mental health all Flashcards
A nurse is caring for a client who has schizophrenia. The client’s employer call to discuss the client’s condition. Which of the
following is the appropriate nursing action?
a) Contact the facility legal department
b) Consult the client
c) Consult the client’s family
d) Contact the provider
Answer: B
A charge nurse is making room assignments for new client admissions. Which of the follow client’s should the nurse place closest
to the nurse’s station?
a) A client who has moderate-stage Alzheimer’s disease
b) A client who has a history of alcohol use disorder
c) A client who has schizotypal personality disorder
d) A client who has history of dependent personality disorder
Answer: A
A nurse is caring for a school-age child who has a new diagnosis of attention- deficit hyperactivity disorder. The nurse should
anticipate a prescription for which of the following medications.
a) Valproate
b) Lithium
c) Methylphendate
d) Risperidone
Answer: C
A nurse in a mental health facility is reviewing the laboratory results of a client who is taking lithium carbonate. Which of the
following findings places the client at risk for lithium toxicity?
a) Sodium 132 mEq/L
b) WBC 6,000/mm
c) Calcium 10.0 mg/dL
d) Aspartate aminotransferase 40 u/L
Answer: A
A nurse is providing counseling for a family that consists of two parents and their two adolescent children. Which of the following
family members should the nurse identify as acting in the role as a monopolizer?
a) The adolescent daughter who attempts to dominate the discussion
b) The adolescent son who refuses to share his personal feelings
c) The mother who expresses hostility toward her spouse
d) The father who intervenes whenever the siblings argue
Answer: A
A nurse is reviewing the medical record of a client who has anorexia nervosa. Which of the following findings should the nurse
report to the provider? Pt ate 80% of lunch w/ encouragement. Mild Edema to the hands, feet & ankles. Client states, “It feels like my
heart is jumping in my chest.” BP 100/64 mm HG; PR 58/min; RR 16/min; Temp 36.4 (97.5); SaO2 96%; BMI 16
a) Temp
b) Intake
c) Heart Rhythm
d) Edema
Answer: C
A nurse is caring for a client who reports that he is angry with his partner because she thinks he is just trying to gain attention.
When the nurse attempts to talk to the client, he becomes angry and tells her to leave. Which of the following defense mechanisms is
the client demonstrating?
a) Compensation
b) Displacement
c) Denial
d) Rationalization
Answer: C/B (not sure)
A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse see first?
a) A client who has bipolar disorder and is speaking loudly
b) A client who is taking clozapine and reports a sore throat
c) A client who has schizophrenia and is experiencing olfactory hallucinations
d) A client who is taking lithium and reports weight gain
Answer: B
A nurse is preparing for an interprofessional team meeting regarding a newly admitted client who has major depressive disorder.
Which of the following find during the initial assessment is the priority to report to other disciplines?
a) Psychomotor retardation
b) Significant weight loss
c) Poor problem-solving skills
d) Markedly neglected hygiene
Answer: B
A nurse is creating a plan of care for a client who has major depressive disorder. Which of the following interventions should the
nurse include in the plan?
a) Keep a bright light on in the client’s room at night
b) Encourage physical activity for the client during the day
c) Identify and schedule alternative group activities for the client
d) Discourage the client from expressing feelings of anger
Answer: B
A nurse is assessing a client who has anorexia nervosa and began treatment 1 month ago. Which of the following findings
indicates the client’s adherence to the treatment plan?
a) The client’s potassium level is 3.2 mEq/L
b) The client reports following various cooking blogs c) The client’s current BMI is 14
d) The client states she knows she can’t be perfect
Answer: D
A nurse is obtaining a medical history from a client who is requesting a prescription for bupropion for smoking cessation. Which
of the following assessment findings in the client’s history should the nurse report to the provider?
a) Hepatitis B infection
b) Recent head injury
c) Knee arthroplasty 1 month ago
d) Hypothyroidism
Answer: B
A nurse is reviewing the laboratory report of a client who has a panic disorder and is taking clonazepam. Which of the of the
following laboratory results should the nurse report to the provider?
a) Platelets 100,100 mm
b) Hemoglobin 16 g/dL
c) WBC count 8,000/mm
d) RBC count 4.9 million/mm
Answer: A
A nurse is caring for a client who has alcohol use disorder and is experiencing withdrawal. The nurse should monitor the client for which of the following manifestations? a) Decreased heart rate b) Decrease BP c) Hyperthermia d) Hyperglycemia
Answer: C
A nurse in an in-patient facility is caring for a client who has an anxiety disorder. Which of the following actions should the nurse
take while the client is experiencing an acute panic attack?
