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RN Nursing School · Mental Health · 351 questions

Foundations of Mental Health Nursing 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 Foundations of Mental Health Nursing, practise in the app.

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  1. 1A nurse is preparing to administer 1,000 mL of lactated Ringer's IV over 6 hr. The drop factor of the manual IV tubing is 10 gtt/ml. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)Answer →
  2. 2A nurse is caring for a client who has a new prescription for an antidepressant medication. The client states, "I don't want to take medication." Which of the following responses by the nurse demonstrates client advocacy?Answer →
  3. 3A client with a history of physically abusing his spouse and children is admitted for alcohol/drug dependency. Which nurse will likely have difficulty establishing a therapeutic relationship?Answer →
  4. 4A nurse is caring for a client who has no past medical history. The client states, "Getting old is so painful. I wish I could be young and healthy again." Which of the following responses should the nurse make?Answer →
  5. 5A client tells the nurse of being seriously concerned about dying since the healthcare provider (HCP) diagnosed the client with heart failure (HF). How should the nurse respond?Answer →
  6. 6The nurse is caring for a client who has been admitted involuntarily for psychiatric treatment. Which of the following information about involuntary commitment should the nurse explain to the client's family?Answer →
  7. 7A nurse explains to a family how the nurse-client relationship differs from social relationships. What is the best explanation?Answer →
  8. 8A nurse in an acute care facility is caring for an older adult client who is being discharged to an extended-care nursing facility the next day. The client asks, "Why do I have to go to that place?" Which of the following responses should the nurse make?Answer →
  9. 9The nurse is preparing the physical environment to interview a new client for admission to the mental health unit. Which environmental setting facilitates the best outcome of the interview?Answer →
  10. 10A nurse is caring for a client whose partner has end-stage lung cancer. The client states, "The doctors say they only have a few months to live, but I know that with treatment they will get better." The nurse should identify that the client is exhibiting which of the following defense mechanisms?Answer →
  11. 11A client who has just received a difficult diagnosis uses humor by joking about their situation during a nursing assessment. How should the nurse best interpret and respond to this behavior?Answer →
  12. 12A homeless male who was found sitting in the middle of a busy street is brought to the emergency department (ED). On admission, the client is confused and has difficulty answering questions. After ruling out a physiological etiology for the client's behavior, he is transferred to the mental health unit. When admitting the client to the unit, which action is most important for the nurse to take?Answer →
  13. 13David, a patient with schizophrenia, tells the nurse, "Sometimes I dreamed I am stoned. When I woke up, I felt emotionally drained." Which comment by the nurse would indicate an appropriate communication technique?Answer →
  14. 14According to Maslow's hierarchy of needs, which need should the nurse address first?Answer →
  15. 15Select the best option to explain MD's order for sedation on this client.Answer →
  16. 16A young adult moves to a new town and is unable to establish relationships because of geographical distance to other towns and a sparsely populated community. This young adult is at greatest risk for which of the following?Answer →
  17. 17Which of the following is an important factor to consider during a mental health assessment?Answer →
  18. 18A nurse is caring for a client who is experiencing delusions. Which of the following actions should the nurse take?Answer →
  19. 19The nurse is caring for a client who is a refugee from another country and who is experiencing daily episodes of anxiety. The client communicates minimally with the nurse, looking away and appearing distressed. Which intervention is most important for the nurse to do first?Answer →
  20. 20The order reads IV fluids: 0.45% NaCl 500 mL in 6 hours. How many micro-drops per minute would you administer, using a drop factor for micro-drops of 60 gtt/ml? Label answer gtt/minAnswer →
  21. 21A nurse who is caring for a mentally ill client establishes a supportive and honest relationship with the client and maintains client confidentiality. This is an example of which principle of mental health care?Answer →
  22. 22A nurse is collaborating in the plan of care for a client who has a schizophrenia-related mental health disorder. Which of the following treatment team members should the nurse contact to arrange transportation to outpatient appointments for the client?Answer →
  23. 23A nurse is planning care for a client who is scheduled for an intravenous pyelogram. Which of the following actions is appropriate for the nurse to include?Answer →
  24. 24A nurse is caring for a client in an acute care mental health unit who was involuntarily admitted for 72 hr after attacking a neighbor. To keep the client in the hospital when the initial time to hold the client expires, which of the following must be determined?Answer →
  25. 25A nursing student, recently reprimanded by an instructor, later curtly tells a family member "You cannot come in now." How should the instructor discuss this based on the defense mechanism used?Answer →
  26. 26How does the experience of entering a psychiatric treatment facility differ from hospitalization for physical reasons? (Select all that apply)Answer →
  27. 27Who was responsible in the 1800s for raising millions of dollars to construct more than 30 mental hospitals?Answer →
  28. 28A nurse educator is discussing major depressive disorder (MDD) with a group of nursing students. The instructor emphasizes the statement, "It is Impossible to convey the personal pain and suffering experienced by an individual going through a severe depressive episode." Which of the following best explains why it is important for nurses to understand this concept?Answer →
  29. 29A client says to the nurse, "I dreamed about the dark hour. When I woke up, I felt emotionally drained, as though I hadn't rested well." Which nursing response would be most appropriate if the nurse wants to seek clarification?Answer →
  30. 30A nurse in a mental health clinic is attempting to develop a therapeutic relationship with a client. Which of the following actions should the nurse take?Answer →
  31. 31A student nurse visiting a senior center says, 'It's depressing to see these old people. They are all weak and frail. I doubt any of them can engage in a discussion.' What is the student expressing?Answer →
  32. 32A client who has agoraphobia is beginning desensitization with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client's plan of care?Answer →
  33. 33When giving medications, the nurse will follow the rights of medication administration. The rights include the right documentation, the right reason, the right response, and the patient's right to refuse. Which of these are additional rights? (Select all that apply.)Answer →
  34. 34Which setup best establishes a therapeutic interview environment while maintaining safety?Answer →
  35. 35The nurse is caring for a client who has been the victim of intimate partner violence. During the interview, the nurse feels angry, embarrassed, and helpless. Which explanation best describes the cause of the nurse's emotions?Answer →
  36. 36While the nurse is talking with a female client, the client becomes silent for several seconds. What is the nurse's best response?Answer →
  37. 37During the orientation phase of a therapeutic relationship with a client, what is not a task to be completed by the nurse on this phase?Answer →
  38. 38A client states, "You and that other staff member were talking about me, weren't you?" The nurse truthfully replies, "We were discussing ways to help you relate to the other clients in a more positive way." What ethical principle is the nurse demonstrating?Answer →
  39. 39A recently widowed 74-year-old male is seen in the mental health clinic for sleep disorders and depression. Which of the following nursing actions demonstrate caring? (Select all that apply.)Answer →
  40. 40A client who has rheumatoid arthritis shows the nurse at her provider's office her magnetic copper bracelet and says that it helps alleviate her pain when she wears it. Which of the following responses should the nurse make?Answer →
  41. 41The nurse understands that psychiatric disorders are clinically diagnosed based on which of the following?Answer →
  42. 42A nurse is evaluating a client's behavior to identify the use of displacement as a defense mechanism. Which of the following client statements or actions demonstrate displacement? (Select all that apply)Answer →
  43. 43An adult male client, who is seen in the outpatient psychiatric clinic, tells the nurse that he is extremely angry with his boss, wife, and landlord because "These people do not appreciate me." Based on the information provided, which interpretation of the client's statement is best?Answer →
  44. 44A client is admitted with symptoms of psychosis lying on the ground. The nurse performs a thorough assessment, informs the physician and completes the incident report. Which statement should the nurse document in the incident report?Answer →
