Mental Health

A nurse is caring for a client who has been sexually abused. Which of the following interventions should the nurse implement to establish rapport and to demonstrate safety?

Which of the following actions become barriers to the nurse-client communication? Select all that apply.

A 30-year-old client with anxiety and depression is undergoing therapeutic counseling with a nurse. The client shares a lot of information with the nurse about his personal life. Which of the following actions by the nurse demonstrates healthy and appropriate boundary setting?

A nurse is teaching a community group about practical care measures to take to protect mental health. Which information is most appropriate to present on this topic?

While caring for a child who has come from an abusive home, a nurse tries to get the child to discuss things by using a stuffed animal to act as a trusted friend. Which technique does this action best describe?

A nurse is working in a therapeutic counseling relationship with a client who has a mental illness. When discussing the terms of the relationship, at which point is it appropriate to bring up the termination of the relationship?

You are beginning a therapeutic relationship with a client who has been admitted to the correctional facility that you work at. She is a Type I diabetic who will be incarcerated for approximately 4 months. When will you begin to plan for the termination phase of this relationship?

A client has bipolar disorder is anxious and is at the hospital for treatment. Which behaviors demonstrate displacement as their defense mechanism? Select all that apply.

A client refuses to take prescribed antihypertensive medication and states, “I can’t swallow pills. They probably would not work anyway because my body is used to high blood pressure.” What defense mechanism is this client using?

A 35-year-old client is being discharged home post-operatively. The client has also recently lost his job and is experiencing denial as an initial defense mechanism when reacting to the change. Which nursing intervention would be most appropriate for the client with denial?

A woman who suffered from physical child abuse while she was growing up has started to use baby talk and will sometimes go into an alternate state where she acts like a child. The nurse recognizes that the client is most likely using which type of defense mechanism?

The nurse is caring for a client who sustained a traumatic leg injury in a motor vehicle collision. The provider has notified the client and family members that the client will likely require amputation. Which statement by the family member to the nurse indicates they are struggling to cope with this news?

A nurse is caring for a 20-year-old client with testicular cancer. The client has expressed feelings of anxiety related to his diagnosis and appears restless and agitated every time the nurse tries to talk with him. Which intervention would be the most appropriate for the nurse to help this client with anxiety?

A client is suffering from stress and anxiety and is being seen at a healthcare clinic for help and management. Which best describes the initial physical effects of stress and anxiety in the body? Select all that apply.

A client who is being prepared for surgery is experiencing severe anxiety about the procedure. Which of the following interventions could the nurse employ to decrease this client’s anxiety levels? Select all that apply.

An emergency department nurse is working with a client who sought care for a sudden panic attack. The client tells the nurse that she feels like she is dying and is sweating and shaking. Which statement by the nurse is best?

A nurse is working with a client to use biofeedback as a method of controlling anxiety. Which of the following outcomes would most likely result from correct use of this mechanism?

A client is scheduled for surgery and admits that he has never been so anxious in his life. Which of the following symptoms are common for a client in this situation? Select all that apply.

The nurse is preparing a presentation on stress and anxiety. Which of the following is included as part of this presentation? Select all that apply.

A client who has been diagnosed with anxiety tells the nurse that his thoughts contribute to his problems. Which information can the nurse give the client that is true about automatic negative thoughts?

A 51-year-old client is getting ready to undergo a cardiac catheterization and is very anxious about the procedure. Which intervention can the nurse provide that will most likely help this client to remain calm?

A nurse has given her client a nursing diagnosis of Anxiety because of her behavior when she found out that she was pregnant. Which of the following interventions would be most appropriate for this type of nursing diagnosis? Select all that apply.

A nurse is working with a client who is having sleep difficulties at night. The nurse recommends that the client keep a sleep diary and write down the times he goes to bed, the times he gets up and how many times he awakens each night. The nurse can best describe the purpose of keeping a sleep diary as which of the following?

