Mental Health Part 1

Question 1

A nurse is assessing a client who is experiencing occasional feelings of sadness because of the recent death of a beloved pet. The client’s appetite, sleep patterns, and daily routine have not changed. How should the nurse interpret the clients behaviors?

1. The client’s behaviors demonstrate mental illness in the form of depression.
2. The client’s behaviors are extensive, which indicates the presence of mental illness.
3. The client’s behaviors are not congruent with cultural norms.
4. The client’s behaviors demonstrate no functional impairment, indicating no mental illness.

Answer 1

4. The client’s behaviors demonstrate no functional impairment, indicating no mental illness.

Rationale: The nurse should assess that the clients daily functioning is not impaired. The client who experiences feelings of sadness after the loss of a pet is responding within normal expectations. Without significant impairment, the clients distress does not indicate a mental illness.

Question 2

At what point should the nurse determine that a client is at risk for developing a mental illness?

1. when thoughts, feelings, behaviors, are not reflective of the DSM-5 criteria
2. When maladaptive responses to stress are coupled with interference in daily functioning.
3. When a client communicates significant distress.
4. When a client uses defense mechanisms as ego protection.

Answer 2

2. When maladaptive responses to stress are coupled with interference in daily functioning.

Rationale: The nurse should determine that the client is at risk for mental illness when responses
to stress are maladaptive and interfere with daily functioning. The DSM-5 indicates that in order
to be diagnosed with a mental illness, daily functioning must be significantly impaired. The
clients ability to communicate distress would be considered a positive attribute

Question 3

Which client should the nurse anticipate to be most receptive to psychiatric treatment?

1. A Jewish, female social worker.
2. A Baptist, homeless male.
3. A Catholic, black male.
4. A Protestant, Swedish business executive.

Answer 3

1. A Jewish, female social worker.

Rationale: The nurse should anticipate that the client of Jewish culture would place a high importance on preventative health care and would consider mental health as equally important as physical health. Women are also more likely to seek treatment for mental health problems than men.

Question 4

A psychiatric nurse intern states, “This client’s use of defense mechanisms should be eliminated.” Which is a correct evaluation of this nurse’s statement?

1. Defense mechanisms can be appropriate responses to stress and need not be eliminated.
2. Defense mechanisms are a maladaptive attempt of the ego to manage anxiety and should always be eliminated.
3. Defense mechanisms, used by individuals with weak ego integrity, should be discouraged and not eliminated.
4. Defense mechanisms cause disintegration of the ego and should be fostered and encouraged.

Answer 4

1. Defense mechanisms can be appropriate responses to stress and need not be eliminated.

Rationale: The nurse should determine that defense mechanisms can be appropriate during times of stress. The client with no defense mechanisms may have a lower tolerance for stress, thus leading to anxiety disorders. Defense mechanisms should be confronted when they impede the client from developing healthy coping skills.

Question 5

During an intake assessment, a nurse asks both physiological and psychosocial questions. The client angrily responds, “I’m here for my heart, not my head problems.” Which is the nurse’s best response?

1. “It’s just a routine part of our assessment. All clients are asked these same questions.”
2. “Why are you concerned about these types of questions?”
3. “Psychological factors, like excessive stress, have been found to affect medical conditions.”
4. “We can skip these questions, if you like. It isn’t imperative that we complete this section.”

Answer 5

3. “Psychological factors, like excessive stress, have been found to affect medical conditions.”

Rationale: The nurse should attempt to educate the client on the negative effects of excessive stress on medical conditions. It is not appropriate to skip physiological and psychosocial questions, as this would lead to an inaccurate assessment.

Question 6

An employee uses the defense mechanism of displacement when the boss openly disagrees with suggestions. What behavior would be expected from this employee?

1. The employee assertively confronts the boss.
2. The employee leaves the staff meeting to work out in the gym.
3. The employee criticizes a coworker.
4. The employee takes the boss out to lunch.

Answer 6

3. The employee criticizes a coworker.

Rationale: The nurse should expect that the client using the defense mechanism displacement would criticize a coworker after being confronted by the boss. Displacement refers to transferring feelings from one target to a neutral or less-threatening target.

Question 7

A fourth-grade boy teases and makes jokes about a cute girl in his class. This behavior should be identified by a nurse as indicative of which defense mechanism?

1. Displacement
2. Projection
3. Reaction formation
4. Sublimation

Answer 7

3. Reaction formation

Rationale: The nurse should identify that the boy is using reaction formation as a defense mechanism. Reaction formation is the attempt to prevent undesirable thoughts from being expressed by expressing opposite thoughts or behaviors. Displacement refers to transferring feelings from one target to another. Rationalization refers to making excuses to justify behavior. Projection refers to the attribution of unacceptable feelings or behaviors to another person. Sublimation refers to channeling unacceptable drives or impulses into more constructive, acceptable activities.

Question 8

Which nursing statement about the concept of neurosis is most accurate?

1. An individual experiencing neurosis is unaware that he or she is experiencing distress.
2. An individual experiencing neurosis feels helpless to change his or her situation.
3. An individual experiencing neurosis is aware of psychological causes of his or her behavior.
4. An individual experiencing neurosis has a loss of contact with reality.

Answer 8

2. An individual experiencing neurosis feels helpless to change his or her situation.

Rationale: The nurse should define the concept of neurosis with the following characteristics: The client feels helpless to change his or her situation, the client is aware that he or she is experiencing distress, the client is aware the behaviors are maladaptive, the client is unaware of the psychological causes of the distress, and the client experiences no loss of contact with reality.

Question 9

Which nursing statement regarding the concept of psychosis is most accurate?

1. Individuals experiencing psychoses are aware that their behaviors are maladaptive.
2. Individuals experiencing psychoses experience little distress.
3. Individuals experiencing psychoses are aware of experiencing psychological problems.
4. Individuals experiencing psychoses are based in reality.

Answer 9

2. Individuals experiencing psychoses experience little distress.

Rationale: The nurse should understand that the client with psychosis experiences little distress owing to his or her lack of awareness of reality. The client with psychosis is unaware that his or her behavior is maladaptive or that he or she has a psychological problem.

Question 10

When under stress, a client routinely uses alcohol to excess. Finding her drunk, her husband yells at the client about her chronic alcohol abuse. Which action alerts the nurse to the client’s use of the defense mechanism of denial?

1. The client hides liquor bottles in a closet.
2. The client yells at her son for slouching in his chair.
3. The client burns dinner on purpose.
4. The client says to the spouse, “I don’t drink too much!”

