NURSING 326 MENTAL EXAM 2
1. Nurse admitting client who is in manic phase of bipolar disorder, nurse should place the client in
which of the following rooms?
- Private room in quiet location of the unit
2. Nurse is a
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NURSING 326 MENTAL EXAM 2
1. Nurse admitting client who is in manic phase of bipolar disorder, nurse should place the client in
which of the following rooms?
- Private room in quiet location of the unit
2. Nurse is admitting client who experienced weight loss of 11kg (25lb) in the past 3m the client
weighed 40kg (88lb) and believed she was fat, what is the priority aspect of care?
- Identify the client’s nutritional status
3. A nurse is caring for a client who has manifestations of schizophrenia and is medicated PRN with
haloperidol, the nurse should assess the client for which of the following adverse effects
- Dysrhythmias
4. A nurse is caring for a client who was involved in heavy combat, the nurse should assess the
client for PTSD if the client makes which statement
- In my dreams all I can see are the wounded reaching out and trying to grab me
5. A school nurse is talking to a 13 year old female at an annual health visit, which of the following
comments are the priority to address
- None of the kids in school like me and I don’t like them either
6. A nurse on a long term unit is creating a plan of care for a client who has Alzheimer’s disease,
which of the following interventions should the nurse consider in the plan
- Talk the client through tasks 1 step at a time
7. A nurse is providing discharge teaching to a client who has bipolar disorder, has a prescription
for lithium…which factor puts at risk for lithium toxicity?
- Client runs 4 miles outdoors every afternoon
8. A nurse is providing teaching for a client who has binge eating disorder and
mobility?...obese….client prescribed orlistat…which statement indicates understanding?
- I will take my orlistat every morning 1hr before breakfast
9. Nurse is caring for a client who has major depressive disorder and was prescribed citalopram 2
weeks ago with a planned dosage increase. One week ago the client responded with improved
appetite, but still feels very depressed and trouble sleeping, which of the following comments
should nurse make
- Explain that antidepressants often take several weeks to be fully effective
10. A nurse is caring for a client who was admitted with acute psychosis and is being treated with
alopredol, the nurse should suspect that the client is experiencing tardive dyskinesia when the
client exibits which of the following
- Tongue thrushy and lip smacking
- Facial grimacing and eye blinking
- Involuntary pelvic rocking and hip thrusting movements
11. A nurse in psych unit is caring for client with bipolar disorder, the client comes to nursing station
at 0300 demanding the nurse calls provider immediately…which of the following responses
appropriate?
- You must be really upset about something
12. A nurse caring for a client with depression observes client come to dinner table looking very
refreshed – freshly bathed, wearing clean clothes, hair combed and styled…what is appropriate
response by the nurse?- I see you have done some grooming today
13. Nurse is caring for client with schizophrenia, client tells nurse they lie about me all the time and
try to poison my food…which of the following statements should nurse make?
- You seem to be having very frightening thoughts
14. A nurse is caring for a client who has been hospitalized for bipolar disorder and will be
discharged with prescription for lithium.
- Discharge teaching – diarrhea may cause lithium toxicity
15. Nurse in ER caring for adolescent client who reported being sexually assaulted, prior to
admitting the client what should the nurse do?
- Ask the client to describe the situation
16. Nurse in ER assessing client who has been taking haloperidol for 3m – client has temp of 103.4 F,
BP 150/110, and muscle rigidity. Which complication should nurse suspect?
- Neuroleptic malignant syndrome
17. Nurse in mental health facility planning care for OCD client, which action should nurse take
regarding compulsive behavior
- Plan the client’s schedule to allow time for rituals
18. Nurse in psych unit caring for several clients, which of them should nurse recommend for group
therapy?
- Client who has been taking amitriptyline for 3m for depression
19. Nurse planning care for client newly admitted for major depressive disorder, which action
should nurse take
- Determine client’s need for assistance with grooming
20. A nurse in drug school detoxication center planning care for client who has alcohol use disorder,
which intervention is priority?
- Provide adequate hydration and rest
21. Nurse caring for client who has bipolar disorder and is bored which of the following is
appropriate activity for nurse to suggest?
