CMS Mental Health Exam 1 with 100% Correct Answers

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CMS Mental Health Exam 1 with 100% Correct Answers 1. A nurse is caring for a client who is experiencing manifestations of alcohol withdrawal. Which of the following medications should the nurse pl... an to administer? a. Chlordiazepoxide 2. A nurse is caring for a client who has binge eating disorder. Which of the following actions should the nurse take? a. Plan a menu with the client 3. A nurse in the emergency department is admitting a client who has a history of alcohol use disorder. The client has a blood alcohol level of 0.26mg/dL. The nurse should anticipate a prescription for which of the following medications? a. Naltrexone 4. A nurse in a mental health facility is interviewing a newly admitted client who is related to the nurse’s neighbor. The nurse should identify which of the following must occur when establishing a therapeutic nurse-client relationship? a. The nurse maintains confidentiality unless the client’s safety is compromised. 5. 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. “Tell me the reasons you think your mother is depressed.” 6. A nurse is speaking with a client. Which of the following responses by the nurse demonstrates the communication technique of reflection? a. “You feel upset when this happens?” 7. 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 family member is displaying which of the following types of family boundaries? a. Clear 8. A nurse is assessing a client who has depression and takes phenelzine. The client reports eating pepperoni pizza while out on a pass during lunchtime. Which of the following assessments should the nurse perform? a. Blood pressure 9. 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 10. A nurse in an in-patient facility is caring for a client who has anxiety disorder. Which of the following actions should the nurse take while the client is experiencing an acute panic attack? a. Administer a dose of alprazolam to the client 11. A nurse is caring for an adolescent whose family has a very rigid system of rules. Which of the following characteristics should the nurse expect when observing the family? a. The communication between family members is minimal 12. 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. Assist the client to lower his anxiety levels 13. 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 but will not sign the consent form. Which of the following actions should the nurse take? a. Cancel the ECT procedure 14. A nurse has placed a client who has become physically aggressive into seclusion. Which of the following actions should the nurse take? a. Obtain the providers prescription within 60 min. 15. A nurse in the emergency department is assessing a client who has major depressive disorder. Which of the following actions should the nurse take? (Click on the “Exhibit” button for additional information about the client. There are three tabs that contain separate categories of data.) a. Ask the client if she has eaten foods containing tyramine. 16. 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. Displacement 17. A nurse in a mental health facility is making plans for a clients discharge. Which of the following interdisciplinary team members should the nurse contact to assist with the housing placement. a. Social worker 18. A nurse is reviewing the medical record of a client who has anorexia nervosa. Which of the following findings should the nurse report to the provider. (Click on the “Exhibit” button for additional information about the client. There are three tabs that contain separate categories of data.) a. 19. A nurse is caring for a client who has bipolar disorder and is refusing to take prescribed medications. Which of the following ethical principles is the nurse displaying when he supports the client's refusal of medication? a. Autonomy 20. A community health nurse is providing an education program about expected age-related changes for a group of older adults. Which of the following statements by a client demonstrates an understanding of the teaching? a. “I should expect an increased risk of depression as I age.” 21. A nurse is assessing a client who has Alzheimer's disease. Which of the following findings should the nurse identify as a priority? a. The client engages in wandering. 22. A nurse is assessing a client during a follow up visit at a behavioral health clinic. The client reports that they have not been taking the prescribed antipsychotic medication on a regular basis. Which of the following actions should the nurse take to improve medication adherence? a. Ask the client whether medication is causing adverse effects. 23. A nurse is assessing a client who is taking chlorpromazine. The clients dosage was decreased 3 months ago to reduce adverse effects. Which of the following findings should the nurse identify as an indication that the reduced dosage of chlorpromazine is effective? a. Improved Gait 24. 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. Unkempt appearance 25. 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 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 26. A nurse is assessing a child in the emergency department. Which of the following findings places the child at greatest risk for physical abuse? a. The child has cystic fibrosis 27. A nurse in an emergency department is caring for a client following a domestic dispute. The client states, “Nothing seems to go right for me and probably never will.” Which of the following statements should the nurse make? a. Are you thinking of harming yourself? question 28/30 28. A nurse is caring for a client who is undergoing electroconvulsive therapy. Which of the following tasks should the nurse delegate to an assistive personnel? a. Assist the client to ambulate for the first time following the procedure 29. A nurse is caring for a client who recently experienced the unexpected death of his child. Which of the following actions should the nurse take first? a. Identify the client's support system 30. A nurse is caring for a client who has schizophrenia and is experiencing delusions. The client states, “I can feel worms crawling through my veins.” Which of the following types of delusions should the nurse document the client is experiencing? a. Somatic Delusion 31. A nurse is providing teaching about disulfiram to a client who has a history of alcohol. Which of the following instructions should the nurse include in the teaching? (Select all that apply.) a. You should avoid using mouthwash that contains alcohol b. You should avoid drinking carbonated beverages while taking the medication 32. 