a) Administer a dose of atomoxetine to the client
b) Administer a dose of alprazolam to the client
c) Encourage the client to watch TV as a distraction
d) Encourage the client to describe their feelings in a journal
Answer: B
A nurse is caring for a client who is undergoing electroconvulsive therapy. Which of the following tasks should the nurse delegate
to an assistive personnel?
a) Give the client atropine 30 mins before the procedure
b) Check the client’s coordination after the procedure
c) Witness the client’s signature on the consent for the procedure
d) Assist the client to ambulate for the first time following the procedure
Answer: D
A nurse is teaching about deep-breathing exercises with a client who reports experiencing intense stress at work. Which of the
following statements by the client indicates by the client indicates an understanding of the teaching?
a) “I will focus on the causes of my stress during the exercise.”
b) “I will inhale through my mouth and exhale through my nose.”
c) “I will hold my breath for 5 or 6 seconds each time.”
d) “I will focus on how the muscles in my stomach feel with each breath.”
Answer: D
A nurse is caring for a client whose partner died about 6 months ago. Which of the following findings is the nurse’s priority?
a) The client frequently recalls negative experiences that occurred during his marriage
b) The client says he feels guilty about not spending more time with his partner
c) The client relates that he is angry that the provider did not save his partner’s life
d) The client states that he is unable to eat more than once a day
Answer: D
A nurse is leading a critical incident stress debriefing with a group of staff members following a mass trauma incident. Which of
the following interventions should the nurse take first?
a) Reassure staff members that the debriefing is confidential
b) Have staff members discuss their involvement in the event
c) Provide stress-management exercises to the staff members
d) Ask staff members to describe their most traumatic memories of the event
Answer: A
A nurse in an alcohol rehabilitation facility is creating discharge plan for clients who has alcohol use disorder. Which of the
following recommendations should the nurse include in the plan?
a) Teach the client to practice systematic desensitization
b) Request a discharge prescription for buprenorphine for the client
c) Contact a close relative of the client to discuss the discharge plan
d) Refer the client to a self-help group
Answer: D
A nurse is providing teaching to a client who is prescribed methylphenidate for ADHD. Which of the following statements by the
client indicates an accurate understanding of this medication’s effects?
a)“I’ll take my medicine at bedtime because it will make me drowsy.”
b)“This medication will help me relax and feel less anxious.”
c) “I need to tell my doctor if I start gaining weight.”
d)“I know that I will be able to think more clearly now.”
Answer: D
A nurse is planning to conduct a support group for adolescents who have cancer. Which of the following actions should the nurse
include during the orientation phase?
a) Manage conflict within the group
b) Encourage the use of problem-solving skills
c) Maintain the group’s focus on identified issues
d) Establish a rapport with group members
Answer: D
A nurse is assessing a client who is restless and constantly mutters to himself. Which of the following findings should the lead the
nurse to suspect delirium?
a) The speech is slow and repetitious
b) The client is unable to recognize objects
c) The client has a flat affect
d) The client’s manifestations develop suddenly delirium
Answer: D
A nurse is caring or a client who is seeking treatment for opioid use disorder. Which of the following actions should the nurse
take? (Exhibit) Client states, “I want to get better. But I don’t want to go through withdrawal.” No history of tobacco use; Client
denies thoughts of self-injury; Urine toxicology: opiates 100mg/mL; Blood alcohol level: 0 mg/dL Hx: of heroin use, denies use of
alcohol or other substances, currently employed part-time
a) Request a prescription for varenicline from the client’s provider
b) Initiate facility procedures for emergency commitment
c) Inform the client about policies for dispensing methadone
d) Assess the client using the CAGE questionnaire
Answer: B
A nurse is caring for a client who receives lamotrigine daily for bipolar disorder and reports a rash on his arm. Which of the
following actions should the nurse take?
a) Ask the client about a recent change in laundry detergent
b) Apply hydrocortisone cream on the client’s rash
c) Withhold the next dose of medication
d) Explain that the medication causes temporary rash
Answer: C
A nurse on a mental health unit placed a client in mechanical restraints after the client assaulted another client. Which of the
following actions should the nurse take?
a) Obtain a prescription for restraints on an as-needed basis
b) Request that the provider renew the prescription for restraints every 8 hrs.
c) Evaluate the client hourly while the restraints are applied
d) Have the provider assess the client within 1 hour after applying the restraints
Answer: D
A nurse is leading a grief support group for bereaved clients. Which of the following client statements should the nurse report to
the provider as an indication of clinical depression?
a) “I don’t know how I could cope if I didn’t have my family’s support.”
b)“It’ll be long time before I’m happy again.”
c) “I don’t feel anything but numbness anymore.”
d) “I feel like I’m angry at the whole world right now.”
