with a newly licensed nurse. Which of the following situations should the nurse identify as an acceptable indication for using restraints for a client?Answer →
  67. 67The nurse is admitting a 34-year-old client to the inpatient psychiatric unit. The client has a history of Bipolar I Disorder and was brought in by family after they found him giving away his prized guitar collection and writing what appeared to be a goodbye letter. During the admission interview, the client states, "Everything will be okay soon. I won't be a problem much longer." The client reports not sleeping for the past three nights, recently purchased a firearm "for protection," and stopped taking lithium two weeks ago because he "felt fine." Vital signs: BP 142/88, HR 104, RR 20, Temp 98.6°F. Which findings require immediate nursing follow-up? Select all that apply.Answer →
  68. 68A nurse is completing a suicide risk assessment. Which factors increase suicide risk? (Select All That Apply)Answer →
  69. 69A nurse is caring for a client who is agitated and threatening to leave against medical advice. The client is pacing the unit and yelling. Which of the following actions should the nurse take?Answer →
  70. 70The nurse is caring for a client who lost their home, vehicle, and personal belongings due to a fire. Using Maslow's hierarchy of needs, which intervention should the nurse address first?Answer →
  71. 71An adolescent with antisocial personality disorder tells the nurse, "I'm going to kill my father, but you can't tell anyone." Select the nurse's best response.Answer →
  72. 72A 28-year-old woman, recently promoted to a managerial position, visits the mental health clinic because she feels overwhelmed and anxious. She reports difficulty falling asleep, irritability, and frequent headaches. She expresses feelings of self-doubt and inadequacy, saying: 'I don't know if I'm ready for this level of responsibility. Everyone seems to expect me to know everything, and I feel like I'm failing.' The nurse learns that she was recently married and is trying to balance her career, new marital responsibilities, and social expectations. She has no prior psychiatric history, and there is no history of trauma or recent loss. Her lab work and vital signs are within normal limits. What type of crisis is this woman experiencing?Answer →
  73. 73A nurse is triaging clients in an emergency department when a client who reports being sexually assaulted is brought in. What is the MOST appropriate initial action the nurse should take in this situation?Answer →
  74. 74A nurse is conducting an in-service for a group of newly licensed nurses about the interventions used for clients experiencing non-suicidal self-harm (NSSH). Which of the following should the nurse include?Answer →
  75. 75The clinic nurse is assessing a male client with a fractured clavicle and a swollen, ecchymotic left orbit. When questioned about the nature of the injuries, the client does not establish eye contact and is evasive, stating, 'I run a forklift at work.' Which question is most important for the nurse to ask?Answer →
  76. 76A woman is admitted to an inpatient psychiatric unit after a suicide attempt by overdose. The primary rationale for her admission is to have?Answer →
  77. 77A child, aged 11 years, stays home from school to care for his siblings while his mother works, because the family cannot afford a babysitter. The home is cluttered and dirty when the community mental health nurse visits to investigate the child's school absences. What is the nurse's legal responsibility in this scenario?Answer →
  78. 78A client with bipolar disorder is hyperactive and has not slept for 3 days. Mood and behavior are labile. This client threatens to hit another client. Which response by the nurse is most appropriate in this scenario?Answer →
  79. 79A 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?Answer →
  80. 80Leo, a teenager who was started on an SSRI a few weeks ago, tells his parents he feels 'awesome' and plans to sell his games. He is later found on a bridge. As the school nurse, what is your priority?Answer →
  81. 81The nurse is asked by the spouse of a client seeking crisis intervention to give an example of an adventitious crisis. What should the nurse mention as an example of an adventitious crisis?Answer →
  82. 82A nurse is assessing two clients who are experiencing crises. Client A was recently laid off from work and is feeling anxious and overwhelmed. Client B was affected by a major earthquake that destroyed their home. Which statement correctly differentiates the type of crisis each client is experiencing?Answer →
  83. 83Click to highlight the findings that require follow-up by the nurse. To deselect a finding, click on the finding again.Answer →
  84. 84A nurse is planning care for a client who has experienced partner violence. Which of the following interventions should the nurse include in the plan of care?Answer →
