Mental 9 2 2022

Question 1

The nurse receives hand-off report on several clients in the mental health unit. Which client should be seen first?
a. Client with bulimia nervosa who has been in the restroom for the past hour since breakfast
b. Client with major depressive disorder who has suicidal ideation with a plan and is on one-to-one observation
c. Client with obsessive-compulsive. disorder who refuses to attend group therapy because it interrupts hand washing rituals
d. Client with schizophrenia who is experiencing delusions and is pacing the room and yelling at other clients

Answer 1

d. Client with schizophrenia who is experiencing delusions and is pacing the room and yelling at other clients

Question 2

The nurse is caring for clients in a mental health unit. Which client behavior is consistent with borderline personality disorder?
a. Asks the therapist to speak on the client’s behalf and requires help with everyday decisions
b. Believes that other clients are gathering information about the client for a local news story
c. States to the nurse, “You’re mean and I hate you” after being denied smoking privileges
d. Takes coffee from the staff lounge and states, “I don’t care if it’s for staff only; I’m thirsty.”

Answer 2

c. States to the nurse, “You’re mean and I hate you” after being denied smoking privileges

Question 3

The clinic nurse is attending group therapy with several clients diagnosed with social anxiety disorder related to fear of public speaking. Which of the following client statements indicate improved coping? Select all that apply.
a. “I arrived early to a conference to meet the attendees so that their faces would be familiar in the audience.”
b. “I attended a conference where my friend presented, and I was able to tolerate sitting on the stage.”
c. “I felt the pounding in my chest begin when I faced my audience, but I practiced my deep-breathing exercises.”
d. “I practiced my presentation-in front of a small group of friends prior to speaking at a work event.”
e. “I submitted a prerecorded video of myself presenting my findings for a conference instead of presenting in person.”

Answer 3

a. “I arrived early to a conference to meet the attendees so that their faces would be familiar in the audience.”
b. “I attended a conference where my friend presented, and I was able to tolerate sitting on the stage.”
c. “I felt the pounding in my chest begin when I faced my audience, but I practiced my deep-breathing exercises.”

Question 4

The nurse is caring for a client who has moderate-stage Alzheimer disease. The client is confused and agitated and begins pulling at the IV insertion site. Which of the following interventions are appropriate? Select all that apply.
a. Ask the unlicensed assistive personnel to stay with the client until a sitter can be secured
b. Assess for and resolve pain or discomfort (eg, hunger, constipation, need to void)
c. Explain the purpose of the IV catheter and that, if it is pulled out, a new one must be inserted
d. Quietly play the client’s favorite music and look at the client’s family photo album together
e. Secure the IV site with gauze and provide the client with reassurance of safety

Answer 4

a. Ask the unlicensed assistive personnel to stay with the client until a sitter can be secured
b. Assess for and resolve pain or discomfort (eg, hunger, constipation, need to void)
d. Quietly play the client’s favorite music and look at the client’s family photo album together
e. Secure the IV site with gauze and provide the client with reassurance of safety

Question 5

The nurse is precepting a graduate nurse (GN) who is caring for an adult client with major depressive disorder. The client is scheduled for electroconvulsive therapy early the next morning. Which action by the GN requires further education?
a. Encourages the client to ask questions and discuss feelings about the procedure
b. Informs the client that headache and temporary confusion are common after the procedure
c. Instructs the client not to consume food or drink after midnight prior to the procedure
d. States that the client’s spouse must sign the informed consent due to the client’s diagnosis

Answer 5

d. States that the client’s spouse must sign the informed consent due to the client’s diagnosis

Question 6

The nurse is providing care for a client with substance use disorder. Which client statement does the nurse recognize as transference?
a. “I may not get good grades, but I lead the baseball team in home runs.”
b. “Marijuana isn’t bad for you; my grandmother has a prescription for it.”
c. “You are like my school guidance counselor, always questioning me.”
d. “You can say whatever you want, but you are just wasting your breath.”

Answer 6

c. “You are like my school guidance counselor, always questioning me.”