  45. 45A client is continually late for his appointment at the mental health clinic. What is a likely reason for his lack of punctuality?Answer →
  46. 46A nurse is caring for an older adult client who has a fractured hip. The client says, "I guess I've lived long enough and my time is up." Which of the following responses should the nurse make?Answer →
  47. 47A nurse is caring for a client who was recently diagnosed with a terminal illness. The client tells the nurse, "I am looking forward to seeing my grandchildren grow up." The nurse should identify that the client is experiencing which of the following stages of grief?Answer →
  48. 48A nurse uses Sullivan's theory while working with an anxious, withdrawn client with BPD. Based on this theory, what should the interventions focus on?Answer →
  49. 49A 38-year-old male client comes to the clinic for a routine sexual health assessment. During the interview, he reveals that he experiences sexual desire and arousal only when his wife wears short, red camisole-style nightgowns. He reports: "Without the red teddies, I am not interested in sex." The client appears comfortable discussing his preferences and does not report any distress or dysfunction in other areas of sexual activity. He denies difficulty achieving erection or orgasm when the conditions he describes are met. He is otherwise healthy, and laboratory work including hormone levels is within normal limits. The nurse notes that this preference is highly specific and consistently required for sexual arousal. What DSM 5 criteria on this scenario will assist to identify this client paraphilic sexual interest?Answer →
  50. 50A nurse is caring for an older adult client admitted to the hospital following a cerebrovascular accident. The client's daughter tells the nurse, "I wish I could stay with my father, but I need to go home to my family." Which of the following responses should the nurse make?Answer →
  51. 51A nurse is caring for a client with severe major depressive disorder. The client speaks very slowly and occasionally remains mute. The nurse feels uncomfortable with the silence during the interaction. Which of the following actions demonstrates the most therapeutic approach in this situation?Answer →
  52. 52A nurse is collaborating with a social worker on the psychiatric care team to develop a discharge plan for a client hospitalized with acute psychosis. Which nursing action best supports the social worker's role in ensuring a safe transition to community care?Answer →
  53. 53A charge nurse overhears another nurse talking with a client who has schizophrenia. Suddenly the client yells, "I am the devil! I am God! Open the gate for me!" Which of the following responses by the nurse requires the charge nurse to intervene?Answer →
  54. 54A client states, "Between the demands of school and my kids needing constant attention, I just don't know how to juggle everything." Which response by the nurse demonstrates effective reflection?Answer →
  55. 55A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following actions should the nurse take?Answer →
  56. 56During change-of-shift report, a nurse discovers they overlooked a prescription for a type and cross-match of a client who is to have surgery the next day. Which of the following actions should the nurse take first?Answer →
  57. 57A young adult client with schizophrenia is scheduled to receive risperidone 2 mg PO at bedtime (HS). When the nurse attempts to administer the medication, the client states, "I am not going to take that medicine, and you can't make me." Which action should the nurse take?Answer →
  58. 58A nurse is collaborating in the plan of care with colleagues for a client who was just discharged from active duty in the military following a mental health crisis. To which of the following facilities should the nurse suggest the client be referred for follow-up care?Answer →
  59. 59A female client becomes combative when the nurse attempts to administer routine medications. The nurse would like to ignore the client but chooses to talk with the client to calm her. The nurse is successful in calming the client, and the client takes her medications. What process best describes how the nurse decided on the course of action taken?Answer →
  60. 60A nurse is caring for a client who has major depressive disorder. After discussing the treatment with their partner, the client verbally agrees to electroconvulsive therapy (ECT) but will not sign the consent form. Which of the following actions should the nurse take?Answer →
  61. 61What is the most appropriate nursing action to deliver culturally competent care?Answer →
  62. 62A nurse is caring for a client with severe major depressive disorder. The client speaks very slowly and occasionally remains mute. The nurse feels uncomfortable with the silence during the interaction. Which of the following actions demonstrates the most therapeutic approach in this situation?Answer →
  63. 63A nurse on a medical-surgical unit is receiving a change-of-shift report for four clients. Which of the following clients should the nurse see first?Answer →
  64. 64A home health nurse is performing a fall risk assessment for an older adult client. Which of the following findings should the nurse identify as a potential fall risk in the home?Answer →
  65. 65Which of the following would be considered registered nurse malpractice?Answer →
  66. 66Based on this clinical presentation, a neuroimaging study would most likely reveal dysfunction in which area of the brain?Answer →
  67. 67A nurse is providing teaching to a client about colorectal cancer prevention guidelines. Which of the following recommendations should the nurse include?Answer →
  68. 68A client with severe orthopedic injuries after an automobile accident is irritable, angry, and belittles the nurses who provide his care. While the nurse is changing the dressing over a deep laceration, the client screams, 'Don't touch me! You are so stupid; you're only making it worse!' Which intervention would be most therapeutic?Answer →
  69. 69The nurse in the emergency department finds a woman collapsed on the floor and crying loudly. The woman's husband was in a car accident and is being attended to by the medical staff. Which statement by the nurse best demonstrates acting in a culturally competent manner?Answer →
  70. 70Cultural assessments allow the health care provider to understand the unique beliefs a client may have regarding mental illness and how they cope. Key areas to assess include which of the following? (Select all that apply.)Answer →
  71. 71Which of the following is a focus when planning care for a client with Trigeminal Neuralgia?Answer →
  72. 72A client tells the nurse, "I'm going to kill my father, but you can't tell anyone." Which response best fulfills the ethical duty of nonmaleficence?Answer →
  73. 73A nurse is working to build rapport and trust with new clients. Which of the following actions should the nurse take?Answer →
  74. 74When the nurse greets a homeless client who was admitted to the mental health unit 2 days ago, the client states, "I haven't really slept well since I got here." Which question is best for the nurse to ask?Answer →
  75. 75A home health nurse is providing teaching about home safety to an older adult client. Which of the following examples of home safety should the nurse include in the teaching?Answer →
  76. 76A client with severe orthopedic injuries after an automobile accident is irritable, angry, and belittles the nurses who provide his care. While the nurse is changing the dressing over a deep laceration, the client screams, "Don't touch me! You are so stupid, you're only making it worse!" Which intervention would be most therapeutic?Answer →
  77. 77A nurse is providing discharge teaching to the partner of a client who has a linear incision site following an open cholecystectomy. Which of the following wound care instructions should the nurse include?Answer →
  78. 78A client tells the nurse, "I'm told that I should reduce the stress in my life, but I have no idea where to start." Which would be the best initial nursing response?Answer →
  79. 79A nurse is teaching about sources of psychological stress to a group of newly licensed nurses. The nurse should identify which of the following qualifies as a source of psychological distress?Answer →
  80. 80A nurse is discussing care options with the family of a client who was recently diagnosed with a serious mental illness. The family wishes to care for the client in their home. Which of the following service options should the nurse recommend?Answer →
  81. 81A client has been given a new prescription for an antidepressant medication during an office visit. The nurse discusses with the client the effects, side effects, and adverse effects of the new medication. The nurse is functioning in the role of:Answer →
  82. 82An adult female client is brought to the emergency department (ED) after fainting at work. The nurse completes an assessment of the client and identifies caregiver role strain as a nursing problem. Which information best supports this problem?Answer →
  83. 83A nurse is speaking with a newly licensed nurse who reports that they fear a client might be dangerous to others due to the client's diagnosis of schizophrenia. Which of the following types of stigma should the nurse identify as being associated with this fear?Answer →
  84. 84A nurse is assessing a client's mental health status. Which of the following client statements should the nurse identify as an indication that the client is in the "struggling zone" of the mental health continuum?Answer →
