Exam Review

A nurse is interviewing a client who states, "I am at a total loss and don't know what to do anymore. I feel hopeless." Which of the following responses should the nurse make?
A)
"Would you like to speak to a therapist after treatment?”
B)
"You feel like you have no remaining options and are struggling to find a solution."
C)
"If you do not like your medication would you like to try an alternative?"
D)
"You would like more information, I will get that for you right away”
A newly licensed nurse is discussing the concept for eustress with another nurse. Which of the following examples provided by the newly licensed nurse indicates an understanding of the teaching?
A)
Receiving a notification of possible layoffs at work
B)
Receiving a notification of insufficient funds in their bank account
C)
Losing a family pet.
D)
Preparing for a vacation with friends
A nurse is preparing to administer fluoxetine 40 mg PO daily. The amount available is fluoxetine 20 mg/5mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer:10 mL
A nurse is talking with the parent of a child who has a history of trauma and was just diagnosed with dissociative identity disorder. The parent states, "I don't think this is right, my daughter is just doing this for attention." Which of the following responses is the most therapeutic response?
A)
"Our physician is very capable of making an accurate diagnosis, I would trust their judgment”
B)
"Dissociation is a symptom that can be overlooked in children. Trauma can increase dissociation.”
C)
"Why would your daughter do something like this for attention?”
D)
"You're right; dissociative identity disorder is commonly over diagnosed in children."

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Exam Review

A nurse is caring for a client with a history of trauma who has a diagnosis of dissociative identity disorder. During a group therapy session, the client becomes unresponsive, stares blankly, and appears unaware of their surroundings. Which of the following is the nurse's best response?”
A)
"Let's pause the group and have you rest as your room for a while”
B)
"Do you remember what we were just talking about in the group?"
C)
"Try not to disassociate. You need to stay focused during group therapy."
D)
"You're safe here. Can you tell me what you're feeling right now?”
A group of nurses is discussing the purpose of mental health documentation. Which of the following descriptions of nursing documentation for a mental health client is accurate?
A)
Documentation for mental health clients provides a record of the nurse's awareness of client behaviors, mental status, interventions, and client response
B)
Documentation for a mental health client outlines the client's therapies, treatments, and needs for discharge planning
C)
Documentation for a mental health client is focused on the client's diagnosis, reason for medications, plan of care, and client progression.
D)
Documentation for a mental health client is a defined process based on hospital specific requirements which highlights client care
A nurse is teaching a client who is prescribed a monoamine oxidase inhibitor (MAO) about how to follow a tyramine-restricted diet. Which of the following meals should the nurse approve?
A)
Smoked salmon bagel with cream cheese, pickled beets, and cola
B)
Pepperoni pizza, mixed greens with blue cheese dressing, and iced tea
C)
Grilled chicken breast, steamed green beans, mashed potatoes, and apple slices
D)
Tuna salad sandwich with aged cheddar cheese and a chocolate protein shake
A soldier returns to the United States after active duty in a combat zone and is diagnosed with posttraumatic stress disorder (PTSD). When planning care, which of the following should the nurse identify as the highest priority for screening?
A)
Risk for substance use as a coping mechanism
B)
Sleep disturbances and recurring nightmares
C)
Suicidal ideation and risk for self-harm
D)
Social isolation and withdrawal from family

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Exam Review

A nurse teaching a patient about a tyramine restricted diet would approve which meal?
A)
Avocado salad, ham, creamed potatoes, asparagus, chocolate cake
B)
Macaroni and cheese, hot dogs, banana bread, caffeinated coffee
C)
Noodles with cheddar cheese sauce, smoked sausage, lettuce salad yeast is
D)
Mashed potatoes, ground beef patty, com, green beans, apple pie
A veteran who served in a combat zone is admitted to the inpatient psychiatric unit for severe anxiety and disrupted sleep. The nurse conducts a mental health assessment. Which client statement most strongly supports a diagnosis of posttraumatic stress disorder (PTSD)?
A)
"I get anxious sometimes when I'm in crowded places like shopping centers."
B)
"I try not to talk about the war much-it's in the past, and I've moved on."
C)
"I think about the war more than I'd like, especially when I see the news."
D)
"I wake up in a sweat almost every night because I'm back on the battlefield in my dreams."
A nurse is caring for a client with schizophrenia who expresses intent to harm a former partner. Which of the following actions by the nurse best demonstrates application of the "duty to warn exception to client confidentiality?
A)
Informing hospital security and placing the client on one-to-one observation
B)
Documenting the client's statement and notifying the healthcare team at shift change
C)
Discussing the threat with the client's family to gain insight into past behavior
D)
Reporting the threat to law enforcement and initiating steps to notify the intended victim
A nurse is reviewing the history of a client recently diagnosed with major depressive disorder. The client has no prior psychiatric history. The client reports the following during assessment: Recently lost a parent to cancer Family history of mood disorders Working two jobs with long hours Reports poor sleep and increased irritability Which of the following should the nurse identify as the primary risk factor for developing depression in this client?
A)
Family history of mood disorders
B)
Working two jobs with long hours
C)
Poor sleep and irritability
D)
Loss of a parent due to cancer