Answer 10

4. The client says to the spouse, “I don’t drink too much!”

Rationale: The client’s statement “I don’t drink too much!” alerts the nurse to the use of the defense mechanism of denial. The client is refusing to acknowledge the existence of a real situation and the feelings associated with it.

Question 11

Devastated by a divorce from an abusive husband, a wife completes grief counseling. Which statement by the wife should indicate to a nurse that the client is in the acceptance stage of grief?

1. “If only we could have tried again, things might have worked out.”
2. “I am so mad that the children and I had to put up with him as long as we did.”
3. “Yes, it was a difficult relationship, but I think I have learned from the experience.”
4. “I still don’t have any appetite and continue to lose weight.”

Answer 11

3. “Yes, it was a difficult relationship, but I think I have learned from the experience.”

Rationale: The nurse should evaluate that the client is in the acceptance stage of grief because during this stage of the grief process, the client would be able to focus on the reality of the loss and its meaning in relation to life

Question 12

A nurse is performing a mental health assessment on an adult client. According to Maslow’s hierarchy of needs, which client action would demonstrate the highest achievement in terms of mental health?

1. Maintaining a long-term, faithful, intimate relationship.
2. Achieving a sense of self-confidence.
3. Possessing a feeling of self-fulfillment and realizing full potential.
4. Developing a sense of purpose and the ability to direct activities.

Answer 12

3. Possessing a feeling of self-fulfillment and realizing full potential.

Rationale: The nurse should identify that the client who possesses a feeling of self-fulfillment and realizes his or her full potential has achieved self-actualization, the highest level on Maslow’s hierarchy of needs

Question 13

According to Maslow’s hierarchy of needs, which situation on an in-patient psychiatric unit would require priority intervention by a nurse?

1. A client rudely complaining about limited visiting hours.
2. A client exhibiting aggressive behavior toward another client.
3. A client stating that no one cares.
4. A client verbalizing feelings of failure.

Answer 13

2. A client exhibiting aggressive behavior toward another client.

Rationale: The nurse should immediately intervene when a client exhibits aggressive behavior toward another client. Safety and security are considered lower-level needs according to Maslow’s hierarchy of needs and must be fulfilled before other higher-level needs can be met. Clients who complain, have feelings of failure, or state that no one cares are struggling with higher-level needs such as the need for love and belonging or the need for self-esteem.

Question 14

How would a nurse best complete the new DSM-5 definition of a mental disorder? “A health condition characterized by significant dysfunction in an individual’s cognitions, or behaviors that reflects a disturbance in the

1. psychosocial, biological, or developmental process underlying mental functioning.”
2. psychological, cognitive, or developmental process underlying mental functioning.”
3. psychological, biological, or developmental process underlying mental functioning.”
4. psychological, biological, or psychosocial process underlying mental functioning.”

Answer 14

3. psychological, biological, or developmental process underlying mental functioning.”

Rationale: “A health condition characterized by significant dysfunction in an individual’s cognitions, or behaviors that reflects a disturbance in the psychological, biological, or developmental process underlying mental functioning”, is the new DSM 5 definition of a mental disorder.

Question 15

16. A nurse is assessing a client who appears to be experiencing some anxiety during questioning. Which symptoms might the client demonstrate that would indicate anxiety? (Select all that apply.)
17. Fidgeting
18. Laughing inappropriately
19. Palpitations
20. Nail biting
21. Limited attention span

Answer 15

1. Fidgeting
2. Laughing inappropriately
3. Nail biting

Rationale: The nurse should assess that fidgeting, laughing inappropriately, and nail biting are indicative of heightened stress levels. The client would not be diagnosed with mental illness unless there is significant impairment in other areas of daily functioning. Other indicators of more serious anxiety are restlessness, difficulty concentrating, muscle tension, and sleep disturbance.

Question 16

_______________________ is a diffuse apprehension that is vague in nature and is associated with feelings of uncertainty and helplessness.

Answer 16

Anxiety

Rationale: The definition of anxiety is a diffuse apprehension that is vague in nature and is associated with feelings of uncertainty and helplessness. Townsend considers this a core concept.

Question 17

_______________________ is a subjective state of emotional, physical, and social responses to the loss of a valued entity.

Answer 17

Grief

Rationale: The definition of grief is a subjective state of emotional, physical, and social responses to the loss of a valued entity. Townsend considers this a core concept.

Question 18

A depressed client states, “I have a chemical imbalance in my brain. I have no control over my behavior. Medications are my only hope to feel normal again.” Which nursing response is appropriate?

A. “Medications only address biological factors. Environmental and interpersonal factors must also be considered.”
B. “Because biological factors are the sole cause of depression, medications will improve your mood.”
C. “Environmental factors have been shown to exert the most influence in the development of depression.”
D. “Researchers have been unable to demonstrate a link between nature (biology and genetics) and nurture (environment).”

Answer 18

A. “Medications only address biological factors. Environmental and interpersonal factors must also be considered.”

The nurse should advise the client that medications address biological factors, but there are other factors that affect mood. The nurse should educate the client on environmental and interpersonal factors that can lead to depression.

Question 19

.A client diagnosed with major depressive disorder asks, “What part of my brain controls my emotions?” Which nursing response is appropriate?

A. “The occipital lobe governs perceptions, judging them as positive or negative.”
B. “The parietal lobe has been linked to depression.”
C. “The medulla regulates key biological and psychological activities.”
D. “The limbic system is largely responsible for one’s emotional state.”

Answer 19

D. “The limbic system is largely responsible for one’s emotional state.”

The nurse should explain to the client that the limbic system is largely responsible for one’s emotional state. This system is often called the “emotional brain” and is associated with feelings, sexuality, and social behavior. The occipital lobes are the area of visual reception and interpretation. Somatosensory input (touch, taste, temperature, etc.) occurs in the parietal lobes. The medulla contains vital centers that regulate heart rate and reflexes.

Question 20

Which part of the nervous system should a nurse identify as playing a major role during stressful situations?

A. Peripheral nervous system
B. Somatic nervous system
C. Sympathetic nervous system
D. Parasympathetic nervous system

Answer 20

C. Sympathetic nervous system

The nurse should identify that the sympathetic nervous system plays a major role during stressful situations. The sympathetic nervous system prepares the body for the fight-or-flight response. The parasympathetic nervous system is dominant when an individual is in a nonstressful state.

Question 21

Which client statement reflects an understanding of the effect of circadian rhythms on psychopathology?

