NR 292 (NR292Mental Health NCLEX QUESTIONS AND ANSWER) (NR 292 (NR292Mental Health NCLEX QUESTIONS AND ANSWER)

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Exam (elaborations) NR 292 (NR292Mental Health NCLEX QUESTIONS AND ANSWER) (NR 292 (NR292Mental Health NCLEX QUESTIONS AND ANSWER)) Mental Health 1. The home care nurse is visiting an older client who... se spouse died 6 months ago. Which behavior by the client indicates ineffective coping? 1. Neglecting personal grooming 2. Looking at old snapshots of family 3. Participating in a senior citizens' program 4. Visiting their spouse's grave once a month 1. Neglecting personal grooming 2. A client with a diagnosis of major depression who has attempted suicide says to the nurse, "I should have died. I've always been a failure. Nothing ever goes right for me." Which response demonstrates therapeutic communication? 1. "You have everything to live for." 2. "Why do you see yourself as a failure?" 3. "Feeling like this is all part of being depressed." 4. "You've been feeling like a failure for a while?" 4. "You've been feeling like a failure for a while?" 3. When the mental health nurse visits a client at home, the client states, "I haven't slept at all the last couple of nights." Which response by the nurse illustrates a therapeutic communication response to this client? 1. "I see." 2. "Really?" 3. "You're having difficulty sleeping?" 4. "Sometimes, I have trouble sleeping too." 3. "You're having difficulty sleeping?" 4. A client experiencing disturbed thought processes believes that his food is being poisoned. Which communication technique should the nurse use to encourage the client to eat? 1. Using open-ended questions and silence 2. Sharing personal preference regarding food choices 3. Documenting reasons why the client does not want to eat 4. Offering opinions about the necessity of adequate nutrition 1. Using open-ended questions and silence 5. A client admitted to a mental health unit for treatment of psychotic behavior spends hours at the locked exit door shouting, "Let me out. There's nothing wrong with me. I don't belong here." What defense mechanism is the client implementing? 1. Denial 2. Projection 3. Regression 4. Rationalization 1. Denial 6. A client diagnosed with terminal cancer says to the nurse, "I'm going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this. After all, I'm the one who's dying." Which response by the nurse is therapeutic? 1. "Have you shared your feelings with your family?" 2. "I think we should talk more about your anger with your family." 3. "You're feeling angry that your family continues to hope for you to be cured?" 4. "You are probably very depressed, which is understandable with such a diagnosis." 3. "You're feeling angry that your family continues to hope for you to be cured?" 7. On review of the client's record, the nurse notes that the mental health admission was voluntary. Based on this information, the nurse anticipates which client behavior? 1. Fearfulness regarding treatment measures. 2. Anger and aggressiveness directed toward others. 3. An understanding of the pathology and symptoms of the diagnosis. 4. A willingness to participate in the planning of the care and treatment plan. 4. A willingness to participate in the planning of the care and treatment plan. 8. When reviewing the admission assessment, the nurse notes that a client was admitted to the mental health unit involuntarily. Based on this type of admission, the nurse should provide which intervention for this client? 1. Monitor closely for harm to self or others. 2. Assist in completing an application for admission. 3. Supply the client with written information about their mental illness. 4. Provide an opportunity for the family to discuss why they felt the admission was needed. 1. Monitor closely for harm to self or others. 9. The nurse is preparing a client for the termination phase of the nurse-client relationship. The nurse prepares to implement which nursing task that is most appropriate for this phase? 1. Planning short-term goals 2. Making appropriate referrals 3. Developing realistic solutions 4. Identifying expected outcomes 2. Making appropriate referrals 10. The nurse in the mental health unit recognizes which as being therapeutic communication techniques? Select all that apply. 1. Restating 2. Listening 3. Asking the client, "Why?" 4. Maintaining neutral responses 5. Providing acknowledgment and feedback 6. Giving advice and approval or disapproval o 1. Restating o 2. Listening o 4. Maintaining neutral responses o 5. Providing acknowledgment and feedback 11. A client being seen in the emergency department immediately after being sexually assaulted appears calm and controlled. The nurse analyzes this behavior as indicating which defense mechanism? 1. Denial 2. Projection 3. Rationalization 4. Intellectualization 1. Denial 12. A client's unresolved feelings related to loss would be most likely observed during which phase of the therapeutic nurse-client relationship? 1. Trusting 2. Working 3. Orientation 4. Termination 4. Termination 13. The nurse is working with a client who despite making a heroic effort was unable to rescue a neighbor trapped in a house fire. Which client-focused action should the nurse engage in during the working phase of the nurse-client relationship? 1. Exploring the client's ability to function 2. Exploring the client's potential for self-harm 3. Inquiring about the client's perception or appraisal of why the rescue was unsuccessful 4. Inquiring about and examining the client's feelings for any that may block adaptive coping 4. Inquiring about and examining the client's feelings for any that may block adaptive coping 14. The nurse employed in a mental health unit of a hospital is the leader of a group psychotherapy session. What is the nurse's role during the termination stage of group development? 1. Acknowledging that the group has identified goals 2. Encouraging the accomplishment of the group's work 3. Acknowledging the contributions of each group member 4. Encouraging members to become acquainted with one another 3. Acknowledging the contributions of each group member 15. Which are characteristics of the termination stage of group development? Select all that apply. 1. The group evaluates the experience. 2. The real work of the group is accomplished. 3. Group interaction involves superficial conversation. 4. Group members become acquainted with each other. 5. Some structuring of group norms, roles, and responsibilities takes place. 6. The group explores members' feelings about the group and the impending separation. o 1. The group evaluates the experience. o 6. The group explores members' feelings about the group and the impending separation. 16. When a client is admitted to an inpatient mental health unit with the diagnosis of anorexia nervosa, a cognitive behavioral approach is used as part of the treatment plan. The nurse understands that which is the purpose of this approach? 1. Providing a supportive environment 2. Examining intrapsychic conflicts and past issues 3. Emphasizing social interaction with clients who withdraw 4. Helping the client to examine dysfunctional thoughts and beliefs 4. Helping the client to examine dysfunctional thoughts and beliefs 17. The nurse understands that which best describes Gestalt therapy? 1. It emphasizes self-expression, self-exploration, and self-awareness in the present. 2. It promotes the individual's comfort in the group, which then transfers to other relationships. 3. The therapist focuses on how irrational beliefs and thoughts contribute to psychological distress. 4. The therapist's goal is to help others express their feelings toward one another during group sessions. 