  85. 85A nurse is caring for a client, in an outpatient setting, who is experiencing poor appetite, fatigue, and thoughts of hopelessness. The nurse uses the SAD PERSONS scale to further assess. Which of the following items is included in SAD PERSONS?Answer →
  86. 86Naloxone is administered to an adult client following a suicide attempt with an overdose of hydrocodone bitartrate. Within 15 minutes, the client is alert and oriented. While planning nursing care, which intervention has the highest priority at this time?Answer →
  87. 87A nurse is ambulating a client who is unsteady. The client begins to fall. Which of the following actions should the nurse take?Answer →
  88. 88A nurse in an inpatient mental health facility is caring for a client who is showing indications of becoming violent. Which of the following actions should the nurse take?Answer →
  89. 89Which of the following should a nurse prioritize when assessing a client for suicide risk?Answer →
  90. 90A nurse is caring for a client whose family has been reported missing. The client is visibly agitated; they are pacing and disregard the nurse's directives. The client loudly tells the nurse, "I want answers NOW". The nurse should identify that this client is in which of the following stages of crisis?Answer →
  91. 91A nurse on an acute care mental health unit is examining the belongings of a client who is being admitted following a suicide attempt. Which of the following belongings should the nurse ask the client's partner to take back home? (Select all that apply.)Answer →
  92. 92The home care nurse has identified the nursing problem, "Risk for hopelessness," for a male client who is terminally ill with a life expectancy of several days. Which instruction should the nurse provide the client's spouse?Answer →
  93. 93Scenario: Jonathan (same as previous) is admitted for 72-hour observation after being found on a bridge. His parents respond to the school by attacking the person providing the information, stating that all people in their son's school are a bunch of incompetents. What emotional response does the parents' reaction reflect?Answer →
  94. 94A nurse in the emergency department is caring for a client who reports feeling sad, worthless, and hopeless 9 months after the death of her son. Which of the following actions should the nurse take first?Answer →
  95. 95A nurse is working with a teenager who has expressed suicidal thoughts. What is the FIRST action that the nurse should take according to suicide prevention protocols?Answer →
  96. 96A 22-year-old patient diagnosed with major depressive disorder, has been started on sertraline (Zoloft). She reports mild nausea, occasional headaches, and difficulty sleeping since starting the medication three days ago. During your assessment, she says, "Sometimes I feel like I don't want to be here anymore." She also reports feeling jittery, having mild tremors, and occasional sweating. Which is the nurse's highest priority action for this patient?Answer →
  97. 97The occupational health nurse is working with an employee who was just notified that their child was involved in a motor vehicle collision and taken to the hospital. The employee states, "I can't believe this. What should I do?" Which response is best for the nurse to provide in this crisis?Answer →
  98. 98A nurse is caring for a client who has depression. After two days of treatment, the nurse notices that the client is suddenly more active and there are no longer signs of a depressive state. Which of the following interventions should the nurse recommend for the plan of care?Answer →
  99. 99A client at risk for suicide is being assessed by a nurse. The client states many different protective factors to the nurse. Which below are considered internal or external factors? (Select all that apply)Answer →
  100. 100A nurse is assessing a newly admitted client who states that they do not want to live anymore and plan to end their life. Which of the following actions does the nurse take?Answer →
  101. 101A nurse is caring for an older adult client who reports their caregiver has been writing checks in their name without their consent. Which of the following types of abuse is the client experiencing?Answer →
  102. 102A nurse is considering placing wrist restraints on a client who has cognitive deficits and has pulled out their IV catheter. Before using wrist restraints, which of the following actions must the nurse take first?Answer →
  103. 103A community health nurse is creating a presentation about mood disorders for a local support group. The nurse should include which of the following as a risk factor for suicide?Answer →