A. “When I dream about my mother’s horrible train accident, I become hysterical.”
B. “I get really irritable during my menstrual cycle.”
C. “I’m a morning person. I get my best work done in the a.m.”
D. “Every February, I tend to experience periods of sadness.”

Answer 21

C. “I’m a morning person. I get my best work done in the a.m.”

By stating, “I am a morning person.” the client demonstrates an understanding that circadian rhythms may influence a variety of regulatory functions, including the sleep-wake cycle, regulation of body temperature, and patterns of activity. Most humans follow a 24-hour cycle that is largely affected by light and darkness.

Question 22

Which types of adoption studies should a nurse recognize as providing useful information for the psychiatric community?

A. Studies in which children with mentally ill biological parents are raised by adoptive parents who were mentally healthy
B. Studies in which children with mentally healthy biological parents are raised by adoptive parents who were mentally ill
C. Studies in which monozygotic twins from mentally ill parents were raised separately by different adoptive parents
D. Studies in which monozygotic twins were raised together by mentally ill biological parents
E. All of the above

Answer 22

E. All of the above

The nurse should determine that all of the studies could possibly benefit the psychiatric community. The studies may reveal research findings relating genetic links to mental illness. Adoption studies allow comparisons to be made of the influences of the environment versus genetics.

Question 23

Six months after her husband and children were killed in a car accident, a client is diagnosed with ulcerative colitis. The nurse should recognize that this situation validates which study perspective?

A. The study of neuroendocrinology
B. The study of psychoimmunology
C. The study of diagnostic technology
D. The study of neurophysiology

Answer 23

B. The study of psychoimmunology

Psychoimmunology is the branch of medicine that studies the effects of social and psychological factors on the functioning of the immune system. Studies of the biological response to stress hypothesize that individuals become more susceptible to physical illness following exposure to stressful stimuli

Question 24

A withdrawn client diagnosed with schizophrenia expresses little emotion and refuses to attend group therapy. What altered component of the nervous system should a nurse recognize as being responsible for this behavior?

A. Dendrites
B. Axons
C. Neurotransmitters
D. Synapses

Answer 24

C. Neurotransmitters

The nurse should recognize that neurotransmitters play an essential function in the role of human emotion and behavior. Neurotransmitters are targeted and affected by many psychotropic medications.

Question 25

An instructor is teaching nursing students about neurotransmitters. Which term best explains the process of how neurotransmitters released into the synaptic cleft may return to the presynaptic neuron?

A. Regeneration
B. Reuptake
C. Recycling
D. Retransmission

Answer 25

B. Reuptake

The nursing instructor should best explain that the process by which neurotransmitters are released into the synaptic cleft and returned to the presynaptic neuron is by reuptake. Reuptake is the process by which neurotransmitters are stored for reuse.

Question 26

A nurse concludes that a restless, agitated client is manifesting a “fight-or-flight” response. The nurse should associate this response with which neurotransmitter?

A. Acetylcholine
B. Dopamine
C. Serotonin
D. Norepinephrine

Answer 26

D. Norepinephrine

The nurse should associate the neurotransmitter norepinephrine with the “fight-or-flight” response. Norepinephrine produces activity in the sympathetic postsynaptic nerve terminal and is associated with the regulation of mood, cognition, perception, locomotion, sleep, and arousal.

Question 27

A client is admitted to a psychiatric unit with the diagnosis of catatonic schizophrenia. Which of the client’s neurotransmitters should a nurse expect to be elevated?

A. Serotonin
B. Dopamine
C. Gamma-aminobutyric acid (GABA)
D. Histamine

Answer 27

B. Dopamine

The nurse should expect that elevated dopamine levels might be an attributing factor to the client’s current level of functioning. Dopamine functions include regulation of movements and coordination, emotions, and voluntary decision-making ability.

Question 28

A client’s wife of 34 years dies unexpectedly. The client cries often and becomes socially isolated. The client’s therapist encourages open discussion of feelings, proper nutrition, and exercise. What is the best rationale for the therapist’s advice?

A. The therapist is using an interpersonal approach.
B. The client has an alteration in neurotransmitters.
C. It is routine practice to remind clients about nutrition, exercise, and rest.
D. The client is susceptible to illness due to effects of stress on the immune system.

Answer 28

D. The client is susceptible to illness due to effects of stress on the immune system.

The therapist’s advice should be based on the knowledge that the client has been exposed to stressful stimuli and is at an increased risk of developing illness due to the effects of stress on the immune system. The study of this branch of medicine is called psychoimmunology.

Question 29

Which mental illness should a nurse identify as being associated with a decrease in prolactin hormone level?

A. Major depression
B. Schizophrenia
C. Anorexia nervosa
D. Alzheimer’s disease

Answer 29

B. Schizophrenia

Although the exact mechanism is unknown, there may be some correlation between decreased levels of the hormone prolactin and the diagnosis of schizophrenia. Some studies have shown an inverse relationship between prolactin concentrations and symptoms of schizophrenia.

Question 30

Which cerebral structure should a nursing instructor describe to students as the “emotional brain”?

A. The cerebellum
B. The limbic system
C. The cortex
D. The left temporal lobe

Answer 30

B. The limbic system

The limbic system is often referred to as the “emotional brain.” The limbic system is largely responsible for one’s emotional state and is associated with feelings, sexuality, and social behavior.

Question 31

A nurse understands that the abnormal secretion of growth hormone may play a role in which illness?

A. Acute mania
B. Schizophrenia
C. Anorexia nervosa
D. Alzheimer’s disease

Answer 31

C. Anorexia nervosa

A nurse should understand that research has found a correlation between abnormal levels of growth hormone and anorexia nervosa. The growth hormone is responsible for growth in children, as well as continued protein synthesis throughout life.

Question 32

A client is admitted to an emergency department experiencing memory deficits and decreased motor function. What alteration in brain chemistry should a nurse correlate with the presentation of these symptoms?

A. Abnormal levels of serotonin
B. Decreased levels of dopamine
C. Increased levels of norepinephrine
D. Decreased levels of acetylcholine

Answer 32

D. Decreased levels of acetylcholine

The nurse should correlate memory deficits and decreased motor function with decreased levels of acetylcholine. Acetylcholine is a major effector chemical of the autonomic nervous system. Functions of acetylcholine include sleep regulation, pain perception, the modulation and coordination of movement, and memory.

Question 33

A nurse should recognize that a decrease in norepinephrine levels would play a significant role in which mental illness?

