RN Mental Health Online practice A
1. A nurse is caring for a client who has schizophrenia in a mental health facility. Which of the following places the client at greatest risk for self-directed injury or injuring othe
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RN Mental Health Online practice A
1. A nurse is caring for a client who has schizophrenia in a mental health facility. Which of the following places the client at greatest risk for self-directed injury or injuring others?
a. Inability to communicate with others
b. Feelings of absence of self-worth
c. Lack of motivation to perform daily tasks
d. Command hallucinations (A client who has schizophrenia and is experiencing command hallucinations may be told to hurt himself or others. Therefore, a client who is experiencing command hallucinations is at greatest risk for self-directed injury or injuring others)
2. A nurse is performing an assessment on a 78-year-old client who has injuries consistent with suspected abuse. Which of the following statements indicates the greatest potential risk factor for abuse?
a. “My children manage my finances, but I still have to sign the checks.”
b. “My son enjoys a couple of drinks each night to unwind.”
c. “My daughter-in-law is expecting another baby soon.”
d. “I plan on living on y own with the help of home health services.”
3. A nurse is obtaining a health history during a client’s admission to a mental health facility. The client begins to talk on her cell phone. When the client finishes talking, she reports to the nurse “That was the president, I leave in the morning on my new mission.” Which of the following is an appropriate response?
a. “Do you want to leave so soon?”
b. “I do not think the president will need you on this mission.”
c. “How long have you been having conversations with the president?”
d. “I think you need to talk to your provider about the mission.”
4. A client recently diagnosed with bipolar disorder is placed in a room with a client who has severe depression reports to the nurse, “That man in my room never sleeps and he keeps me up, too.” Which of the following is an appropriate intervention for the nurse to take?
a. Move the client who has bipolar disorder to private room (clients who have bipolar disorder can disrupt the therapeutic milieu for other clients; therefore, the nurse should move this client to a private room)
b. Administer sleep medication to the client who has bipolar disorder (not an appropriate intervention)
c. Move the client who has severe depression to a private room (client who have severe depression are often at risk for self-harm and feel isolated; therefore, the nurse should not move this client to a private room)
d. Administer sleep medication to the client who has severe depression
5. The nurse is caring for a client who has anorexia nervosa. Which of the following criteria requires hospitalization?
a. Weight loss 10% of total body weight (weight loss over 30% of total body weight in six months)
b. Temperature of 35.6˚C (96.1˚F)(severe hypothermia (temperature lower than 96.8˚F) due to loss of subcutaneous tissue or dehydration requires hospitalization)
c. Serum potassium 3.8 mEq/L (WNL)
d. Heart rate 54/min (HR is less than 40/min)
6. A nurse is caring for a client whose child recently died in motor vehicle crash and states. “I just want to join him.” Which of the following is the nurse’s priority response?
a. “You may find it helpful to talk about your experience with a support person.”
b. “Would you like me to stay with you so you don’t feel alone?”
c. “Are you thinking about harming yourself?”
d. “What you have gone through must be very difficult.”
7. A nurse is caring for a client receiving imipramine for depression. For which of the following adverse effects should the nurse monitor?
a. Vertigo
b. Decreased appetite
c. Bradycardia
d. Urinary retention
8. A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the following medications should the nurse administer?
a. Methadone
b. Disulfiram
c. Naltrexone
d. Chlordiazepoxide (Librium)
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