  85. 85A nurse is considering the therapeutic value of touch for an anxious client. During the pre-orientation phase, what is the initial question the nurse should answer?Answer →
  86. 86Which patient response best indicates effective therapeutic communication?Answer →
  87. 87A charge nurse is reviewing Freud's psychoanalytical theory with a group of newly hired nurses. One of the nurses states, "I remember from school that the conscious mind is what determines right from wrong." Which of the following statements should be the charge nurse's reply?Answer →
  88. 88A nurse is caring for an adolescent who is experiencing significant stress and is unable to self-regulate their thoughts, emotions, and behaviors. Which of the following factors is the best indicator of the client's inability to regulate their stress response?Answer →
  89. 89A nurse is assessing a client's behavior to understand underlying motivations influenced by Freud's three levels of awareness: conscious, preconscious, and unconscious. Which nursing action best demonstrates application of this theory in planning care?Answer →
  90. 90Order the nurse's actions from first to last, showing the most therapeutic progression. Items to be Ordered: a. Sit quietly with the client, maintaining eye contact b. Say, "Can you tell me more about what's going on?" c. Say, "Things will get better soon; don't worry" d. Say, "Everyone feels that way sometimes; it's normal."Answer →
  91. 91A client with borderline disorder states, "It's hard to figure out who I am. Sometimes I'm sexually attracted to women and sometimes to men." How can the nurse analyze this as a developmental problem related to Freudian concepts?Answer →
  92. 92A nurse is caring for a client with whom he has developed a therapeutic relationship and who will be discharged later in the day. The client thanks the nurse for his help during the hospitalization. Which of the following responses should the nurse make?Answer →
  93. 93A nurse is discussing strategies to develop nurse-client therapeutic relationships with a newly licensed nurse. Which statement by the nurse accurately describes strategies for building a therapeutic relationship?Answer →
  94. 94A nurse facilitating a group therapy session is listening to clients discuss their coping strategies when feeling stressed. Which of the following statements indicate adaptive coping? (Select all that apply.)Answer →
  95. 95A nurse is contributing to the plan of care for his client during the termination phase of the nurse-client relationship. Which of the following interventions should the nurse include?Answer →
  96. 96A nurse is reflecting on different types of relationships encountered in clinical practice to better understand their roles and boundaries. Which of the following are recognized types of relationships relevant to nursing care? (Select all that apply)Answer →
  97. 97A nurse is teaching a client about logrolling while in bed. Which of the following information should the nurse include in the teaching?Answer →
  98. 98A nurse is providing psychoeducation on mental illness to a group of high school students. One student asks, "What causes mental illness?" Based on the diathesis-stress model, which statement by the nurse is most accurate?Answer →
  99. 99A nurse is teaching an older adult client about reducing the risk for osteoporosis. Which of the following statements by the client indicates an understanding of the teaching?Answer →
  100. 100Which of the following best describes a stuporous level of consciousness?Answer →
  101. 101A client is in Erikson's stage of identity vs. role confusion. Which client is most likely in this stage?Answer →
  102. 102A nurse in an acute care mental health facility is sitting with a client who has schizophrenia. The client whispers to the nurse, "I'm being kept in this prison against my will. Please try to get me out." Which of the following responses should the nurse make?Answer →
  103. 103The nurse is reviewing the client's medical record. Click to highlight the information that requires intervention by the nurse. To deselect information, click on the information again.Answer →
  104. 104A nurse is teaching a client how to self-administer daily low-dose heparin injections. Which of the following factors is most likely to increase the client's motivation to learn?Answer →
  105. 105A nurse is caring for a client who shares, when they become angry at their partner, they write in a journal. Which of the following defense mechanisms should the nurse recognize this action is an adaptive example of?Answer →
  106. 106What actions by a nurse do not constitute a breach of a client's right to privacy? (Select all that apply.)Answer →
  107. 107A charge nurse is instructing a newly licensed nurse about mental health disorders. Which of the following statements by the nurse indicates an understanding of mental health disorders?Answer →
  108. 108A newly licensed nurse is discussing the concept for eustress with another nurse. Which of the following examples provided by the newly licensed nurse indicates an understanding of the teaching?Answer →
  109. 109The theorist, Hildegard Peplau, identified which concept as foundational of psychiatric-mental health nursing?Answer →
  110. 110A nurse is talking with a newly licensed nurse about appropriate actions to take when a client threatens to harm a specific individual. Which of the following statements by the newly licensed nurse indicates understanding?Answer →
  111. 111A nurse is assessing a client whose partner is receiving hospice care and is dying. The client states, "I should start planning the trip that we want to take." Which of the following ego-defense mechanisms is the client expressing?Answer →
  112. 112A client requests permission for the spouse to remain in the room during the admission assessment. While interviewing the client, the nurse notes a discrepancy between the client's verbal and nonverbal communication. Which action should the nurse take?Answer →
  113. 113A nurse is planning care for a client who has a prescription for knee-length anti embolic stockings. Which of the following actions should the nurse take?Answer →
  114. 114A nurse is caring for a client who is concerned about developing a mental health disorder as a result of their childhood experiences. Which of the following familial characteristics is a protective factor for adverse childhood experiences?Answer →
  115. 115A nurse is caring for a client who has schizophrenia. The client states, "They lie about me all the time and are trying to poison my food." Which of the following responses should the nurse make?Answer →
  116. 116The mental health nurse observes that a female client with delusional disorder carries some of her belongings with her because she believes that others are trying to steal them. Which nursing action will promote trust?Answer →
  117. 117A nurse who works in a psychiatric unit is caring for a client who has bipolar disorder. The client comes to the nurse's station at 0300 demanding that the nurse calls the provider immediately. Which of the following responses by the nurse is appropriate?Answer →
  118. 118A client feeling anxious has requested their prn antianxiety medication be administered. The nurse informs the client that the medication can only be administered every 4 hours and was given 3 hours ago. The nurse promises to give the client the medication as soon as it is time, but then goes to lunch 1 hour later without giving the client the medication. Which ethical principle did the nurse violate?Answer →
  119. 119A client should be considered for involuntary commitment for psychiatric care when demonstrating what behavior?Answer →
  120. 120A nurse in an acute care facility is caring for an older adult client who is being discharged to an extended-care nursing facility the next day. The client asks, "Why do I have to go to that place?" Which of the following responses should the nurse make?Answer →
  121. 121A client is admitted to the rehabilitation unit following a cerebrovascular accident (CVA), which resulted in paralysis of the right arm. When the nurse enters the room, the client is struggling to put on a shirt, and curses at the nurse. Which response is best for the nurse to provide?Answer →
  122. 122Which factor(s) are the most important for the nurse to include in an initial assessment of the client? Select all that apply.Answer →
  123. 123Complete the following sentence using the lists of options. The client is at risk for developing ___ due to ___.Answer →
  124. 124Which factor(s) is/are the most important for the nurse to include in an initial assessment of the client? Select all that apply.Answer →
  125. 125A client requests permission for the spouse to remain in the room during the admission assessment. While interviewing the client, the nurse notes a discrepancy between the client's verbal and nonverbal communication. Which action should the nurse take?Answer →
  126. 126A nurse is caring for a client and notes that the client appears disheveled, frightened, and seems to be talking to someone who is not there. The nurse should identify that this is an example of which of the following steps of the nursing process?Answer →
  127. 127A nurse is explaining the role of a psychiatrist to a group of nursing students. Which of the following best describes the primary responsibilities of a psychiatrist?Answer →
  128. 128A nurse in an emergency department is assessing a client who reports right lower quadrant pain, nausea, and vomiting for the past 48 hr. Which of the following actions should the nurse take first?Answer →