A. Mania
B. Schizophrenia
C. Anxiety
D. Depression

Answer 33

D. Depression

The nurse should recognize that a decrease in norepinephrine levels would play a significant role in generating the symptoms of depression. The functions of norepinephrine include the regulation of mood, cognition, perception, locomotion, cardiovascular functioning, and sleep and arousal.

Question 34

Which client diagnosis should a nurse associate with a decrease in gamma-aminobutyric acid (GABA)?

A. Alzheimer’s disease
B. Schizophrenia
C. Panic disorder
D. Depression

Answer 34

C. Panic disorder

The nurse should associate a decrease in GABA with panic disorder. Enhancement of the GABA system is the mechanism of action by which benzodiazepines produce a calming effect, thus reducing anxiety. Alterations in the GABA system are also associated with movement disorders and epilepsy.

Question 35

A nurse should expect that an increase in dopamine activity might play a significant role in the development of which mental illness?

A. Schizophrenia
B. Depression
C. Body dysmorphic disorder
D. Parkinson’s disease

Answer 35

A. Schizophrenia

The nurse should expect that an increase in dopamine activity might play a significant role in the development of schizophrenia. Dopamine functions include regulation of emotions, coordination, and voluntary decision-making ability. Increased dopamine activity is also associated with mania.

Question 36

In response to a student’s question regarding choosing a psychiatric specialty, a charge nurse states, “Mentally ill clients need special care. If I were in that position, I’d want a caring nurse also.” From which ethical framework is the charge nurse operating?

A. Kantianism
B. Christian ethics
C. Ethical egoism
D. Utilitarianism

Answer 36

B. Christian ethics

The charge nurse is operating from a Christian ethics framework. The imperative demand of Christian ethics is to treat others as moral equals by permitting them to act as we do when they occupy a position similar to ours. Kantianism states that decisions should be made based on moral law and that actions are bound by a sense of moral duty. Utilitarianism holds that decisions should be made focusing on the end result being happiness. Ethical egoism promotes the idea that what is right is good for the individual.

Question 37

During a hiring interview, which response by a nursing applicant should indicate that the applicant operates from an ethical egoism framework?

A. “I would want to be treated in a caring manner if I were mentally ill.”
B. “This job will pay the bills, and the workload is light enough for me.”
C. “I will be happy caring for the mentally ill. Working in Med/Surg kills my back.”
D. “It is my duty in life to be a psychiatric nurse. It is the right thing to do.”

Answer 37

B. “This job will pay the bills, and the workload is light enough for me.”

The applicant’s comment reflects an ethical egoism framework. This framework promotes the idea that decisions are made based on what is good for the individual and may not take the needs of others into account.

Question 38

Without authorization, a nurse administers an extra dose of narcotic tranquilizer to an agitated client. The nurse’s coworker observes this action but does nothing for fear of repercussion. What is the ethical interpretation of the coworker’s lack of involvement?

A. Taking no action is still considered an unethical action by the coworker.
B. Taking no action releases the coworker from ethical responsibility.
C. Taking no action is advised when potential adverse consequences are foreseen.
D. Taking no action is acceptable because the coworker is only a bystander.

Answer 38

A. Taking no action is still considered an unethical action by the coworker.

The coworker’s lack of involvement can be interpreted as an unethical action. The coworker is experiencing an ethical dilemma in which a decision needs to be made between two unfavorable alternatives. The coworker has a responsibility to report any observed unethical actions.

Question 39

Group therapy is strongly encouraged, but not mandatory, on an inpatient psychiatric unit. The unit manager’s policy is that clients can make a choice about whether or not to attend group therapy. Which ethical principle does the unit manager’s policy preserve?

A. Justice
B. Autonomy
C. Veracity
D. Beneficence

Answer 39

B. Autonomy

The unit manager’s policy regarding voluntary client participation in group therapy preserves the ethical principle of autonomy. The principle of autonomy presumes that individuals are capable of making independent decisions for themselves and that health-care workers must respect these decisions.

Question 40

Which is an example of an intentional tort?

A. A nurse fails to assess a client’s obvious symptoms of neuroleptic malignant syndrome.
B. A nurse physically places an irritating client in four-point restraints.
C. A nurse makes a medication error and does not report the incident.
D. A nurse gives patient information to an unauthorized person.

Answer 40

B. A nurse physically places an irritating client in four-point restraints.

A tort is a violation of civil law in which an individual has been wronged and can be intentional or unintentional. A nurse who physically places an irritating client in restraints has touched the client without consent and has committed an intentional tort.

Question 41

An involuntarily committed client is verbally abusive to the staff and repeatedly threatening to sue. The client records the full names and phone numbers of the staff. Which nursing action is most appropriate to decrease the possibility of a lawsuit?

A. Verbally redirect the client, and then limit one-on-one interaction.
B. Involve the hospital’s security division as soon as possible.
C. Notify the client that documenting personal staff information is against hospital policy.
D. Continue professional attempts to establish a positive working relationship with the client.

Answer 41

D. Continue professional attempts to establish a positive working relationship with the client.

The most appropriate nursing action is to continue professional attempts to establish a positive working relationship with the client. The involuntarily committed client should be respected and has the right to assert grievances if rights are infringed.

Question 42

Which statement should a nurse identify as correct regarding a client’s right to refuse treatment?

A. Clients can refuse pharmacological but not psychological treatment.
B. Clients can refuse any treatment at any time.
C. Clients can refuse only electroconvulsive therapy (ECT).
D. Professionals can override treatment refusal if the client is actively suicidal or homicidal.

Answer 42

D. Professionals can override treatment refusal if the client is actively suicidal or homicidal.

The nurse should understand that health-care professionals can override treatment refusal when a client is actively suicidal or homicidal. A suicidal or homicidal client who refuses treatment may be a danger to self or others. This situation should be treated as an emergency, and treatment may be performed without informed consent.

Question 43

Which client should a nurse identify as a potential candidate for involuntary commitment?

A. A client living under a bridge in a cardboard box
B. A client threatening to commit suicide
C. A client who never bathes and wears a wool hat in the summer
D. A client who eats waste out of a garbage can

Answer 43

B. A client threatening to commit suicide

The nurse should identify the client threatening to commit suicide as eligible for involuntary commitment. The suicidal client who refuses treatment is a danger to self and requires emergency treatment.

Question 44

Which statement should a nurse identify as correct regarding a clients right to refuse treatment?

1. Clients can refuse pharmacological but not psychological treatment.
2. Clients can refuse any treatment at any time.
3. Clients can refuse only electroconvulsive therapy (ECT).
4. Professionals can override treatment refusal by an actively suicidal or homicidal client.

