ATI Mental Health A B and C Graded

ATI Mental Health A,B& C 1) A nurse is teaching a client who has schizophrenia about her new prescription for risperidone. Which of the following statements should the nurse include in the teaching? a. “You shoul ...

ATI Mental Health A,B& C 1) A nurse is teaching a client who has schizophrenia about her new prescription for risperidone. Which of the following statements should the nurse include in the teaching? a. “You should continue this medication if you develop muscle rigidity”. b. “You will experience weight loss while taking this medication.” c. “You will notice your symptoms improve within 24 hours of taking this medication.” d. “You should increase your consumption of complex carbohydrates.” 2) A nurse is admitting a client who has generalized anxiety disorder. Which of the following actions should the nurse plan to take first? a. Provide the client with a quiet environment b. Determine how the client handles stress. c. Teach the client to use guided imagery. d. Ask the client to identify her strengths 3) A nurse is conducting an admission interview with a client who is experiencing mania. Which of the following should the nurse report to the provider? a. States that he hasn’t bathed in 2 days b. Reports eating twice in the past two weeks. c. Makes inappropriate sexual comments. d. Speaks in rhyming sentences. 4) A nurse is planning care for a client who has obsessive-compulsive disorder. Which of the following recommendation should the nurse include in the clients plan of care? a. Validation therapy b. Thought stopping c. Operant conditioning d. Reality orientation therapy 5) A nurse is caring for a client who has bipolar disorder and is experiencing a manic episode. Which of the following actions should the nurse take? a. Encourage the client to join group activities b. Dim the lights in the clients room c. Provide detailed explanations to the client d. Administer methylphenidate 6) A nurse is leading a crisis intervention group for adolescents who witnessed the suicide of a classmate. Which of the following actions should the nurse take first. a. Initiate referrals b. Review community resources c. Identify prior coping skills d. Discuss the importance of confidentiality 7) A nurse overhears a client saying, "I am a spy, a spy for the FBI. I am an I, an eye for an eye in the sky. Sky is up high." The nurse should document the client's statement as which of the following speech alterations? a. Echolalia b. Word salad c. Neologism d. Clang association 8) An older adult client is brought to the mental health clinic by her daughter. The daughter reports that her mother is not eating and seems uninterested in routine activities. The daughter states "I'm so worried that my mother is depressed" which of the following responses should the nurse make? a. Everyone gets depressed from time to time. b. You shouldn't worry about this because depressive disorder is easily treated. c. Older adults are usually diagnosed with depressive disorder as they age. d. Tell me the reasons you think your mother is depressed. 9) A nurse is planning care for an adolescent who has autism spectrum disorder. Which of the following outcomes should the nurse include in the plan care? a. Meets own needs without manipulating others. b. Initiates social interactions with caregivers. c. Changes behavior as a result of peer pressure. d. Acknowledges his delusions are not real. 10) A nurse is providing behavior therapy for a client who has obsessive-compulsive disorder. The client repeatedly checks that the doors are locked at night. Which of the following instructions should the nurse give the client when using thought stopping technique? a. Snap a rubber band on your wrist when you think about checking the locks. b. Ask a family member to check the locks for you at night. c. Focus on abdominal breathing whenever you go to check the locks. d. Keep a journal of how often you check the locks each night. 11) A nurse is caring for a client who is starting treatment for substance use disorder. Which of the following actions indicate the nurse is practicing the ethical principle of nonmaleficence? a. Provide the client with quality care regardless of their ability to pay for treatment. b. Educating the client about legal rights concerning treatment. c. Withholding the prescribed medication that is causing adverse effects for the client. d. Being truthful with the client about the manifestations of withdrawl. 12) A nurse in a group home facility is caring for a client who is developmentally disabled. The client has been stealing belongings from other clients. Which of the following techniques should the nurse use? a. Crisis intervention to decrease anxiety. b. Aversion therapy to provide distraction c. Positive reinforcement to increase desired behavior. d. Systematic desensitization to extinguish the behavior. 13) A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take? a. Ask the client to discuss precipitating events b. Speaks to the client in a high-pitched voice. c. Place the client in seclusion d. Have the client breathe into a paper bag. 14) The nurse is caring for a client following a physical assault. The client states "I don’t remember what happened to me." The nurse should recognize that the client is using which of the following defense mechanisms? a. Repression b. Displacement c. Rationalization d. Denial 15) A nurse is caring for a client who has anorexia nervosa. Which of the following findings require immediate intervention by the nurse? a. +2 edema of the lower extremities b. BUN 21 mg/dL c. Lanugo covering the body d. Blood pH 7.60 16) A nurse is caring for a client in a mental health facility. The client is agitated and threatens to harm herself and others. Which of the following is the priority intervention? a. Place the client in restraints b. Administer an anti-anxiety medication to the client c. Put the client in seclusion d. Set limits on the client's behavior 17) Dosage Calculation Question. 18) A nurse is caring for a client who was involuntarily committed and is scheduled to receive electroconvulsive therapy (ECT). The client refuses the treatment and will not discuss why with the health care team. Which of the following actions should the nurse take? a. Ask the clients family to encourage the client to receive ECT b. Inform the client that ECT does not require a consent. c. Document the client's refusal of the treatment in the medical record. d. Tell the client he cannot refuse the treatment because he was involuntarily committed. 19) A nurse in the emergency department is caring for a client who reports feeling sad, worthless, and hopeless 9 months after the death of her son. Which of the following actions should the nurse take first? a. Request a mental health consult for the client. b. Ask the client if she has thought about harming herself. c. Encourage the client to attend a grief support group. d. Discuss the clients coping skills. 20) A nurse is caring for a client who has borderline personality disorder and has been engaging in self- mutilation. The nurse should encourage the client to participate in which of the following groups. a. Dual diagnosis treatment group b. Dialectical treatment group c. Desensitization therapy d. Co-dependents support group. 21) The nurse is reviewing the medication administration record of a client who has schizophrenia. The nurse should plan to initiate the Abnormal Involuntary Movement Scale to monitor for adverse effects of which of the following medications.? a. Amantadine b. Diphenhydramine c. Benztropine d. Haloperidol 22) A nurse is counseling a client following the death of a clients partner 8 months ago. Which of the following client statements indicates maladaptive grieving? a. I am so sorry for the times I was angry with my partner. b. I find myself thinking about my partner often. c. I still don't feel up to returning to work. d. I like looking at his personal items in the closet. 23) A nurse is caring for a client who has borderline personality disorder. Which of the following outcomes should the nurse include in the treatment plan? a. The client will report a decrease in hallucinations. b. The client will communicate needs c. The client will verbalize improved mood d. The client will attend to personal hygiene. 24) A nurse is caring for a client who is prescribed massage therapy to treat panic disorder. The client states "I can't stand to be touched by another person." Which of the following responses should the nurse make? a. Why don’t you like to be touched by others b. Don’t worry about it. Your anxiety will lessen once the massage begins. c. I will tell your provider you would like a treatment other than a massage. d. I will request that the massage therapist wear gloves during your treatment. 25) A nurse is creating a plan of care for a client who has major depressive disorder. Which of the following interventions should the nurse include in the plan? a. Encourage physical activity for the client during the day b. Discourage the client from expressing feelings of anger c. Keep a bright light on in the client's room at night. d. Identify and schedule alternative group activities for the client. 