Question 7

While making rounds on the mental health unit, the nurse witnesses a client diagnosed with posttraumatic stress disorder (PTSD) awaken from a nightmare. The client is diaphoretic and extremely anxious and repeatedly states, “Hot. Hurry. See the smoke.” Which nursing action is appropriate?
a. Avoid discussing aspects of the previous traumatic event with the client
b. Reinforce that nightmares are common in PTSD and reassure the client of present safety
c. Teach the client a new relaxation technique such as guided imagery or meditation
d. Turn on the television to provide a distraction for the client

Answer 7

b. Reinforce that nightmares are common in PTSD and reassure the client of present safety

Question 8

The emergency department nurse is discharging a client who is the victim of intimate partner violence. Which communication by the nurse is most important at this time?
a. “Here are the numbers for two local safe shelters.”
b. “I’m concerned for the safety of you and your children.”
c. “Remember, you do not deserve abuse. It is not your fault.”
d. “You should ask your friends to help you develop a safety plan.”

Answer 8

a. “Here are the numbers for two local safe shelters.”

Question 9

The nurse is caring for a client with major depressive disorder who has not showered since being admitted 3 days ago. When the nurse suggests a shower the client states, “I don’t have the energy or desire to take a shower.” Which response by the nurse is appropriate?
a. “I will get a basin of water and help you; you can begin by washing your face and hands.”
b. “I will let your therapist know about your lack of participation in your treatment plan.”
c. “Sometimes, you have to snap out of it and do things even when you do not feel like it.”
d. “You will feel like showering in a few days when the antidepressants begin to work.

Answer 9

a. “I will get a basin of water and help you; you can begin by washing your face and hands.”

Question 10

A preoperative client awaiting bariatric surgery states, “I hope I’m not making the wrong decision.” Which response by the nurse is appropriate?
a. “Do you want to talk more about the surgery?”
b. “Is something else bothering you besides the surgery?”
c. What concerns do you have about the surgery?”
d. What makes you think this is the wrong decision?”

Answer 10

c. What concerns do you have about the surgery?”

Question 11

The nurse is caring for a client with obsessive-compulsive disorder who was admitted earlier in the day. The client has stayed in the room performing a handwashing ritual multiple times each hour and has not participated in unit activities. Which statement by the nurse is appropriate at this time?
a. “I am concerned about the redness and cracks on your hands because germs can enter the cracks.”
b. “Our next group meets in 10 minutes; I will stay while you get ready, and then we can walk together.”
c. “There are other things that you can do to relieve your anxiety instead of washing your hands.”
d. “To help you gain control, you can wash your hands twice each hour, and at other times you must stay with the group.”

Answer 11

b. “Our next group meets in 10 minutes; I will stay while you get ready, and then we can walk together.”

Question 12

The school nurse develops a community education program on eating disorders for parents of adolescents. Which of the following situations should the nurse include as potential indications of anorexia nervosa? Select all that apply.
a. Excessive exercise routines
b. Irregular or absent menstrual cycles
c. Profound fear of gaining weight
d. Rituals such as cutting food into very small pieces
e. Satisfaction with body image despite being very thin

Answer 12

a. Excessive exercise routines
b. Irregular or absent menstrual cycles
c. Profound fear of gaining weight
d. Rituals such as cutting food into very small pieces

Question 13

The nurse is planning care for an older adult client who underwent a total hip replacement 5 days ago and has since developed new-onset confusion. Which of the following nursing interventions are appropriate to include in the plan of care? Select all that apply.
a. Encourage a family member to stay with the client at the bedside when possible
b. Ensure that frequently used personal items are placed within the client’s reach
c. Introduce self and provide reorientation to the client with each interaction
d. Maintain dim lighting throughout the day to support a calm environment
e. Request that the charge nurse assign the same staff to care for the client each day

Answer 13

a. Encourage a family member to stay with the client at the bedside when possible
b. Ensure that frequently used personal items are placed within the client’s reach
c. Introduce self and provide reorientation to the client with each interaction

Question 14

The clinic nurse is assisting with the development of a teaching presentation about the signs of amphetamine use disorder in adolescents. Which of the following teaching points should the nurse include? Select all that apply.
a. “Increased appetite and weight gain are typically present.”
b. “Insomnia, or sleeping less, is a common finding.”
c. “The adolescent may appear restless and agitated.”
d. “The adolescent may be irritable and easily angered.”
e. “Tremors and increased perspiration may be present.”

Answer 14

b. “Insomnia, or sleeping less, is a common finding.”
c. “The adolescent may appear restless and agitated.”
d. “The adolescent may be irritable and easily angered.”
e. “Tremors and increased perspiration may be present.”

