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    Exam Review

    1. A nurse is assisting with the care of a client. The nurse is contributing to the plan of care for the client. Which of the following interventions should the nurse include in the plan? Select 5 interventions the nurse should include in the plan.
      (SATA)
      A)
      Teach behavior modification techniques.
      B)
      Place the client in isolation.
      C)
      Limit client privileges on the unit.
      D)
      Touch the client's arm for reassurance.
      E)
      Use nonthreatening body language when addressing the client.
      F)
      Confront the client's aggressive behavior.
      G)
      Redirect the client to an appropriate activity.
      H)
      Role play responses to offensive behavior.
      I)
      Provide structure and boundaries for the client.
    2. A nurse is preparing to administer haloperidol 4 mg IM to a client who has schizophrenia. Available is haloperidol injection 5 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
      Correct Answer:0.8 mL
    3. A nurse is caring for an adolescent who was recently sexually assaulted. Which of the following statements by the adolescent's guardian represents the presence of a positive support system?
      A)
      "I can encourage my child to think about what they did that allowed this event to happen."
      B)
      "I anticipate that my child will feel some self-blame."
      C)
      "I should encourage my child to focus solely on the future."
      D)
      "I will have to do all I can to monitor my child's relationships."
    4. A nurse is caring for a client who has borderline personality disorder and recently used manipulation to gain access to a restricted area. Which of the following responses should the nurse make?
      A)
      "Why are you not following your treatment plan?"
      B)
      "Let's discuss the consequences of your actions."
      C)
      "You know that manipulation is not the appropriate thing to do."
      D)
      "I can request that your provider decrease the restriction."
    Page 1 of 15

    Exam Review

    1. A nurse is sitting with a client in the dayroom. The client jumps up and states, "There are snakes coming toward me!" Which of the following responses should the nurse make?
      A)
      "What do you usually do when this happens?"
      B)
      "Let's move to a different room to avoid the snakes."
      C)
      "I understand that you're seeing snakes, but I don't see any."
      D)
      "Would you like to play cards?"
    2. A nurse is caring for a client who has a depressive disorder. Which of the following factors should the nurse identify as a risk factor for developing this condition?
      A)
      Prior head trauma
      B)
      High level of norepinephrine
      C)
      Serotonin deficiency
      D)
      Viral infections
    3. A nurse is sitting with a client and asks how the client is feeling. The client replies, "Who would feel anything but rotten in my position?" Which of the following actions should the nurse take?
      A)
      Sympathize with the client's situation.
      B)
      Observe the client's nonverbal behaviors.
      C)
      Remind the client that they will feel better in a few days.
      D)
      Ignore the client's negative response and leave the room.
    4. A nurse is speaking with the partner of a client who is beginning treatment for obsessive-compulsive disorder. Which of the following statements by the partner indicates an understanding of the treatment plan?
      A)
      "For now, we should schedule enough time for my partner to complete rituals."
      B)
      "I should ignore the stressors that cause my partner to perform the ritualistic behaviors."
      C)
      "To prevent stress, we should avoid trying to make a schedule for daily activities."
      D)
      "I should expect my partner to begin exhibiting paranoid behaviors."
    Page 2 of 15

    Exam Review

    1. A nurse is collecting data from a client who reports cessation of nicotine use. Which of the following manifestations should the nurse expect? (Select all the apply.)
      (SATA)
      A)
      Decreased appetite
      B)
      Restlessness
      C)
      Weight gain
      D)
      Difficulty concentrating
      E)
      Diarrhea
    2. A nurse is collecting data from a client who has schizophrenia. Which of the following findings is the nurse's priority?
      A)
      The client is experiencing command hallucinations.
      B)
      The client is refusing to take their medication.
      C)
      The client is unable to initiate personal grooming tasks.
      D)
      The client is experiencing flight of ideas.
    3. A nurse at an inpatient mental health facility is receiving report on four clients. Which of the following clients should the nurse see first?
      A)
      A client who requires constant attention from staff
      B)
      A client who is being discharged to a group home
      C)
      A client who refuses to attend group therapy
      D)
      A client who displays a dramatic change in mood
    4. A nurse is caring for a client who has a depressive disorder. Which of the following findings should the nurse expect?
      A)
      Hypersensitivity to criticism
      B)
      Grandiosity
      C)
      Racing thoughts
      D)
      Pressured speech
    Page 3 of 15