26) A nurse is providing counseling for a family that consists of two parents and their two adolescent children. Which of the following family members should the nurse identify as acting in the role as the monopolizer? a. The mother who expresses hostility toward her spouse. b. The adolescent son who refuses to share personal feelings. c. The father who intervenes whenever the siblings argue. d. The adolescent daughter who attempts to dominate the conversation. 27) A nurse is developing a teaching plan for the family of an older adult client who is to receive transcranial magnetic stimulation. Which of the following information should the nurse include in the teaching plan? a. The client might have a headache after treatment. b. The client will experience seizure during treatment. c. The client will require intubation after treatment. d. The client is at risk for aspiration during treatment. 28) A nurse is providing teaching about disulfiram to a client who has a history of alcohol use. Which of the following instructions should the nurse include in the teaching? (Select all that apply) a. “You will need to take the medication once daily” b. “you will receive treatment in an inpatient setting” c. “You should avoid using mouthwash that contains alcohol” d. “you should avoid drinking carbonated beverages while taking the medication” e. “you can expect to develop a physical dependence to the medication” 29) A nurse is caring for a client who is in the manic phase of bipolar disorder. Which of the following actions should the nurse take? a. Avoid power struggles by remaining neutral b. Allow the client to set limits for his behavior c. Provide in-depth explanation of nursing expectations d. Encourage the client to participate in group activities 30) A nurse is assessing a young adult female client for schizophrenia. Which of the following findings should the nurse identify as a risk factor for this condition? a. Environmental stress b. Gender c. Depression d. Birth order 31) A nurse is providing discharge teaching about manifestations of relapse to the family of a client who has schizophrenia. Which of the following information should the nurse include in the teaching? a. The client exhibits an inflated sense of self b. The client develops an inability to concentrate c. The client increases participation in social activities d. The client begins sleeping more than usual 32) A nurse is assessing a client who is restless and constantly mutters to himself. Which of the following findings should lead the nurse to suspect delirium? a. The client is unable to recognize objects. b. The client manifestations developed suddenly c. The client has a flat affect d. The client’s speech is slow and repetitious 33) A nurse is caring for a client in an inpatient mental health facility. The client tells the nurse that the government is reading her mail. Which of the following responses should the nurse make? a. “ You know that’s not true, because it is against the law for others to read your mail” b. “All of your letters come sealed, so that seems unlikely” c. “It must be frightened to think that someone is reading your mail” d. “Why do you think the government wants to read your mail?” 34) A nurse is assessing a client who has neuroleptic malignant syndrome. Which of the following clinical findings should the nurse expect? a. Heart rate 48/min b. Temperature 40 C (104 F) c. WBC 3,000/mm3 d. Hypotonicity 35) A nurse is reviewing the medical record of a client who is taking clozapine. For which of the following findings should the nurse withhold the medication and notify the provider? (Click on the “Exhibit” button for additional information about the client. There are three tabs that contain separate categories of data.) a. WBC count b. Blood glucose level c. Report of photosensitivity d. Heart Rate 36) A nurse is caring for a client who has personality disorder and is using transference to cope. Which of the following behaviors should the nurse expect? a. Talking negatively about other staff members b. Expressing frustration regarding unit rules c. Reacting to the nurse as though she were his mother d. Refusing to participate in group activities 37) A nurse in a mental health facility is caring for a newly admitted client. Which of the following resources should the nurse recommend to help the client adapt to the health care setting? a. A community meeting b. A medication group c. A self-help meeting d. A symptom-management group 38) A nurse is assisting with obtaining informed consent for a client who has been declared legally incompetent. Which of the following actions should the nurse take? a. Request that the client’s guardian sign the consent b. Ask the charge nurse to obtain informed consent c. Contact the facility social worker to obtain the consent d. Explain implied consent to the client’s family 39) A nurse is caring for a client who has cocaine use disorder. Which of the following manifestations should the nurse expect the client to have during withdrawal? a. Hand tremors b. Rapid speech c. Fatigue d. Seizures 40) A nurse is providing teaching about disorder management for a client who has posttraumatic stress disorder (PTSD). Which of the following statements should the nurse include in the teaching? a. “Avoiding stimuli that trigger memories of the trauma can help you overcome your PTSD” b. “Talking about the traumatic experience is recommended” c. “Response prevention is an effective treatment for PTSD” d. “You should try to limit the number of hours that you sleep each day” 41) A nurse is assessing a client who has bipolar disorder and is taking lamtropine. Which of the following findings is the nurse’s priority? a. Thyroid-stimulating hormone (TSH) 4.0 microunits/mL b. Alanine transaminase (ALT) 20 IU/L c. Skin rash d. Epistaxis 42) A nurse is caring for a client who has schizophrenia and displays severe negative symptoms of the disorder. Which of the following actions should the nurse take? a. Manage the client’s loud, rambling, and incoherent communication patterns b. Direct the client to perform her own daily hygiene and grooming tasks c. Assist the client to identify somatic and thought-broadcasting delusions d. Use medication to decrease frequency of auditory and visual hallucination. 43) A nurse is beginning a therapeutic relationship with a client. The nurse should plan to accomplish which of the following tasks during the working phase? a. Inform the client about confidentiality rights b. Establish boundaries between the nurse and the client c. Set short and long-term objectives for the future d. Evaluate progress toward predetermined goals 44) A nurse in a mental health facility is making plans for a client’s discharge. Which of the following interdisciplinary team members should the nurse contact to assist the client with housing placement? a. Clinical nurse specialist b. Recreational therapist c. Occupational therapist d. Social worker 45) A nurse is caring for a client who reports that he is angry with his partner because she thinks he is just trying to gain attention. When the nurse attempts to talk to the client, he becomes angry and tells her to leave. Which of the following defense mechanism is the client demonstrating? a. Denial b. Displacement c. Compensation d. Rationalization 46) A charge nurse is discussing the care of a client who has a substance use disorder with a staff nurse. Which of the following statements by the staff nurse should the charge nurse identify as countertransference? a. “The client is just like my brother who finally overcame his habit” b. “The client needs to accept responsibility for his substance use” c. “The client generally shares his feelings during group therapy session” d. “The client asked me to go on a date with him, but I refuse” 47) A nurse is caring for a client who is admitted to a mental health facility after attempting suicide. Which of the following actions should the nurse take first? a. Establish a rapport to foster trust b. Implement continuous one-to-one observation c. Ask the client to sign a no-suicide contract d. Encourage the client to participate in group therapy 48) A nurse is providing teaching for a newly licensed nurse about the constructive use of defense mechanism. Which of the following examples should the nurse include in the teaching? a. A student who is upset with her teacher writes a story about an excellent student b. A school-age child whose mother died 2 years ago talks about her in present tense. c. A woman who has health concern postpones a medical appointment until after a vacation. d. An adult who was sexually abused as a child is unable to remember the incident 49) A nurse in an inpatient mental health facility is assessing a client who has schizophrenia and is taking haloperidol. Which of the following clinical findings is the nurse’s priority? a. High fever b. Urinary hesitancy c. Insomnia d. Headache 50) A nurse is planning care for a client who has a recent diagnosis of antisocial personality disorder. Which of the following outcomes should the nurse include in the care plan? a. The client recognizes the importance of others b. The client conforms to social norms regarding clothing choices c. The client reduces self-dramatization d. The client treats others with respect 51) A nurse is planning care for a newly admitted client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan? a. Negotiate with the client how much weight she should gain each week. b. Decrease the client’s daily intake