Answer 44

4. Professionals can override treatment refusal by an actively suicidal or homicidal client.

Question 45

A client diagnosed with schizophrenia refuses to take medication, citing the right of autonomy. Under which circumstance would a nurse have the right to medicate the client against the client’s wishes?

A. When the client makes inappropriate sexual innuendos to a staff member
B. When the client constantly demands inappropriate attention from the nurse
C. When the client physically attacks another client after being confronted in group therapy
D. When the client refuses to bathe or perform hygienic activities

Answer 45

C. When the client physically attacks another client after being confronted in group therapy

The nurse would have the right to medicate a client against his or her wishes if the client physically attacks another client. This client poses a significant risk to safety and is incapable of making rational choices. The client’s refusal to accept treatment can be challenged because the client is endangering the safety of others.

Question 46

A psychiatric nurse working on an inpatient unit receives a call asking if an individual has been a client in the facility. Which nursing response reflects appropriate legal and ethical obligations?

A. Refusing to give any information to the caller, citing rules of confidentiality
B. Refusing to give any information to the caller by hanging up
C. Affirming that the person has been seen at the facility but providing no further information
D. Suggesting that the caller speak to the client’s therapist

Answer 46

A. Refusing to give any information to the caller, citing rules of confidentiality

The most appropriate action by the nurse is to refuse to give any information to the caller. Admission to the facility would be considered protected health information (PHI) and should not be disclosed by the nurse without prior client consent.

Question 47

A client requests information on several medications in order to make an informed choice about management of depression. A nurse should provide this information to facilitate which ethical principle?

A. Autonomy
B. Beneficence
C. Nonmaleficence
D. Justice

Answer 47

A. Autonomy

The nurse should provide the information to support the client’s autonomy. A client who is capable of making independent choices should be permitted to do so. In instances when clients are incapable of making informed decisions, a legal guardian or representative would be asked to give consent.

Question 48

An inpatient psychiatric physician refuses to treat clients without insurance and prematurely discharges those whose insurance benefits have expired. Which violation of an ethical principle should a nurse recognize in this situation?

A. Autonomy
B. Beneficence
C. Nonmaleficence
D. Justice

Answer 48

D. Justice

The nurse should determine that the ethical principle of justice has been violated by the physician’s actions. The principle of justice requires that individuals should be treated equally regardless of race, sex, marital status, medical diagnosis, social standing, economic level, or religious belief.

Question 49

Which situation violates the ethical principle of veracity?

A. A nurse provides a client with outpatient resources to benefit recovery.
B. A nurse refuses to give information to a physician who is not responsible for the client’s care.
C. A nurse tricks a client into seclusion by asking the client to carry linen to the seclusion room.
D. A nurse treats all of the clients equally regardless of illness severity.

Answer 49

C. A nurse tricks a client into seclusion by asking the client to carry linen to the seclusion room.

The nurse who tricks a client into seclusion has violated the ethical principle of veracity. The principle of veracity refers to one’s duty to always be truthful and not intentionally deceive or mislead clients.

Question 50

A client who will be receiving electroconvulsive therapy (ECT) must provide informed consent. Which situation should cause a nurse to question the validity of the informed consent?

A. The client is paranoid.
B. The client is 87 years old.
C. The client incorrectly reports his or her spouse’s name, date, and time of day.
D. The client relies on his or her spouse to interpret the information.

Answer 50

C. The client incorrectly reports his or her spouse’s name, date, and time of day.

The nurse should question the validity of informed consent when the client incorrectly reports the spouse’s name, date, and time of day. This indicates that this client is disoriented and may not be competent to make informed choices.

Question 51

A client diagnosed with schizophrenia receives fluphenazine decanoate (Prolixin Decanoate) from a home health nurse. The client refuses medication at one regularly scheduled home visit. Which nursing intervention is ethically appropriate?

A. Allow the client to decline the medication and document.
B. Tell the client that if the medication is refused, hospitalization will occur.
C. Arrange with a relative to add medication to the client’s morning orange juice.
D. Call for help to hold the client down while the injection is administered.

Answer 51

A. Allow the client to decline the medication and document.

It is ethically appropriate for the nurse to allow the client to decline the medication and provide accurate documentation. The client’s right to refuse treatment should be upheld unless the refusal puts the client or others in harm’s way.

Question 52

Which situation exemplifies both assault and battery?

A. The nurse becomes angry, calls the client offensive names, and withholds treatment.
B. The nurse threatens to “tie down” the client and then does so against the client’s wishes.
C. The nurse hides the client’s clothes and medicates the client to prevent elopement.
D. The nurse restrains the client without just cause and communicates this to family.

Answer 52

B. The nurse threatens to “tie down” the client and then does so against the client’s wishes.

The nurse in this situation has committed both assault and battery. Assault refers to an action that results in fear and apprehension that the person will be touched without consent. Battery is the touching of another person without consent.

Question 53

A geriatric client is confused and wandering in and out of every door. Which scenario reflects the least restrictive alternative for this client?

A. The client is placed in seclusion.
B. The client is placed in a geriatric chair with tray.
C. The client is placed in soft Posey restraints.
D. The client is monitored by an ankle bracelet.

Answer 53

D. The client is monitored by an ankle bracelet.

The least restrictive alternative for this client would be monitoring by an ankle bracelet. The client does not pose a direct dangerous threat to self or others, so neither physical restraints nor seclusion would be justified.

Question 54

A brother calls to speak to his sister who has been admitted to the psychiatric unit. The nurse connects him to the community phone and the sister is summoned. Later the nurse realizes that the brother was not on the client’s approved call list. What law has the nurse broken?

A. The National Alliance for the Mentally Ill Act
B. The Tarasoff Ruling
C. The Health Insurance Portability and Accountability Act
D. The Good Samaritan Law

Answer 54

C. The Health Insurance Portability and Accountability Act

The nurse has violated the Health Insurance Portability and Accountability Act (HIPAA) by revealing that the client had been admitted to the psychiatric unit. The nurse should not have provided any information without proper consent from the client.

Question 55

An inpatient client, whom the treatment team has determined to be a danger to self, gives notice of intention to leave the hospital. What information should the nurse recognize as having an impact on the treatment team’s next action?

A. State law determines how long a psychiatric facility can hold a client.
B. Federal law determines if the client is competent.
C. The client’s family involvement will determine if discharge is possible.
D. Hospital policies will determine treatment team actions.