  104. 104A nurse is conducting a home health visit for an older adult client who lives with family members. The nurse notices that the client has multiple unusual bruises, and, based on several other factors, the nurse suspects that the client has been physically abused. Which of the following actions should the nurse take first?Answer →
  105. 105A woman victim of a violent rape was treated in the hospital. As discharge preparation begins, the victim says softly, "I will never be the same again. People believe I was responsible because the way I was dressed, even woman that knows me. Do you think I am responsible for what happened to me." Select the nurse's most critical response to this statement.Answer →
  106. 106A nurse is assessing a client who has recently expressed suicidal thoughts. Which behavioral cues should the nurse recognize as indicators of increased suicide risk? (Select all that apply)Answer →
  107. 107The nurse is completing an intake interview with a client who is a victim of constant domestic abuse. During the interview, the client shares the following: "My husband limits my contact with my family and friends, will not let me talk on my phone unless he can listen, and keeps the keys to my car in his pocket." Based on the "Power and Control Wheel," which label will you give to this behavior?Answer →
  108. 108A nurse is assessing clients diagnosed with major depressive disorder (MDD) and bipolar disorder. Understanding when suicide risk is highest is essential for safety planning. Which of the following statements indicates a correct understanding of suicide risk in these populations?Answer →
  109. 109A client states, "I have pills at home, and tonight I'm going to take them all." What is the nurse's best initial action?Answer →
  110. 110A nurse is caring for a client who is in mechanical restraints. Which of the following actions should the nurse take?Answer →
  111. 111A nurse is caring for four clients at an urgent care center. Which of the following clients should the nurse suspect has been physically abused?Answer →
  112. 112The nurse is preparing to use a standardized screening tool to assess the client for partner violence. Click to highlight the actions the nurse should take during the assessment. To deselect an action, click on the action again.Answer →
  113. 113A nurse is leading a group therapy session. A client with a history of violence suddenly stands up and appears angry. Which of the following actions should the nurse take?Answer →
  114. 114A nurse is discussing restraints with a newly licensed nurse. Which of the following situations should the nurse identify as an acceptable indication for using restraints for a client?Answer →
  115. 115A 32-year-old patient with bipolar I disorder is involuntarily admitted under court order for acute mania. The patient is loud, intrusive, pacing, and making threatening gestures toward peers. Verbal redirection and a PRN antipsychotic were offered but refused. The patient suddenly throws a chair toward another patient. Which action should the nurse take first immediately before applying restraints?Answer →
  116. 116When responding to a call light, the nurse finds a client with aggressive behaviors pacing and restless in the room. The client shouts, "What took you so long to get in here!" Which action should the nurse implement?Answer →
  117. 117A nurse is caring for a client who begins yelling and pacing around the room. Which of the following actions should the nurse take? (Select all that apply.)Answer →
  118. 118The nurse should immediately follow up on the client's Target 1 and Target 2Answer →
  119. 119An adolescent whose class's peer committed suicide attempts suicide himself and is admitted to an inpatient mental health unit and assessed as being at high risk for self-harm. Which of the following actions would be most appropriate to assure his safety during his first day in the hospital?Answer →
  120. 120A client is admitted for psychiatric observation after being arrested for breaking windows in the home of his former girlfriend, who had refused to see him. His history reveals abuse as a child by a punitive father, torturing family pets, and one arrest for disorderly conduct. What is the priority nursing diagnosis that should be considered in this scenario?Answer →
  121. 121A nurse is educating a new graduate nurse about crisis types. Which of the following statements demonstrates an accurate understanding of a situational crisis?Answer →
  122. 122A client is pacing the hall near the nurses' station, swearing loudly. What is the most appropriate initial intervention by the nurse?Answer →
  123. 123A nurse is caring for a client following reported physical abuse. Which of the following actions should the nurse take?Answer →
  124. 124A nurse is making a home visit for a 16-year-old adolescent who attempted suicide. Which of the following behaviors should alert the nurse that the adolescent still has suicidal intent?Answer →