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Exam Review

A nurse in an inpatient psychiatric unit is caring for a 28-year-old client diagnosed with generalized anxiety disorder. The client recently started group therapy and states, "I don't belong here. Everyone else seems to be doing better. I haven't even talked in group. I'm just a failure." The client also reports difficulty sleeping and has been requesting to speak privately with the nurse multiple times per day Based on Maslow's Hierarchy of Needs, which of the following should the nurse prioritize?
A)
The client's lack of participation in group therapy
B)
The client's desire for one-on-one attention and validation
C)
The client's verbalized low self-worth and negative self-talk
D)
The client's need to establish trust and psychological safety
A nurse is discussing the psychological and behavioral manifestations of stress with a group of clients. The nurse should include which of the following manifestations?
A)
Weakened immune system
B)
Increased sadness
C)
High blood pressure
D)
Disordered eating
E)
Delayed development
A nurse in an acute mental health facility is caring for a client who suddenly jumps out of her chair and begins shouting angrily at the other clients. The client appears tense and is pacing rapidly. Which of the following therapeutic responses should the nurse use first?
A)
"if you don't stop shouting I have to call security."
B)
"I can see you're upset. Let's step into the hallway and talk privately”
C)
"Why are you yelling at the others? What happened to cause this?”
D)
"You need to calm down before someone gets hurt."
A nurse is conducting an admission interview with a client who is withdrawn and offers only short responses. Which of the following actions by the nurse demonstrates effective use of therapeutic communication techniques?
A)
Asking the client to explain why they are being so quiet
B)
Sting in silence until the client begins to talk more freely
C)
Telling the client. "You' feel better once we get through this interview."
D)
Using open-ended questions to encourage client expression

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Exam Review

A nurse in a mental health facility is planning holistic care for their clients. Which of the following actions should the nurse include? (Select all that apply.)
A)
Ask for a social worker referral for clients who cannot afford their medications
B)
Demonstrate empathy when clients explain their concerns
C)
Assist the clients in identifying coping strategies
D)
Address physical concerns the clients might have.
E)
Teach clients that adherence to their medication regimen is their priority.
A nurse is caring for a client 3 days after admission for treatment of depression. The client leaves her current activity, approaches the nurse and states, "There's no reason to go on living. I just want to end it all." Which of the following actions should the nurse take?
A)
Ask the client if she has a plan to commit suicide.
B)
Notify the client's family and request a visitor to stay with the client until thoughts of suicide are gone.
C)
Recognize the attempt at manipulation and escort the client back to her activity.
D)
Assist the client to her room and allow her to rest before resuming activity.
A nurse on a mental health unit is caring for a client. Exhibits The nurse is planning care for the client. Which of the following actions should the nurse plan to take? (Select all that apply.)
A)
Instruct the client on coping mechanisms and relaxation techniques
B)
Encourage the client to verbalize their feelings.
C)
Establish consequences for unacceptable behaviors.
D)
Bargain with the client when setting behavioral expectations
E)
Provide clear boundaries for behavior toward peers and staff members
F)
Determine if the client is having thoughts of harming themselves or others.
A nurse is reviewing five different interventions provided to clients with mental illness. Which of the following actions best demonstrates respect for client autonomy?
A)
Administering medication after informing the client of the risks and benefits, despite their verbal refusal
B)
Informing the client of the care plan and allowing them to select from available treatment options
C)
Documenting that the client is noncompliant after they express concern about side effects of medication
D)
Asking the client's spouse to consent to treatment decisions during a care conference

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Exam Review

A nurse is discussing the process of evidence-based practice (EBP) with a newly licensed nurse. Which of the following statements made by the newly licensed nurse indicates an understanding of the process?
A)
"Identifying the problem is the first step of the EP process."
B)
“Reviewing the effectiveness of the findings is the last step of the EBP process."
C)
"Reliance on personal experiences is important to the process of EBP."
D)
"There are four steps in the process of EBP."
Client: A.S., 34-year-old male Setting: Outpatient Veterans Affairs Mental Health Clinic Presenting Complaint: "I can't sleep and I keep reliving what happened." History: A.S. is a recently discharged military veteran who survived an improvised explosive device (IED) attack during deployment. He reports persistent nightmares, emotional numbing, and avoiding crowded environments. His spouse notes increased irritability and detachment from family members. A.S. denies substance use and suicidal ideation but expresses "hopelessness about things ever changing." Exhibits Select the assessment findings that require immediate follow-up
A)
Sleep disturbance
B)
Avoids group interaction
C)
Verbalized hopelessness
D)
Startled by loud noise
E)
Preoccupation with trauma
Client: A.S., 34-year-old male Setting: Outpatient Veterans Affairs Mental Health Clinic Presenting Complaint: "I can't sleep and I keep reliving what happened." History: A.S. is a recently discharged military veteran who survived an improvised explosive device (IED) attack during deployment. He reports persistent nightmares, emotional numbing, and avoiding crowded environments. His spouse notes increased irritability and detachment from family members. A.S. denies substance use and suicidal ideation but expresses "hopelessness about things ever changing." Exhibits Complete the following sentence by using the list of options. The client is at risk for developing dropdown Clinical Disorder/Clinical Manifestation due to dropdown
Client: A.S., 34-year-old male Setting Outpatient Veterans Affairs Mental Health Clinic Presenting Complaint: "I can't sleep and I keep reliving what happened." History: A.S. is a recently discharged military veteran who survived an improvised explosive device (IED) attack during deployment. He reports persistent nightmares, emotional numbing, and avoiding crowded environments. His spouse notes increased irritability and detachment from family members. A.S. denies substance use and suicidal ideation but expresses "hopelessness about things ever changing." Exhibits For each intervention below, identify whether it is indicated, nonessential, or contraindicated based on the client's current presentation.
A)
Reinforce consistent medication adherence
B)
Recommend discontinuing SSRI after one week if no signs of improvement
C)
Performing suicide risk assessment every other day.
D)
Discuss long-term goals for reintegration and recovery
E)
Explore feelings of survivor guilt in individual therapy
F)
Perform Abnormal Involuntary Movement Scale (AIMS) assessment
G)
Encourage sleep avoidance to reduce nightmare

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