1. It emphasizes self-expression, self-exploration, and self-awareness in the present. 18. A client is preparing to attend a Gamblers Anonymous meeting for the first time. The nurse should tell the client that which is the first step in this 12-step program? 1. Admitting to having a problem 2. Substituting other activities for gambling 3. Stating that the gambling will be stopped 4. Discontinuing relationships with people who gamble 1. Admitting to having a problem 19. Which describes the primary focus of milieu therapy? 1. A form of behavior modification therapy 2. A cognitive approach to changing behavior 3. A living, learning, or working environment 4. A behavioral approach to changing behavior 3. A living, learning, or working environment 20. While being treated, a client is introduced to short periods of exposure to the phobic object while in a relaxed state. What term is used to describe this form of behavior modification? 1. Milieu therapy 2. Aversion therapy 3. Self-control therapy 4. Systematic desensitization 4. Systematic desensitization 21. A client is planning to attend Overeaters Anonymous. Which statement by the client indicates a need for additional information regarding this self-help group? 1. "The leader is a nurse or psychiatrist." 2. "The members provide support to each other." 3. "People who have a similar problem are able to help others." 4. "It is designed to serve people who have a common problem." 1. "The leader is a nurse or psychiatrist." 22. What is the most appropriate nursing action to help manage a manic client who is monopolizing a group therapy session? 1. Ask the client to leave the group for this session only. 2. Refer the client to another group that includes other manic clients. 3. Tell the client to stop monopolizing in a firm but compassionate manner. 4. Thank the client for the input, but inform the client that now others need a chance to contribute. 4. Thank the client for the input, but inform the client that now others need a chance to contribute. 23. Which type of therapeutic approach has the characteristic that all team members are seen as equally important in helping clients meet their goals? 1. Milieu therapy 2. Interpersonal therapy 3. Behavior modification 4. Rational emotive therapy 1. Milieu therapy 24. A client says to the nurse, "The federal guards were sent to kill me." What is the best nursing response to the client's concern? 1. "I don't believe this is true." 2. "The guards are not out to kill you." 3. "Do you feel afraid that people are trying to hurt you?" 4. "What makes you think the guards were sent to hurt you?" 3. "Do you feel afraid that people are trying to hurt you?" 25. A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially? 1. Move the client next to the nurse's station. 2. Use an indirect light source and turn off the television. 3. Keep the television and a soft light on during the night. 4. Play soft music during the night, and maintain a well-lit room. 2. Use an indirect light source and turn off the television. 26. A client is admitted to the mental health unit with a diagnosis of depression. The nurse should develop a plan of care for the client that includes which intervention? 1. Encouraging quiet reading and writing for the first few days 2. Identification of physical activities that will provide exercise 3. No socializing activities, until the client asks to participate in milieu 4. A structured program of activities in which the client can participate 4. A structured program of activities in which the client can participate 27. When planning the discharge of a client with chronic anxiety, the nurse directs the goals at promoting a safe environment at home. Which is the most appropriate maintenance goal? 1. Suppressing feelings of anxiety 2. Identifying anxiety-producing situations 3. Continued contact with a crisis counselor 4. Eliminating all anxiety from daily situations 2. Identifying anxiety-producing situations 28. A client is unwilling to go out of the house for fear of "making a fool of myself in public." Because of this fear, the client remains homebound. Based on these data, which mental health disorder is the client experiencing? 1. Agoraphobia 2. Social phobia 3. Claustrophobia 4. Hypochondriasis 2. Social phobia 29. The nurse is conducting a group therapy session. During the session, a client diagnosed with mania consistently disrupts the group's interactions. Which intervention should the nurse initially implement? 1. Setting limits on the client's behavior 2. Asking the client to leave the group session 3. Asking another nurse to escort the client out of the group session 4. Telling the client that they will not be able to attend any future group sessions 1. Setting limits on the client's behavior 30. A client is admitted to a medical nursing unit with a diagnosis of acute blindness after being involved in a hit-and-run accident. When diagnostic testing cannot identify any organic reason why this client cannot see, a mental health consult is prescribed. Which condition will be the focus of this consult? 1. Psychosis 2. Repression 3. Conversion disorder 4. Dissociative disorder 3. Conversion disorder 31. A manic client begins to make sexual advance towards visitors in the dayroom. When the nurse firmly states that this is inappropriate and will not be allowed, the client becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of this situation, which intervention should the nurse implement? 1. Place the client in seclusion for 30 minutes. 2. Tell the client that the behavior is inappropriate. 3. Escort the client to their room, with the assistance of other staff. 4. Tell the client that their telephone privileges are revoked for 24 hours. 3. Escort the client to their room, with the assistance of other staff. 32. Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply. 1. Communicate expected behaviors to the client. 2. Ensure that the client knows that they are not in charge of the nursing unit. 3. Assist the client in identifying ways of setting limits on personal behaviors. 4. Follow through about the consequences of behavior in a nonpunitive manner. 5. Enforce rules by informing the client that they will not be allowed to attend therapy groups. 6. Have the client state the consequences for behaving in ways that are viewed as unacceptable. o 1. Communicate expected behaviors to the client. o 3. Assist the client in identifying ways of setting limits on personal behaviors. o 4. Follow through about the consequences of behavior in a nonpunitive manner. o 6. Have the client state the consequences for behaving in ways that are viewed as unacceptable. 33. The nurse observes that a client is pacing, agitated, and presenting aggressive gestures. The client's speech pattern is rapid, and affect is belligerent. Based on these observations, what is the nurse's immediate priority of care? 1. Provide safety for the client and other clients on the unit. 2. Provide the clients on the unit with a sense of comfort and safety. 3. Assist the staff in caring for the client in a controlled environment. 4. Offer the client a less stimulating area to calm down in and gain control. 1. Provide safety for the client and other clients on the unit. 34. The nurse is preparing a client with a history of command hallucinations for discharge by providing instructions on interventions for managing hallucinations and anxiety. Which statement in response to these instructions suggests to the nurse that the client understands the instructions? 1. "My medications aren't likely to make me anxious." 2. "I'll go to support group and talk so that I don't hurt anyone." 