A client presents to the emergency department with an anxiety attack, stating that he has had multiple attacks over the last six months. The client is hyperventilating, so the nurse administers a benzodiazepine to help with the acute attack. The nurse anticipates that the client will begin to take which of the following medications on a regular basis to help with the anxiety?

A case management nurse is reviewing the chart for a client in a psychiatric hospital who has been diagnosed with panic disorder. The client is anxious and irritable. The nurse has done teaching on relaxation techniques, but the client requires close monitoring due to lack of adherence to the regimen. Which action of the case manager will most likely support this client best?

A client is experiencing an anxiety attack. The nurse reviews the client’s home medications and notes that they take an anti-anxiety medication. Which of the following medications is likely prescribed to this client?

A client with anxiety disorder is in a state of panic after becoming injured while outside. The nurse caring for this client would most likely observe which behaviors? Select all that apply.

A nurse is caring for a client who is hospitalized in a very busy unit. The client complains to the nurse that it is too noisy to sleep and that he is not getting rest. Which of the following nursing interventions is most appropriate to better help this client sleep?

The nurse is caring for a client with generalized anxiety disorder requiring treatment. Which of the following treatments does the nurse anticipate the client will need? Select all that apply.

A 46-year-old client is experiencing symptoms of post-traumatic stress disorder after being involved in a traumatic accident. The client has symptoms of nightmares and flashbacks about the event. The nurse knows that these symptoms most likely develop because of which of the following?

A client is being seen for care at her primary care clinic. The client tells the nurse that she has difficulty sleeping because of nightmares. Identify which description best explains the difference between night terrors and nightmares.

A nurse is providing care to a client who has just witnessed a shooting at a shopping mall. Which of the following interventions would the nurse employ to help the client cope with this traumatic event? Select all that apply.

A client was recently treated for sepsis and may have developed post-sepsis PTSD. Which information is accurate for the nurse to give the client about how this condition is treated?

A client is experiencing stress response syndrome after losing his job where he had worked for 21 years. What describes the difference between stress response syndrome and clinical depression?

A 29-year-old client suffered a subarachnoid hemorrhage 4 months ago and has now been diagnosed with post-traumatic stress disorder (PTSD). Based on this diagnosis, the nurse knows that the client would most likely demonstrate which of the following symptoms?

A nurse is caring for a 40-year-old client with post-traumatic stress disorder following a severe injury last year. The client requires a morning dose of an antidepressant medication and is scheduled for EMDR therapy in 2 hours. The provider has been in to see the client for the day and has also left new orders. Which task can the nurse delegate to the nursing assistant who is helping her?

A client on the mental health unit has been diagnosed with cancer and is displaying a lack of healthy coping mechanisms to deal with this diagnosis. The client is unable to make any decisions for herself and has developed headaches and fatigue. Which of the following nursing interventions is most appropriate for this client?

A nurse is caring for a client who is displaying symptoms of dissociative identity disorder (DID). Which of the following is an appropriate intervention for DID? Select all that apply.

A client who has been diagnosed with bipolar disorder is seeking treatment during the manic phase of illness. Based on the nurse’s knowledge of this mental state, the nurse understands that which of the following is likely during this phase?

A client is undergoing a clinical interview as part of diagnostic testing for bipolar disorder. Which best describes why a clinical interview would be conducted?

A client is undergoing behavioral therapy through counseling for manic behaviors exhibited during episodes of bipolar disorder. Which best describes how cognitive-behavioral therapy is used as treatment for a client with bipolar disorder?

A 44-year-old client is being seen for symptoms of bipolar disorder. After talking with the client, the provider has determined that the client should start taking medication. The client says to the nurse, “How do you know for sure? Isn’t there a lab test that will tell you if I have this condition?” Which response from the nurse is accurate?