Question 15

The nurse is caring for a client who has bipolar disorder and is experiencing an acute manic episode. Which breakfast menu is best to provide for the client?
a. Boiled egg, bacon, banana, apple juice
b. Cereal with milk, apple slices, orange juice
c. Oatmeal, strawberries, bran muffin, grape juice
d. Scrambled eggs, pancakes with syrup, milk

Answer 15

a. Boiled egg, bacon, banana, apple juice

Question 16

The home health nurse is visiting an older adult client who lives in the home of an adult child. Which of the following findings require follow-up for potential elder abuse and neglect? Select all that apply.
a. Blood stains are noted on the client’s underwear and bedding
b. Bruises in various stages of healing are noted on the client’s body
c. The client asks if the nurse can provide a toothbrush and toothpaste
d. The client becomes agitated when the nurse suggests a physical assessment
e. The client’s weight has increased by 6 Ib (2.72 kg) since the previous month

Answer 16

a. Blood stains are noted on the client’s underwear and bedding
b. Bruises in various stages of healing are noted on the client’s body
c. The client asks if the nurse can provide a toothbrush and toothpaste
d. The client becomes agitated when the nurse suggests a physical assessment

Question 17

The nurse is caring for a client who had an acute myocardial infarction 8 hours ago. The client states, “I am worried about how this is going to affect my job and family.” Which of the following responses by the nurse is therapeutic?
a. “As long as you make some healthy lifestyle changes, you should be able to continue working.”
b. “I will have the social worker visit you to review the available community resources.”
c. “It is too soon to worry about those things; focus on the health of your heart right now.”
d. “These are common concerns. It must be frightening to feel unsure about meeting your family’s needs.”

Answer 17

d. “These are common concerns. It must be frightening to feel unsure about meeting your family’s needs.”

Question 18

The nurse is assessing a 17-year-old client with restrictive anorexia nervosa. Which of the following findings should the nurse expect? Select all that apply.
a. Amenorrhea
b. Cold intolerance
c. Erosion of tooth enamel
d. Hypotension
e. Lanugo-type hair on body

Answer 18

a. Amenorrhea
b. Cold intolerance
d. Hypotension
e. Lanugo-type hair on body

Question 19

The clinic nurse is evaluating the treatment plan for a child with attention deficit hyperactivity disorder. Which of the following parent statements indicate that the treatment plan has been effective? Select all that apply.
a. “A teacher recently asked me to work with my child on waiting to be acknowledged before speaking.”
b. *I can successfully get my child to sit and do homework for 30-minute intervals until it’s complete.”
c. “I have had to replace my child’s eyeglasses twice in the past 3 months because they were lost.”
d. “My child has always struggled to make friends but recently received two playdate invitations from classmates.”
e. While eating a snack after school, my child recalls and explains new material learned in class that day.”

Answer 19

b. *I can successfully get my child to sit and do homework for 30-minute intervals until it’s complete.”
d. “My child has always struggled to make friends but recently received two playdate invitations from classmates.”
e. While eating a snack after school, my child recalls and explains new material learned in class that day.”

Question 20

A client with alcohol use disorder is discussing treatment progress with the clinic nurse. Which client statement does the nurse recognize as a lack of progress toward the goal of abstinence and long-term recovery?
a. *I am pushing myself to finish the last few classes for my college degree so I can make more money than I do now.”
b. “I sometimes attend events that might trigger me to drink, but I call my Alcoholics Anonymous sponsor first.”
c. *My adult children had quit visiting me because I was usually drinking heavily and became belligerent.”
d. “My old job was very stressful, which is what made me start drinking so much. My new job will be easier.”

Answer 20

d. “My old job was very stressful, which is what made me start drinking so much. My new job will be easier.”

Question 21

The nurse is caring for a client with schizophrenia who says, “The voices and noises in my head are very distracting. What can I do?” Which of the following statements by the nurse are appropriate? Select all that apply.
a. *Counting backwards from 100 helps some people tune out the noises.”
b. “Some people find listening to music through headphones to be helpful.”
c. *Talk to your health care provider about modifying your medication.:
d. *Try reading a magazine or book out loud when the voices begin.”
e. When the voices and sounds are present, hum your favorite song.”

Answer 21

a. *Counting backwards from 100 helps some people tune out the noises.”
b. “Some people find listening to music through headphones to be helpful.”
c. *Talk to your health care provider about modifying your medication.:
d. *Try reading a magazine or book out loud when the voices begin.”
e. When the voices and sounds are present, hum your favorite song.”