  129. 129Which statement by the nurse would be considered nontherapeutic?Answer →
  130. 130A nurse is assessing a client whose therapy has included bed rest for several weeks. Which of the following findings should the nurse identify as the priority?Answer →
  131. 131A nurse at a rehabilitation facility is caring for a client who was admitted the previous day. The nurse is reviewing the client's medical record. Which of the following findings require immediate follow-up? Select all that apply.Answer →
  132. 132During a one-to-one session, the nurse begins to become angry with the client. Which action should the nurse take?Answer →
  133. 133A nurse is observing a client's nonverbal behavior. When evaluating this behavior, the nurse should factor in which of the following principles that influence nonverbal communication?Answer →
  134. 134A nurse says to their nurse manager that, "I'm the only one on my team who is working hard." Which of the following responses should the nurse manager make?Answer →
  135. 135"In today's society many people behave immaturely when they say, 'I want it, and I want it now!'. The truth is people cannot always have what they want, when they want it. Those who behave like this are seen as spoiled, out-of-self-control, or hedonistic (self-indulgent). People have to make healthy choices for themselves. This sometimes means fighting impulses and doing things they may not want to do, but need to do. Only then they will be able to make positives choices and be able to build self-control and will power". Using Erikson's theory, which psychosocial crisis explained and support previous statements?Answer →
  136. 136A nurse who lost her adolescent child to suicide is caring for a client with BPD who recently attempted suicide. Which occurrence suggests countertransference?Answer →
  137. 137A male client presents to the clinic informing that he has a high stress job and is having difficulty falling asleep at night. The client reports having a constant headache and is seeking medication to help him sleep. Which intervention should the nurse implement?Answer →
  138. 138During the admission assessment to the mental health unit, a client reports that the people at the office, where the client works, are antagonistic and the client is thinking of shooting the supervisor. The client asks the nurse not to reveal this to anyone else. The nurse immediately notifies the client's therapist and other team members of the client's thoughts. The therapist then calls the client's supervisor and shares the client's thoughts about shooting the supervisor. Which outcome is best based on the action of the nurse?Answer →
  139. 139A nurse is assessing a client's cranial nerve VII. Which of the following responses should the nurse expect?Answer →
  140. 140A nurse is preparing to administer prescribed medications to a client. According to the rights of medication administration, when should the nurse compare the medication administration record against the medication container? (Select all that apply.)Answer →
  141. 141A passage describes selfish behavior and ends with "Only then we will start believing that the world might be safe and others can be relied upon." Using Erikson's theory, which psychosocial crisis is explained?Answer →
  142. 142When making a home visit to a client with Alzheimer's disease, the nurse finds that the client's wife has obviously been crying and appears disheveled. The nurse asks the wife about her husband and the wife replies, "Go see for yourself." Which action should the nurse take?Answer →
  143. 143A nurse is teaching about confidentiality. Which situation requires the nurse to break confidentiality?Answer →
  144. 144A nurse is caring for a newly admitted client who is suspicious of the nursing staff and other clients. Which of the following actions should the nurse take to establish a relationship with this client?Answer →
  145. 145After her husband died of heart failure, a wife approaches the nurse who cared for her husband. In the hospital hallway the wife shouts angrily, 'He'd still be alive if you'd given him your undivided attention!' Which response should the nurse implement?Answer →
  146. 146A nurse is planning to use nonpharmacological pain relief methods for a client who reports continued mild back pain after receiving analgesia 1 hr. ago. Which of the following actions should the nurse include in the plan?Answer →
  147. 147A 16-year-old female client with an eating disorder is an inpatient at a mental health clinic. A mutually agreed upon goal is for her to limit her amount of exercise to 1 hour per day and to consume at least 1000 calories per day for 1 week. This is an example of an interaction that occurs during which phase of the therapeutic relationship?Answer →
  148. 148The nurse is administering peritoneal dialysis to a client. The nurse notes the presence of a cloudy dialysate return. After notifying the health-care provider, which action by the nurse is the most appropriate?Answer →
  149. 149A nurse is caring for a client on an acute care mental health unit who was involuntarily admitted for 72 hr after attacking a neighbor. To keep the client in the hospital when the initial time to hold the client expires, which of the following must be determined?Answer →
  150. 150A nurse is caring for a young adult client who says he is experiencing increased anxiety and an inability to concentrate. Which of the following responses should the nurse make?Answer →
  151. 151A woman whose husband is terminally ill says, "I don't want to cry in front of him. I don't want him to know how soon death will occur or how sad I am." Which response by the nurse would be most therapeutic?Answer →
  152. 152A nurse is caring for a client who becomes visibly anxious and withdrawn when asked to change into a hospital gown. The nurse recognizes this may be a trauma response. Which statement by the nurse best reflects trauma-informed care?Answer →
  153. 153A nurse is teaching a group of newly licensed nurses about the Braden scale. Which of the following responses by a newly licensed nurse indicates an understanding of the teaching?Answer →
  154. 154A female client with obsessive-compulsive disorder is undergoing treatment in an outpatient setting and is attending group therapy sessions. She is working on controlling the compulsion of touching her head three times every time she talks. To maintain the therapeutic relationship established with the client, by which action can the nurse show acceptance?Answer →
  155. 155During psychiatric nursing care, a nurse recognizes feelings of frustration and protectiveness toward a client who reminds them of a family member. How should the nurse best manage this countertransference to ensure effective client care?Answer →
  156. 156A nurse realizes that they feel unusually protective of a client who reminds them of their younger sibling. The nurse begins spending more time with this client than with others. Which concept does this behavior illustrate?Answer →
  157. 157A nurse is teaching about Piaget's preoperational stage. Which behavior is expected?Answer →
  158. 158A nurse is caring for a client who has a traumatic brain injury and needs to relearn how to use eating utensils. The nurse should refer the client to which of the following members of the interprofessional team?Answer →
  159. 159The nurse is giving discharge instructions to the client with uric acid renal calculi. Which statement by the client indicates they understand the prescribed diet?Answer →
  160. 160A newly licensed nurse has forgotten their password and asks another nurse to access the computer system for them so they can document care before transferring the client to another unit. Which of the following responses should the nurse make?Answer →
  161. 161While interviewing a client, the nurse takes notes to assist with accurate documentation later. Which statement is most accurate regarding note taking during an interview?Answer →
  162. 162A nurse is teaching a client about the use of cognitive reframing for stress management. Which of the following statements by the client indicates an understanding of the teaching?Answer →
  163. 163A mentally ill client who has been involuntarily hospitalized in an inpatient psychiatric unit finds a back stairwell and leaves the unit and hospital without the knowledge of staff. This is an example of which of the following?Answer →
  164. 164A nurse is communicating with a client who was admitted for treatment of a substance use disorder. Which of the following communication techniques should the nurse identify as a barrier to therapeutic communication?Answer →
  165. 165A nurse assesses a confused older adult. The nurse experiences sadness and reflects, "The client is like one of my grandparents...so helpless." Based on the psychoanalytic theory studied in class, what is the nurse experiencing in this scenario?Answer →
  166. 166During a family group meeting, the client's daughter tells the group, "I hope I didn't cause mom to be depressed." Which response is best for the nurse to provide?Answer →
  167. 167A nurse on an inpatient mental health unit is caring for a group of clients. Which of the following actions by the nurse demonstrates the ethical concept of autonomy?Answer →
  168. 168The nurse is preparing to give an emergency sedative injection to an agitated client. Which action by the nurse comprises a tort?Answer →