3. "It's not likely that I'll get anxious or hear things if I get enough sleep and eat well." 4. "When I begin to hallucinate, I'll call my therapist and talk about what I should do." 4. "When I begin to hallucinate, I'll call my therapist and talk about what I should do." 35. The nurse is caring for a client diagnosed with catatonic stupor who is lying on the bed in a fetal position. What is the most appropriate nursing intervention? 1. Ask direct questions to encourage talking. 2. Leave the client alone so as to minimize external stimuli. 3. Sit beside the client in silence with occasional open-ended questions. 4. Take the client into the dayroom with other clients so that they can help watch him. 3. Sit beside the client in silence with occasional open-ended questions. 36. The nurse is caring for a client who is experiencing disturbed thought processes as a result of paranoia. In formulating nursing interventions with the members of the health care team, what best instruction should the nurse provide to the staff? 1. Increase socialization of the client with peers. 2. Avoid laughing or whispering in front of the client. 3. Begin to educate the client about social supports in the community. 4. Have the client sign a release of information to appropriate parties for assessment purposes. 2. Avoid laughing or whispering in front of the client. 37. The nurse is planning activities for a client diagnosed with bipolar disorder with aggressive social behavior. Which activity would be most appropriate for this client? 1. Chess 2. Writing 3. Ping pong 4. Basketball 2. Writing 38. The home health nurse visits a client at home and determines that the client is dependent on drugs. During the assessment, which action should the nurse take to plan appropriate nursing care? 1. Ask the client why he started taking illegal drugs. 2. Ask the client about the amount of drug use and its effect. 3. Ask the client how long he thought that he could take drugs without someone finding out. 4. Not ask any questions for fear that the client is in denial and will throw the nurse out of the home. 2. Ask the client about the amount of drug use and its effect. 39. Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply. 1. Monitor vital signs. 2. Maintain NPO status. 3. Provide a safe environment. 4. Address hallucinations therapeutically. 5. Provide stimulation in the environment. 6. Provide reality orientation as appropriate. o 1. Monitor vital signs. o 3. Provide a safe environment. o 4. Address hallucinations therapeutically. o 6. Provide reality orientation as appropriate. 40. The nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group if the nurse hears the wife make which statement? 1. "I no longer feel that I deserve the beatings my husband inflicts on me." 2. "My attendance at the meetings has helped me to see that I provoke my husband's violence." 3. "I enjoy attending the meetings because they get me out of the house and away from my husband." 4. "I can tolerate my husband's destructive behaviors now that I know they are common with alcoholics." 1. "I no longer feel that I deserve the beatings my husband inflicts on me." 41. A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I have to go. I don't want any more treatment. I have things that I have to do right away." The client has not been discharged and is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. What action should the nurse take? 1. Call the nursing supervisor. 2. Call security to block all exit areas. 3. Restrain the client until the health care provider (HCP) can be reached. 4. Tell the client that the client cannot return to this hospital again if the client leaves now. 1. Call the nursing supervisor. 42. The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa. Which assessment findings does the nurse expect to note? Select all that apply. 1. Dental decay 2. Moist oily skin 3. Loss of tooth enamel 4. Electrolyte imbalances 5. Body weight well below ideal range o 1. Dental decay o 3. Loss of tooth enamel o 4. Electrolyte imbalances 43. The nurse is caring for a female client who was admitted to the mental health unit recently for anorexia nervosa. The nurse enters the client's room and notes that the client is engaged in rigorous push-ups. Which nursing action is most appropriate? 1. Interrupt the client and weigh her immediately. 2. Interrupt the client and offer to take her for a walk. 3. Allow the client to complete her exercise program. 4. Tell the client that she is not allowed to exercise rigorously. 2. Interrupt the client and offer to take her for a walk. 44. A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a two-bed room. A newly admitted client will be assigned to this client's room. Which client would be the best choice as a roommate for the client with anorexia nervosa? 1. A client with pneumonia 2. A client undergoing diagnostic tests 3. A client who thrives on managing others 4. A client who could benefit from the client's assistance at mealtime 2. A client undergoing diagnostic tests 45. The nurse is monitoring a hospitalized client who abuses alcohol. Which findings should alert the nurse to the potential for alcohol withdrawal delirium? 1. Hypotension, ataxia, hunger 2. Stupor, lethargy, muscular rigidity 3. Hypotension, coarse hand tremors, lethargy 4. Hypertension, changes in level of consciousness, hallucinations 4. Hypertension, changes in level of consciousness, hallucinations 46. The spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse, "I should get out of this bad situation." What is the most helpful response by the nurse? 1. "Why don't you tell your wife about this?" 2. "What do you find difficult about this situation?" 3. "This is not the best time to make that decision." 4. "I agree with you. You should get out of this situation." 2. "What do you find difficult about this situation?" 47. A client with anorexia nervosa is a member of a predischarge support group. The client verbalizes that she would like to buy some new clothes, but her finances are limited. Group members have brought some used clothes to the client to replace the client's old clothes. The client believes that the new clothes were much too tight and has reduced her calorie intake to 800 calories daily. How should the nurse evaluate this behavior? 1. Normal behavior 2. Evidence of the client's disturbed body image 3. Regression as the client is moving toward the community 4. Indicative of the client's ambivalence about hospital discharge 2. Evidence of the client's disturbed body image 48. The nurse in the emergency department is caring for a young female victim of sexual assault. The client's physical assessment is complete, and physical evidence has been collected. The nurse notes that the client is withdrawn, confused, and at times physically immobile. How should the nurse interpret these behaviors? 1. Signs of depression 2. Normal reactions to a devastating event 3. Evidence that the client is a high suicide risk 4. Indicative of the need for hospital admission 2. Normal reactions to a devastating event 49. The nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented that the client is experiencing anxiety as a result of a situational crisis. The nurse determines that this type of crisis could be caused by which event? 1. Witnessing a murder 2. The death of a loved one 3. A fire that destroyed the client's home 4. A recent rape episode experienced by the client 2. The death of a loved one 50. The nurse is conducting an initial assessment on a client in crisis. When assessing the client's perception of the precipitating event that led to the crisis, what is the most appropriate question? 1. "With whom do you live?" 2. "Who is available to help you?" 3. "What leads you to seek help now?" 4. "What do you usually do to feel better?" 3. "What leads you to seek help now?" 51. The nurse is developing a plan of care for a client in a crisis state. When developing the plan, the nurse should consider which factor? 