Question 22

The nurse is caring for a client with schizophrenia who has not showered in several days, is wearing visibly soiled clothing, and has noticeable body odor. The client appears lethargic and has little interest in interacting with others. Based on this assessment, which statement by the nurse is appropriate?
a. “I understand you don’t want to shower, but you can have extra TV time if you do.”
b. “I will leave towels and soap in your room for when you are ready to shower.”
c. “It is time for your shower. I will gather some supplies and help you.”
d. “Please take a shower. You will feel so much better once you freshen up a bit.”

Answer 22

c. “It is time for your shower. I will gather some supplies and help you.”

Question 23

The nurse on an inpatient psychiatric unit is conducting group therapy when a client with schizophrenia stands up and yells, “The dragons are telling me that you all want to hurt me!* What is the nurse’s priority intervention?
a. Promote discussion among group members about how to cope with hallucinations
b. Remove the client from group therapy and assist the client to a quiet area
c. Teach the client to command the voices to go away and leave the client alone
d. Tell the client the dragons must be frightening, although others do not hear or see them

Answer 23

b. Remove the client from group therapy and assist the client to a quiet area

Question 24

The school nurse has concerns about anabolic steroid abuse among students. During assessment of several male students, which findings are consistent with possible anabolic steroid abuse?
a. A student becomes anxious in the locker room and must count the lockers before changing clothes or taking a shower
b. A student declined to be in the team photograph because he believes his chin is too small and he cannot grow a goatee like his peers
c. A student has increasingly aggressive behavior and has begun to wear baggy shirts to conceal gynecomastia
d. A student is experiencing elevated blood glucose, a puffy face, and frequent sore throats

Answer 24

c. A student has increasingly aggressive behavior and has begun to wear baggy shirts to conceal gynecomastia

Question 25

A nurse is caring for adolescent clients who are receiving cognitive-behavioral therapy for anorexia nervosa. Which client statement indicates positive treatment progress? a. I have begun running as a way to manage my stress and anxiety." b. "I was able to tell my mother how I feel when she compares me to my sister." c. "My friends tell me I am pretty because they want me to feel better." d. "When I prepare exotic meals for others it makes me feel special and needed."

Answer 25

b. "I was able to tell my mother how I feel when she compares me to my sister."

Question 26

The employee health nurse is called to the office of a client who is actively experiencing a panic attack. Which of the following actions by the nurse are appropriate during an acute panic attack? Select all that apply, a. Ask the client what happened to precipitate the attack b. Encourage the client to take slow, deep breaths c. Remain in the room with the client d. Speak in a calm, soothing voice using simple statements e. Teach the client new techniques to control the anxiety

Answer 26

b. Encourage the client to take slow, deep breaths c. Remain in the room with the client d. Speak in a calm, soothing voice using simple statements

Question 27

The nurse is evaluating the response of a client who had a disturbed body image following a lower limb amputation and prosthesis placement 2 months ago. Which of the following client statements support an improved body image? Select all that apply. a. "I am planning a romantic weekend getaway with my spouse next month." b. *I am researching required modifications on my car so that I can start driving again." c. *I have requested a transfer from the sales floor to a bookkeeping position at work." d. *I told my friends I want to watch the big game from home instead of our usual sports bar." e. "I used to love going to the mall, but I have started doing my shopping online."

Answer 27

a. "I am planning a romantic weekend getaway with my spouse next month." b. *I am researching required modifications on my car so that I can start driving again."

Question 28

The nurse is caring for a pediatric client with a fracture. When the parents leave the room the child states, "I am afraid to go home. They will be very angry and probably hurt me again." Which of the following communications by the nurse are appropriate? Select all that apply. a. "I need to tell a few other people what happened, but you will be kept safe." b. *I will get you the help you need. Telling someone was the right thing for you to do." c. "It must be sad to fear your parents. Do not worry; they will not be able to hurt you again d. "What happened to cause this? Your parents do not seem to be the type to hurt a child." e. "You are not to blame for what has happened, and you are not in any trouble."

Answer 28

a. "I need to tell a few other people what happened, but you will be kept safe." b. *I will get you the help you need. Telling someone was the right thing for you to do." e. "You are not to blame for what has happened, and you are not in any trouble."