Answer 55

A. State law determines how long a psychiatric facility can hold a client.

Most states commonly cite that in an emergency a client who is dangerous to self or others may be involuntarily hospitalized.

Question 56

A client is concerned that information given to the nurse remains confidential. Which is the nurse’s best response?

A. “Your information is confidential. It will be kept just between you and I.”
B. “I will share the information with staff members only with your approval.”
C. “If the information impacts your care, I will need to share it with the treatment team.”
D. “You can make the decision whether your physician needs this information or not.”

Answer 56

C. “If the information impacts your care, I will need to share it with the treatment team.”

Basic to the psychiatric client’s hospitalization is his or her right to confidentiality and privacy. When admitted to an inpatient psychiatric facility, a client gives implied consent for information to be shared with health-care workers specifically involved in the client’s care.

Question 57

The nursing staff is discussing the concept of competency. Which information about competency should a nurse recognize as true?

A. Competency is determined with a client’s compliance with treatment.
B. Refusal of medication can initiate an incompetency hearing leading to forced medications.
C. A competent client has the ability to make reasonable judgments and decisions.
D. Competency is a medical determination made by the client’s physician.

Answer 57

C. A competent client has the ability to make reasonable judgments and decisions.

A competent individual’s cognition is not impaired to an extent that would interfere with decision making.

Question 58

A nursing instructor is presenting content on the provisions of the nurse practice act as it relates to their state. Which student statement indicates a need for further instruction?

A. “The nurse practice act provides a list of definitions of important terms including the definition of nursing.”
B. “The nurse practice act lists education requirements for licensure and reciprocity.”
C. “The nurse practice act contains detailed statements that describe the scope of practice for registered nurses (RNs).”
D. “The nurse practice act lists the general authority and powers of the state board of nursing.”

Answer 58

C. “The nurse practice act contains detailed statements that describe the scope of practice for registered nurses (RNs).”

The nurse practice act contains broad, not detailed, statements that describe the scope of practice for various levels of nursing (APN, RN, LPN), not just for the RN. This student statement indicates a need for further instruction.

Question 59

Which is an accurate description of a common law?

A. A common law would be invoked to deal with a nurse who, without justification, threatens a client with restraints.
B. A common law would be invoked to deal with a nurse who touches a client without the client’s consent.
C. A common law would be invoked to deal with a hospital employee who steals drugs, hospital equipment, or both.
D. A common law would be invoked to deal with a nurse’s refusal to provide care for a specific client.

Answer 59

D. A common law would be invoked to deal with a nurse’s refusal to provide care for a specific client.

Common laws apply to a body of principles that evolve from court decisions resolving various controversies. Common law may vary from state to state. Assault (threats) and battery (touch) are governed by civil law. Stealing is governed by criminal law.

Question 60

The experience of being physically restrained can be traumatic. Which nursing intervention would best help the client deal with this experience?

A. Administering a tranquilizing medication before applying the restraints
B. Talking to the client at brief but regular intervals while the client is restrained
C. Decreasing stimuli by leaving the client alone most of the time
D. Checking on the client infrequently, in order to meet documentation requirements

Answer 60

B. Talking to the client at brief but regular intervals while the client is restrained

Restraints are never to be used as punishment or for the convenience of the staff. Connecting with the client by maintaining communication during the period of restraint will help the client recognize this intervention as a therapeutic treatment versus a punishment.

Question 61

A client who will be receiving electroconvulsive therapy (ECT) must provide informed consent. Which situation should cause a nurse to question the validity of the informed consent?

1. The client is paranoid.
2. The client is 87 years old.
3. The client incorrectly reports his or her spouse’s name, date, and time of day.
4. The client relies on his or her spouse to interpret the information.

Answer 61

3. The client incorrectly reports his or her spouse’s name, date, and time of day.

Rationale: The nurse should question the validity of informed consent when the client incorrectly reports the spouse’s name, date, and time of day. This indicates that this client is disoriented and may not be competent to make informed choices.

Question 62

What is the most essential task for a nurse to accomplish prior to forming a therapeutic relationship with a client?

A. To clarify personal attitudes, values, and beliefs
B. To obtain thorough assessment data
C. To determine the client’s length of stay
D. To establish personal goals for the interaction

Answer 62

A. To clarify personal attitudes, values, and beliefs

Question 63

If a client demonstrates transference toward a nurse, how should the nurse respond?

1. Promote safety and immediately terminate the relationship with the client.
2. Encourage the client to ignore these thoughts and feelings.
3. Immediately reassign the client to another staff member.
4. Help the client to clarify the meaning of the relationship, based on the present situation.

Answer 63

4. Help the client to clarify the meaning of the relationship, based on the present situation.

Question 64

What should be the priority nursing action during the orientation (introductory) phase of the nurse-client relationship?

A. Acknowledge the client’s actions and generate alternative behaviors.
B. Establish rapport and develop treatment goals.
C. Attempt to find alternative placement.
D. Explore how thoughts and feelings about this client may adversely impact care.

Answer 64

B. Establish rapport and develop treatment goals.

The priority nursing action during the orientation phase of the nurse-client relationship should be to establish rapport and develop treatment goals. Rapport implies feelings on the part of both the nurse and the client based on respect, acceptance, a sense of trust, and a nonjudgmental attitude. It is the essential foundation of the nurse-client relationship.

Question 65

Which client response should a nurse expect during the working phase of the nurse-client relationship?

A. The client gains insight and incorporates alternative behaviors.
B. The client and nurse establish rapport and mutually develop treatment goals.
C. The client explores feelings related to reentering the community.
D. The client explores personal strengths and weaknesses that impact behaviors.

Answer 65

A. The client gains insight and incorporates alternative behaviors.

The nurse should expect that the client would gain insight and incorporate alternative behaviors during the working phase of the nurse-client relationship. The client may also overcome resistance, problem-solve, and continually evaluate progress toward goals.

Question 66

Which client statement should a nurse identify as a typical response to stress most often experienced in the working phase of the nurse-client relationship?

A. “I can’t bear the thought of leaving here and failing.”
B. “I might have a hard time working with you. You remind me of my mother.”
C. “I can’t tell my husband how I feel; he wouldn’t listen anyway.”
D. “I’m not sure that I can count on you to protect my confidentiality.”

Answer 66

C. “I can’t tell my husband how I feel; he wouldn’t listen anyway.”

The nurse should identify that the client statement “I can’t tell my husband how I feel; he wouldn’t listen anyway” reflects resistance to change, which is a common behavior in the working phase of the nurse-client relationship. The working phase includes overcoming resistant behaviors on the part of the client as the level of anxiety rises in response to discussion of painful issues.

