PRACTICE ASSESSMENT: RN Mental Health Online Practice 2019 B 1. A nurse is talking with a group of parents who have recently experienced the death of a child which of the following actions should the nurse take? • Encour
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PRACTICE ASSESSMENT: RN Mental Health Online Practice 2019 B 1. A nurse is talking with a group of parents who have recently experienced the death of a child which of the following actions should the nurse take? • Encourage the parents to avoid discussing the death of their other children to protect their feelings • Recommend each parent grieve in a private to avoid hindering each other’s healing • Suggest forming a weekly support group for parents who have experienced the death of a child. • Advise the parents to begin counseling if they are still grieving in a few months 2. A nurse in a community Health Center is working with a group of clients who have post- traumatic stress disorder. Which of the following interventions should the nurse include to reduce anxiety among the group members? • Response prevention • Guided imagery • Aversion therapy • Light therapy 3. A nurse is planning care for a client who is to undergo electroconvulsive therapy (ECT). Which of the following actions should the nurse include in the plan? • Administer phenytoin 30 min prior to procedure • Instruct the client to expect a headache following the procedure • Place the client in a four-point restraint prior to the procedure • Monitor the client’s cardiac rhythm during the procedure 4. A nurse is planning prevention strategies for partner violence in the community. Which of the following strategies should the nurse include as a method of secondary prevention? • Provide teaching about the use of positive coping mechanisms • Establish screening programs to identify at risk clients • Refer survivors to intimate partner abuse to a legal advocacy program • Organize rehabilitation therapy for clients who have experienced intimate partner abuse 5. A nurse in a mental health facility is caring for a client who has schizophrenia. Which of the following findings places the client at a greater risk for self-directed injury or injuring others? • Inability to communicate with others • Feelings of absence of self-worth • Lack of motivation to perform daily tasks • Command hallucinations 6. A nurse is caring for a child who is taking methylphenidate. The nurse should monitor the child for which of the following findings as an adverse effect of methylphenidate? • Weight gain • Tinnitus • Tachycardia • Increased salivation 7. A nurse observes a client on a mental health unit pushing on the locked unit door. Which of the following statements should the nurse make? • “It appears as though you would like to open the door.” • “You will feel more comfortable after you've been here for a while.” • “It is ok to not want to be here.” • “You really shouldn't be pushing on the door.” 8. A nurse is assisting a client who has a terminal illness adjust to progressive loss of independence. Which of the following statements by the client indicates acceptance of her illness? • “I am going to order a wheelchair for when I'm unable to walk.” • “I am going to stop paying my bills since I won't be around much longer.” • “I wish you would go take care of somebody who actually needs you.” • “I am sure I'm going to be able to continue to care for myself without help.” 9. A nurse is preparing to participate in an interdisciplinary conference or client who has bipolar disorder. Which of the following behaviors is the priority for the nurse to report to the treatment team? • Calling family members • Spending time alone • Giving away possessions • Excessive crying 10. A nurse is teaching the partner of a client who has bipolar disorder how to identify manifestations of acute mania. Which of the following findings should the clients partner report to the provider? • Obsessive attention to detail • Inability to sleep • Reports of fatigue • Isolation from others 11. A nurse on an acute mental health facility is receiving change of shift report for four clients which of the following clients should the nurse assess first? • A client who does not recognize familiar people • A client who cannot verbalize their needs • A client who is awake and disoriented at night • A client who is experiencing delusions of persecution 12. A nurse is counseling and adolescent who has anorexia nervosa and reports excessive laxative use and a fear of gaining weight. The client states “I'm so fat I can't even stand to look at myself.” Which of the following therapeutic responses demonstrate the nurses use of summarizing? • “You've discussed several concerns about your weight let's go back and talk about your belief that you are fat.” • “You are saying that you think you are fat and are using laxatives because you are afraid of gaining weight.” • “You don't want to look at yourself because you think you are fat.” • “You and I can work together to overcome your fears of gaining weight.” 13. A nurse in a mental health clinic is caring for a client who has post-traumatic stress disorder (PTSD) after returning from military deployment which of the following is the priority action for the nurse to take? • Assist the client to identify personal areas of strength • Encourage the client to talk about experiences during the deployment • Stay with the client when flashbacks occur • Teach the client stress management techniques 14. A nurse is discussing a 12-step-program with a client who has alcohol use disorder and is in an acute care facility undergoing detoxification. Which of the following information should the nurse include in the teaching? • The program will help the client accept responsibility for the disorder • the client should obtain a sponsor before discharge for an increased chance of recovery • the client will need to identify individuals who have contributed