  169. 169The nurse often assists in the process of obtaining informed consent from the client for treatment and/or procedures. Who has the responsibility of providing information to the client so he can give informed consent?Answer →
  170. 170Which of the following is a stage of the illness experience?Answer →
  171. 171A nurse is caring for a child whose family environment is characterized by high stress and minimal social support. Based on Sullivan's Interpersonal Theory, which nursing intervention is most appropriate to promote the child's healthy self-development?Answer →
  172. 172The nurse working on a psychiatric unit is concerned about providing ethical and legally defensible care for clients on the unit. Which occurrence is an indication that a client's civil rights are being violated?Answer →
  173. 173A client newly diagnosed with stage 3 lung cancer becomes angry with the healthcare provider (HCP) and nursing staff. Which intervention is most important for the nurse to implement?Answer →
  174. 174After her husband died of heart failure, a wife approaches the nurse who cared for her husband. In the hospital hallway the wife shouts angrily, "He'd still be alive if you'd given him your undivided attention!" Which response should the nurse implement?Answer →
  175. 175For a nurse or care provider to be found negligent, what requirements must the provider's misconduct meet? (Select All that Apply.)Answer →
  176. 176A nurse on a surgical unit is caring for a client who is scheduled for surgery. The client states, "I cannot do this. I do not want this surgery." Which of the following actions should the nurse take?Answer →
  177. 177A nurse is assessing a client diagnosed with schizophrenia who reports seeing snakes crawling on the walls. What is the nurse's best response?Answer →
  178. 178A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions. Which of the following is an appropriate action to include in the plan of care?Answer →
  179. 179A nurse is interviewing a client who tells the nurse, "I feel irritable, distracted, and worried when thinking about how I am handling my problems at work." The nurse should recognize that this client is in which of the following zones of the mental health continuum?Answer →
  180. 180A nurse is assessing several clients in an inpatient mental health unit. The nurse documents the following statements and behaviors. For each client statement/behavior (blank 1) select the defense mechanism (blank 2) being demonstrated.Answer →
  181. 181A nurse is caring for a client who has schizophrenia and tells the nurse, "They lie about me all the time and they are trying to poison my food." Which of the following statements should the nurse make?Answer →
  182. 182A female college student presents to the health center reporting anxiety related to her fear that she has contracted genital herpes. The student tells the nurse that she has vaginal irritation and is embarrassed by the possibility of having acquired a sexually transmitted disease. Which response should the nurse provide?Answer →
  183. 183A nurse asks a hospice nurse, 'Who should be referred for hospice care?' Select the most correct reply.Answer →
  184. 184Which of the following relationships refers to a consciously directed exchange that is focused on moving the client toward more constructive ways of thinking?Answer →
  185. 185When a male client is asked about his reason for coming to the mental health clinic he replies, "It all started because I work in a hostile work environment. My boss would not let me go to a religious service, so I went to human resources, and they didn't want to do anything. It has been a really difficult time for me." Which response should the nurse provide?Answer →
  186. 186The nurse notes that a 30-year-old client has a gait disturbance and scanning speech. The client reports experiencing double vision, incontinence, intention tremor, right sided facial numbness, and clumsiness. When giving an SBAR report, the nurse recommends the client be evaluated for which condition?Answer →
  187. 187A nurse is preparing to lift a box of personal items off the floor in a client's room. Which of the following actions should the nurse take to help prevent injury when lifting the box?Answer →
  188. 188The patient states to the nurse, "Have you ever been depressed?". Select the response that best protects the boundaries of the therapeutic relationship.Answer →
  189. 189Which behavior supports the failure to successfully achieve the oral stage of Freud's psychosexual stages of development?Answer →
  190. 190A nurse is teaching a client about progressing from a clear liquid diet to a full liquid diet. Which of the following food selections by the client indicates an understanding of the teaching?Answer →
  191. 191Which statement about aging provides the best rationale for focused assessment of older adult patients?Answer →
  192. 192A nurse is caring for a client who came to the emergency department with abdominal distention and is now on the medical-surgical unit with an NG tube in place to low gastric suction. The client reports anxiety, discomfort, and a feeling of bloating. Which of the following actions is the nurse's priority?Answer →
  193. 193Which assumption is consistent with the foundation of behaviorism?Answer →
  194. 194A nurse is caring for a client in the oliguric phase of acute kidney injury (AKI). The client's cardiac monitor reveals tall, peaked T-waves. Which medication should the nurse anticipate administering first?Answer →
  195. 195A nurse is preparing to collect a sputum specimen from a client. Which of the following actions should the nurse take?Answer →
  196. 196Terry 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. If the nurse is concerned about posttraumatic stress disorder (PTSD) what will be the best therapeutic question to ask?Answer →
  197. 197An older adult tells the clinic nurse about frequently awakening during the night and often not being able to go back to sleep. Which action(s) should the nurse suggest to the client to help improve sleep? Select all that apply.Answer →
  198. 198What criteria for hospice care are applicable for this client in this scenario? (Select all that apply.)Answer →
  199. 199A nurse is caring for a newly admitted patient with uncontrolled hypertension. After obtaining a full set of vital signs and completing a head-to-toe assessment, the nurse collaborates with the healthcare team to prioritize goals such as achieving systolic blood pressure below 140 mmHg within 72 hours. Which step of the nursing process is the nurse performing when identifying this goal?Answer →
  200. 200A nurse is caring for a client who is 6 hr. postoperative following abdominal surgery and is having difficulty voiding. Which of the following actions should the nurse take?Answer →
  201. 201A nurse is educating a group of clients about healthy and unhealthy coping skills in response to stress. Which of the following coping strategies should the nurse identify as healthy? (Select all that apply)Answer →
  202. 202The model views clients holistically with the goal of creating a support system designed to encourage independence in the client with a mental health disorder.Answer →
  203. 203Which is the nurse's most therapeutic comment?Answer →
  204. 204A nurse in an acute mental health center is performing a physical assessment on a client. Which of the following findings should the nurse document under the integumentary system? (Select all that apply.)Answer →
  205. 205A nurse is working in a community mental health facility. Which of the following services does this type of program provide? (Select all that apply.)Answer →
  206. 206Which medications does the nurse identify as potentially nephrotoxic for a client with acute kidney injury? Select all that apply.Answer →
  207. 207A nurse manager is evaluating the structure of a state acute care psychiatric hospital known for having an integrated forensic care unit. Which rationale best explains why nearly all state acute care psychiatric hospitals include forensic care units?Answer →
  208. 208Which statement about aging provides the best rationale for focused assessment of older adult patients?Answer →
  209. 209The nurse is preparing the physical environment to interview a new client for admission to the mental health unit. Which environmental setting facilitates the best outcome of the interview?Answer →
  210. 210is a disturbance in a client's ability to cope effectively.Answer →
  211. 211Which situation is an example of battery?Answer →
  212. 212Which client should the nurse identify as meeting criteria for involuntary inpatient admission?Answer →
  213. 213A charge nurse overhears another nurse talking with a client who has schizophrenia. Suddenly the client yells, "I am the devil I am God! Open the gate for me!" Which of the following replies by the nurse requires intervention?Answer →
  214. 214The nurse ends the assessment of a client by performing a mental status exam. Which statement correctly describes the purpose of the mental status exam?Answer →
  215. 215The client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. Which action should the nurse implement?Answer →
  216. 216The introduction of in the 1950s led to the deinstitutionalization of many mentally ill individuals.?Answer →
  217. 217A nurse is speaking with a client who reports increased difficulty with anxiety and not wishing to engage in social occasions after the death of a parent. Which of the following zones of the mental health care continuum model should the nurse identify the client is experiencing?Answer →