of fiber c. Weight the client weekly for the first month d. Notify the client about designated time for meals 52) A client is fearful of driving and enters a behavioral therapy program to help him overcome his anxiety. Using systematic desensitization, he is able to drive down a familiar street without experience a panic attack. The nurse should recognize that to continue positive results, the client should participate in which of the following? a. Therapist modeling b. Positive reinforcement c. Frequent practice d. Biofeedback 53) A nurse in the emergency department is counseling a client who reports experiencing intimate partner violence. Which of the following actions should the nurse take? a. Request permission from the client to take photographs of the injuries b. Offer to help the client escape form the partner the next time violence occurs c. Determine what the client did to trigger the violent incident d. Tell the client that staying with the partner shows a lack of judgment 54) A nurse is caring for a client who has prescription for phenelzine. The nurse should instruct the client to avoid which of the following over-the-counter medications? a. Ranitidine b. Pseudoephedrine c. Ibuprofen d. Docusate sodium 55) A nurse is caring for a client who is experiencing active auditory hallucinations. Which of the following actions should the nurse take? a. Avoid asking direct questions about the client’s experience b. Convey sympathy for the client’s experience c. Tell her client her experience is not real d. Focus the client on reality-based activities 56) A nurse is caring for a client who has just returned to the unit after receiving an electroconvulsive therapy treatment. Which of the following assessments is the nurse’s priority? a. First voiding b. Short-term memory c. Presence of gag reflex d. Return of bowel sounds 57) A nurse is talking to a client following a group therapy session. The client tells the nurse that one of the other clients in the group made an inappropriate comment. Which of the following responses should the nurse make? a. “I think you should ignore the comment” b. “You sound upset about today’s session” c. “Why do you think that he said that to you?” d. “I agree that the comment was inappropriate” 58) A nurse is assessing a client who is experiencing acute alcohol withdrawal. Which of the following findings should the nurse expect? a. Hypotension b. Insomnia c. Bradycardia d. Diminished reflexes 59) A nurse is teaching a client who has bipolar disorder and a new prescription for lithium carbonate. Which of the following statements by the client indicates an understanding of the teaching? a. “I should drink at least 6 liters of water per day” b. “I should be on a low-sodium diet” c. “I will call my doctor if I have diarrhea” d. “I will see my doctor to check my lithium levels annually” 60) A nurse in an acute care mental health facility is planning discharge care for a client who sustained a traumatic brain injury. For which of the following needs should the nurse collaborate with a clinical psychologist? a. The client needs a prescription for medication to promote nighttime sleep while in the facility b. The client needs to find a place to live after discharge c. The client needs to begin a group therapy program prior to discharge d. The client needs to relearn how to perform skill that require fine motor coordination 61) A nurse is reviewing the laboratory report of a client who is taking carbamazepine for bipolar disorder. Which of the following laboratory results should the nurse report to the provider? a. Urine specific gravity 1.029 b. Platelets 90,000/mm3 c. Urine pH 5.6 d. RBC 4.7/mm3 62) A nurse is teaching the caregiver of a client who has advanced Alzheimer’s disease about home safety. Which of the following statements by the caregiver indicates an understanding of the teaching? a. I will ensure the bedroom is dark while he is sleeping at night b. I will place a sliding bolt lock just above the doorknob c. I will notify law enforcement within 2 hours if he cannot be found d. I will give his most recent photo to the police 63) A nurse is teaching a client who has a new prescription for phenelzine to treat depression. The nurse instructs the client to avoid foods with tyramine to prevent which of the following? a. Hypertensive crisis b. Cardiac toxicity c. Serotonin Syndrome d. Urinary retention 64) A nurse in an outpatient clinic is assessing a client who has anorexia nervosa. Which of the following findings indicates the need for hospitalization? a. Potassium 3.8mEq/L b. Heart Rate 56/min c. Temperature 35.6C (96.1F) d. Weight 10% below ideal weight 65) A nurse us obtaining a medical history from a client who is requesting a prescription for bupropion for smoking cessation. Which of the following assessment finding in the client’s history should the nurse report to the provider? a. Hepatitis B Infection b. Hypothyroidism c. Knee arthroplasty 1 month ago d. Recent head injury 66) A nurse is providing crisis intervention for a client who was involved in a violent mass causality situation in the community. Which of the following actions should the nurse take during the initial session with the client? a. help the client focus on a wide variety of topics regarding the crisis b. identify the client’s usual coping style c. tell the client that his life will soon return to normal d. encourage the client to display anger toward the cause of the crisis 67) A nurse in the community health facility is interviewing a client who recently lost his job. The client states “I was fired because my boss doesn’t like me” Which of the following defense mechanisms is the client displaying? a. Rationalization b. Displacement c. Dissociation d. Repression 68) A nurse is providing teaching to a client who has depressive disorder and a new prescription for doxepin. Which of the following instructions should the nurse include in the teaching? a. sit on the side of the bed for a few minutes before standing b. decrease the prescribed dose by half when mood improves c. avoid over the counter magnesium when taking this medication d. eat a snack before going to bed 69) A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse include in the plan? a. give detailed instructions for completion of self-care activities b. confront the client when he exhibits inappropriate behavior c. provide finger foods to enhance caloric intake d. remove clocks from the client’s room 70) A nurse is planning overall strategies to address problems for a client who has borderline personality disorder. Which of the following strategies is the priority for the nurse to incorporate in the plan of care? a. discuss the appropriate use of assertive behavior with the client b. encourage the client to attend weekly support group meetings c. assist the client to maintain awareness of her thoughts and feelings d. implement measures to prevent intentional self-inflicted injury 1. A nurse is caring for a school-aged child who has conduct disorder and is being physically aggressive toward other children in the unit. Which of the following actions should the nurse take first? a. Place the child in seclusion b. Use therapeutic hold technique c. Apply wrist restraints d. Administer risperidone 2. A nurse is caring for a client who has a new diagnosis of bulimia nervosa. Which of the following diagnosis procedures should the nurse anticipate the provider should describe during the medical evaluation? a. Chest x-ray b. ECG c. Coagulation studies d. Liver function test 3. A nurse is caring for a client who exhibits excessive compliance, passivity, and self-denial. The nurse should recognize that these findings are associated with which of the following personality disorders? a. Dependent b. Paranoid c. Borderline d. Histrionic 4. A nurse is caring for a client who is involuntarily admitted for major depressive disorder and refuses to take prescribed antianxiety medication. Which of the following actions should the nurse take? a. Inform the client that he does not have the right to refuse medication b. Administer the medication to the client via IM injection c. Offer the client the medication at the next scheduled dose time d. Implement consequences until the client take the medication 5. A nurse is caring for a client in the emergency department who states she was beaten and sexually assault by her partner. After a rapid assessment, which of the following actions should the nurse plan to take next? a. Conduct a pregnancy test b. Requests mental health consultation for the client c. Provide a trained advocate to stay with the client d. Offer prophylactic medication to prevent STI’s 6. A nurse is caring for a client who has major depressive disorder. After discussing the treatment with his partner, the client verbally agrees to electroconvulsive therapy (ECT) but will not sign the consent form. Which of the following actions should the nurse take? a. Request that the client’s partner sign the consent form b. Cancel the scheduled ECT procedure c. Proceed with the preparation for ECT based on implied consent d. Inform the client about the risks of refusing the ECT 7. A nurse is caring for a client who reports that he is angry with his partner because she thinks he is just trying to gain attention. When the nurse attempts to talk to the client, he becomes angry and tells