to the disorder • The program will need a prescription for the clients provider prior to attendance 15. A client who has a recent diagnosis of bipolar disorder is placed in a room with a client who has severe depression the client who has depression reports to the nurse “My roommate never sleeps and keeps me up, too.” Which of the following actions should the nurse take? • Move the client who has bipolar disorder to a private room • administer sleep medication to the client who has bipolar disorder • move the client who has severe depression to a private room • administer sleep medication to the client who has severe depression 16. A nurse is performing an admission assessment on a client and notices that the client appears withdrawn and fearful to establish a trusting nurse client relationship. Which of the following actions should the nurse take first? • Inform the client that this admission is confidential • Introduce the client to other clients in the dayroom • Assist the client in facilitating behavioral change • Determine coping strategies that the client has used in the past 17. A nurse is teaching coping strategies to a client who is experiencing depression related to partner violence. Which of the following statements by the client indicates an understanding of the teaching? • I will spend extra time at work to keep from feeling depressed • I will talk about my feelings with a close friend • I will be able to learn how to prevent my partner's attacks • I will use meditation instead of taking my anti depressants 18. A nurse is assessing a school age child who experienced the traumatic loss of a parent 8 months ago. Which of the following findings should the nurse identify as an indication of the child is it is experiencing post-traumatic stress disorder (PTSD)? • Clinging behaviors directed toward a teacher • Increased time spending sleeping • Intense focus on schoolwork • Lack of interest in an upcoming holiday 19. A nurse on a mental health unit is caring for a group of clients. Which of the following actions by the nurse is an example of the ethical principle of justice? • Allowing a client to choose which unit activities to attend • Attempting alternative therapies instead of restraints for a client who is combative • Providing a client with accurate information about their prognosis • Spending adequate time with a client who is verbally abusive 20. A nurse is performing a cognitive assessment to distinguish delirium from dementia in a client whose family reports episodes of confusion. Which of the following assessment findings support the nurse’s suspicion of delirium? • Slow onset • Aphasia • Confabulation • Easily distracted 21. A nurse is assessing a client who has bulimia nervosa. The nurse should expect which of the following findings? • Amenorrhea • Lanugo • Cold extremities • Tooth erosion 22. A nurse is teaching the guardians of a client about their adolescent child's diagnosis of bulimia nervosa. Which of the following statements made by the guardian indicates an understanding of their child's illness? • “The disease will increase our child's risk of high blood pressure.” • “It is important for our child to have regular dental checkups.” • “We need to weigh our child daily for several weeks then once per week.” • “Bleeding during our child's periods will increase because of this disease.” 23. A nurse any providers office is interviewing older adult which of the following action should the nurse plan to take? (Click on exhibit button for additional information about the client there are 3 tabs that contain separate categories of data). • Use a screening tool to evaluate the client for depression • ask the provider to decrease the dosage of the client’s blood pressure medication • instruct the client to decrease intake of vitamin B12 • suggest the client go for brisk walk 20 minutes just before bedtime 24. A nurse is caring for an older adult client who is experiencing delirium. Which the following intervention should the nurse include in the client's plan of care? • Offer the client various choices for milk selection • Assign different nursing personnel for each shift • Permit the client to perform daily rituals to decrease anxiety • Maintain an environment that has low lighting 25. A nurse is facilitating a community meeting for acute care clients. One client is constantly talking and using the majority of the group’s time. Which of the following interventions should the nurse implement? • Tell the client to talk less or risk being removed from the meeting • Ask the group members to discuss their feelings about the client’s monopolizing behavior • End the group meeting and take the client aside to discuss the disruptive behavior • Focus on the group members and ignore the client who is doing all the talking 26. A nurse is assessing a family’s dynamics during a counseling session. The nurse should recognize which of the following findings as an indication of a boundary issue? • An adolescent family member who questions parental authority • A family with three generations in the same household • Older children who are responsible for their younger siblings • Two adults and their children from prior relationships in the same household 27. A nurse is admitting a client who has a major depressive disorder and a new prescription for tranylcypromine. Which of the following over-the-counter medications that the client report staking should alert the nurse to a potential adverse reaction? • Lansoprazole • Naproxen • Magnesium hydroxide • Phenylephrine 28. The nurse is receiving change of shift report for four clients. Which of the following client should the nurse plan to see first? • A client who has avoidant personality and refuses to attend group therapy • A client who has bipolar disorder in reports being kidnapped by aliens overnight • A client who's taking bupropion and reports having insomnia the past 2 nights • A client