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. Hypertension 33. A nurse is providing teaching to a client who has a substance use disorder and a new prescription of methadone. Which of the following information should the nurse include in the teaching? a. You might experience constipation while taking this medication 34. A nurse is evaluating the medication response of a client who takes naltrexone for the treatment of alcohol use disorder. The nurse should identify which of the following therapeutic effects of this medication? a. Reduces substance craving 35. 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 36. A nurse is interviewing a client who reports ongoing feelings of depression after the death of his siblings 9 months ago. Which of the following actions should the nurse take? a. Explain to the client that the duration of the grief is highly variable and can last for years 37. 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 38. A nurse is planning care for a client who is experiencing acute alcohol withdrawal. The nurse should anticipate that the provider will prescribe which of the following medications for the client? a. Diazepam 39. 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? a. Maintain a low level of environmental stimuli 40. A nurse is assessing a client who has a family history of Alzheimer's disease. The nurse should identify which of the following findings as an additional risk factor for dementia? a. Head Injury 41. 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 42. A nurse in an acute care mental health facility is receiving a morning report for a group of clients. Which of the following clients should the nurse plan to assess first? a. 43. 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. Dim the lights in the clients room. 44. 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 or the client during the day. 45. A nurse is speaking to a former high school friend. The friend states “I heard one of our high school teachers was admitted to your hospital, is everything okay?” Which of the following responses should the nurse make? a. I can only discuss the status of a client with the client's family. 46. A charge nurse is discussing 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.” 47. 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. Repression 48. A nurse is caring for a client who has anxiety disorder and is scheduled for a procedure. The client informs the nurse that they do not want to have the procedure. Which of the following actions should the nurse take? a. Inform the client that they have the legal right to refuse treatment at any time. 49. A nurse is assessing a client who has a post-traumatic stress disorder. Which of the following findings should the nurse expect? (Select all that apply.) a. Difficulty concentrating - Has difficulty concentrating on set tasks b. Negative self-image - holds persistent negative beliefs about self c. Recurring nightmares - difficulty falling or staying asleep 50. A nurse is providing teaching for a newly licensed nurse about the constructive use of defense mechanisms. Which of the following examples should the nurse include in the teaching? a. A client who is upset with her teacher writes a story about an excellent student. 51. A nurse is assessing a client who has bipolar disorder. Which of the following findings should the nurse identify as an indication that the client is experiencing acute mania? a. Reports a lack of sleep 52. A nurse manager is observing a newly licensed nurse preparing to administer an IM medication to a client who is manic and refuses the medication. Which of the following actions should the nurse manager take first? a. Stop the newly licensed nurse from administering the medication. 53. 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. Lead the client outside for a walk. 54. A nurse in an acute 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 the clinical psychologist? a. The client needs to begin a group therapy program prior to discharge. 55. A nurse is assessing a client who has a new prescription for disulfiram. Which of the following statements by the client indicates understanding of the teaching? a. I can continue to eat aged cheeses and chocolate 56. A nurse is caring for a client who has been placed in restraints. Which of the following actions should the nurse take? a. Document the client behavior hourly on the flowchart. 57. A nurse is caring for a client who was involuntarily committed and is scheduled to review electroconvulsive therapy. The client refuses the treatment and will not discuss why with the healthcare team. Which of the following actions should the nurse take? a. Document the client’s refusal of the treatment in the medical record. 58. A nurse is creating a plan of care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan? a. Set a weight gain goal of 2.2 kg (4.9 lb) per week. 59. A nurse is caring for a client who was just placed in mechanical restraints. Which of the following actions should the nurse take? a. Request that the provider provide an as-needed prescription for restraints. 60. A nurse is caring for a client who states, “I have been having trouble sleeping for the last several months.” Which of the following responses should the nurse make? a. You should avoid stressful activities prior to going to sleep 61. 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 develops an inability to concentrate. 62. 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. Ask the client if she has thought about harming herself. [Show More]

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