1. A crisis state indicates that the client has a mental illness. 2. A crisis state indicates that the client has an emotional illness. 3. Presenting symptoms in a crisis situation are similar for all clients experiencing a crisis. 4. A client's response to a crisis is individualized and what constitutes a crisis for one client may not constitute a crisis for another client. 4. A client's response to a crisis is individualized and what constitutes a crisis for one client may not constitute a crisis for another client. 52. The nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway, and is making aggressive and belligerent gestures at other clients. Which statement would be most appropriate to make to this client? 1. "You need to stop that behavior now." 2. "You will need to be placed in seclusion." 3. "You seem restless; tell me what is happening." 4. "You will need to be restrained if you do not change your behavior." 3. "You seem restless; tell me what is happening." 53. A depressed client on an inpatient unit says to the nurse, "My family would be better off without me." What is the nurse's best response? 1. "Have you talked to your family about this?" 2. "Everyone feels this way when they are depressed." 3. "You will feel better once your medication begins to work." 4. "You sound very upset. Are you thinking of hurting yourself?" 4. "You sound very upset. Are you thinking of hurting yourself?" 54. The nurse has been observing a client closely who has been displaying aggressive behaviors. The nurse observes that the behavior displayed by the client is escalating. Which nursing intervention is least helpful to this client at this time? 1. Initiate confinement measures. 2. Acknowledge the client's behavior. 3. Assist the client to an area that is quiet. 4. Maintain a safe distance from the client. 1. Initiate confinement measures. 55. Which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may be suicidal? 1. The adolescent gives away a DVD and a cherished autographed picture of a performer. 2. The adolescent runs out of the therapy group, swearing at the group leader, and runs to her room. 3. The adolescent becomes angry while speaking on the telephone and slams down the receiver. 4. The adolescent gets angry with her roommate when the roommate borrows the client's clothes without asking. 1. The adolescent gives away a DVD and a cherished autographed picture of a performer. 56. The police arrive at the emergency department with a client who has lacerated both wrists. What is the initial nursing action? 1. Administer an antianxiety agent. 2. Examine and treat the wound sites. 3. Secure and record a detailed history. 4. Encourage and assist the client to ventilate feelings. 2. Examine and treat the wound sites. 57. A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally cured." How should the nurse interpret this behavior as a cue to modify the treatment plan? 1. Suggesting a reduction of medication 2. Allowing increased "in-room" activities 3. Increasing the level of suicide precautions 4. Allowing the client off-unit privileges as needed 3. Increasing the level of suicide precautions 58. The nurse is planning care for a client being admitted to the nursing unit who attempted suicide. Which priority nursing intervention should the nurse include in the plan of care? 1. One-to-one suicide precautions 2. Suicide precautions with 30-minute checks 3. Checking the whereabouts of the client every 15 minutes 4. Asking the client to report suicidal thoughts immediately 1. One-to-one suicide precautions 59. The emergency department nurse is caring for an adult client who is a victim of family violence. Which priority instruction should be included in the discharge instructions? 1. Information regarding shelters 2. Instructions regarding calling the police 3. Instructions regarding self-defense classes 4. Explaining the importance of leaving the violent situation 1. Information regarding shelters 60. A female victim of a sexual assault is being seen in the crisis center. The client states that she still feels "as though the rape just happened yesterday," even though it has been a few months since the incident. What is the most appropriate nursing response? 1. "You need to try to be realistic. The rape did not just occur." 2. "It will take some time to get over these feelings about your rape." 3. "Tell me more about the incident that causes you to feel like the rape just occurred." 4. "What do you think that you can do to alleviate some of your fears about being raped again?" 3. "Tell me more about the incident that causes you to feel like the rape just occurred." 61. A client is admitted to the mental health unit after an attempted suicide by hanging. The nurse can best ensure client safety by which action? 1. Requesting that a peer remain with the client at all times 2. Removing the client's clothing and placing the client in a hospital gown 3. Assigning a staff member to the client who will remain with the client at all times 4. Admitting the client to a seclusion room where all potentially dangerous articles are removed 3. Assigning a staff member to the client who will remain with the client at all times 62. A client is admitted with a recent history of severe anxiety following a home invasion and robbery. During the initial assessment interview, which statement by the client would indicate to the nurse the possible diagnosis of posttraumatic stress disorder? Select all that apply. 1. "I'm afraid of spiders." 2. "I keep reliving the robbery." 3. "I see his face everywhere I go." 4. "I don't want anything to eat now." 5. "I might have died over a few dollars in my pocket." 6. "I have to wash my hands over and over again many times." o 2. "I keep reliving the robbery." o 3. "I see his face everywhere I go." o 5. "I might have died over a few dollars in my pocket." 63. The emergency department nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which is the priority nursing action? 1. Adhering to the mandatory abuse-reporting laws 2. Notifying the case worker of the family situation 3. Removing the client from any immediate danger 4. Obtaining treatment for the abusing family member 3. Removing the client from any immediate danger 64. The nurse assesses a client with the admitting diagnosis of bipolar affective disorder, mania. Which client symptoms require the nurse's immediate action? 1. Incessant talking and sexual innuendoes 2. Grandiose delusions and poor concentration 3. Outlandish behaviors and inappropriate dress 4. Nonstop physical activity and poor nutritional intake 4. Nonstop physical activity and poor nutritional intake 65. The nurse is performing an assessment on a client with dementia. Which data gathered during the assessment indicates a manifestation associated with dementia? 1. Uses confabulation 2. Improvement in sleeping 3. Absence of sundown syndrome 4. Presence of personal hygienic care 1. Uses confabulation 66. The nurse is caring for a client with anorexia nervosa. Which behavior is characteristic of this disorder and reflects anxiety management? 1. Engaging in immoral acts 2. Always reinforcing self-approval 3. Observing rigid rules and regulations 4. Having the need always to make the right decision 3. Observing rigid rules and regulations 67. A depressed client verbalizes feelings of low self-esteem and self-worth typified by statements such as "I'm such a failure. I can't do anything right." How should the nurse plan on responding to the client's statement? 1. Reassure the client that things will get better. 2. Tell the client that this is not true and that we all have a purpose in life. 3. Identify recent behaviors or accomplishments that demonstrate the client's skills. 