Question 67

A mother who has learned that her child was killed in a tragic car accident states, “I can’t bear to go on with my life.” Which nursing statement conveys empathy?
A. “This situation is very sad, but time is a great healer.”
B. “You are sad, but you must be strong for your other children.”
C. “Once you cry it all out, things will seem so much better.”
D. “It must be horrible to lose a child; I’ll stay with you until your husband arrives.”

Answer 67

D. “It must be horrible to lose a child; I’ll stay with you until your husband arrives.”

The nurse’s response, “It must be horrible to lose a child; I’ll stay with you until your husband arrives,” conveys empathy to the client. Empathy is the ability to see the situation from the client’s point of view. Empathy is considered to be one of the most important characteristics of the therapeutic relationship.

Question 68

If an individual is “two-faced,” which characteristic essential to the development of a therapeutic relationship should a nurse identify as missing?

A. Respect
B. Genuineness
C. Sympathy
D. Rapport

Answer 68

B. Genuineness

The nurse should identify that genuineness is missing in the relationship. Genuineness refers to an individual’s ability to be open and honest and maintain congruence between what is felt and what is communicated. Genuineness is essential to establishing trust in a relationship.

Question 69

On which task should a nurse place priority during the working phase of relationship development?

A. Establishing a contract for intervention
B. Examining feelings about working with a particular client
C. Establishing a plan for continuing aftercare
D. Promoting the client’s insight and perception of reality

Answer 69

D. Promoting the client’s insight and perception of reality

The nurse should place priority on promoting the client’s insight and perception of reality during the working phase of relationship development. Establishing a contract for intervention would occur in the orientation phase. Examining feelings about working with a client should occur in the preinteraction phase. Establishing a plan for aftercare would occur in the termination phase.

Question 70

Which therapeutic communication technique is being used in this nurse-client interaction?
Client: “When I am anxious, the only thing that calms me down is alcohol.” Nurse: “Other than drinking, what alternatives have you explored to decrease anxiety?

A. Reflecting
B. Making observations
C. Formulating a plan of action
D. Giving recognition

Answer 70

C. Formulating a plan of action

The nurse is using the therapeutic communication technique of formulating a plan of action to help the client explore alternatives to drinking alcohol. The use of this technique, rather than direct confrontation regarding the client’s poor coping choice, may serve to prevent anger or anxiety from escalating.

Question 71

A client exhibiting dependent behaviors says, “Do you think I should move from my parent’s house and get a job?” Which nursing response is most appropriate?

1. “It would be best to do that in order to increase independence.”
2. “Why would you want to leave a secure home?”
3. “Let’s discuss and explore all of your options.”
4. “I’m afraid you would feel very guilty leaving your parents.”

Answer 71

3. “Let’s discuss and explore all of your options.”

Rationale: The most appropriate response by the nurse is, “Let’s discuss and explore all of your options.” In this example, the nurse is encouraging the client to formulate ideas and decide independently the appropriate course of action.

Question 72

A mother rescues two of her four children from a house fire. In an emergency department, she cries, “I should have gone back in to get them. I should have died, not them.” What is the nurse’s best response?

1. “The smoke was too thick. You couldn’t have gone back in.”
2. “You’re experiencing feelings of guilt, because you weren’t able to save your children.”
3. “Focus on the fact that you could have lost all four of your children.”
4. “It’s best if you try not to think about what happened. Try to move on.”

Answer 72

2. “You’re experiencing feelings of guilt, because you weren’t able to save your children.”

Rationale: The best response by the nurse is, “You’re experiencing feelings of guilt, because you weren’t able to save your children.” This response uses the therapeutic communication technique of restating what the client has said. This lets the client know whether an expressed statement has been understood or if clarification is necessary.

Question 73

A newly admitted client, diagnosed with obsessive-compulsive disorder (OCD), washes his hands continually. This behavior prevents unit activity attendance. Which nursing statement best addresses this situation?

1. “Everyone diagnosed with OCD needs to control their ritualistic behaviors.”
2. “It is important for you to discontinue these ritualistic behaviors.”
3. “Why are you asking for help, if you won’t participate in unit therapy?”
4. “Let’s figure out a way for you to attend unit activities and still wash your hands.”

Answer 73

4. “Let’s figure out a way for you to attend unit activities and still wash your hands.”

Rationale: The most appropriate statement by the nurse is, “Let’s figure out a way for you to attend unit activities and still wash your hands.” This statement reflects the therapeutic communication technique of formulating a plan of action. The nurse attempts to work with the client to develop a plan without damaging the therapeutic relationship.

Question 74

Which of the following characteristics should be included in a therapeutic nurse-client relationship? (Select all that apply.)

1. Meeting the psychological needs of the nurse and the client
2. Ensuring therapeutic termination
3. Promoting client insight into problematic behavior
4. Collaborating to set appropriate goals
5. Meeting both the physical and psychological needs of the client

Answer 74

2. Ensuring therapeutic termination
3. Promoting client insight into problematic behavior
4. Collaborating to set appropriate goals
5. Meeting both the physical and psychological needs of the client

Rationale: The nurse-client therapeutic relationship should include promoting client insight into problematic behavior, collaboration to set appropriate goals, meeting the physical and psychological needs of the client, and ensuring therapeutic termination. Meeting the nurse’s psychological needs should never be addressed within the nurse-client relationship.

Question 75

The term ________________________ implies special feelings on the part of both the client and the nurse, based on acceptance, warmth, friendliness, common interest, a sense of trust, and a nonjudgmental attitude.

Answer 75

Rapport

Rationale: Rapport implies special feelings on the part of both the client and the nurse, based on acceptance, warmth, friendliness, common interest, a sense of trust, and a nonjudgmental attitude. Establishing rapport may be accomplished by discussing non-health-related topics.

Question 76

___________________ refers to a nurse’s behavioral and emotional response to a client. These responses may be related to unresolved feelings toward significant others from the nurse’s past.

Answer 76

Countertransference

Rationale: Countertransference refers to a nurse’s behavioral and emotional response to a client. These responses may be related to unresolved feelings toward significant others from the nurse’s past or they may be generated in response to transference feelings on the part of the client.

Question 77

Which statement regarding nursing interventions should a nurse identify as accurate?

1. Nursing interventions are independent from the treatment teams goals.
2. Nursing interventions are solely directed by written physician orders.
3. Nursing interventions occur independently but in concert with overall treatment team goals.
4. Nursing interventions are standardized by policies and procedures.