her to leave. Which of the following defense mechanisms is the client demonstrating? a. Rationalization b. Denial c. Compensation d. Displacement 8. A nursing is advising an assistive personnel (AP) on the care of a client who has major depressive disorder. The AP states that he is irritated by the client’s depression. Which of the following statements by the nurse is appropriate? a. Please don’t take what the client said seriously when she is depressed b. It’s important that the client feel safe verbalizing how she is feeling c. Everybody feels that way about this client so don’t worry about it d. I’ll change your assignment to someone who doesn’t have depressive disorder 9. A nurse is assessing a child in the emergency department. Which of the following findings places the child at the greatest risk for physical abuse? a. The child is 10years old b. The child is homeschooled c. The has no siblings d. The child has cystic fibrosis 10. A nurse is providing behavioral therapy for a client who has obsessive-compulsive disorder. The client repeatedly checks that the doors are locked at night. Which of the following instructions should the nurse give the client when using thought stopping technique? a. Keep a journal of how often you check the locks each night b. Snap a rubber band on your wrist when you think about checking the locks c. Ask a family member to check the lock for you at night d. Focus on abdominal breathing whenever you go to check the locks 11. A nurse is assessing a client who is experiencing alcohol withdrawal. For which of the following findings should the nurse anticipate administration of lorazepam/ a. Bradycardia b. Stupor c. Afebrile d. Hypertension 12. A nurse is creating a plan of care of a client who has anorexia nervosa. Which of the following intervention should the nurse include in the plan? a. Weigh the client twice per day b. Prepare the client for electroconvulsive therapy c. Set a weight gain goal of 2.2kg (5lbs) per week d. Encourage the client to participate in family therapy 13. A nurse is planning care for a 3-year-old child who has autism spectrum disorder. Which of the following finding should the nurse expect? a. Readily initiates conversation b. Enjoys imaginative play c. Strong relationship with sibling and peers d. Attachment to objects that spin 14. A nurse is planning care for a client who has bipolar disorder. The client reports not sleeping for 3 days and is exhibiting a euphoric mood. The nurse should identify which of the following as the priority intervention. a. Secure the client’s valuable possessions b. Limit loud noises in the client’s environment c. Encourage the client to participate in structured solitary activities d. Provide high calorie snacks to the client 15. A nurse is evaluating the medication response of a client who takes naltrexone for the treatment of alcohol use disorder. The nurse should identify that which of the following is a therapeutic effect of this medication. a. Blocks aldehyde dehydrogenase b. Prevents the anxiety of abstinence c. Reduces substance craving d. Decreases the likelihood of seizures 16. A nurse in an alcohol treatment facility is caring for a client who states “my job is so stressful that the only way I can come it is to drink.” The nurse should recognize that the client is displaying which of the following defense mechanisms? a. Repression b. Rationalization c. Introjection d. Intellectualization 17. A nurse is caring for a client who has depression following a recent job loss. Which of the following questions should the nurse ask to assess the client’s personal coping skills? a. How does this situation affect your life? b. Do you see your current situation affecting your future? c. Can you describe how you are currently feeling? d. How have you dealt with similar situations in the past 18. A school nurse is caring for an adolescent client whose teacher reports changes in school performance and withdrawal from interaction with classmates. Which of the following intervention is the nurse’s priority at this time? a. Contact the adolescent’s parents b. Suggest the adolescent join support groups c. Ask the adolescent if he is considering hurting himself d. Determine when the adolescent’s change in behavior began 19. A nurse is assessing a client who is withdrawing from heroin. Which of the following manifestations should the nurse expect? a. Slurred speech b. Hypotension c. Bradycardia d. Hyperthermia 20. A nurse is assessing a client who has histrionic personality disorder. Which of the following finds should the nurse expect? a. Lack of remorse b. Attention seeking c. Splitting of staff d. Identity disturbance 21. A nurse is providing teaching to the daughter of an older client who has obsessive-compulsive disorder. Which of the following statements by the daughter indicates an understanding of the disorder? a. I will limit my mother’s clothing choices when she is getting dressed b. I will provide my mother with detailed instructions about how to perform self-care c. I will wake my mother up a couple of times in the night to check on her d. I will discourage my mother from talking about physical complaints 22. A nurse in a mental health facility is caring for a client who has borderline personality disorder. Which of the following should the nurse expect? a. Self-mutation b. Pacing back and forth c. Preoccupation with details d. Disorganized speech 23. a nurse is reviewing the laboratory results on adolescent who has anorexia nervosa. Which of the following findings should the nurse expect? a. Blood glucose 100 mg/dL b. T4 11 mcg/dL c. Potassium 3.7 mEq/L d. Hgb 10 g/dL 24. A nurse is teaching about benztropine to a client who has schizophrenia. Which of the following statements should the nurse include in the teaching? a. This medication is given to help with extrapyramidal side effects b. This medication is given to help with your depression c. Benztropine helps alleviate your hallucinations d. Benztropine is used to counteract your tachycardia 25. A nurse is planning care for a client with acute delirium. Which of the following instructions should the nurse include in the plan? a. Reinforce the clients orientation with the calendar b. Refute the clients perception of visual hallucinations c. Teach the client assertive techniques d. Assigned the client to a different caregiver each shift 26. A nurse is creating a plan of care for a client who has major depressive disorder. Which of the following interventions should the nurse include in the plan? a. Discouraged client from expressing feelings of anger b. Identify and schedule alternative group activities for the client c. Encourage physical activity for the client during the day d. Keep a bright light on in the clients room at night 27. A nurse is caring for a client who has posttraumatic stress disorder related to military service. Which of the following actions should the nurse take? a. Encourage the client to suppress feelings of trauma b. Assign the same staff to care for the client each day c. Address the client in an authoritative manner d. Limit the amount of time spent with the client 28. A nurse is providing teaching for school age child and his parents regarding a new prescription for risperidone. Which of the following statements by the parent indicates an understanding of the teaching? a. I will provide a low sodium diet for my son b. I will make sure my son takes the last dose of the day by 4 PM c. I should expect my son to develop hand tremors d. I should contact my doctor if my son urinates excessively 29. A nurse is caring for a client who has a lithium level of 0.8 mEq/L. Which of the following actions should the nurse take? a. Withhold the next does of lithium b. Repeat the lithium level test c. Administer the next does of lithium d. Recommended a low sodium diet 30. A nurse in a community mental health clinic is caring for a group of clients. The nurse should encourage participation in cognitive behavioral family therapy in response to which of the following client statements. a. I want to learn how to change the way I react to problems within my family b. I want to understand why my past experiences are affecting my family relationships c. I want to improve my family’s understanding of each other’s boundaries d. I want each of my family members to be more aware of each other’s feelings 31. A nurse is providing teaching to the caregiver of an older adult client who has Alzheimer’s disease and is being cared for at home. The client wonders at night and has a history of previous falls. Which of the fund instructions should nurse including? (select all) in the teaching a. position the mattress on the floor b. Install sensor devices on outside doors c. Encourage physical activity prior to bedtime d. put locks at top of doors e. place the client in a reclining chair 32. A nurse is reviewing laboratory values for a client who has bipolar disorder and a prescription for lithium. The nurse should identify that which of the following laboratory results places the client at risk for lithium toxicity? a. Calcium 9.0 mg/dL b. sodium 130 mEq/L c. chloride 98 mEq/L d. potassium 5.0 mEq/L 33. A nurse is assisting with obtaining informed consent from client who has been declared legally incompetent. Which of the following actions should the nurse take? a. Contact the facility social