A nurse is caring for a client with bipolar disorder. The client has been taking antidepressants for depression but is most recently in a manic state and for the past three days has not been sleeping or eating. Which of the following questions from the nurse is correct in this assessment?

A nurse is caring for a client who has been diagnosed with bipolar disorder, type I. Which best describes the difference between bipolar type I and type II?

A client with a history of bipolar disorder has been brought in to the hospital because the client was running through a neighborhood without any clothes on. Which of the following is evidence that the client is voluntarily willing to be admitted to the hospital? Select all that apply.

A client has been newly diagnosed with acute bipolar depression. What medications does the nurse plan to administer? Select all that apply.

A nurse is caring for a client with bipolar disorder who is frequently manic. What describes the most appropriate psychotherapy for a client with this condition? Select all that apply.

A public health nurse is caring for a client in a psychiatric facility who has a diagnosis of bipolar disorder. Which best demonstrates that the nurse is acting as a liaison to coordinate this client’s plan of care?

A nurse is working with a client who suffers from depression. The client has started taking medications and is engaged in group therapy, but still tells the nurse, “I do not like myself. I am annoying, even to me.” Which activities can the nurse suggest that would most likely increase this client’s self-concept? Select all that apply.

A nurse is assisting a client who has undergone electroconvulsive therapy for treatment of severe depression. Following the procedure, the client develops postictal agitation. Based on the nurse’s knowledge of this condition, the nurse would expect to see which of the following?

A 30-year-old client has been diagnosed with major depressive disorder. Which nutrition guideline should the nurse give to this client that could help with some symptoms of depression?

A client in the psychiatric unit has been diagnosed with severe, intractable depression and is preparing to undergo electroconvulsive therapy (ECT). Which best describes the role of the nurse during ECT? Select all that apply.

A client who has developed depression after experiencing chronic back pain is being seen at the acute care clinic. Which best describes how the nurse would demonstrate psychoeducation when working with this client?

An 11-year-old boy has been diagnosed with depression after his parents’ divorce. The nurse understands that depression in children of this age most commonly manifests as:

A nurse is caring for a client has undergone ECT for the treatment of severe depression and has developed some complications afterward. Which of the following is a physical side effect that has been associated with ECT?

A nurse is performing depression screenings in the community. Which question would most likely be included in this screening?

A nurse is counseling a client who has been diagnosed with depression to attend a support group as part of treatment. Which best describes how the nurse would explain what to expect for the client?

A 25-year-old client with mental illness is having delusions of grandeur. Which tasks would the nurse utilize when orienting this client to reality? Select all that apply.

A client is demonstrating catatonic schizophrenia. Which of the following characteristics would the nurse most likely see with this condition?

A 50-year-old client with schizophrenia is being seen by the mental health nurse. The client is demonstrating signs of altered thought processes. Which communication pattern would most be associated with schizophrenia or psychosis? Select all that apply.

A nurse is working with a client who has schizophrenia. The client is demonstrating clang associations. Which of the following statements by the client best displays this speech alteration?

A nurse is working with a client who has schizoaffective disorder and believes that the hospital has poisoned the food. Which response from the nurse is most appropriate?

The nurse is caring for a schizophrenic client who is talking to someone who is not there. The client states, “I am talking to Cheryl. She’s right here.” No one is there. What is the most appropriate response for the nurse?

A nurse is providing reality orientation to a client who has been experiencing auditory hallucinations. Which of the following elements should the nurse consider when orienting this client to reality? Select all that apply.

A nurse is working with a client who is experiencing hallucinations of water running down the walls. Which of the following intervention would be most helpful for the client?

A nurse is caring for a client with schizophrenia who tells her he believes that everyone else in the inpatient unit is secretly laughing at him behind his back. Which response by the nurse is best?

A 45-year-old client with schizophrenia has been brought to the hospital after trying to commit suicide. The client tells the nurse that the voices he hears told him to do it. He is extremely anxious and upset. Which assessment question would most likely help the nurse to assess the client’s perception of this event?

