Question: A charge nurse is discussing the care of a client who has a substance disorder with a staff nurse. Which of the following statements by the staff nurse should the charge nurse identify as countertransference?
Answer Options: The client asked me to go on a date with him, but I refused, The client needs to accept responsibility for his substance use, The client is just like my brother who finally overcame his habit, The client generally shares his feelings during group therapy sessions
Answer: The client is just like my brother who finally overcame his habit
Question: A nurse is caring for a client who is going through the grieving process. Which of the following actions should the nurse take to meet the client’s spiritual needs?
Answer Options: Change the subject when the client expresses anger about their situation, Offer to contact the client’s spiritual advisor if they have one, Allow the client to be alone during times of spiritual inadequacy, Encourage the client to internalize their feelings related to the loss
Answer: Offer to contact the client’s spiritual advisor if they have one
Question: A nurse is receiving change-of-shift report about a group of assigned clients at a mental health facility. Which of the following clients should the nurse assess for risks related to sensory impairments?
Answer Options: A client who has narcissistic personality disorder, A client who has mild anxiety disorder, A client who has severe obsessive-compulsive disorder, A client who has conversion disorder
Answer: A client who has conversion disorder
Question: A nurse is caring for a client who has Alzheimer’s disease. Which of the following findings should the nurse expect?
Answer Options: Altered level of consciousness, Excessive motor activity, Failure to recognize familiar objects, Rapid mood swings
Answer: Failure to recognize familiar objects
Question: 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?
Answer Options: Role model healthy ways to express anger, Ask the client if he intends to harm others, Suggest the client make a list of things that make him angry, Assist the client to explore techniques to reduce stress
Answer: Ask the client if he intends to harm others
Question: A nurse is creating a plan of care for a client who has schizophrenia and is experiencing command hallucinations. Which of the following interventions should the nurse include in the plan?
Answer Options: Encourage increased socialization during group therapy, Avoid making eye contact when speaking with the client, Provide reassurance and comfort for the client through touch, Maintain a low level of environmental stimuli
Answer: Maintain a low level of environmental stimuli
Question: A nurse is caring for a client who is involuntarily admitted for major depressive disorder and refuses to take a prescribed oral antianxiety medication. Which of the following actions should the nurse take?
Answer Options: Implement consequences until the client takes the medication, Offer the client the medication at the next scheduled dose time, Inform the client that he does not have the right to refuse the medication, Administer the medication to the client via IM injection
Answer: Offer the client the medication at the next scheduled dose time
Question: 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?
Answer Options: The client will attend to personal hygiene, The client will report a decrease in hallucinations, The client will communicate needs, The client will verbalize improved mood
Answer: The client will communicate needs
Question: A nurse is caring for a client who is taking lithium and reports experiencing lethargy, muscle weakness, and blurred vision. Which of the following responses should the nurse make?
Answer Options: “Continue the medication as prescribed.”, “These symptoms will improve over time.”, “You should decrease your intake of sodium.”, “You will need to have your blood drawn.”
Answer: “You will need to have your blood drawn.”
Question: A nurse in a rehabilitation center is caring for a client who has bipolar disorder. Which of the following actions by the client indicates mania?
Answer Options: The client is sleeping over 10 hr a day, The client displays memory loss, The client expresses feelings of inferiority, The client is constantly talking
Answer: The client is constantly talking
Question: A nurse in an outpatient mental health facility is preparing to administer phenelzine to a client who has been taking this medication for several years. The client reports eating a grilled cheese sandwich and banana for lunch and is feeling dizzy. Which of the following vital signs should the nurse assess first?
Answer Options: Blood pressure, Temperature, Respiration, Pulse
Answer: Blood pressure
Question: A nurse is caring for a client who just received lorazepam 1 mg IM for anxiety. Which of the following actions should the nurse take?
Answer Options: Initiate fall precautions for the client, Repeat the dose in 15 min if the client is still anxious, Place the client in restraints for 1 hr, Instruct the client to expect ringing in the ears
Answer: Initiate fall precautions for the client
Question: A nurse on an inpatient mental health unit is caring for a client. The nurse is discussing the assessment findings on day 3 of admission during the 1900 change-of-shift report. The nurse must decide if the client’s condition is improving or worsening based on the assessment findings.
Answer Options: Food intake, Condition of skin on right hand, Rapid change in mood, Giving away car, Hygiene
Answer: Food intake (Improving), Condition of skin on right hand (Worsening), Rapid change in mood (Worsening), Giving away car (Worsening), Hygiene (Improving)
Question: A nurse in a mental health facility is admitting a client who was brought in by the police department. The client is showing signs of possible schizophrenia. What actions should the nurse take and what should be monitored?
Answer Options: Offer the client frequent finger food, Place the client in a room near the nurses’ station, Ensure the client is taking their prescribed medications, Request a prescription for physical restraints, Request a prescription for diazepam
Answer: Ensure the client is taking their prescribed medications, Place the client in a room near the nurses’ station
Question: A nurse in a mental health facility is preparing to administer phenelzine to a client who has been taking this medication for several years. The client reports eating a grilled cheese sandwich and banana for lunch and is feeling dizzy. Which of the following vital signs should the nurse assess first?
Answer Options: Blood pressure, Temperature, Respiration, Pulse
Answer: Blood pressure
Question: A nurse is caring for a client who just received lorazepam 1 mg IM for anxiety. Which of the following actions should the nurse take?
Answer Options: Initiate fall precautions for the client, Repeat the dose in 15 min if the client is still anxious, Place the client in restraints for 1 hr, Instruct the client to expect ringing in the ears.
Answer: Initiate fall precautions for the client
Question: A nurse on an inpatient mental health unit is caring for a client. The nurse is discussing the assessment findings on day 3 of admission during the 1900 change-of-shift report. The nurse must decide if the client’s condition is improving or worsening based on the assessment findings.
Answer Options: Various symptoms and behaviors such as Food intake, Condition of skin on right hand, Rapid change in mood, Giving away car, Hygiene
Answer: Condition of skin on right hand (Worsening), Rapid change in mood (Worsening), Giving away car (Worsening), Food intake (Improving), Hygiene (Improving)