worker to obtain the consent b. Explain implied consent to the clients family c. Request that the clients Guardian signed the consent d. Ask the charge nurse to obtain an informed consent 34. A nurse is giving a presentation about intimate partner abuse for community group. Which of the following statements buy a group member indicates understanding of teaching? a. Survivors of abuse often feel guilty b. abusers often have high self-esteem c. the honeymoon stage of violence usually gets longer over time d. as abuse continues, victims become more determined to be independent 35. A nurse is planning care for a client who has experienced intimate partner abuse. The nurse should identify which of the following outcomes as the priority? a. The client joins a support group b. the client identifies techniques to reduce her stress c. The client develops a safety plan d. The client identify support systems 36. A nurse is developing a behavioral contract with the client who has antisocial personality disorder. Which of the following client goals should the nurse include in the contract? a. Use projection during group therapy b. increase self-esteem c. use bargaining skills for behavioral consequences d. Decrease the number of verbal outbursts 37. A nurse is caring for a client who has schizophrenia and takes clozapine. Which of the following findings is a priority for the nurse to report to the provider? a. Nausea b. Random blood glucose 130 mg/dL c. Heart rate 104 per minute d. sore throat 38. A nurse is counseling and adult client whose parent just died. The client states, “My son is 4, and I don’t know how he’ll react when he finds out that grandpa died.” The nurse should inform the client that the preschool age child commonly has which of the following concepts of death? a. Death is not permanent and the loved one may come back to life b. Death is contagious and can cause other people he loves to die c. Death creates an interest in the physical aspects of dying d. Death is a part of life that eventually happens to everyone 39. A nurse is reviewing the medical records for clients. Which of the following findings should the nurse identified as a risk factor for violent behavior? a. Schizoid personality disorder b. Alcohol intoxication c. Dysthymic disorder d. long-term isolation 40. A nurse in a provider’s office is assessing a school age child who has a spiral fracture. The parent of the child provides different accounts for the cause of the injury. Which of the following actions should the nurse take first? a. Request that the parent leaves the room while you interview the child b. Report suspected abuse to child protective services c. Ask the child how the injury occurred 41. An older adult client is brought to the mental clinic by her daughter. The daughter reports that her mother is not eating and seems uninterested in routine activities. The daughter states, I'm so worried that my mother is depressed. Which of the following responses should the nurse make? a. Older adults are usually diagnosed with depressive disorder as they age b. everyone gets depressed from time to time c. you shouldn’t worry about this, because depressive disorder is easily treated 42. A nurse in a mental health facility is caring for a client. Which of the following actions the nurse take during though working phase of the nurse-client relationship? a. Summarize goals and objectives b. Address confidentiality d. establish a participation contract 43. a nurse is caring for a client who suddenly directs profanities at her, then abruptly hangs his head and says, “please forgive me, I’m not sure what came over me I don’t know why said those things.” The nurse interprets this behavior as which of the following? a. Emotional lability b. Confabulation c. flight of ideas d. Neologism 44. A nurse is providing teaching for the family of a client who has dementia. Which of the following should the nurse include in the teaching as a contributing factor for this disorder? a. Hypotension b. alcohol use disorder c. Dehydration d. change in environment 45. A nurse is caring for a client who has been taking valproic acid. Which of the following is expected outcome of the medication? a. The client reports improved short-term memory b. the client has a decreased euphoric mood c. the client reports absence of auditory hallucinations d. the client has decreased anxiety 46. A nurse is teaching a client who has major depressive disorder about electroconvulsive therapy. Which of the phone information should the nurse include? a. This therapy works as a cure for major depressive disorders b. You will be awake and alert during the procedure c. You might experience confusion for a few hours after treatment d. This therapy will stimulate the vagus nerve to improve your mood 47. A nurse emergency department is assessing a client who has major depressive disorder. Which of the following actions should the nurse take? (Exhibit question) a. ask the client if she has eaten foods containing thyramine b. Give regular insulin subcutaneously to the client c. Prepare the client for electroconvulsive therapy d. administer dantrolene IV bolus to the client 48. A nurse is reviewing the laboratory report of a client who is taking carbamazepine for bipolar disorder. Which of the following laboratory results should the nurse report to the provider? a. Urine specific gravity 1.029 b. Platelets 90,000/mm3 c. urine pH 5.6 d. RBC 4.7/mm3 49. A nurse is caring for a client who has schizophrenia and started taking clozapine two months ago. Which of the following laboratory results should the nurse report to the provider? a. WBC 3,000/mm3 b. Potassium 4.2 mEq/L c. Hgb 16 g/dL d. Platelets 300,000/mm3 50. A nurse is assessing the boundaries of a client’s family one of the family members says to the client, “ I know exactly what you’re thinking right now.” The nurse should recognize that the following family boundaries? a. Rigid b. Inconsistent c. Enmeshed d. Clear 51. A nurse is assessing a client who requires bupropion for smoking cessation. Which of the following findings in the client’s history should the nurse recognized as a contraindication for taking this medication? a. Seizures b. Anemia c. Migraines d. Asthma 52. A nurse is caring for a client with Alzheimer’s disease. Which of the following actions should the nurse take? a. Seat the client at a dining table with six or more residents b. provide the client with several choices for meal selection c. give complete directions before starting client care d. use symbols to assist the client in locating rooms 53. A nurse is assessing a newly admitted client who has schizophrenia and takes thioridazine. Which of the following findings should the nurse document as an adverse effect of this medication? a. Anhedonia b. Waxy flexibility c. contractions of the jaw d. incongruent affect 54. A nurse in an inpatient mental health facility is assessing a client who has schizophrenia and is taking haloperidol. Which of the following clinical findings is the nurse’s priority? a. High fever b. Insomnia c. Urinary hesitancy d. Headache 55. A nurse is speaking with a client. Which of the following responses by the nurse demonstrates the communication technique of reflection? a. “I would like to sit with you for a while” b. “You feel upset when this happens?” c. “Let’s work together to try to solve your problem” d. “Can you tell me what is happening now?” 56. A nurse is leading grief support group for bereaved clients. Which of the following client statements should the nurse report to the provider as an indication of clinical depression? a. “I don’t know how I could cope if I didn’t have my family’s support” b. “It’ll be a long time before I’m happy again” c. “I don’t feel anything but numbness anymore” d. “I feel like I’m angry at the whole world right now” 57. A nurse is preparing to administer chlorpromazine hydrochloride 25 mg PO to an older adult client. Available is chlorpromazine hydrochloride syrup 10 mg/5 mL. How many mL should the nurse administer? (Round to nearest tenth) a. 12.5 58. A nurse is teaching the parent of a school age child who has ADHD and a prescription for atomoxetine 40 mg daily. Which of the following information should the nurse include in the teaching? a. Expect the child to gain weight while taking this medication b. Crush the medication and mix it with 120 mL (4 oz) of juice c. Therapeutic effects will occur within 24 hr of starting treatment d. Administer the medication before the child goes to school in the morning 59. A nurse is caring for a client who has bipolar disorder and is experiencing a manic episode. Which of the following actions should the nurse take? a. Place the client in a group therapy session b. Rotate staff members who work with the client c. Encourage the client to participate in physical activities d. Distract the client with increased environmental stimuli 60. A nurse in a mental facility is assessing a client for suicide risk factors using the SAD PERSONS scale. Which of the following findings indicates a risk for suicide? a. The client is married b. The client is female c. The client is 50 years of age d. The client has diabetes mellitus 61. A nurse is performing a mental status examination for a client who has schizophrenia. The nurse should recognize that which of the following actions requires the client to think