Answer: C
A nurse is caring for a client who has schizophrenia and is taking clozapine. Which of the following findings is the priority for the nurse to report to the provider? a) Heart rate 104/min b) Sore throat c) Nausea d) Random blood glucose 130 mg/dL
Answer: B
A nurse is caring for a client in the emergency department who state was beating and sexually assaulted by her partner. After a
rapid assessment, which of the following actions should the nurse plan to take next?
a) Provide a trained advocate to stay with the client b) Offer prophylactic medication to prevent STIs
c) Request a mental health consultation for the client d) Conduct a pregnancy test
Answer: A
A nurse is assessing a client who has delirium. Which of the following findings requires immediate interventions by the nurse?
a) Inappropriate speech patterns
b) Rapid mood swings
c) Command hallucinations
d) Impaired memory
Answer: C
A nurse is assessing a client who recently experiencing the loss of their partner. Which of the following questions is the priority
for the nurse to ask during this situational crisis?
a) “How do you think this event is affecting your life right now?”
b) “Who do you talk to when you need help?”
c) “Are you having thoughts about harming yourself.”
d) “What do you usually do to cope with problems in your life.”
Answer: C
A nurse is caring for a client who states, “I am too embarrassed to tell anymore what I did last night.” Which of the following
responses should the nurse make?
a) “Lots of people feel ashamed to tell their secrets.”
b) “You will feel better if you tell me what you did last night.” c) “Let’s discuss what you feel embarrassed about.”
d) “You shouldn’t feel embarrassed to talk to me.”
Answer: C
A nurse is conducting an admission interview with a new client who tells the nurse, “My life is so stressful. I can’t take it
anymore. ” Which of the following responses should the nurse make first?
a) “Let’s talk more about what you are experiencing.”
b) “Are you thinking of harming yourself?
c) “How have you dealt with stress in the past?”
d) “Tell me what makes you feel stressed.”
Answer: B
A nurse is caring a client who was involuntary committed and is scheduled to receive electroconvulsive therapy (ECT). The client
refuses treatment and will not discuss why with the health care team. Which of the following actions should the nurse take?
a) Inform the client that the ECT does not require client consent
b) Document the client’s refusal of the treatment in the medical record
c) Ask the client’s family to encourage the client to receive ECT
d) Tell the client he cannot refuse the treatment because he was involuntarily committed
Answer: B
A nurse in a mental health facility is caring for a client who is a being aggressive toward other clients. Which of the following
actions is the priority for the nurse to take?
a) Ask the client if he intends to harm others
b) Assist the client to explore techniques to reduce stress
c) Role model healthy ways to express anger
d) Suggest the client make a list of things make him angry
Answer: A
A nurse is assisting with obtained informed consent for a client who has been declared legally incompetent. Which of the
following actions should the nurse take?
a) Explain implied consent to the client’s family.
b) Ask the charge nurse to obtain informed consent.
c) Contact the facility social worker to obtain the consent.
d) Request that the client’s guardian sign the consent.
Answer: D
A nurse is caring for a client who has depression following a recent job loss. Which of the following questions should the nurse
ask to assess the client’s personal coping skills?
a) “How does this situation affect your life?”
b) “How have you dealt with similar situations in the past?
c) “Can you describe how you are currently feeling?”
d) “Do you see your current situation affecting your future?”
Answer: B
A nurse manager is observing a newly licensed nurse preparing an IM medication to a client who is manic and refuses the
medication. Which of the follow actions should the nurse manger take first?
a) Assess the need for physical restraints
b) Demonstrate how to verbally de-escalate the situation
c) Discuss the purpose of the medication with the client
d) Stop the newly licensed nurse from administering the medication
Answer: D
A nurse is caring for a client who is involuntarily admitted for major depressive disorder and refuses to take a prescribed oral anti-
anxiety medication. Which of the following actions should the nurse take?
a) Inform the client that he does not have the right to refused the medication
b) Offer the client the medication at the next scheduled dose time
c) Administer the medication to the client via IM injection
d) Implement consequences until the client takes the medication
Answer: B
A charge nurse is discussing the care of a client who has a substance use disorder with a staff nurse. Which of the following
statements by the staff nurse should the charge nurse identify as countertransference? (Nurse to client)
a) “The client generally shares his feelings during group therapy session.”
b) “The client asked me to go on a date with him but I refused.”
c) “The client is just like my brother who finally overcame his habit.”
d) “The client needs to accept responsibility for his substance use.”