Question 29

The nurse participates in the multidisciplinary evaluation of several clients and understands which of the following clients satisfies the criteria for involuntary admission to the inpatient mental health facility? Select all that apply. a. Client with a personality disorder who spray-painted a neighbor's car with graffiti b. Client with anxiety disorder who has repeatedly threatened to kill a spouse c. Client with bipolar disorder who has not eaten or slept in 3 days d. Client with depression who has stopped reporting to work e. Clint with schizophrenia who has bought a gun and made suicidal threats

Answer 29

b. Client with anxiety disorder who has repeatedly threatened to kill a spouse c. Client with bipolar disorder who has not eaten or slept in 3 days e. Clint with schizophrenia who has bought a gun and made suicidal threats

Question 30

The nurse is caring for a client who recently began taking haloperidol. Which of the following assessment findings should alert the nurse that the client has developed neuroleptic malignant syndrome? Select all that apply. a. High fever b. Mental status changes c. Muscle stiffness d. Peeling skin rash e. Wide changes in blood pressure

Answer 30

a. High fever b. Mental status changes c. Muscle stiffness e. Wide changes in blood pressure

Question 31

Exhibit A graduate nurse (GN) is caring for a client in the mental health unit who was voluntarily admitted and will undergo colonoscopy tomorrow afternoon. Which action by the GN requires the supervising nurse to intervene? Click the exhibit button for additional information. a. Advises the client to listen to music or the television while attempting to fall asleep b. Calls the client's spouse to request a signature on the informed consent document c. Encourages oral fluid intake and provides clear liquids that are not red Of d. Monitors the client's output after administering bowel preparation medications

Answer 31

b. Calls the client's spouse to request a signature on the informed consent document

Question 32

The nurse is caring for an 18-year-old client diagnosed with depression who attempted suicide 4 days ago. Which client behavior is most concerning? a. The client gave a recent model cell phone to another client b. The client has not showered since admission c. The client has slept 10-12 hours each night d. The client requests that the parents not be allowed to visit

Answer 32

a. The client gave a recent model cell phone to another client

Question 33

The nurse on the mental health unit is caring for multiple clients who have the potential for violence against others. Which client behavior is the most concerning for impending violence? a. A client who asks loudly, "How do you expect us to get better when you cancel recreation therapy?" b. A client who is maintaining intense, direct eye contact with the therapist during group therapy c. A client who is moving from chair to chair in the common room while swearing at the television announcer d. A client who states, "This is embarrassing; I always cry when something makes me angry."

Answer 33

c. A client who is moving from chair to chair in the common room while swearing at the television announcer

Question 34

The home health nurse follows up with a client who is 4 weeks postpartum and tearfully states, "I just can't handle all of this. I am so tired that I can't think, and I feel worthless as a mother." Which communication by the nurse is a priority? a. "Do you have any history of depression?" b. *Have you had any thoughts about harming yourself or your baby?" c. *How have you coped with stress in the past?" d. *How many hours of sleep have you been getting on most nights?"

Answer 34

b. *Have you had any thoughts about harming yourself or your baby?"

Question 35

The nurse is caring for a client in the emergency department who was sexually assaulted 1 hour ago. While waiting for the sexual assault nurse examiner to arrive, which of the following actions by the nurse are appropriate? Select all that apply. a. Asks if the client wishes to have anyone present for support b. Assesses the client's level of anxiety and ability to process information c. Assists the client to the bathroom to wash the face and perform oral hygiene d. Ensures that a private care area is available for the assessment and interview e. Provides a hospital gown and places the client's clothing in a biohazard bag

Answer 35

a. Asks if the client wishes to have anyone present for support b. Assesses the client's level of anxiety and ability to process information d. Ensures that a private care area is available for the assessment and interview

Question 36

The clinic nurse receives a call from an adolescent's parent who is concerned that the teenager may be depressed. Which statement by the parent is most concerning to the nurse? a. *After years of enjoying football, my child recently quit playing on the football team. b. "I found empty beer bottles in my child's bedroom several times in the past few weeks." c. *Last week, my child attended the funeral of a classmate who was killed in an accident." d. Yesterday, my child gave away a favorite signed football from a professional player."

Answer 36

d. Yesterday, my child gave away a favorite signed football from a professional player."