abstractly? a. Explain what to do if he misses the bus b. Determine the meaning of a proverb c. Name the last three presidents of the United States of America d. Count by adding sevens consecutively 62. A nurse is developing a plan of care for a school age child who has ADHD. Which of the following interventions should the nurse include in the plan? a. Administer olanzapine b. Institute consequences for deliberate behaviors c. Provide a stimulating environment d. Encourage thought stopping techniques 63. A nurse in a mental health facility is making plans for a client’s discharge. Which of the following interdisciplinary team members should the nurse contact to assist the client with housing placement? a. Clinical nurse specialist b. Recreational therapist c. Social worker d. Occupational therapist 64. A nurse is providing crisis intervention for a client who was involved in a violent mass casualty situation in the community. Which of the following actions should the nurse take during the initial session with the client? a. Encourage the client to display anger toward the cause of the crisis b. Tell the client that his life will soon return to normal c. Identify the client’s usual coping style d. Help the client focus on a wide variety of topics regarding the crisis 65. A nurse is planning to conduct a support group for adolescents who have cancer. Which of the following actions should the nurse include during the orientation phase? a. Manage conflict within the group b. Establish rapport with group members c. Encourage the use of problem-solving skills d. Maintain the group’s focus on identified issues 66. A nurse is assessing a client who recently started antidepressant therapy for the treatment of major depressive disorder. Which of the following findings indicates the client is at an increased risk for suicide? a. Increased energy b. Hypersomnia c. Unkempt appearance d. Psychomotor retardation 67. A nurse in a rehabilitation unit is caring for a client who has a traumatic brain injury. To which of the following members of the client’s interprofessional team should the nurse refer the client in order to help him relearn how to use eating utensils? a. Neuropsychiatrist b. Occupational therapist c. Physical therapist d. Social worker 68. A nurse is caring for a group of clients on a mental health unit. For which of the following clients is the nurse mandated to report to the appropriate agency? a. A client who reports that she took $20 from the cash register where she works b. A client who reports that her partner ties their child to a bed as punishment c. A client who reports that he enjoys smoking marijuana on weekends d. A client who reports lying to his provider about having suicidal ideation 69. A nurse is obtaining a medical history from a client who is requesting a prescription for bupropion for smoking cessation. Which of the following assessment findings in the client’s history should the nurse report to the provider? a. Recent head injury b. Hepatitis B infection c. Hypothyroidism d. Knee arthroplasty 1 month ago 70. A charge nurse is orienting a newly licensed nurse and observes the newly licensed nurse imitating her behaviors. The nurse should recognize this behavior as which of the following defense mechanisms? a. Suppression b. Reaction formation c. Identification d. Compensation 1. A nurse is reviewing the medication administration record of a client who has major depressive disorder and a new prescription for selegiline. The nurse should recognize that which of the following client medications is contraindicated when taken with selegiline? a. Wafarin b. Fluoxetine c. Calcium carbonate d. Acetaminophen 2. A nurse in a long-term care facility is assessing a client who has dementia. Which of the following findings should the nurse identify as a risk for this client? a. Outside doors have locks b. The bed is in the low position c. Hallways are long distances d. The room has an area rug 3. A nurse is providing behavioral therapy for a client who has obsessive-compulsive disorder. The client repeatedly checks that the doors are locked at night. Which of the following instructions should the nurse give the client when using thought stopping technique? a. “Ask a family member to check the locks for you at night” b. “Keep a journal of how often you check the locks each night” c. “Snap a rubber band on your wrist when you think about checking the locks” d. “Focus on abdominal breathing whenever you go to check the locks” 4. A nurse in an inpatient mental health facility is assessing a client who has schizophrenia and is taking haloperidol. Which of the following clinical findings is the nurse’s priority? a. Insomnia b. Urinary hesitancy c. Headache d. High fever 5. A nurse is caring for a client who has Alzheimer’s disease. Which of the following findings should the nurse expect? a. Failure to recognize familiar objects b. Altered level of consciousness c. Excessive motor activity d. Rapid mood swings 6. A nurse in a mental health facility is interviewing a new client. Which of the following outcomes must occur if the nurse is to establish a therapeutic nurse-client relationship? a. The nurse is seen as an authority figure b. A written contract is established to clarify the steps of the treatment plan c. The nurse maintains confidentiality unless the client’s safety is compromised d. The nurse is seen as a friend 7. A nurse is teaching a client who has a new prescription for disulfiram. Which of the following statements by the client indicates an understanding of the teaching? a. “If I cut myself, I can clean the wound with isopropyl alcohol” b. “I can wear my cologne on special occasions” c. “When I bake my favorite cookies, I can use pure vanilla extract for flavoring” d. “I can continue to eat aged cheese and chocolate” 8. A nurse is planning care for a client who has narcissistic personality disorder. Which of the following actions is appropriate for the nurse to include in the plan of care? a. Ask the client to sign a no-suicide contract b. Remain neutral when communicating with the client c. Request an antipsychotic medication from the provider d. Provide the client with high-calorie finger foods 9. A nurse is reviewing the laboratory report of a client who is taking carbamazepine for bipolar disorder. Which of the following laboratory results should the nurse report to the provider? a. Urine specific gravity 1.029 b. Platelets 90,000/mm3 c. Urine pH 5.6 d. RBC 4.7/mm3 10. A nurse is providing teaching about relapse prevention to a client who has schizophrenia. Which of the following statements by the client indicates an understanding of the teaching? a. “I should avoid being around others if I think I’m having a relapse” b. “I should let my counselor know if I am having trouble sleeping” c. “I shouldn’t worry about the voices because they are a part of my illness” d. “I should increase my carbohydrate intake to maintain my energy level” 11. A nurse is assessing a client for negative manifestations of schizophrenia. Which of the following findings should the nurse expect? a. Echopraxia b. Delusions c. Anergia d. Tangentiality 12. A nurse is preparing for an interprofessional team meeting regarding a newly admitted client who has major depressive disorder. Which of the following findings obtained during the initial assessment is the priority to report to other disciplines? a. Poor problem-solving skills b. Markedly neglected hygiene c. Significant weight loss d. Psychomotor retardation 13. A nurse is preparing to administer methylphenidate 25 mg PO to a school age child who has ADHD. Available is methylphenidate 10mg/5mL liquid. How many mL should the nurse administer? (Round to nearest tenth) a. 12.5 14. A nurse is caring for a school age child who has a fractured arm. The child has other injuries that cause the nurse to suspect abuse. Which of the following actions is appropriate for the nurse to take when assessing the child’s situation? a. Ask the parents directly if the child’s fracture is due to physical abuse b. Direct the parents to the waiting room before interviewing the child c. Interview the child with the provider and social worker present d. Ask clarifying questions as the child explains how the injuries occurred 15. A nurse is assisting with obtaining consent for a client who has been declared legally incompetent. Which of the following actions should the nurse take? a. Ask the charge nurse to obtain informed consent b. Contact the facility social worker to obtain consent c. Request that the client’s guardian sign the consent d. Explain implied consent to the clients family 16. A nurse in a mental health facility is reviewing a client’s medical record. Which of the following actions should the nurse take first? (Click on the exhibit button for additional information about the client. There are 3 tabs that contain separate categories of data) a. Teach the client about nutritional needs b. Initiate 0.9% sodium chloride with 40 mEq potassium chloride c. Administer acetaminophen 500 mg PO d. Encourage the client to attend group therapy sessions 17. A nurse is assessing a client who has delirium. Which of the following findings requires immediate intervention by the nurse? a. Rapid mood swings b. Command hallucinations c. Impaired memory d. Inappropriate speech patterns 18. A nurse is developing a teach