  218. 218During an assessment, the nurse notices that an older adult client's responses are vague or unrelated to the questions asked. The client leans forward and frowns while listening intently. Which nursing statement best assesses the quality of message transmission?Answer →
  219. 219A nurse is discussing torts with a newly licensed nurse. Which of the following information should the nurse include?Answer →
  220. 220A nurse is caring for a client who reports difficulty coping with several recent stressors. Which of the following responses should the nurse make?Answer →
  221. 221A patient states, "I can't sleep and my mind won't stop racing." Select the most therapeutic response.Answer →
  222. 222A charge nurse has four new clients arriving on the unit for admission. Which of the following clients should the nurse place in airborne precautions?Answer →
  223. 223A charge nurse is instructing a newly licensed nurse about mental health disorders. Which of the following statements by the nurse indicates an understanding of mental health disorders?Answer →
  224. 224A woman whose husband is terminally ill says, "I don't want to cry in front of him. I don't want him to know how soon death will occur or how sad I am." Which response by the nurse would be most therapeutic?Answer →
  225. 225A nurse is teaching about the therapeutic use of Carl Rogers' approach. Which nurse behavior best reflects Rogers' theory?Answer →
  226. 226A client with borderline personality disorder begins a program to build social skills. In which part of the interview should a nurse record the item "Encourage client to attend one psychoeducational group daily"?Answer →
  227. 227Which definition best describes transference?Answer →
  228. 228A nurse is assessing a client who recently started taking an antibiotic. The nurse should identify that which of the following findings is an indication of a mild allergic reaction?Answer →
  229. 229The nurse is caring for a client who is experiencing extreme sadness after the passing of a companion of 30 years. The client describes not being able to think of other things and finds it difficult to control emotions. Which action should the nurse take first?Answer →
  230. 230The nurse is collecting the health history of a client and determines that the client has risk factors for developing mental illness. Which of the following should the nurse identify as a possible contributing factor in the development of a mental health disorder?Answer →
  231. 231A nurse reports that all mentally ill persons were abused as children. This is an example of which of the following?Answer →
  232. 232A nurse mistakenly gives a client the wrong medication, which results in the client's death. This type of health care crime is which of the following?Answer →
  233. 233A nurse is working with a client who uses the defense mechanism of projection. Which client statement best demonstrates projection?Answer →
  234. 234A nurse is teaching a client about stress management techniques. Which of the following client statements indicates an understanding of the teaching?Answer →
  235. 235A nurse on a mental health unit is teaching a newly licensed nurse about client rights. Which of the following statements indicates an understanding of the teaching?Answer →
  236. 236A client sustained a closed-head injury 4 hours ago and is now taken to the emergency room by ambulance. The client has an irregular rate and depth of respiration and cannot swallow. The nurse providing care recognizes these symptoms are a result of trauma to which brain structure?Answer →
  237. 237A client with schizophrenia tells the nurse, "The government implanted a chip in my head." After recognizing the client's delusion, which nurse's response best demonstrates therapeutic communication to support the client while addressing the delusion?Answer →
  238. 238A nurse is completing discharge teaching about ostomy care with a client who has a new stoma. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)Answer →
  239. 239A client underwent psychotherapy weekly for 3 years. The therapist used free association, dream analysis to investigate the interaction of conscious and unconscious elements in the mind, and facilitated transference to help the client understand unconscious processes and foster personality changes. Which type of therapy was used?Answer →
  240. 240A nurse is discussing insomnia management with a group of clients and asks which of the following techniques mentioned by a client requires further teaching?Answer →
  241. 241A nurse is caring for a client who reports that she has insomnia. Which of the following interventions is appropriate for the nurse to recommend?Answer →
  242. 242The nurse observes a client sitting alone in the dayroom. The client appears tearful, avoids eye contact, and has declined to attend group therapy. The client has been isolating from peers since admission yesterday. The nurse approaches the client to begin a brief interview. Which nursing responses demonstrate therapeutic communication techniques?Answer →
  243. 243A 52-year-old states, "I enjoy volunteering at the election polls and mentoring new employees at our company". This statement would indicate success in which Erikson task?Answer →
  244. 244A client reports to the nurse about feeling upset because no family or friends have visited in two days. The client then begins to shout and toss small objects toward the nurse. Which defense mechanism should the nurse recognize the client is displaying?Answer →
  245. 245A 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 →
  246. 246A nursing student mentions using open-ended questions. In what situation is it most imperative to use a close-ended question instead?Answer →
  247. 247A nurse is providing mental health education to a group of high school students. Which of the following information about screening for mental illness should the nurse include?Answer →
  248. 248The emergency room triage nurse would prioritize evaluation for which client?Answer →
  249. 249An adult client reports having insomnia and asks the nurse to recommend a sleeping pill. Which reply is best for the nurse to provide?Answer →
  250. 250An adult female client with bipolar disorder is seen in the outpatient psychiatric clinic and tells the nurse that she is thinking of harming her sister. Which action is most important for the nurse to take?Answer →
  251. 251A nurse is teaching a group of older adult clients about medication safety. Which of the following client statements indicates an understanding of the teaching?Answer →
  252. 252A nurse is conducting a health assessment for a client who takes herbal supplements. Which of the following statements by the client indicates an understanding of the use of the supplements?Answer →
  253. 253A nurse is interviewing a client who was recently admitted to a psychiatric unit of an acute care facility. Which of the following nursing interventions should the nurse initiate as a secondary prevention strategy?Answer →
  254. 254A nurse is caring for a client who refuses to attend group therapy. Which of the following statements should the nurse make?Answer →
  255. 255A home care nurse is visiting an older adult client who tells the nurse that she is feeling tired, is unable to shop for groceries, and would like the nurse to shop for her. Shopping and performing personal errands for the client is prohibited in the nurse's job description. Which of the following is an appropriate nursing response?Answer →
  256. 256A client with paranoia is admitted to the mental health unit and immediately goes to the corner of the room and sits quietly without communicating. While approaching the client, which intervention should the nurse implement?Answer →
  257. 257The nurse is caring for a client on peritoneal dialysis receiving hourly exchanges. At 0900 the nurse notes 2000 mL of dialysate was instilled and 1800 mL drained. During the exchange, the client drinks 1 cup of orange juice, 4 oz of milk with cereal, and 1 cup of water. The client also had one egg and a 4 oz cup of gelatin. What is the client's net intake? Enter numerical value only.Answer →
  258. 258A client with Multiple Sclerosis is receiving the drug ocrelizumab. The nurse teaches a group of students which of the following applies to this medication? Select all that apply.Answer →
  259. 259A nurse caring for a client who has depression observes the client comes to breakfast freshly bathed, wearing clean clothes, and with combed and styled hair. Which of the following responses by the nurse is therapeutic?Answer →
  260. 260Which response by the nurse is most therapeutic?Answer →
  261. 261A newly licensed nurse is assisting with the involuntary admission of a client who has depression to an acute care mental health facility. Which of the following guidelines should the nurse follow when caring for the client?Answer →
  262. 262A client describes therapy: "I told her I was the only survivor in a plane crash... We talked about my feelings related to being a survivor, and now I'm fine." Which type of therapy was used?Answer →
  263. 263A nurse working in a mental health facility is caring for a client who was involuntarily admitted. Which of the following client statements should the nurse recognize as accurate? (Select All that Apply.)Answer →
  264. 264A sales executive presents to the psychiatric clinic for an initial evaluation, and tells the nurse, "My therapist said I needed to come. Last fall, I found out my spouse was having an affair. I had a drinking problem for years, but I've been sober for three years. I believe in God. I care about my kids." Which response is best for the nurse to provide?Answer →