who is taking clozapine and reports of sore throat and chills 29. A nurse is caring for a client who has alcoholic cardiomyopathy. Which of the following laboratory findings should the nurse expect? • Increased creatine phosphokinase (CPK) • Increased low density lipoproteins (LDL) • Decreased fasting blood sugar • Decreased aspartate aminotransferase (AST) 30. A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take? • Orient the client to person place and time • Assist the client with deep breathing exercises • Calm the client by using therapeutic touch • Have the client sit alone in a quiet room 31. The charge nurse on a mental health unit is discussing client’s rights with a newly licensed nurse. Which of the following statements should the charge nurse make? • “Clients can't refuse to take medications if they are admitted involuntarily”. • “You can notify a client’s family if they are admitted involuntarily”. • “Clients who are admitted involuntarily maintain the right to give informed consent for procedures.” • “You can remove a client's privileges if they are admitted involuntarily and refused to attend therapy sessions.” 32. Nurse is planning discharge teaching for a client who has a severe schizoaffective disorder. The nurse should identify which of the following treatment options can offer interdisciplinary services for the client at home? • Community mental Health Center • Mental health day program • Partial hospitalization program • Assertive community treatment 33. A nurse on a mental health unit observes a client who has acute mania hit another client. Which of the following action should the nurse take first? • Call the provider to obtain an immediate prescription for restraint • Prepare to administer benzodiazepine I am • Call for a team of staff members to help with the situation • Check the client who was hit for injuries 34. A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan of care? • Encourage the client to participate in Group therapy • Instruct the client to avoid napping during the day • Offer the client high calorie finger foods frequently • Decrease the client's daily fiber intake 35. A nurse is caring for a child who has conduct disorder and is behaving in a destructive manner, throwing objects, and kicking others. Which of the following therapeutic nursing interventions is the priority? • Encourage expression of feelings • Support the child's attendance at an assertiveness training group • Assist the child to perform relaxation breathing • Reduce environmental stimuli 36. A nurse on a medical surgical unit is assessing a client who sustained injuries 12 hours ago following a motor vehicle crash the client's admission blood alcohol level was 325 mg/dL. Which of the following findings should indicate to the nurse that the client is experiencing alcohol withdrawal? • Somnolence • Blood pressure 154 /96 mm Hg • Pinpoint pupils • Blood glucose 210 mg/dL 37. A nurse is assessing a client who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect? • Sedation • Rhinorrhea • Bradycardia • Hypothermia 38. A nurse in a community Health Center is teaching families of clients who have post-traumatic stress disorder (PTSD) about expected clinical manifestations which of the following manifestation should the nurse include? • Repeatedly talks about the traumatic incident • Sleeps excessively • Experiences feelings of isolation • Uses repetitive speech 39. A nurse is updating the plan of care for a client who has bulimia nervosa and is 5% above their ideal body weight. Which of the following interventions should the nurse include in the plan? • Include a liquid supplement with meals • Identify the clients trigger foods • Allow the client at least 1 hour for each meal • Weigh the client at bedtime each day 40. Nurse is educating a parent of a child who has a new diagnosis of autism spectrum disorder. Which of the following manifestations of the of this disorder should the nurse include in the teaching? • Fear of abandonment • Motor and verbal tics • Hostile behavior • Language delay 41. A nurse is caring for an older adult who begins to cry and states “I knew God would punish me and I deserve this horrible sickness!” Which of the following responses should the nurse make? • “Why do you think you deserve this punishment?” • “Don't worry about being punished by God.” • “Let's talk about what is upsetting you.” • “You shouldn't say things that will upset you so much.” 42. Nurse is reviewing laboratory results for a client who has schizophrenia and is taking clozapine. Which of the following values should the nurse identify as a contraindication for receiving clozapine? • WBC count 2,500/mm^3 • Hgb 11.5 mg/dL • Platelets 150,000/mm^3 • RBC count 3.5 million/mm^3 43. Nurse in a mental health clinic is planning care for four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? • Discuss outpatient resources with a client who has post-traumatic stress disorder • Create a plan of care for a client who is experiencing alcohol withdrawal • Explain sleep hygiene to a client who has insomnia • Stay with a client who has anorexia nervosa for 1 hour after mealtimes 44. Nurse is teaching a group of newly licensed nurses about the use of mechanical restraints. Which of the following information should the nurse include in the teaching? • Complete documentation about the client status every hour while they are in restraints • Maintain the client in restraints for a minimum of 4 hour • Apply restraints when other means of managing a client's behavior have failed • Request the provider assess the client with an 8 hour of application of restraints 45. Nurse is planning discharge teaching with a family member of a client who has a new diagnosis of depression. Which of the following information about relapse should the nurse include? • Additional acute episodes of depression are unlikely following in patient care • Early identification of