  125. 125A nurse is caring for a client who has been placed in restraints. Which of the following actions should the nurse take?Answer →
  126. 126A victim of physical abuse by her domestic partner is being treated for a broken humerus. Which indicator for the outcome of abuse is most important to achieve before the client leaves the emergency department?Answer →
  127. 127A nurse is caring for a client who has been admitted for a psychiatric evaluation after displaying aggressive behavior towards their partner and 2-year-old child. Which of the following client statements should the nurse identify as potentially contributing to aggression?Answer →
  128. 128A 32-year-old patient with bipolar I disorder is involuntarily admitted under court order for acute mania. The patient is loud, intrusive, pacing, and making threatening gestures toward peers. Verbal redirection and a PRN antipsychotic were offered but refused. The patient suddenly throws a chair toward another patient. Which patient behavior supports or does not support the nurse's use of restraints at this moment?Answer →
  129. 129A victim of physical abuse by her domestic partner is being treated for a broken humerus. Which indicator for the outcome of abuse is most important to achieve before the client leaves the emergency department?Answer →
  130. 130A nurse is talking to a client who is explaining about her home situation and the intimate partner violence she recently experienced. Which of the following responses should the nurse make?Answer →
  131. 131A client is admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt. Which nursing problem has the highest priority?Answer →
  132. 132A nurse in an emergency department is caring for a client following a domestic dispute. The client states, "Nothing seems to go right for me and probably never will." Which of the following statements should the nurse make?Answer →
  133. 133A child drowned and died while swimming in a local lake 2 years ago. Which behavior indicates the child's parents are grieving in an effective way?Answer →
  134. 134A male client with major depression says, "I just want to go to sleep and never wake up." Which action should the nurse take first?Answer →
  135. 135A nurse is speaking about types of aggression to a group of residents at a community outreach center. One of the attendees states, "I keep seeing the same person outside my apartment, and they are leaving me items at my door." Which of the following types of aggression should the nurse identify the client is experiencing?Answer →
  136. 136An employee with a history of hypertension visits the employee clinic weekly for blood pressure checks. During the assessment the client reports being upset with coworkers and would like to shoot them. Which action should the nurse take first?Answer →
  137. 137A nurse is caring for a client, in an outpatient setting, who is experiencing poor appetite, fatigue, and thoughts of hopelessness. The nurse uses the SAD PERSONS scale to further assess. Which of the following items is included in SAD PERSONS?Answer →
  138. 138A rape victim tells the emergency room nurse, "I feel so dirty. Help me take a shower before the doctor examines me." What should the nurse do?Answer →
  139. 139A married woman, who is the mother of two children, has been in an abusive relationship for 4 years. She decides to leave her husband after suffering an episode of severe physical abuse. She and her children, ages 7 and 9, arrive at a crisis intervention center. What is the nurse's priority intervention?Answer →
  140. 140The nurse is caring for the client. Which of the following actions should the nurse take? Select all that apply.Answer →
  141. 141A young-adult client is admitted to the psychiatric unit because of a recent suicide attempt. The client's spouse filed for divorce six months ago, the client lost a job three months ago, and the best friend moved to another city two weeks ago. Which intervention should the nurse include in this client's plan of care (POC)?Answer →
  142. 142A nurse is caring for a client who is in physical restraints. Which of the following actions should the nurse take?Answer →
  143. 143Leo, a teenager who has been on SSRIs for 2 weeks, tells his parents he feels 'awesome' and plans to sell his games. He is later found on a bridge. As the school nurse, what is your priority?Answer →
  144. 144A client has been responding to auditory hallucinations throughout the day. The client approaches the nurse, shaking a fist and shouting, "Back off!" and then goes into the day room. As the nurse follows the client into the day room, the nurse should:Answer →
  145. 145A nurse is caring for an agitated client who is pacing and raising their voice. Which nonverbal behavior should the nurse prioritize to reduce escalation?Answer →