plan for the family of an older adult client who is to receive transcranial magnetic stimulation. Which of the following information should the nurse include n the teaching plan? a. The client is at risk for aspiration during treatment b. The client will experience a seizure during treatment c. The client will require intubation after treatment d. The client might have a headache after treatment 19. A nurse is obtaining a medical history from a client who is requesting a prescription for bupropion for smoking cessation. Which of the following assessment findings in the client’s history should the nurse report to the provider? a. Recent head injury b. Hypothyroidism c. Knee arthroplasty 1 month ago d. Hepatitis B infection 20. A nurse is developing a plan of care for a client who has paranoid personality disorder. Which of the following actions should the nurse include in the plan? a. Provide written information about the client’s treatment plan b. Monitor the client for splitting behaviors c. Encourage countertransference when developing the nurse-client relationship d. Isolate the client from social or group interactions 21. A nurse is caring for a client who receives lamotrigine daily for bipolar disorder and reports a rash on his arm. Which of the following actions should the nurse take? a. Ask the client about a recent change in laundry detergent b. Explain that the medication causes a temporary rash c. Apply hydrocortisone cream on the client’s rash d. Withhold the next dose of the medication 22. A nurse is caring for a client who begins yelling and pacing around the room. Which of the following actions should the nurse take? (select all that apply) a. Stand directly in front of the client b. Identify the client’s stressors c. Request that security guards restrain the client d. Talk to the client using short, simple sentences e. Speak to the client in a loud voice 23. A nurse is developing a plan of care for a school-age child who has autism spectrum disorder. Which of the following interventions should the nurse include in the plan? a. Allow flexibility in the child’s daily schedule b. Assign the child to a room with another child of the same age c. Discourage the child from making eye contact with caregivers d. Use a reward system for appropriate behavior 24. A nurse is caring for a client who has post-traumatic stress disorder. Which of the following clinical findings is associated with this disorder? a. Depersonalization b. Pressured speech c. Hypervigilance d. Compulsive behavior 25. A nurse is teaching a client about the use of cognitive reframing for stress management. Which of the following statements by the client indicates an understanding of the teaching? a. “I will focus on a mental image while concentration on my breathing.” b. “I will practice replacing negative thoughts with positive self-statements.” c. “I will progressively relax each of my muscle groups when feeling stressed.” d. “I will learn how to voluntarily control my blood pressure and heart rate.” 26. A nurse is caring for a client who has schizophrenia and has been taking chlorpromazine for 5 years. Which of the following assessment tools should the nurse use to determine if the client is experiencing adverse effects of the medication? a. Addiction Severity Index (ASI) b. Mood Disorder Questionnaire (MDQ) c. Abnormal Involuntary Movement Scale (AIMS) d. Hamilton Depression Scale 27. A nurse in a mental health facility is assessing a client for suicide risk factors using the SAD PERSONS scale. Which of the following finding indicates a risk suicide? a. The client is married b. The client has diabetes mellitus c. The client is 50 years of age d. The client is female 28. A nurse is providing crisis intervention for a client who was involved in a violent mass casualty situation in the community. Which of the following actions should the nurse take during the initial session with the client? a. Identify the client’s usual coping style b. Help the client focus on a wide variety of topics regarding the crisis c. Tell the client that his life will soon return to normal d. Encourage the client to display anger toward the cause of the crisis 29. A nurse is caring for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following actions should the nurse take first? a. Encourage the client to listen to music b. Monitor the client for indications of anxiety c. Ask the client what she is missing d. Focus the client on reality-based topics 30. A nurse is planning to lead a support group for clients who have alcohol use disorder. One of the group members is a client who speaks a different language than the nurse. The nurse should ask which of the following individuals to assist with communication? a. A family member of the client b. Another client who speaks the same language as the client c. A translator of the same gender as the client d. A unit secretary who speaks the same language as the client 31. A nurse in an emergency department is assessing a client who reports recently using cocaine. Which of the following clinical manifestations should the nurse expect? a. Lethargy b. Hypothermia c. Hypertension d. Bradycardia 32. A nurse is caring for a client who has severe depression and is scheduled to receive electroconvulsive therapy. The nurse should recognize that the client will receive succinylcholine to prevent which of the following adverse effects? a. Muscle distress b. Aspiration c. Elevated blood pressure d. Decreased heart rate 33. A nurse in an outpatient clinic is assessing a client who has anorexia nervosa. Which of the following findings indicates the need for hospitalization? a. Temperature 35.6 C (96.1 F) b. Heart rate 56/min c. Weight 10% below ideal weight d. Potassium 3.8 mEq/L 34. A nurse is caring for a client who is under observation for suicidal ideations and has verbalized a suicide plan. The client demands privacy and to be left alone. Which of the following statements should the nurse make? a. “Since you are trying to follow the treatment plan, we can submit your request to the provider.” b. “We are concerned about you and need to keep you safe.” c. “Until your medication has reached therapeutic levels, you will need constant observation.” d. “If you complete a contract that states you will not harm yourself, you can be alone.” 35. A nurse on a mental health unit is leading a therapy session for a group of clients. One client challenges the nurse and shows no empathy for others in the group. Which of the following actions should the nurse take? a. Request that the client leave the therapy session immediately b. Place the client in seclusion c. Reassign the client to another group d. Ask the client privately what is causing the anger 36. A nurse in a mental health clinic is assessing a client who has borderline personality disorder. Which of the following findings should the nurse expect? a. Inability to maintain employment b. Intense efforts to avoid abandonment c. Avoidance of interpersonal relationships d. Reluctance to discard worthless objects 37. A nurse in a long-term care facility is assessing an older adult client for depression. Which of the following findings should the nurse expect? a. Rapid mood swings b. Sun downing c. Insomnia d. Rambling speech 38. A nurse is assessing a client who has been taking thioridazine for 2 weeks. The client reports an inability to be still. Which of the following adverse effects should the nurse suspect? a. Tardive dyskinesia b. Pseudo parkinsonism c. Akathisia d. Acute dystonia 39. A nurse in a mental health facility is making plans for a client’s discharge. Which of the following interdisciplinary team members should the nurse contact to assist the client with housing placement? a. Clinical nurse specialist b. Social worker c. Occupational therapist d. Recreational therapist 40. A nurse is interviewing a client who was recently sexually assaulted. The client cannot recall the attack. The nurse should identify that the client is using which of the following defense mechanisms? a. Sublimation b. Reaction formation c. Suppression d. Repression 41. A nurse is assessing a client who has antisocial personality disorder. Which of the following client behaviors should the nurse expect? a. Attention-seeking b. Anxious c. Projects blame d. Manipulative 42. A nurse is caring for a client who has physical restraints applied. The nurse determines that the restraints should be removed when which of the following occurs? a. The client states that he will harm himself unless the restraints are removed b. The client refuses to take his medication unless he is released c. The client demonstrates that he is oriented to person, place, and time d. The client is able to follow commands 43. A nurse is caring for a client who states, “Things will never work out.” Which of the following responses should the nurse make? a. “Why do you feel like things will never work?” b. “Have you been thinking about harming yourself?” c. “You should try to focus on yourself for a change.” d. “Maybe an antidepressant will make you feel better.” 