4. Remain with the client and sit in silence; this will encourage the client to verbalize feelings. 3. Identify recent behaviors or accomplishments that demonstrate the client's skills. 68. A client with diabetes mellitus is told that amputation of the leg is necessary to sustain life. The client is very upset and tells the nurse, "This is all my health care provider's fault. I have done everything I've been asked to do!" Which nursing interpretation is best for this situation? 1. An expected coping mechanism 2. An ineffective coping mechanism 3. A need to notify the hospital lawyer 4. An expression of guilt on the part of the client 1. An expected coping mechanism 69. A client experiencing a great deal of stress and anxiety is being taught to use self-control therapy. Which statement by the client indicates a need for further teaching about the therapy? 1. "This form of therapy can be applied to new situations." 2. "An advantage of this technique is that change is likely to last." 3. "Talking to oneself is a basic component of this form of therapy." 4. "This form of therapy provides a negative reinforcement when the stimulus is produced." 4. "This form of therapy provides a negative reinforcement when the stimulus is produced." 70. The nurse is caring for a client who is at risk for suicide. What is the priority nursing action for this client? 1. Provide authority, action, and participation. 2. Display an attitude of detachment, confrontation, and efficiency. 3. Demonstrate confidence in the client's ability to deal with stressors. 4. Provide hope and reassurance that the problems will resolve themselves. 1. Provide authority, action, and participation. 71. A client comes to the emergency department after an assault and is extremely agitated, trembling, and hyperventilating. What is the priority nursing action for this client? 1. Begin to teach relaxation techniques. 2. Encourage the client to discuss the assault. 3. Remain with the client until the anxiety decreases. 4. Place the client in a quiet room alone to decrease stimulation. 3. Remain with the client until the anxiety decreases. 72. The nurse is developing a plan of care for a client who was experiencing anxiety after the loss of a job. The client is now verbalizing concerns regarding the ability to meet role expectations and financial obligations. What is the priority problem for this client? 1. Anxiety 2. Unrealistic outlook 3. Lack of ability to cope effectively 4. Disturbances in thoughts and ideas 3. Lack of ability to cope effectively 73. The nurse has developed a plan of care for a client diagnosed with anorexia nervosa. Which client problem would the nurse select as the priority in the plan of care? 1. Disrupted appearance because of weight 2. Inability to feed self because of weakness 3. Pain because of an inflamed gastric mucosa 4. Nutritional imbalance because of lack of intake 4. Nutritional imbalance because of lack of intake 74. Which statement made by an unlicensed assistive personnel (UAP) indicates to the registered nurse that the UAP understands the concepts related to suicide? 1. "Discussing suicide with a client is not harmful." 2. "Those clients who talk about suicide never do it." 3. "Depressed clients are the only persons who commit suicide." 4. "When a person talks about making suicide threats, the only thing the person wants is attention from family and friends." 1. "Discussing suicide with a client is not harmful." 75. Which client is most at risk for committing suicide? 1. A 75-year-old client with metastatic cancer 2. A 71-year-old client with a cardiac disorder 3. A 24-year-old client who just had an argument with her roommate 4. A 30-year-old newly divorced client who states she has custody of the children 1. A 75-year-old client with metastatic cancer 76. A nursing instructor teaches a group of nursing students about violence in the family. Which statement by a student indicates a need for further teaching? 1. "Abusers use fear and intimidation." 2. "Abusers usually have poor self-esteem." 3. "Abusers often are jealous or self-centered." 4. "Abuse occurs more often in low-income families." 4. "Abuse occurs more often in low-income families." 77. A client is being prepared for electroconvulsive therapy (ECT). The nurse's plan of care for the day before ECT includes ensuring that the client follows which guideline? 1. Does not smoke at all 2. Receives no visitors and participates in limited unit activities 3. Reports to the clinic for blood draws and an electrocardiogram (ECG) 4. Is placed on nothing by mouth (NPO) status for 16 to 24 hours before the ECT 3. Reports to the clinic for blood draws and an electrocardiogram (ECG) 78. A nursing student is assisting with the care of a client with a chronic mental illness. The nurse informs the student that a behavior modification approach (operant conditioning) will be used in treatment for the client. Which statement by the student indicates a need for further information about the therapy? 1. "It uses positive reinforcement." 2. "It uses negative reinforcement." 3. "It increases social behaviors in the client." 4. "It increases the level of self-care in the client." 2. "It uses negative reinforcement." 79. The nurse is performing an admission assessment on a client at high risk for suicide. The nurse should prepare to ask the client which assessment question to elicit data related to this risk? 1. "What are you feeling right now?" 2. "Do you have a plan to commit suicide?" 3. "How many times have you attempted suicide in the past?" 4. "Why were your attempts at suicide unsuccessful in the past?" 2. "Do you have a plan to commit suicide?" 80. The nurse in the mental health unit is performing an assessment in a client who has a history of multiple somatic complaints involving several organ systems. Diagnostic studies revealed no organic pathology. The care plan developed for this client will reflect that the client is experiencing which disorder? 1. Depression 2. Schizophrenia 3. Somatization disorder 4. Obsessive-compulsive disorder 3. Somatization disorder 81. A mental health nurse in a psychiatric unit is meeting with a client who has a long history of acting out and violent behavior. The client also is known to have abused drugs on numerous occasions. During the session the client says to the nurse, "I'm feeling much better now, and I'm ready to go straight." Which response by the nurse would be therapeutic? 1. "You have said this many times before!" 2. "Tell me what makes you feel that you are ready." 3. "I have not seen any changes in you to believe that you are ready to go straight." 4. "I'm so glad to hear you talking this way. I will let your health care provider know." 2. "Tell me what makes you feel that you are ready." 82. A client with a diagnosis of depression has been meeting with the mental health nurse for therapy sessions for the past 6 weeks. During the session the client says to the nurse, "I lost my job this week, and I'm going to be evicted from my apartment if I can't pay my bill. The only person that I have is my daughter, but I don't want to burden her with my problems." Which response by the nurse would be therapeutic? 1. "Why did you lose your job?" 2. "There are homeless shelters available, and we will get you into one if you are evicted from your apartment." 3. "If you get evicted from your apartment, we will commit you to the hospital, so you will have a place to eat and sleep." 4. "Let's talk about contacting your daughter. Wouldn't you want to know if your daughter was having difficulty and try to help her if you could?" 4. "Let's talk about contacting your daughter. Wouldn't you want to know if your daughter was having difficulty and try to help her if you could?" 