Question 37

The clinic nurse is caring for an adolescent client prescribed a back brace for treatment of scoliosis. The client states, "It is embarrassing to wear this in front of my friends at school." Which response by the nurse is appropriate? a. *Don't be embarrassed; some of your friends probably have medical issues, too." b. "How would you feel about having surgery on your back?" c. "It is important to like yourself the way you are and not look to others for approval." d. “What types of reactions have your friends had to your brace?"

Answer 37

d. “What types of reactions have your friends had to your brace?"

Question 38

The clinic nurse evaluates a parent's understanding of home care management for a child diagnosed with attention deficit hyperactivity disorder. Which parent statement indicates a need for the nurse to provide additional instruction? a. "I met with my child's babysitter and teacher to discuss how behavior should be handled." b. "I placed a desk with new school supplies in my child's bedroom to encourage completion of homework." c. "I posted a sign showing the steps of our morning routine in my child's bedroom and bathroom." d. "I use a sticker chart with a reward system to encourage my child to complete chores and tasks on time."

Answer 38

b. "I placed a desk with new school supplies in my child's bedroom to encourage completion of homework."

Question 39

The nurse provides home care for a client with severe physical and mental disabilities. The client's parent is the primary caregiver. Which caregiver statement is most concerning to the nurse? a. "I am considering getting assistance with transportation to medical appointments. b. "I'm so exhausted. All I do is yell at my child, and then I feel guilty about it." c. "My child refuses to go to a special needs day care, even for just one day a week." d. "My siblings help care for my child on weekends so I can go drink a few beers with friends."

Answer 39

b. "I'm so exhausted. All I do is yell at my child, and then I feel guilty about it."

Question 40

The public health nurse is conducting suicide screenings for clients in the community. The nurse understands that which of the following clients are at an increased risk for suicide? Select all that apply. a. 17-year-old client who identifies as bisexual and reports being bullied at school b. 25-year-old client with paraplegia and chronic pain following a recent motor vehicle collision c. 32-year-old client with a history of bipolar disorder and previous suicide attempts d. 37-year-old client with generalized anxiety disorder seeing a psychiatrist for therapy e. 58-year-old client with a history of alcohol dependence who is recently divorced

Answer 40

a. 17-year-old client who identifies as bisexual and reports being bullied at school b. 25-year-old client with paraplegia and chronic pain following a recent motor vehicle collision c. 32-year-old client with a history of bipolar disorder and previous suicide attempts e. 58-year-old client with a history of alcohol dependence who is recently divorced

Question 41

The nurse is caring for a client who was recently admitted to the psychiatric unit due to complications of anorexia nervosa. Which of the following interventions should the nurse include in the plan of care? Select all that apply. a. Assess for suicidal ideation and self-destructive behaviors b. Monitor vital signs, urine output, and skin turgor c. Supervise restroom breaks, especially after meals d. Teach coping mechanism; such as journaling e. Weigh the client each morning prior to any oral intake

Answer 41

a. Assess for suicidal ideation and self-destructive behaviors b. Monitor vital signs, urine output, and skin turgor c. Supervise restroom breaks, especially after meals d. Teach coping mechanism; such as journaling e. Weigh the client each morning prior to any oral intake

Question 42

The nurse is evaluating the effectiveness of newly prescribed clozapine in a client who has schizophrenia. The nurse understands that which of the following clinical data indicate appropriate therapeutic response? Select all that apply. a. Blood pressure is 112/69 mm Hg compared to admission baseline of 142/88 mm Hg b. Client exhibits decreased mumbling and speaking to self while in the dayroom c. Client spontaneously contributes during group therapy and interacts more with peers d. Client stops speaking mid sentence less frequently and is more conversational e. Pulse is 98/min compared to admission pulse of 62/min

Answer 42

b. Client exhibits decreased mumbling and speaking to self while in the dayroom c. Client spontaneously contributes during group therapy and interacts more with peers d. Client stops speaking mid sentence less frequently and is more conversational

Question 43

The nurse is caring for a transgender client. Which question by the nurse demonstrates an understanding of therapeutic communication and gender assessment? a. "Do you consider yourself a man or a woman?" b. What was your assigned gender at birth?" c. "What words would you use to describe your gender?" d. Which name would you like me to call you?"

Answer 43

c. "What words would you use to describe your gender?"