- Walking with nurse in court yard
22. Nurse in hospital is caring for client who has agoraphobia, which of the following statements by
the client indicates understanding of the goal of treatment
- I plan to sit on a park bench for a few minutes each day
23. Nurse asked client who is suicidal to make a safety contract but the client declined, which of the
following actions should the nurse identify as the priority?
- Assign staff member to stay with client at all times
24. Nurse in ER is assessing client with suspected cocaine intoxication, which of the following
findings should the nurse expect
- Dilated pupils
25. Nurse caring for client who is extremely suspicious of the nurse staff, which of the following
approaches is necessary when establishing therapeutic relationship?
- Neutral attitude when providing care
26. Nurse at mental health clinic is assessing client experiencing severe anxiety, the nurse should
recognize the client might exhibit which of the following manifestations?
- Threatening behavior27. Nurse observes depressed client crying alone in the room. Client states hes really down and do
not want to talk to anyone right now, which of the following responses should the nurse make?
- I will just sit here with you for a few minutes
28. Nurse caring for a client who has anorexia nervosa and over-exercises to avoid gaining weight,
which of the following actions should the nurse take?
- Ask client to agree to talk to any of the nurses whenever she feels the urge to exercise
29. Nurse caring for a client who has history of alcohol use disorder and has been hospitalized for
detoxification, the nurse enters the client’s room and finds him shouting in terrified voice GET
THIS BUG OFF OF ME, which of the following responses by the nurse is appropriate?
- I don’t see any bug but you seem very frightened
30. Nurse is conducting group therapy session for several clients, the group was laughing at a joke
someone made when one client with schizophrenia jumped up and ran out of the room yelling
YOU ARE ALL MAKING FUN OF ME, he nurse should identify this behavior as which of the
following characteristics of schizophrenia?
- Ideas of reference
31. Community health nurse is providing teaching to a family of a client who has primary dementia,
which of the following manifestations should the nurse tell the family to expect?
- Forgetfulness gradually progressing to disorientation
32. Nurse in psychiatric unit is admitting client who attacked a neighbor, the nurse should know that
the client can be kept for more than 72 hours
33. Nurse caring for client with bipolar disorder and new prescription for valproate, which of the
following instructions should the nurse give the client about the use of this medication
- Liver function tests must be monitored
34. Nurse in acute care mental facility is preparing to administer morning meds to a client who has
been taking lithium for two weeks and has a current lithium level of 1.0 meq/L, which of the
following actions should the nurse take?
- Administer morning dose of lithium
- Lithium normal range is 0.6-1.3
35. Nurse observes client’s spouse sitting alone in waiting room and crying and says she is really
concerned about her husband, which of the following is an appropriate response?
- Tell me what is concerning you
36. Nurse is caring for a client who is depressed and refuses to participate in group therapy or
perform activities of daily living, which of the following statements should the nurse make?
- I will assist you in getting out of bed and getting dressed
37. A nurse is caring for a client who has borderline personality disorder, the nurse reviews the days
schedule with the client as the client says “why don’t you show up already I cannot read it
myself you know, which of the following responses is appropriate?
- I do not like it when you address me with that tone of voice
38. Nurse is caring for a client who has been diagnosed with OCD and is consistently picking up after
others in the day room. Nurse should recognize that client uses this behavior to do which of the
following?
- Decrease anxiety to tolerable level
39. Nurse assessing client who lost a 12 year old child in a car crash 2 years ago, which of the
following findings indicates the client as……? Incomplete question.40. Nurse on crisis hotline is speaking to client who says I just took an entire bottle of amitriptyline,
which of the following responses by the nurse is appropriate?
- I am glad you called, I will send an ambulance to help you
41. Possible side effects of electroconvulsive therapy?
- Temporary memory loss,
- Headache
- confusion
42. Chronic alcohol use disorder – risk for vit b6 deficiency
43. Nurse caring for adolescent client who is experiencing indications of depression, which of the
following findings should nurse expect?
- Irritability
- Insomnia
- Low self esteem
- Chronic pain
44. Nurse caring for hospitalized client who lies about other clients and people frequently
complain…how should nurse respond?
- Nurse should set limits to promote good behavior
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