changes such as decrease social involvement is important • Medication compliance will prevent further need for inpatient hospitalization • It is helpful to regularly reinforce to the client that things will get better 46. Nurse is caring for a client who is in an abusive relationship and is assisting in the development of a safety plan. Which of the following actions is the first component of a safety plan? • Develop a code word that means “time to go.” • Identify signs of escalation of violence • Have a predetermined place to go in an event of violence • Keep a hidden packed bag of necessities 47. Nurse is planning care for a client who has generalized anxiety disorder. Which of the following levels of anxiety should the nurse plan to teach the client relaxation techniques? • Panic • Moderate • Severe • Mild 48. Nurse is assessing a client who has major depressive disorder and has been receiving amitriptyline for 1 week which of the following outcomes should the nurse expect? • Rapid improvement in effect with 30 to 60 minutes after taking the medication • Greater risk of attempting suicide as affect and energy improve • Onset of frequent loose stools • Development of physiologic dependence on the medication 49. A nurse is caring for four clients in an emergency department. The nurse should identify that which of the following clients can give informed consent? • A 17- year- old client who lives with friends • a 50- year- old client who has a blood alcohol level of 80 milligrams per deciliter • a 35- year- old client who has major depressive disorder • a 65 -year- old client who just received a dose of morphine 50. A nurse in an emergency department is caring for a female adolescent who has a diagnosis of bulimia nervosa and had a fainting episode during a ballet performance. Which of the following statements by the parent acknowledges the client’s diagnosis? • “She works so hard at ballet. Will she still be able to perform?” • “She won't let me take the trash from her room I'm concerned about what she has in there.” • “She told me she was tired, so I did her chores for her today.” • “She is happier with her appearance now that she's lost some weight.” 51. Nurse is preparing to discharge to hold an older adult client who attempted suicide. The client lives alone and passed difficulty performing ADL’s. Which of the following referrals should the nurse initiate (select all that apply) • Occupational therapy • Meal delivery services • Speech language pathologist • Physical therapy • Home health services 52. The nurse is reviewing the medication administration record for a client who is experiencing adverse effects of chlorpromazine. The nurse should administer benzotropine and to relieve which of the following adverse effects? • blurred vision • orthostatic hypotension • dry mouth • acute dystonia 53. The nurse is creating a plan of care for a client who has been placed in seclusion after threatening to harm others on the unit which of the following interventions should the nurse include in the plan? • Document the client’s behavior every 8 hours • Limit the client’s fluid intake to 50 mL/hr • Renew the prescription for the client every 4 hour • Toilet the client every 4 hour 54. The nurse is teaching a newly licensed nurse about nursing care plans for clients who have depressive disorders. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? • “I will use the same plan of care and interventions for each client who has depression.” • “Each nurse will develop a separate plan of care for each client who has depression.” • “I will update the plan of care as a client’s manifestations of depression change.” • “An assistive - personnel can use the plan of care for client teaching.” 55. The nurse is preparing to administer diazepam 7.5 IV bolus to a client for alcohol withdrawal. Available is diazepam injection 5 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero. • 1.5 ml 56. A nurse is providing teaching to the partner of a client who is in a rehabilitation program for alcohol use disorder. The nurse should identify that which of the following statements by the client's partner indicates an understanding of the teaching? • “I will avoid social events until my partner has completed treatment.” • “It is important for me to focus my attention on my partner's addiction.” • “I will not take charge of my partners or responsibilities.” • “I want my partner to promise to change addictive behaviors.” 57. A nurse in the emergency department is caring for four clients. Which of the following clients is the nurse required to report as a potential victim of abuse? • High school age child who has bruises on the knees • An older adult client who is bed bound and has a stage IV pressure ulcer • An adolescent who has a vaginal candida infection • A young adult who is pregnant and has a sprained ankle 58. Nurse is caring for a client who gave birth to a stillborn baby. Which of the following statements should the nurse make? • “You probably want to hold your baby.” • “I’ll stay with you just in case you want to talk.” • “I know how you must be feeling.” • “It hurts now but things will be better soon.” 59. A nurse is planning care for a client who has made repeated physical threats toward others on the unit. Although the client does not want to leave the unit, the nurse requests the provider to transfer the client to a unit that is equipped to manage my behavior. Which of the following ethical principles should the nurse apply in this situation? • Nonmaleficence • Veracity • Justice • Autonomy 60. A nurse is assessing a client for risk factors for the development of depression. The nurse should identify that which of the following factors places the client at an increased risk for depression? • The client is married • The client recently received a promotion at work • The client has COPD • The client is male
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