  146. 146A public health nurse is applying for a grant related to suicide prevention. When describing social groups at highest risk, which of the following should the nurse include?Answer →
  147. 147A college student who is the victim of a car jacking presents to the community health center and reports increased anxiety. During the interview, which nursing intervention should take the highest priority?Answer →
  148. 148A nurse is caring for a client following a suicide attempt. The client has a history of depression, substance abuse, and anorexia nervosa. Which of the following actions is the nurse's priority?Answer →
  149. 149A nurse is assessing two clients who are experiencing crises. Client A was recently laid off from work and is feeling anxious and overwhelmed. Client B was affected by a major earthquake that destroyed their home. Which statement correctly differentiates the type of crisis each client is experiencing?Answer →
  150. 150Which of the following is the nurse's responsibility in managing the care of a patient who is restrained on a psychiatric unit?Answer →
  151. 151A nurse is caring for a client who has a substance use disorder. The client states, 'The state took my child away after my overdose. I don't want to go on living without them.' Which of the following therapeutic responses should the nurse make?Answer →
  152. 152An adult is been hospital admitted with depression after declaring bankruptcy. The client takes an antidepressant medication for five days. The client is now more talkative and shows increased energy. Select the highest priority nursing intervention.Answer →
  153. 153A nurse is assessing clients diagnosed with major depressive disorder (MDD) and bipolar disorder. Understanding when suicide risk is highest is essential for safety planning. Which of the following statements indicates a correct understanding of suicide risk in these populations?Answer →
  154. 154A client with bipolar disorder is hyperactive and has not slept for 3 days. Mood and behavior are labile. This client threatens to hit another client. Which response by the nurse is most appropriate in this scenario?Answer →
  155. 155The nurse is interviewing a woman who is experiencing intimate partner violence (IPV). Which therapeutic communication technique(s) should the nurse use to encourage the client's self-expression? Select all that apply.Answer →
  156. 156A rape victim tells the emergency room nurse, 'I feel so dirty. Help me take a shower before the doctor examines me.' What should the nurse do?Answer →
  157. 157A nurse is caring for a 42-year-old client who was recently diagnosed with type 2 diabetes. The client reports feeling anxious, overwhelmed, and tearful, saying, "I don't know how I will manage this new lifestyle and all the medications." The client states that they have no history of mental illness and were previously coping well with stress. What is the client experiencing?Answer →
  158. 158A nurse in the emergency department is assigned four clients. Which client should the nurse assess first?Answer →
  159. 159A 32-year-old patient with bipolar I disorder is involuntarily admitted under court order for acute mania. The patient is loud, intrusive, pacing, and making threatening gestures toward peers. Verbal redirection and a PRN antipsychotic were offered but refused. The patient suddenly throws a chair toward another patient. Which client findings should the nurse identify as requiring emergency intervention at this time? (Select all that apply.)Answer →
  160. 160A nurse in an acute care mental health facility is assessing a client who has bipolar disorder. Which of the following findings indicates the client is at risk for suicide?Answer →
  161. 161Which client is most appropriate for outpatient treatment now?Answer →
  162. 162A nurse in a long-term care facility notices two residents arguing in the day room over a game they are playing. Which of the following interventions should the nurse use first?Answer →
  163. 163A nurse at a community mental health clinic is caring for a group of clients. The nurse should identify that which of the following clients is at risk for a maturational crisis?Answer →
  164. 164A client with posttraumatic stress disorder (PTSD) is experiencing a dissociative disorder episode. The situation quickly escalates, and the client becomes physically aggressive. Which intervention should the nurse implement first?Answer →
  165. 165Leo, a teenager started on SSRIs a few weeks ago, tells his parents he feels 'awesome' and plans to sell his games. He is later found on a bridge. As the school nurse, what is your priority?Answer →
  166. 166The nurse is assisting a client who is a victim of spousal abuse to create a plan for escape if it becomes necessary. The client has a 9-year-old and a 13-year-old. What components should the plan include? Select all that apply.Answer →