44. A nurse in an emergency department is caring for a client who reports a recent sexual assault by her partner. Which of the following statements is the priority for the nurse make? a. “I want you to know that you are in a safe place here.” b. “I can contact a support person for you.” c. “A trained sexual-assault nurse will be assigned to your care.” d. “I can provide information about an advocacy group in your area” 45. After assessing a client in a crisis situation, a nurse determines the client is safe. Which of the following actions should the nurse take first? a. Help the client identify social support b. Involve the client in planning interventions c. Assist the client to lower his anxiety level d. Teach the client specific coping skills to handle stressful situations 46. A nurse is assessing a client who has bulimia nervosa. Which of the following findings should the nurse expect? a. Acrocyanosis b. Amenorrhea c. Lanugo d. Hyponatremia 47. A nurse is caring for client who reports smoking marijuana several times per day. The client tells the nurse, “ I don’t know what the big deal is marijuana is a harmless herb” The nurse should identify that the client is displaying which of the following mechanisms? a. Rationalization b. reaction formation c. compensation d. suppression 48. A nurse is creating a plan of care for a client who has major depressive disorder. Which of the following interventions should the nurse include in the plan? a. identify and schedule alternative group activities for the client b. encourage physical activity for the client during the day c. discourage the client from expressing feelings of anger d. keep a bright light on in the client’s room at night. 49. A nurse is teaching the family of a client who has Alzheimer’s disease about the safety interventions for nighttime wandering, which of the following interventions should the nurse include? a. place rubber backed throw rugs on tile floors b. encourage the client to take naps during the day c. install locks at the bottom of exit doors d. place the clients mattress on the floor. 50. A nurse in a mental health facility is reviewing the lab results of a client who is taking lithium carbonate. Which of the following findings places the client at risk for lithium toxicity. a. calcium 10.0 b. WBC 6,0000 c. sodium 132 mEq/L d. aspartate aminotransferase 40 units/L 51. a nurse in an acute care facility is planning care for a client who has a history of alcohol use disorder and is admitted while intoxicated. Which of the following interventions should the nurse plan for the client a. monitor for orthostatic hypotension b. administer methadone hydrochloride c. implement seizure precautions d. acidify the client’s urine 52. a nurse is developing a safety plan for a client who has experienced intimate partner abuse. Which of the following items should the nurse include in the plan that will provide immediate safety for the client and her children? a. the phone numbers for law enforcement agencies b. a code phrase to use when it is time to leave the house c. the phone number of the local shelter d. a referral to a support group 53. A nurse is caring for a client who reports that he is angry with his partner because she thinks he is just trying to gain attention. When the nurse attempts to talk to the client, he becomes angry and tells her to leave. Which of the following defense mechanisms is the client demonstrating? a. Denial b. Rationalization c. displacement d. compensation 54. A nurse is observing a newly licensed nurse administer an IM medication to a client who is manic and refuses the medication. Which of the following actions should the nurse take first? a. stop the newly licensed nurse from administering the medication b. call the provider for an alternate medication route c. report the occurrence to the nurse manager d. talk to the newly licensed nurse about the incident 55. A nurse is planning care for a client who demonstrates prolonged depression related to the loss of her partner 6 months ago. Which of the following actions should the nurse take? a. explain that it can take a year or more to learn to live with loss b. discourage the client from reliving the events surrounding her loss c. suggest that the client avoid social interactions that remind her of her partner d. direct the client to maintain an unstructured daily routine 56. A nurse is caring for a client who has bipolar disorder. The client is walking in and out of rooms, speaking inappropriately, and giggling. Which of the following actions should the nurse take? a. tell the client there will be negative consequences for her behavior b. take the client to the day room to watch a movie with the other clients c. have the client return to her room to read a book d. lead the client outside for a walk 57. A nurse is admitting a client who has a new diagnosis of schizophrenia and a history of aggression. Which of the following actions should the nurse include in the clients initial plan of care? a. agree with the client when he is upset until he can calm down b. provide physical exercise activity for the client c. avoid eye contact with the client for the first few days d. ignore the clients hallucinations 58. a nurse is caring for a client who has bipolar disorder and is exhibiting mania. Which of the following findings should the nurse expect? a. disorganized speech b. heightened concentration c. hypersomnia d. agoraphobia 59. a nurse is caring for a client who has schizophrenia. The client’s employer calls to discuss the client’s condition. Which of the following is the appropriate nursing action? a. consult the client b. consult the client’s family c. contact the provider d. contact the facility legal department 60. A nurse is providing teaching to a client who is prescribed methylphenidate for ADHD. Which of the following statements by the client indicates accurate understanding of this medications effects? a. I know that I will be able to think more clearly now b. this medicine will help me relax and feel less anxious c. ill take my medicine at bedtime because it will make my drowsy d. I need to tell my doctor if I start gaining weight 61. An older adult client is brought to the mental health clinic by her daughter. The daughter reports that her mother is not eating and seems very uninterested in routine activities. The daughter states “ im so worried that my mother is depressed” Which of the following responses should the nurse take? a. “you shouldn’t worry about this, because depressive disorder is easily treated” b. older adults are usually diagnosed with depressive disorder as they age c. tell me the reasons you think your mother is depressed d. everyone gets depressed from time to time. 62. A nurse is providing teaching to a client who has a new prescription for tranylcypromine. Which of the following over the counter medications should the nurse instruct the client to avoid taking due to adverse interactions? a. Ranitidine b. Pseudoephedrine c. Ibuprofen d. magnesium hydroxide 63. A nurse in the ED is admitting a client who has a history of alcohol use disorder. The client has a blood alcohol level of 0.26 g/dl. The nurse should anticipate a prescription for which of the following medications? a. Disulfiram b. Cholridiazepoxide c. Naltrexone d. Acamprosate 64. A nurse is building a therapeutic relationship with a client who has an eating disorder. Which of the following activities should the nurse initiate during the relationships orientation phase? a. Mutually deciding and agreeing on the goals of the relationship b. using memories to validate the relationship experience c. discussing the incorporation of new strategies into daily life d. teaching and encouraging the use of problem solving skills 65. A nurse is assessing a client who has schizophrenia. The client tells the nurse, “My heart exploded and my blood is draining out” The nurse should interpret this statement as which of the following manifestations? a. concrete thinking b. a visual hallucination c. a somatic delusion d. paranoia 66. A nurse is interviewing a client who has schizophrenia. The client states, “aliens are going to abduct me at midnight tonight” Which of the following responses should the nurse make? a. why are the aliens going to abduct you? b. you are safe from aliens here c. believing that aliens will abduct you must be scary d. have you ever been abducted by aliens before? 67. A nurse is caring for a client who has generalized anxiety disorder and a history of substance abuse use disorder. Which of the following medications would the nurse expect the provider to prescribe? a. Chlordiazepoxide b. Clonazepam c. Busprione d. Alprazolam 68. A nurse in an ED is creating a plan of care for a client who reports experiencing intimate partner violence. Which of the following interventions should the nurse include as the priority? a. teach the client stress reduction techniques b. help the client devise a safety plan c. refer the client to a support group d. follow the facilities protocol for reporting the abuse 69. A nurse in a mental health facility is caring for a client who is being aggressive toward other clients. Which of the following actions is the priority for the nurse to take? a. Assist the client to explore techniques to reduce stress b. Ask the client if he intends to harm others, c. role model healthy ways to express anger d. suggest the client make a list of things that make him angry. 70. A nurse in the ED is caring for a client who has serotonin syndrome. The nurse should assess the client for which of the following manifestations? a. Hyperpyrexia b. Priapism c. Parathesisa d. bradycardia