Question 44

The nurse is obtaining health histories from clients in a mental health clinic. The nurse recognizes that which client statement is consistent with symptoms of agoraphobia? a. *Despite years of voice lessons, I feel faint and anxious when I try to sing in the church choir." b. *I do not go into the basement of our home because my heart races if I see a spider and I get numb with anxiety." c. "I was sitting in the park and suddenly became very anxious and felt as though I was having a heart attack." d. "My boyfriend loves outdoor music festivals, but I do not attend them because I get anxious and afraid in crowds."

Answer 44

d. "My boyfriend loves outdoor music festivals, but I do not attend them because I get anxious and afraid in crowds."

Question 45

The adult child of a client with advanced dementia tearfully confides to the nurse, "I'm so exhausted. I have a full-time job that I'm going to lose if I keep missing work, and I can't safely leave my parent alone." Which of the following would be appropriate interventions? Select all that apply. a. Consult the social worker for suspected caregiver neglect b. Discuss the possibility of transitioning to a dementia care facility c. Encourage involvement in a caregiver support group d. Provide information about community adult day care programs e. Suggest asking friends or family for help to allow time for self-care

Answer 45

b. Discuss the possibility of transitioning to a dementia care facility c. Encourage involvement in a caregiver support group d. Provide information about community adult day care programs e. Suggest asking friends or family for help to allow time for self-care

Question 46

The nurse plans care for a client who is exhibiting sundowning behavior in a long-term care facility. Which of the following interventions are appropriate for the nurse to include? Select all that apply. a. Eliminate afternoon caffeine intake b. Limit daytime napping c. Reason with the client when the client refuses care d. Turn on lights and open blinds during the day e. Use a dim night-light in the client's room

Answer 46

a. Eliminate afternoon caffeine intake b. Limit daytime napping d. Turn on lights and open blinds during the day e. Use a dim night-light in the client's room

Question 47

The clinic nurse is caring for a 9-year-old client who was recently diagnosed with type 1 diabetes mellitus. Which of the following statements by the parent indicate acceptance and understanding of the child's disease? Select all that apply. a. *I feel responsible because I put sugar-filled snacks in my child's lunches in the past." b. *I have been encouraging my child to participate in self-administration of insulin shots." c. "I researched symptoms online, and I do not believe that my child has diabetes." d. "I will begin homeschooling my child so that I can better monitor dietary selections." e. *I will promote team sports as long as extra snacks are available and my child can check glucose levels."

Answer 47

b. *I have been encouraging my child to participate in self-administration of insulin shots." e. *I will promote team sports as long as extra snacks are available and my child can check glucose levels."

Question 48

The graduate nurse and the nurse preceptor are planning care for a client with somatic symptom disorder. The client continues to report hip and leg pain although the health care provider has ruled out medical causes. Which of the following statements by the graduate nurse would cause the preceptor to intervene? a. "I will assess the symptom frequency and intensity and the client's concurrent level of stress. b. *I will assist the client to identify the underlying benefits of having the symptoms." c. "If any new symptoms occur, I will report them to the health care provider." d. When the client requests pain medication, I will reinforce the lack of a medical cause for the pain."

Answer 48

d. When the client requests pain medication, I will reinforce the lack of a medical cause for the pain."

Question 49

The nurse precepts a graduate nurse (GN) who will be caring for clients in a mental health care setting using milieu therapy. Which statement by the GN demonstrates a correct understanding of milieu therapy? a. *Clients with active hallucinations benefit from milieu therapy because the other clients can help reorient them." b. "I should not enforce firm rules during milieu therapy because it discourages client participation." c. *I should provide clients in milieu therapy with a schedule of structured activities throughout the day. d. "The highest nursing priority of milieu therapy is forming a therapeutic relationship with each client."

Answer 49

c. *I should provide clients in milieu therapy with a schedule of structured activities throughout the day.

Question 50

The nurse is caring for a client who is dying due to extreme neurological deficits following a head injury. The client's spouse, who has been visiting twice daily, states, "I can't keep visiting and watching my spouse fade away; it is too painful." Which response by the nurse is therapeutic? a. *Although it is painful for you to watch, your spouse can sense your presence and is comforted by it." b. *Focusing on happy memories during your visit, instead of your spouse's condition, may be less painful for you." c. "Perhaps a few days away will help you but stopping visits altogether may cause you to feel guilty later." d. Watching someone that you love die is difficult. What kind of time have you been able to take for yourself?"

Answer 50

d. Watching someone that you love die is difficult. What kind of time have you been able to take for yourself?"