  167. 167What client should be assessed as being at highest risk for directing violent behavior rather than aggression toward others?Answer →
  168. 168A 32-year-old patient with bipolar I disorder is involuntarily admitted under court order for acute mania. The patient is loud, intrusive, pacing, and making threatening gestures toward peers. Verbal redirection and a PRN antipsychotic were offered but refused. The patient suddenly throws a chair toward another patient. Which action is required after restraints are initiated?Answer →
  169. 169A nurse is caring for a postoperative client. Which of the following findings indicate the client may be actively bleeding?Answer →
  170. 170A nurse is planning post-discharge care for a patient who recently survived a suicide attempt. During which time frame should the nurse prioritize intensive monitoring and support to best prevent a repeat attempt?Answer →
  171. 171A nurse is providing teaching to a newly licensed nurse on ways to promote staff safety when caring for a client who is displaying manifestations of aggression. Which of the following information should the nurse include in the teaching?Answer →
  172. 172A nurse in an urgent care center is caring for a child who reports maltreatment by a parent. Which of the following actions is the nurse's priority?Answer →
  173. 173A client with known auditory hallucinations begins talking loudly and gesturing wildly while in the unit's day room. Which action should the nurse implement first?Answer →
  174. 174The nurse is caring for a client on an inpatient psychiatric unit. Based on the nurse's note, which of the following actions should the nurse take next? The nurse should [blank1] followed by [blank2].Answer →
  175. 175A community health nurse is creating a presentation about mood disorders for a local support group. The nurse should include which of the following as a risk factor for suicide?Answer →
  176. 176A nurse is planning care for a newly admitted client who has major depressive disorder following the loss of a child. Which of the following goals should the nurse identify as the priority?Answer →
  177. 177A college student who attempted suicide by overdose is hospitalized. When the parents are contacted, they respond, "There must be a mistake. This could not have happened. We've given our child everything." Select the correct answer.Answer →
  178. 178An adolescent who was arrested a month ago for gang-related activities has a court order to attend weekly group therapy sessions at the mental health clinic. Today the adolescent's mother calls the clinic nurse to report that her child became angry last night and put a fist through the window. Which intervention is most important for the nurse to implement?Answer →
  179. 179A client is pacing the hall near the nurses' station, swearing loudly. What is the most appropriate initial intervention by the nurse?Answer →
  180. 180A nurse has volunteered to provide care following a human-caused disaster. Which of the following settings are related to a human-caused disaster? (Select All that Apply.)Answer →
  181. 181For most people, being hospitalized is seen as a?Answer →
  182. 182A nurse is assessing a child in the emergency department. Which of the following findings is recognized as a risk for physical abuse?Answer →
  183. 183A 7-year-old boy presents with multiple bruises in various healing stages, is withdrawn and fearful, and the mother is evasive and controlling. What is the priority?Answer →
  184. 184A client diagnosed with schizophrenia says, "I hear the voices every day. They always say bad things about me." Which action by the nurse has the highest priority?Answer →
  185. 185A nurse is reviewing room assignments for a group of clients. Which of the following clients should the nurse assign to a room that is near the nurses' station? (Select All that Apply.)Answer →
  186. 186When responding to a client experiencing a mental health crisis, which of the following factors can negatively impact the effectiveness of the crisis response? (Select all that apply.)Answer →
  187. 187A nurse on a mental health unit is caring for clients who have various depressive disorders. The nurse should identify which of the following client diagnoses as presenting the greatest risk for suicide?Answer →
  188. 188What client's behavior provided the most definitive clue about a possible suicide attempt?Answer →
  189. 189What client should be assessed as being at highest risk for directing violent behavior rather than aggression toward others?Answer →
  190. 190Why is so important that nurses differentiate aggression from violence?Answer →
  191. 191A nurse in a mental health facility is caring for a client who becomes upset and breaks a chair when a visitor does not arrive. The client remains agitated following initial verbal attempts to calm him down. Which of the following interventions should the nurse implement first?Answer →