    Exam Review

    1. A nurse is collecting data from an older adult client who was admitted with heart failure. The nurse should report which of the following findings to the provider as an indication of delirium?
      A)
      Fluctuating level of orientation
      B)
      Consistent state of depression
      C)
      Demonstrates obsessive behaviors
      D)
      Family report of gradual memory loss
    2. A nurse is contributing to the plan of care for a client who has schizophrenia. The client often directs brief, hostile verbal outbursts toward the staff. Which of the following interventions should the nurse recommend?
      A)
      Bring a security guard whenever approaching the client.
      B)
      Use a calm, clear tone when speaking to the client.
      C)
      Encourage the client to participate in a board game.
      D)
      Touch the client on the shoulder to console them.
    3. A nurse in a substance treatment facility is contributing to the plan of care for a newly admitted client. Which of the following interventions should the nurse recommend? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.)
      A)
      Administer disulfiram.
      B)
      Complete a CAGE questionnaire every 4 hr.
      C)
      Implement seizure precautions.
      D)
      Assist with a client referral to Al-Anon.
    4. A nurse is assisting with reminiscence therapy for a group of older adult clients. Which of the following strategies should the nurse implement?
      A)
      Discussing childhood memories during group therapy
      B)
      Making a unit calendar to promote orientation
      C)
      Playing board games with other clients to enhance cognition
      D)
      Encouraging thought-stopping to block undesirable thoughts
    Page 4 of 15

    Exam Review

    1. A nurse in an inpatient mental health facility is caring for a client who states, "I do not want anyone to know I am in a mental hospital." Which of the following responses should the nurse make?
      A)
      "We have to notify your insurance company that you are here."
      B)
      "We have to inform your immediate family members that you are here."
      C)
      "We have to report your admission to the National Alliance on Mental Illness."
      D)
      "We have to obtain your permission to discuss your care with others."
    2. A nurse in a mental health clinic is collecting data from a client to determine the client's risk for suicide. Which of the following findings should the nurse identify as a risk factor for suicide? (Select all that apply.)
      A)
      Terminal liver cancer
      B)
      Sibling history of suicide
      C)
      Access to guns in the home
      D)
      Alcohol use disorder
      E)
      Currently married
    3. A nurse is caring for multiple clients on a mental health unit. Which of the following clients should the nurse attend to first?
      A)
      A client in the dayroom who is screaming at other clients about what is on the television
      B)
      A client who has bipolar disorder and is continuously pacing at the end of the hall
      C)
      A client who is repeatedly approaching the nurses' station to request medication for their anxiety
      D)
      A client who is standing in their room, yelling obscenities, and throwing their clothes
    4. A nurse is speaking with the sibling of a client who refuses to see visitors. Which of the following actions should the nurse take?
      A)
      Encourage the client to visit with the sibling.
      B)
      Refer the sibling to the client's provider.
      C)
      Arrange for the sibling to visit the client in the dayroom.
      D)
      Tell the sibling the client does not want visitors.
    Page 5 of 15

    Exam Review

    1. A nurse is collecting data from an adult client in an outpatient mental health clinic. Which of the following events should the nurse identify as a potential cause of a maturational crisis?
      A)
      Motor-vehicle crash
      B)
      A child leaving for college
      C)
      Loss of job
      D)
      Divorce
    2. A nurse is caring for a client who has a new diagnosis of cancer. The client states, "I can't think about my health until after my son is married next week." The nurse should identify the client's statement as an indication of which of the following maladaptive defense mechanisms?
      A)
      Suppression
      B)
      Projection
      C)
      Splitting
      D)
      Reaction formation
    3. A client who delivered a healthy newborn 4 weeks ago calls their provider's office and tells the nurse, "This baby constantly cries. My partner works all the time, and I can't take any more." Which of the following responses is the nurse's priority?
      A)
      "Have you discussed this with your partner?"
      B)
      "Do you have a friend who could help you?"
      C)
      "Having a newborn must be stressful. Do you have other children?"
      D)
      "Tell me about your baby. Where are they now?"
    4. A nurse is reinforcing teaching with the caregiver of a client who has Alzheimer's disease. The caregiver reports that the client awakens at night and wanders. Which of the following strategies should the nurse suggest?
      A)
      Place a lock at the top of doors leading outside.
      B)
      Encourage the client to nap during the day.
      C)
      Administer an antianxiety medication before bedtime.
      D)
      Use light restraints while the client is in bed.
    Page 6 of 15