Answer: C
A nurse is caring for a client who has a personality disorder and is using transference to cope. Which of the following behaviors
should the nurse expect? (transference: client to nurse)
a) Refusing to participate in group activities
b) Talking negatively about the staff members
c) Reacting to the nursing as though she were his mother d) Expressing frustration regarding unit rules
Answer: C
A nurse is teaching a newly licensed nurse about contributing factors that can lead to the development of conduct disorder. Which
of the following related to family dynamics should the nurse include in the teaching?
a) The client is the oldest of their siblings
b) The client mother has asthma
c) The client has several siblings
d) The client’s father lives in the client’s home
Answer: C
A nurse is assessing a client who has a history of substance use disorder and states, “People are out to get me.” The client has
tachycardia and hypertension. The nurse should suspect acute toxicity of which of the following substances?
a) Heroin
b) Cocaine
c) Opium
d) Alcohol
Answer: B
A nurse is caring for a client who has borderline personality disorder. Which of the following actions should the nurse take?
a) Provide consistent boundaries for the client
b) Encourage the use of countertransference for the client
c) Demonstrate a sympathetic attitude toward the client when providing care.
d) Maintain consistency in assigning health care staff for client
Answer: D
A nurse is caring for a client who has Alzheimer’s disease. Which of the following findings should the nurse expect?
a) Excessive motor activity
b) Rapid mood swings
c) Failure to recognize familiar objects
d) Altered level of consciousness
Answer: C
A nurse is caring for client who has bipolar disorders and is refusing to take prescribed medications. Which of the following
ethical principles is the nurse displaying when he supports the client’s refusal of medication?
a) Veracity
b) Beneficence
c) Justice
d) Autonomy
Answer: D
A nurse is caring for a school aged child who has conduct disorder and requires wrist restraints. Which of the following actions
should the nurse take?
a) Have the child perform range of motion exercise every 3 hrs.
b) Obtain a prescription for the restraints within 2 of initiating them
c) Ensure three fingers will fit between the child’s wrists and the restraints
d) Monitor the child’s vital signs every 15 min
Answer: D
A home health nurse is caring for a client who is in the continuation phase of major depressive disorder. The client states, “I feel
unmotivated and don’t feel like leaving my home.” Which of the following recommendation should the nurse make to address the
client’s social isolation?
a) Write in a journal daily
b) Join a low-impact exercise class.
c) Practice guided imagery each morning d) Enroll in an online self-help course
Answer: B
A nurse is assessing a client who has anorexia nervosa. Which of the following findings should the nurse expect? (SATA)
a) Lanugo
b) Diarrhea
c) Russell’s sign
d) Bradycardia
e) Hypotension
Answer: A, D, E
A charge nurse is educating a newly licensed nurse about various defense mechanisms. Which of the following examples should
the charge nurse provide when discussing rationalization?
a) A client whose partner died 5 years ago still talks about him in the present tense
b) A client who states she will worry about her grade after she finishes planning a party
c) A client who has stomach pain before presenting a project to his co-workers
d) A client who states she did not get a promotion because her boss doesn’t like her
Answer: D
A nurse is reviewing the medication administration record of a client who has major depressive disorder and a new prescription
for selegiline. The nurse should recognize that which of the following client medications is contraindicated when taken with
selegiline?
a) Calcium carbonate
b) Acetaminophen
c) Warfarin
d) Fluoxetine
Answer: D
A nurse is provider’s office is assessing a school-age child who has a spiral fracture. The parent of the child provides different
accounts of the cause of the injury. Which of the following actions should the nurse take first?
a) Determine the immediate safety needs of the child.
b) Ask the child how the injury occurred
c) Request that the parent leave the room while interview the child d) Report suspected abuse to Child Protective Services
Answer: A
A nurse is caring for a client who is admitted to mental health facility after attempting suicide. Which of the following actions
should the nurse take first?
a) Ask the client to sign a no-suicide contract
b) Encourage the client to participate in group therapy
c) Implement continuous one-to-one observation
d) Establish a rapport to foster trust
Answer: C
A home health nurse visits a client who lost their partner 2 years ago. Which of the following behaviors by the client indicates a
maladaptive grief?
a) The client expresses feelings of guilt
b) The client gives away some of the partner’s belongings
c) The client is unable to perform basic hygiene tasks
d) The client relocates from a nurse to an apartment
Answer: C
A nurse in a long-term care facility is caring for a client. The nurse should identify risk for developing delirium?
a) Neuropathy
b) Bun 16 mg/dL
c) Hypertension
d) WBC count 13,000/mm
Answer: D
A nurse is caring for a client who has a binge eating disorder. Which of the following actions should the nurse take?