Answer 77

3. Nursing interventions occur independently but in concert with overall treatment team goals.

Rationale: The nurse should understand that nursing interventions occur independently but in concert with overall treatment goals. Nursing interventions should be developed and implemented in collaboration with other health-care professionals involved in the client’s care.

Question 78

Within the nurse’s scope of practice, which function is exclusive to the advanced practice psychiatric nurse?

1. Teaching about the side effects of neuroleptic medications
2. Using psychotherapy to improve mental health status
3. Using milieu therapy to structure a therapeutic environment
4. Providing case management to coordinate continuity of health services

Answer 78

2. Using psychotherapy to improve mental health status

Rationale: The advanced practice psychiatric nurse is authorized to use psychotherapy to improve mental health. This includes individual, couples, group, and family psychotherapy. Education, case management, and milieu therapy can be provided by registered psychiatric mental health nurses.

Question 79

The nurse should recognize which acronym as representing problem-oriented charting?

1. SOAPIE
2. APIE
3. DAR
4. PQRST

Answer 79

1. SOAPIE

Rationale: The acronym SOAPIE represents problem-oriented charting, which reflects the subjective, objective, assessment, plan, implementation, and evaluation format. Used in nursing, nursing diagnoses (problems) are identified on a written plan of care, with appropriate nursing interventions described for each.

Question 80

Which tool would be appropriate for a nurse to use when assessing mental acuity prior to and immediately following electroconvulsive therapy (ECT)?

1. CIWA scale
2. GGT
3. MMSE
4. CAPS scale

Answer 80

3. MMSE

Rationale: The MMSE, or mini mental status exam, would be the appropriate tool to use to assess the mental acuity of a client prior to and immediately following ECT. The CIWA scale, or clinical institute withdrawal assessment scale, would be used to assess withdraw from substances such as alcohol. The CAPS refers to the clinician-administered PTSD scale and would be used to assess signs and symptoms of PTSD. The GGT test is a blood test used to assess gamma-glutamyl transferase levels, which may be an indication of alcoholism.

Question 81

What is being assessed when a nurse asks a client to identify name, date, residential address, and situation?

1. Mood
2. Perception
3. Orientation
4. Affect

Answer 81

3. Orientation

Rationale: The nurse should ask the client to identify name, date, residential address, and situation to assess the clients orientation. Assessment of the clients orientation to reality is part of a mental status evaluation.

Question 82

Prayer group members at a local Baptist church are meeting with a poor, homeless family whom they are supporting. Which member statement is an example of Yalom’s curative group factor of altruism?

1. “I’ll give you the name of a friend that rents inexpensive rooms.”
2. “The last time we helped a family, they got back on their feet and prospered.”
3. “I can give you all of my baby clothes for your little one.”
4. “I can appreciate your situation. I had to declare bankruptcy last year.”

Answer 82

3. “I can give you all of my baby clothes for your little one.”

Yalom’s curative group factor of altruism occurs when group members provide assistance and support to each other that creates a positive self-image and promotes self-growth. Individuals gain self-esteem through mutual caring and concern.

Question 83

During an inpatient educational group, a client shouts out, “This information is worthless. Nothing you have said can help me.” These statements indicate to a nurse leader that the client is assuming which group role?

1. The group role of aggressor
2. The group role of initiator
3. The group role of gatekeeper
4. The group role of blocker

Answer 83

1. The group role of aggressor

Rationale: The nurse should identify that the client is assuming the group role of the aggressor. The aggressor expresses negativism and hostility toward others in the group or to the group leader and may use sarcasm in an effort to degrade the status of others.

Question 84

During a group session, which client statement demonstrates that the group has progressed to the middle, or working, phase of group development?

1. “It’s hard for me to tell my story when I’m not sure about the reactions of others.”
2. “I think Joe’s Antabuse suggestion is a good one and might work for me.”
3. “My situation is very complex, and I need professional, not peer, advice.”
4. “I am really upset that you expect me to solve my own problems.”

Answer 84

2. “I think Joe’s Antabuse suggestion is a good one and might work for me.”

Rationale: The nurse should recognize that group members have progressed to the working phase of group development when members begin to look to each other instead of to the leader for guidance. Group members in the working phase begin to accept criticism from each other and use it constructively to create change.

Question 85

Which group leader activity should a nurse identify as being most effective in the final, or termination, phase of group development?

1. The group leader establishes the rules that will govern the group after discharge.
2. The group leader encourages members to rely on each other for problem solving.
3. The group leader presents and discusses the concept of group termination.
4. The group leader helps the members to process feelings of loss.

Answer 85

4. The group leader helps the members to process feelings of loss.

Rationale: The most effective intervention in the final, or termination, phase of group development would be for the group leader to help the members to process feelings of loss. The leader should encourage the members to review the goals and discuss outcomes, reminisce about what has occurred, and encourage members to provide feedback to each other about progress.

Question 86

Which of the following behavioral skills should a nurse implement when leading a group that is functioning in the orientation phase of group development? Select all that apply)

A. Encouraging members to provide feedback to each other about individual progress
B. Ensuring that rules established by the group do not interfere with goal fulfillment
C. Working with group members to establish rules that will govern the group
D. Emphasizing the need for and importance of confidentiality within the group

Answer 86

B. Ensuring that rules established by the group do not interfere with goal fulfillment
C. Working with group members to establish rules that will govern the group
D. Emphasizing the need for and importance of confidentiality within the group

Question 87

Order the following leadership expectations that occur in the three phases of the group development process.

_____The leader encourages members to provide feedback to each other about individual progress and to review goals and discuss outcomes.
_____The leader promotes an environment of trust and ensures that rules established by the group do not interfere with fulfillment of the goals.
_____The leader helps to resolve conflict and fosters cohesiveness, while ensuring that members do not deviate from the intended task.

Answer 87

The correct order is 3, 1, 2

Question 88

While conducting the brief mental status evaluation in a client, the nurse evaluates various areas of mental function such as orientation to time, ability to concentrate, and abstract thinking by questioning the client. Which questions posed by the nurse will enable the nurse to evaluate these areas of mental function? Select all that apply.

1.
“What year is it?”

2.
“Where are you now?”

3.
“What does this mean: ‘No use crying over spilled milk’?”

4.
“Name the months of the year in reverse, starting with December.”

5.
“Repeat these words now: bell, book, and candle.”

Answer 88

1.
“What year is it?”

3.
“What does this mean: ‘No use crying over spilled milk’?”

4.
“Name the months of the year in reverse, starting with December.”