83. During a therapy session with a client with paranoid disorder, the client says to the nurse, "You look so nice today. I love how you do your hair, and I love that perfume you're wearing." Which response by the nurse would be therapeutic? 1. "Your comment is inappropriate." 2. "Thank you for noticing. I just bought this new perfume." 3. "My hair has been a mess. I really needed to have it done." 4. "We are not here to discuss how I look or smell. We are here to talk about you." 4. "We are not here to discuss how I look or smell. We are here to talk about you." 84. The nurse in the mental health unit is assigned to care for a female client with a diagnosis of acute depression. In communicating with the client, which statement would be appropriate for the nurse to make? 1. "You look lovely today." 2. "You're wearing a new blouse." 3. "Don't worry–everyone gets depressed once in a while." 4. "You will feel better when your medication starts to work." 2. "You're wearing a new blouse." 85. The nurse is planning care for a client with bipolar disorder who is experiencing psychomotor agitation. Which activity should the nurse plan for this client? 1. Reading letters and books in a quiet environment 2. Providing an activity such as checkers for the client 3. Involving the client in a card game with other clients on the unit 4. Including the client in a clay-molding class that is scheduled for today 4. Including the client in a clay-molding class that is scheduled for today 86. The nurse is developing a plan of care for a client with depression whose food intake is poor. The nurse should include which interventions in the plan of care? Select all that apply. 1. Assist the client in selecting foods from the food menu. 2. Offer high-calorie fluids throughout the day and evening. 3. Allow the client to eat alone in the room if the client requests to do so. 4. Offer small high-calorie, high-protein snacks during the day and evening. 5. Select the foods for the client to be sure that the client eats a balanced diet. o 1. Assist the client in selecting foods from the food menu. o 2. Offer high-calorie fluids throughout the day and evening. o 4. Offer small high-calorie, high-protein snacks during the day and evening. 87. The nurse is monitoring a client with a diagnosis of schizophrenia. The nurse notes that the client's emotional responses to situations occurring throughout the day are incongruent with the tone of the situation. The nurse should document the findings using which description of the client's behavioral response? 1. Flat affect 2. Bizarre affect 3. Blunted affect 4. Inappropriate affect 4. Inappropriate affect 88. A mental health nurse notes that a client with schizophrenia is exhibiting an immobile facial expression and a blank look. Which should the nurse document in the client's record? 1. The client has a flat affect. 2. The client has an inappropriate affect. 3. The client is exhibiting bizarre behavior. 4. The client's emotional responses exhibit a blunted affect. 1. The client has a flat affect. 89. The nurse is developing a plan of care for the client with a diagnosis of paranoia and should include which interventions in the plan of care? Select all that apply. 1. Provide a warm approach to the client. 2. Ask permission before touching the client. 3. Eliminate physical contact with the client. 4. Defuse any anger or verbal attacks with a nondefensive stance. 5. Use simple and clear language when communicating with the client. o 2. Ask permission before touching the client. o 3. Eliminate physical contact with the client. o 4. Defuse any anger or verbal attacks with a nondefensive stance. o 5. Use simple and clear language when communicating with the client. 90. The nurse is preparing a client for electroconvulsive therapy (ECT), which is scheduled for the next morning. Which interventions would be included in the preprocedural plan? Select all that apply. 1. Obtain an informed consent. 2. Have the client void before the procedure. 3. Remove dentures and contact lenses before the procedure. 4. Withhold food and fluids for 6 hours before the treatment. 5. Administer tap water enemas on the evening before the procedure. o 1. Obtain an informed consent. o 2. Have the client void before the procedure. o 3. Remove dentures and contact lenses before the procedure. o 4. Withhold food and fluids for 6 hours before the treatment. 91. A hospitalized client is receiving clozapine (Clozaril) for the treatment of a schizophrenic disorder. The nurse determines that the client may be having an adverse reaction to the medication if abnormalities are noted on which laboratory study? 1. Platelet count 2. Cholesterol level 3. Blood urea nitrogen 4. White blood cell (WBC) count 4. White blood cell (WBC) count 92. A client has been prescribed disulfiram (Antabuse). Before giving the client the first dose of this medication, what should the psychiatric home health nurse determine? 1. If there is a history of hyperthyroidism 2. When the last full meal was consumed 3. If there is a history of diabetes insipidus 4. When the last alcoholic drink was consumed 4. When the last alcoholic drink was consumed 93. A home care nurse making an initial home visit notes that a client is taking donepezil hydrochloride (Aricept). The nurse questions the client's spouse about a history of which disorder that is treated with this medication? 1. Dementia 2. Schizophrenia 3. Seizure disorder 4. Obsessive-compulsive disorder 1. Dementia 94. The nurse is caring for a client with a diagnosis of agoraphobia. When communicating with the client about the disorder, the nurse should expect the client to describe which behavior? 1. A fear of dirt and germs 2. A fear of leaving the house 3. A fear of speaking in public 4. A fear of riding in elevators 2. A fear of leaving the house 95. A client recently admitted to the hospital in the manic phase of bipolar disorder is dehydrated, unkempt, taking antipsychotic medications, and complaining of abdominal fullness and discomfort. The nurse determines that which intervention is most appropriate for these complaints? 1. Teach self-grooming skills. 2. Reward cleanliness with unit privileges. 3. Monitor the adequacy of the antipsychotic dosage. 4. Encourage frequent fluid intake and a high-fiber diet. 4. Encourage frequent fluid intake and a high-fiber diet. 96. A homebound client confidentially discusses suicidal plans with the visiting nurse. Based on professional duty to observe confidentiality, which statement bestdescribes the nurse's obligation to the client? 1. The nurse must have the client go to the local mental health center daily for counseling. 2. The nurse must ask the client not to reveal suicidal plans if the information needs to be kept confidential. 3. The nurse cannot tell anyone what the client said and must strictly adhere to the professional duty for confidentiality. 4. The nurse must override the duty to observe confidentiality and notify the client's health care provider (HCP) about the suicidal ideation. 4. The nurse must override the duty to observe confidentiality and notify the client's health care provider (HCP) about the suicidal ideation. 97. The mental health nurse is reviewing the discharge plan for a hospitalized client. In reviewing the plan, the nurse recognizes that which is the most prominent problem in the management of a client with a mental health problem in the community? 1. The community's opposition 2. The client's noncompliance with medication therapy 3. The associated increased incidence of social problems 4. The family's reaction to keeping the client in the community 2. The client's noncompliance with medication therapy 98. During a home visit, the nurse suspects that a young daughter of the client is bulimic. The nurse bases this suspicion on which primary characteristic of bulimia? 