  265. 265A nurse wants to reinforce positive self-esteem for a client diagnosed with major depressive disorder. Today, the client is wearing a new shirt and has neat, clean hair. Which remark is most appropriate?Answer →
  266. 266A client is in the terminal stage of lung cancer. Outside the room, the client's spouse expresses to the nurse feeling helpless and without hope for the future. How should the nurse respond?Answer →
  267. 267A caregiver is said to be practicing. care not only when she takes into consideration the client's actual or potential problems but also when she considers the client's family, work responsibilities, and social aspects of life. Which of the following best describes this caregiving concept?Answer →
  268. 268A 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 →
  269. 269A nurse is performing a spiritual assessment for a client using the FICA tool. Which of the following questions should the nurse ask to address the "C" in the FICA tool?Answer →
  270. 270A student nurse visiting a senior center says, "It's depressing to see these old people. They are all weak and frail. I doubt any of them can engage in a discussion." What is the student expressing?Answer →
  271. 271A nurse in a mental health facility is preparing to interview a client who is has schizophrenia. Which of the following actions should the nurse take?Answer →
  272. 272A nurse is preparing to administer 0.9% sodium chloride 1 L IV to infuse over 8 hr. The drop factor of the manual IV tubing set is 15 gtts/ml. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)Answer →
  273. 273A nurse is admitting a client who has end-stage chronic obstructive pulmonary disease (COPD) and has been intubated on previous hospitalizations. The client refuses intubation and any invasive treatment. Which of the following client rights is the client exercising?Answer →
  274. 274A nurse assesses that a client is suspicious and frequently manipulates others to satisfy his own desires. Using the Freudian theory, these traits are related to which psychosexual stage?Answer →
  275. 275The physician orders heparin IV drip at 1700 units/h. The medication is supplied in 50,000 units/500mL of D₅W. Calculate the flow rate in milliliters per hour. Insert the correct response. Round your answer to the nearest whole number.Answer →
  276. 276A nurse is preparing to document in the client's medical record. The nurse should identify that which of the following abbreviations are specified by The Joint Commission for placement on a facility's Do Not Use list? (Select all that apply.)Answer →
  277. 277A nurse is caring for a client who has sleep dysregulation, poor memory, and poor concentration. Which of the following neurotransmitters should the nurse identify as being responsible for the client's manifestations?Answer →
  278. 278Which of the following resources would the nurse find standards of care for nursing practice? Select All that Apply.Answer →
  279. 279A staff nurse is teaching a newly hired nurse how to complete an informed consent document for a client. The staff nurse should include that the nurse's signature on the form confirms which of the following requirements? (Select all that apply.)Answer →
  280. 280During a family group meeting, the client's daughter tells the group, "I hope I didn't cause mom to be depressed." Which response is best for the nurse to provide?Answer →
  281. 281A 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 →
  282. 282A nurse in an acute mental health facility is assisting with discharge planning for a client who has a severe mental illness and requires supervision. The client's partner works all day but is home by late afternoon. Which of the following strategies should the nurse suggest for follow-up care?Answer →
  283. 283A male adult client is transferred to a psychiatric facility following release from the hospital for treatment of a self-inflicted gunshot wound. In attempting to develop a therapeutic relationship with this client, which information is most important for the nurse to determine?Answer →
  284. 284A charge nurse is instructing a newly licensed nurse about mental health disorders. Which of the following statements by the nurse indicates an understanding of mental health disorders?Answer →
  285. 285A nurse observes a client sitting alone in her room crying. As the nurse approaches her, the client states, "I'm feeling sad. I don't want to talk now." Which of the following responses should the nurse make?Answer →
  286. 286A client arrives to the clinic describing concerns to the nurse about mood swings, insomnia, and a lack of focus. Which information should the nurse obtain first?Answer →
  287. 287A nurse is performing an eye assessment for a newly admitted client. Which of the following findings should the nurse expect?Answer →
  288. 288A client has been admitted to an acute inpatient psychiatric unit due to severe mental health symptoms that impair their daily functioning and safety. Which of the following treatments and interventions are appropriate to include in the client's care plan? (Select all that apply)Answer →
  289. 289What is the purpose of a therapeutic relationship in mental health?Answer →
  290. 290A nurse is reviewing a client's medical record. The nurse should anticipate which of the following as a classification within the Diagnostic and Statistical Manual of Mental Disorders 5th edition Text Revision (DSM-5 TR)?Answer →
  291. 291A client says, "I can't go to therapy today. My car is broken," but the nurse observes the client arrived in a rideshare. Which defense mechanism is the client using?Answer →
  292. 292A nurse is conducting the Weber's test on a client. Which of the following is an appropriate action for the nurse to take?Answer →
  293. 293A nurse is caring for a client who has sleep dysregulation, poor memory, and poor concentration. Which of the following neurotransmitters should the nurse identify as being responsible for the client's manifestations?Answer →
  294. 294A nurse asks a client why they did not attend their scheduled group therapy session. The client responds, "Group therapy is a waste of time. I already know everything they're going to say anyway." The nurse notes that the client had previously expressed anxiety about speaking in front of others. Which defense mechanism is the client demonstrating?Answer →
  295. 295A young female client is admitted to the emergency department (ED) because she was raped that evening by her date. Which computer documentation should the nurse enter in the electronic medical record (EMR) as the client's chief concern?Answer →
  296. 296Stress job is causing trouble in the employee's personal life. The employee describes becoming so angry while driving that the employee becomes engaged in heated verbal altercations with other drivers and is concerned that this may progress to physical altercations. Which technique should the nurse recommend to help the employee deal with the road rage?Answer →
  297. 297A young adult client is preparing to be discharged from the psychiatric unit. Which nursing intervention is most important for the nurse to include in this phase of the nurse and client relationship?Answer →
  298. 298A nurse is teaching a newly licensed nurse about the importance of therapeutic communication. Which of the following statements should the nurse include in the teaching?Answer →
  299. 299During the first interview with a young mother whose child died recently in a car accident, her female nurse feels touched by client's situation and reaches out to take the client's hand. Select the correct analysis of the nurse's behavior.Answer →
  300. 300A charge nurse on a mental health unit is preparing an in-service for staff members about client rights. Which of the following information should the nurse include?Answer →
  301. 301A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. Which action should the nurse implement?Answer →
  302. 302A nurse is caring for a client who has dysphagia. When assisting the client during breakfast, which of the following actions by the client indicates the nurse should intervene?Answer →
  303. 303A charge nurse in an emergency department is assigning tasks. Which of the following tasks should the nurse delegate to an assistive personnel?Answer →
  304. 304A client cries as the nurse explores the client's relationship with a deceased parent. The client says, "I shouldn't be crying like this. It happened a long time ago." Which responses by the nurse will facilitate communication? (Select all that apply)Answer →
  305. 305A nurse overhears two staff members in the cafeteria discussing the treatment plan of a client. Which of the following actions should the nurse take first?Answer →
  306. 306A nurse is teaching a group of high school students about mental health. Based on the mental health-mental illness continuum and societal norms in the United States, which behavior most strongly suggests the presence of a mental illness?Answer →
  307. 307While sitting in the day-room of the mental health unit, a male adolescent avoids eye contact, looks at the floor, and talks softly when interacting verbally with the nurse. The two trade places, and the nurse demonstrates the client's behaviors. Which is the main goal of this therapeutic technique?Answer →
  308. 308A nurse is speaking with a client who reports increased difficulty with anxiety and not wishing to engage in social occasions after the death of a parent. Which of the following zones of the mental health care continuum model should the nurse identify the client is experiencing?Answer →