a) Offer snacks when the client is hungry
b) Weigh the client every other day
c) Plan a menu with the client
d) Remain with the client for 1 hr. after meals
Answer: D
A nurse is caring for a client who has anorexia nervosa. Which of the following findings requires immediate intervention by the nurse? a) +2 edema of the lower extremities b) BUN 21 mg/dL c) Lanugo covering the body d) Blood pH 7.50
Answer: B
A nurse is providing behavioral therapy for a client who has obsessive-compulsive disorder. The client repeatedly checks that the
doors are locked at night. Which of the following instructions should the nurse give when using thoughts stopping technique?
a) “Ask a family member to check the locks for you at night.”
b) “Keep a journal of how often you check the locks each night.”
c) “Snap a rubber band on your wrist when you think about checking the locks.”
d) “Focus on abdominal breathing whenever you go to heck on the locks.”
Answer: C
A nurse is assessing a client who has depression and takes phenelzine. The client reports eating pepperoni pizza while out on a
pass during lunchtime. Which of the following assessments should the nurse perform?
a) Bowel sounds
b) Blood Pressure
c) Oxygen Saturation
d) Pupil response
Answer: B
A nurse is caring for a client who has an anxiety disorder and is scheduled for a procedure. The client informs the nurse that they
do not want to have the procedure. Which of the following actions should the nurse take?
a) Inform the client that they have the legal right to refuse treatment any time
b) Obtain consent from the client’s family member
c) Encourage the client to have the procedure
d) Request another nurse to review the procedure with the client
Answer: A
A nurse is caring for a client who has borderline personality disorder and has been engaging in self-mutilation. The nurse should
encourage the client to participate in which of the following groups?
a) Dual diagnosis treatment group
b) Desensitization therapy
c) Dialectical behavior treatment group
d) Co-dependents support group
Answer: C
A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse document as positive symptoms of schizophrenia (SATA) a) Auditory Hallucinations b) Decreased motivation c) Delusions of grandeur d) Impaired memory e) Flight of ideas
Answer: A, C, E
A nurse is caring for a client who has just received a terminal cancer diagnosis from his provider. Which of the following actions
should the nurse take?
a) Change the subject when the client becomes upset
b) Discourage the client from forming new relationships
c) Allow the client unlimited time for the grieving process
d) Offer the client advice about various treatment choices
Answer: C
A nurse is developing a behavior contract with a client who has antisocial personality disorder. Which of the following client goals
should the nurse include in the contract?
a) Decrease the number of verbal out bursts
b) Increased self-esteem
c) Use projection during group therapy
d) Use bargaining skills for behavior consequences
Answer: A
A nurse is planning care for a newly admitted client who has anorexia nervosa. Which of the following interventions should the
nurse include in the plan?
a) Negotiate with the client how much weight she should gain each week
b) Weigh the client weekly for the first month
c) Notify the client about designated times for meals
d) Decrease the client’s daily intake of fiber
Answer: C
A nurse has placed a client who has become physically aggressive into seclusion. Which of the following actions should the nurse
take?
a) Document the client’s behaviors every 15 mins
b) Offer the client food and fluids every 2 hrs.
c) Monitor the client’s vital signs every 4 hrs.
d) Obtain the provider’s prescription within 60 min
Answer: A
A nurse is reviewing the medical record of a client who is to begin taking aripiprazole. The nurse should identify that which of the
following findings is contraindication for aripiprazole therapy?
a) Seizure disorder
b) Asthma
c) Hypothyroidism
d) Crohn’s Disease
Answer: D
A nurse is caring for a client who has been taking valporic acid. Which of the following is an expected outcome of the
medication?
a) The client has decreased euphoric mood
b) The client has decreased anxiety.
c) The client reports improved short-term memory
d) The client reports absences of auditory hallucinations
Answer: B
A nurse is a mental health facility is making plans for a client’s discharge. Which of the following interdisciplinary team members
should the nurse contact to assist the client with housing placement?
a) Recreational Therapist
b) Clinical nurse specialist
c) Social worker
d) Occupation Therapist
Answer: C
An older adult is brought to the mental health clinic by her daughter. The daughter reports that her mother is not eating and seems
uninterested in routine activities. The daughter states, “I’m so worried that my mother is depressed.” Which of the following responses
should the nurse make?
a) “Tell me the reasons you think your mother is depressed.”
b) “Everyone gets depressed from time to time.”
c) “You shouldn’t worry about this, because depressive disorder is easily treated.”
d) “Older adults are usually diagnosed with depressive disorder as the age.”
Answer: A