1. Refusing to eat and excessive exercising 2. Eating only vegetables and fruits and fasting 3. Hoarding of food and difficulty controlling food intake 4. Eating a lot of food in a short period of time and misuse of laxatives 4. Eating a lot of food in a short period of time and misuse of laxatives 99. The mental health nurse is talking to a client who has been diagnosed with posttraumatic stress disorder. During the conversation, the nurse notes that the client is exhibiting a paranoid stare and that he begins to pace and fidget. What is the appropriate nursing intervention? 1. Allow the client to pace. 2. Escort the client to a quiet room. 3. Change the conversation to a less threatening subject. 4. Share the observation with the client and help the client to recognize his feelings. 4. Share the observation with the client and help the client to recognize his feelings. 100. The nurse is reviewing the record of a client admitted to the mental health unit. The nurse notes documentation that the client experiences flashbacks. What diagnosis should the nurse expect to be documented for this client? 1. Anxiety 2. Agoraphobia 3. Schizophrenia 4. Posttraumatic stress disorder (PTSD) 4. Posttraumatic stress disorder (PTSD) 101. The nurse is admitting a client with a diagnosis of posttraumatic stress disorder to the mental health unit. The client is confused and disoriented. During the assessment, what is the nurse's primary goal for this client? 1. Explain the unit rules. 2. Orient the client to the unit. 3. Stabilize the client's psychiatric needs. 4. Accept the client and make the client feel safe. 4. Accept the client and make the client feel safe. 102. The nurse in the mental health unit is having a conversation with a client diagnosed with posttraumatic stress disorder. The client seems upset and looks anxious. What is the appropriate nursing statement the nurse should make to the client? 1. "Don't worry so much." 2. "I can see that you are upset." 3. "Everything is going to be all right." 4. "Why are you having so much trouble controlling your anxiety?" 2. "I can see that you are upset." 103. A client with depression is scheduled to receive three sessions of electroconvulsive therapy (ECT). The client asks the nurse about the length of time it will take for improvement in the condition. The nurse should tell the client he or she will see improvement approximately how long after the three treatments? 1. 1 week 2. 3 weeks 3. 4 weeks 4. 8 weeks 1. 1 week 104. A client has been diagnosed with major depression. The nurse notes that the client is not eating adequately and at times refuses to eat. What should the nurse plan to do to meet the client's nutritional needs? 1. Force foods and fluids. 2. Provide small, frequent meals. 3. Provide snacks and meals as requested. 4. Tell the client that social activities will be restricted unless food intake is increased. 2. Provide small, frequent meals. 105. The health care provider has prescribed medication therapy for a client with an alcohol abuse problem to assist in the maintenance of sobriety. The nurse reviews the client's record and expects to note that which medication has been prescribed? 1. Clonidine (Catapres) 2. Disulfiram (Antabuse) 3. Pyridoxine hydrochloride (vitamin B6) 4. Chlordiazepoxide hydrochloride (Librium) 2. Disulfiram (Antabuse) 106. The mental health nurse is caring for a client with a social phobia. The nurse tells the client that a music therapy session has been scheduled as part of the treatment plan. The client tells the nurse that she cannot sing and refuses to attend. What is the appropriate nursing response? 1. "You must go. You have no choice." 2. "Why don't you want to attend? What is the real reason?" 3. "The health care provider has prescribed this therapy for you." 4. "You don't have to sing at the session. You can listen and enjoy the music." 4. "You don't have to sing at the session. You can listen and enjoy the music." 107. The nurse is monitoring a client who has been placed in restraints because of violent behavior. When should the nurse determine that it will be safe to remove the restraints? 1. Administered medication has taken effect. 2. The client verbalizes the reasons for the violent behavior. 3. The client apologizes and tells the nurse that it will never happen again. 4. No acts of aggression have been observed within 1 hour after the release of two of the extremity restraints. 4. No acts of aggression have been observed within 1 hour after the release of two of the extremity restraints. 108. The mental health nurse is conducting a group therapy session and is monitoring a client with a diagnosis of agoraphobia who has been attending the sessions for several months. The nurse notes that the client is cooperative, sharing with peers, and making appropriate suggestions during group discussions. How should the nurse interpret this behavior? 1. Manipulation 2. Improvement 3. Attention seeking 4. Desire to be accepted 2. Improvement 109. The nurse is preparing a client for electroconvulsive therapy (ECT). The family of the client asks the nurse about this treatment. The nurse responds, knowing that which statements are accurate regarding this treatment? Select all that apply. 1. The average series involves 6 to 12 treatments. 2. Some confusion may be noted after the procedure. 3. Memory loss will occur but will resolve with time. 4. This treatment is a permanent cure to the condition. 5. This treatment is tried before the use of medications. o 1. The average series involves 6 to 12 treatments. o 2. Some confusion may be noted after the procedure. o 3. Memory loss will occur but will resolve with time. 110. The nurse is planning a stress management seminar for clients in an ambulatory care setting. Which concept should the nurse plan to include in the content of the seminar? 1. Biofeedback has the advantage of using no equipment at all. 2. Guided imagery is a helpful technique but requires video equipment for its use. 3. Confrontation is a useful method for solving potentially stressful conflicts with others. 4. Progressive muscle relaxation techniques are useful for easing tension from many causes. 4. Progressive muscle relaxation techniques are useful for easing tension from many causes. 111. A 15-year-old client who is pregnant and unwed tells the nurse, "My life was unbearable before I met Johnny. My mother beats me up every day, and my dad has been sleeping with me since I was 10 years old!" Which response is appropriate for the nurse to make? 1. "Why didn't you just report your parents for abuse?" 2. "What are you saying? Your parents abused you so you got pregnant?" 3. "Sounds like you decided to have a baby so you'd have someone for yourself." 4. "It seems that you needed help to separate from your family. Do you feel you are ready to have a baby with Johnny?" 4. "It seems that you needed help to separate from your family. Do you feel you are ready to have a baby with Johnny?" 112. A 10-year-old girl who has been referred for evaluation for drawing sexually explicit scenes in her textbooks says to the psychiatric nurse, "I just felt like it." Which response is therapeutic for the nurse to make in order to assess abuse-related symptoms? 1. "Well, a picture paints a thousand words." 2. "You just felt like destroying your textbooks?" 3. "Your parents and teachers are very concerned about your drawings." 4. "I am concerned about you. Are you now or have you ever been abused?" 4. "I am concerned about you. Are you now or have you ever been abused?" 