  309. 309While sitting in the day-room of the mental health unit, a male adolescent avoids eye contact, looks at the floor, and talks softly when interacting verbally with the nurse. The two trade places, and the nurse demonstrates the client's behaviors. Which is the main goal of this therapeutic technique?Answer →
  310. 310A nurse is planning to meet with a client for the first time to start developing a helping relationship. Which of the following actions should take the nurse take during the orientation phase?Answer →
  311. 311A nurse is caring for a client who has a new diagnosis of fibromyalgia. The client tells the nurse that she wants to use traditional Chinese medicine for treatment instead of the medication prescribed by their provider. Which of the following is an appropriate response by the nurse?Answer →
  312. 312A nurse is admitting a new client to the unit. Which of the following actions should the nurse take to build a rapport with the client?Answer →
  313. 313The nurse identifies which patient cues as criteria for inpatient hospital admission?Answer →
  314. 314A client who is also a nurse initiates a conversation during a clinic visit: "I understand that neurotransmitters are endogenous chemicals that play a major role in brain function and everyday life, but I don't really know how to differentiate them from hormones. My doctor says mine are out of balance. Can you explain the difference?" Which is the nurse's best response?Answer →
  315. 315A nurse is caring for a couple who experienced a fetal death at 37 weeks of gestation. Which of the following responses by the nurse is therapeutic?Answer →
  316. 316A client is admitted involuntarily. Which statement by the nurse is accurate?Answer →
  317. 317A nursing instructor has finished teaching a class on therapeutic communication. Which of the following aspects of communication should her students identify as a component of verbal communication?Answer →
  318. 318A community health nurse is caring for a group of families. The nurse should identify that which of the following families is experiencing a maturational loss?Answer →
  319. 319A nurse is developing a therapeutic relationship with a client who is anxious about a new diagnosis. Which component is most critical for the nurse to demonstrate in order to effectively understand and support the client's emotional experience?Answer →
  320. 320Which of the following statements best describes countertransference?Answer →
  321. 321The nurse is reviewing the client's medical record. Which of the following actions should the nurse take? Select all that apply.Answer →
  322. 322A nurse telling a mentally-ill client that she will be physically forced to do something if uncooperative is an example of which of the following?Answer →
  323. 323During a mental status exam, a nurse is checking the client's remote memory. Which of the following tasks would be most appropriate for assessing remote memory?Answer →
  324. 324A young Filipino-American female client avoided eye contact when interacting with the nurse. The nurse concluded that the client had low self-esteem. Interventions were used to raise the client's self-esteem; however, after 3 weeks, the client's eye contact did not improve. What is the most accurate analysis of this scenario?Answer →
  325. 325A client with generalized anxiety disorder reports palpitations and trembling. Which nursing response best demonstrates therapeutic communication?Answer →
  326. 326A psychiatric nurse is experiencing signs of compassion fatigue after months of caring for clients with severe mental illnesses. When discussing strategies to manage this condition, which statement best reflects the nurse's understanding of self-care importance?Answer →
  327. 327A nurse is interviewing a client who has a personality disorder. The nurse and client have agreed on an interview time, but the client resists discussing her feelings until 5 min prior to the end of the session and then asks for additional time. Which of the following actions should the nurse take?Answer →
  328. 328The nurse is admitting a client and asks the client about social support. The client states "I have no family and am newly divorced. I don't have many friends either." Which of the following statements should the nurse make?Answer →
  329. 329A nurse is preparing to transfer a client to the radiology department using a wheelchair. Which of the following actions should the nurse take?Answer →
  330. 330A nurse is preparing to administer cefoxitin 80 mg/kg/day IV every 6 hr. to a 6-year-old child who weighs 20 kg. How many mg should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)Answer →
  331. 331A charge nurse is observing a staff nurse performing a wound irrigation for a client who has a pressure injury. Which of the following actions by the staff nurse indicates an understanding of the procedure?Answer →
  332. 332A nurse is caring for a client who was admitted to the hospital for treatment of a mental health disorder and will soon be discharged. Which of the following mental health care settings should the nurse anticipate the client may go to help prevent rehospitalization?Answer →
  333. 333A male client is seeking help in a mental health clinic for anger management problems. He voices that he is fearful that his wife may divorce him because of his anger problem, and he is willing to do "whatever it takes" to control his anger. Later in the week, the client's wife also seeks assistance because she is going to divorce her husband. The nurse who is caring for both of these clients tries to decide the correct action to take. The nurse experiencing it?Answer →
  334. 334Which description best defines the defense mechanism of intellectualization?Answer →
  335. 335A nurse is preparing to interview a client and is reviewing therapeutic communication techniques. Which of the following should the nurse included in the interview to invite the client to clarify feelings?Answer →
  336. 336A client discloses to the nurse they started drinking alcohol again after six months of sobriety. Which response made by the nurse would be most therapeutic?Answer →
  337. 337A nurse on a mental health unit is preparing an in-service about ethical concepts when providing client care. Which of the following definitions should the nurse include when discussing advocacy?Answer →
  338. 338A nurse is assessing a client who has hypocalcemia. Which of the following findings should the nurse expect? (Select all that apply.)Answer →
  339. 339A nurse is assessing a client's abdomen. In what order should the nurse complete the steps of the assessment? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)Answer →
  340. 340A nurse is about to begin the initial assessment of a newly admitted patient. Which step should the nurse prioritize first to ensure effective and safe care planning?Answer →
  341. 341Scenario: A woman whose husband is terminally ill says, "I don't want to cry in front of him. I don't want him to know how soon death will occur or how sad I am." Which response by the nurse would be most therapeutic?Answer →
  342. 342A nurse is reinforcing discharge teaching with a client who has several new prescriptions for psychotropic medications. The client tells the nurse that she has always had trouble following a medication regimen. Which of the following responses should the nurse make?Answer →
  343. 343A nurse is discussing the different levels of mental health promotion with a newly licensed nurse. Which of the following should the nurse include as an example of a tertiary prevention?Answer →
  344. 344A nurse is teaching a client who can only bear weight on one leg how to ambulate using crutches. Which of the following crutch gaits should the nurse plan to instruct the client to use?Answer →
  345. 345A nurse in a mental health clinic is attempting to develop a therapeutic relationship with a client. Which of the following actions should the nurse take?Answer →
  346. 346A client is discussing feelings related to a recent loss with the nurse. The nurse remains silent when the client says, "I don't know how I will go on." Which is the reason for the nurse's behavior?Answer →
  347. 347Complete the following sentence by using the list of options. The nurse should first address the client's risk for developing ___ as evidenced by the client's ___.Answer →
  348. 348A psychiatric nurse notices that a client frequently refers to the nurse with terms and attitudes resembling those the client used for a significant caregiver in childhood. The client shows both affection and hostility toward the nurse at different times. How should the nurse best respond to this transference phenomenon to maintain therapeutic progress?Answer →
  349. 349A nurse is discussing bias issues in mental health with a newly licensed nurse. Which of the following statements should the nurse include in the discussionAnswer →
  350. 350Marcus a male client who visits the mental health clinic monthly tells the nurse he has been feeling very stressed, nervous, and increasingly angry during the past month. During the session, the nurse documents: "Throughout a 5-minute interaction, client fidgeted and tapped his left foot, periodically covered his face with his hands, and looked under the chair while stating, I enjoy spending time with you." Based on this documentation, which analysis is most accurate by the nurse?Answer →
  351. 351During the 1930s, what common treatment for schizophrenia caused clients to fall into a coma that could last as long as 50 hours?Answer →