113. During a nursing interview, a client says, "My daughter was murdered in her New York apartment, and her estranged husband called to tell me. I can't help wondering if he killed her, but the police have eliminated him as a suspect." Which statement is a therapeutic nursing response? 1. "I agree. What do you want to bet he did it?" 2. "Have you shared your concerns with the police?" 3. "I don't think that you should blame yourself one little bit." 4. "It feels terrible to lose a daughter. I'd have suspicions about him, too." 2. "Have you shared your concerns with the police?" 114. The nurse is assessing a client in the coronary care unit (CCU) who seems to fluctuate in his ability to focus during the day. On the basis of this assessment, which client problem should the nurse suspect? 1. Dementia as a result of isolation 2. Acute confusion as a result of CCU psychosis 3. Dementia as a result of substance intoxication 4. Interruption in the family as a result of alcohol withdrawal 2. Acute confusion as a result of CCU psychosis 115. A client with diabetes mellitus is told that amputation of the leg is necessary to sustain life. The client is very upset and tells the nurse, "This is all the health care provider's fault. I have done everything that he has asked me to do!" How should the nurse interpret the client's statement? 1. An expected coping mechanism 2. An ineffective coping mechanism 3. A need to notify the hospital lawyer 4. An expression of guilt on the part of the client 1. An expected coping mechanism 116. The nurse is planning to formulate a psychotherapy group. Several clients are interested in attending the session. The nurse plans the group, knowing that which is the maximum number of group members that can be included? 1. 3 2. 8 3. 14 4. 16 2. 8 117. A nurse assists a client with a diagnosis of obsessive-compulsive disorder (OCD) in his preparations for bedtime. One hour later the client calls the nurse and says that he is feeling anxious; he asks the nurse to sit and talk for a while. Which is the appropriate initial nursing action? 1. Sit and talk with the client. 2. Ask the unlicensed assistive personnel to sit with the client. 3. Administer the prescribed as-needed antianxiety medication. 4. Tell the client that it is time for sleep and that you will talk with him tomorrow. 1. Sit and talk with the client. 118. A nurse is planning care for a group of clients on a mental health unit. The nurse notes that most of the assigned clients require interventions commonly used to treat anxiety disorders. Such antianxiety interventions would be appropriate for which clients? Select all that apply. 1. A client with panic disorder 2. Generalized anxiety disorder 3. A client with multiple personality disorder 4. A client with posttraumatic stress disorder (PTSD) 5. A client with obsessive-compulsive disorder (OCD) o 1. A client with panic disorder o 2. Generalized anxiety disorder o 4. A client with posttraumatic stress disorder (PTSD) o 5. A client with obsessive-compulsive disorder (OCD) 119. A nurse is preparing to admit a client with a diagnosis of obsessive-compulsive disorder (OCD) to the mental health unit. The nurse would expect to note which behaviors in the client? 1. Suspicious and hostile 2. Flexible and adaptable 3. Frightened and delusional 4. Rigidness in thought and inflexibility 4. Rigidness in thought and inflexibility 120. A nurse is performing an assessment on a client admitted to the mental health unit. The client tells the nurse that she cannot leave home without checking numerous times that the iron and coffee pot have been shut off. The client states that this activity makes her late for many functions and that she misses engagements on occasion because of it. The nurse would expect to note which anxiety disorder documented in the client's record? 1. A phobia 2. Generalized anxiety disorder 3. Posttraumatic stress disorder (PTSD) 4. Obsessive-compulsive disorder (OCD) 4. Obsessive-compulsive disorder (OCD) 121. A nurse is performing an assessment on a client admitted to the mental health unit. The nurse notes that the client's diagnosis is documented as obsessive-compulsive disorder. The nurse plans care knowing that the client is most likely to experience which type of compulsive behavior? 1. Fears 2. Actions 3. Illusions 4. Thoughts 2. Actions 122. A mental health nurse asks a nurse orientee to describe the underlying pathophysiology associated with acts of compulsion, such as repeated hand washing, performed by clients with obsessive-compulsive disorder (OCD). The nurse determines that the orientee understands this disorder if the orientee identifies which characteristic of the client? 1. Unaware that the client is performing the ritual 2. Consciously attempting to punish the self or others 3. Unconsciously controlling unpleasant thoughts or feelings 4. Responding to "the voices" telling the client to perform rituals 3. Unconsciously controlling unpleasant thoughts or feelings 123. A nurse is performing an assessment on a client being admitted to the mental health unit. During the interview, the nurse discovers that the client suffered a severe emotional trauma 1 month earlier and is now experiencing paralysis of the right arm. Which is the initial nursing action? 1. Refer the client to a psychiatrist. 2. Encourage the client to move and use the arm. 3. Assess the client for organic causes of the paralysis. 4. Encourage the client to talk about his or her feelings. 3. Assess the client for organic causes of the paralysis. 124. A nurse is developing a plan of care for a client admitted to the mental health unit with a diagnosis of obsessive-compulsive disorder (OCD). What is the nurse's first priority in the plan of care? 1. Monitor for repetitive behavior. 2. Demand active participation in care. 3. Educate the client about self-care needs. 4. Establish a trusting nurse-client relationship. 4. Establish a trusting nurse-client relationship. 125. A nurse is preparing to develop a care plan for a client admitted to the mental health unit with a diagnosis of obsessive-compulsive disorder (OCD). The nurse should plan to include which component as a priority in the nursing plan of care? 1. The medical diagnosis of the client 2. Individualized goals and objectives 3. Attendance at group therapy sessions 4. Self-care measures to improve hygiene 2. Individualized goals and objectives 126. A nurse is reviewing the assessment findings documented in the chart of a client who is newly admitted to the mental health unit. The nurse notes that the client has experienced emotional turmoil and is exhibiting signs and symptoms that usually result from a loss of physical functioning, although no such loss can be confirmed medically. The nurse interprets these findings as indicating which condition? 1. Depression 2. Somatization disorder 3. Posttraumatic stress disorder 4. Obsessive-compulsive disorder 2. Somatization disorder 127. The home health nurse visits an older adult client who has recently lost her husband. The client says, "No one cares about me anymore. All the people I loved are dead." Which is the appropriate response? 1. "Right! Why not just ‘pack it in'?" 2. "That seems rather unlikely to me." 3. "I don't believe that, and neither do you." 4. "You must be feeling all alone at this point." 4. "You must be feeling all alone at this point." 128. A depressed client who appeared sullen, distraught, and hopeless a few days ago now suddenly appears calm, relaxed, and more energetic. Which is the nurse's best initialaction with regard to the client's altered demeanor? 1. Continue to assess the client's behaviors and document clearly in the chart. 2. Report to the health care provider that the client is adapting to the unit and is feeling safe. 3. Notify the health team of these o [Show More]

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