The nurse is planning care for a client with schizophrenia. Which of the following is an appropriate goal for this client?

Which of the following are common findings in a client with schizophrenia? Select all that apply.

A 39-year-old client has been diagnosed with schizoaffective disorder after demonstrating various changes in behavior and cognition. The nurse is educating the family about behavioral changes they can expect to see. Which of the following information should the nurse include?

A client is brought into the emergency room by a family member. The client states she is being followed by people who are trying to kill her. The nurse reviews the client’s medications and notes that the client is likely to have schizophrenia based on which medication?

A client with catatonic schizophrenia is in the hospital on the mental health unit. The client has not moved for three days. Which of the following nursing interventions best demonstrates that the nurse is upholding the client’s safety in this situation?

A nurse is working with a client who has schizophrenia. The client is demonstrating clang associations. Which of the following statements by the client best displays this speech alteration?

A client is demonstrating catatonic schizophrenia. Which of the following characteristics would the nurse most likely see with this condition?

A client has been brought into the emergency department under the influence of illicit drugs. The client is experiencing paranoia and yells at the nurse, “You can’t hurt me! I am more powerful than you!” Which tactics would the nurse use that would help to orient this client to reality? Select all that apply.

A nurse is working with a client who has paranoid thinking. The client believes that a secret chip has been implanted under the client’s skin by the government. Which is the most appropriate first approach from the nurse?

A client with obsessive-compulsive disorder (OCD) is in the hospital after having been diagnosed with a chronic illness. Which best describes what the nurse would see in this client while trying to provide care?

A 23-year-old client is being seen for treatment after purposely cutting the skin on her arm. The client has impulsive behavior, is angry, and has been losing friends because of intense and needy behavior. Which type of personality disorder does this best describe?

A nurse is working with a family who home schools their three children and also cares for an aging parent with Alzheimer’s in the home. Which statement by the family best indicates that they are considering the needs of the older adult who is receiving care in the home?

A 9-year-old child has been diagnosed with ADHD and is acting impulsively with hyperactivity. Which developmental activity would most likely be difficult for this child to achieve?

A nurse is helping a client who has been developing dementia. The client expresses fears about his condition to the nurse. Which nursing interventions would be most appropriate in this case? Select all that apply.

A client with Alzheimer’s disease has been transferred to the medical unit accompanied by the spouse. The client is cognitively impaired and confused. The nurse assigns the client a room with low lighting near the nurse’s station. Which of the following best explains the reason for this room assignment?

A nurse is caring for a client with dementia as a result of progressive Alzheimer’s disease. The client’s family requests that the client eat fewer carbohydrates because of recent research the daughter has been studying. Which response from the nurse best indicates respect for this family’s choices?

A nurse is caring for an older adult who is experiencing wasting and malnutrition as a result of dementia. The client’s daughter asks the nurse about giving her mother a nutritional shake. Which response from the nurse is accurate?

A 68-year-old client is being seen because of problems with memory loss. Which best describes an example of the difference between normal memory changes with aging versus dementia?

A family whose father has Alzheimer’s disease is struggling with keeping their parent safe at home. The nurse can suggest which of the following strategies?

Which medical condition has been shown to cause dementia in some adults?

A married couple is talking with a nurse about the wife’s diagnosis of dementia. Since becoming ill, the wife has not been able to take on her responsibilities at home and her husband now performs most of the cooking and cleaning, in addition to yard work and paying bills. The husband complains to the nurse that he feels tired and the illness is putting a strain on their relationship. Which response from the nurse is most appropriate?

A nurse is assessing a client who is being seen for malnutrition associated with a history of anorexia. Which of the following characteristics of the nervous system would the nurse expect to see in this client?

A nurse is discussing inpatient treatment options for a client who has an eating disorder. The client wants to try to manage the condition independently instead. Which response from the nurse is most appropriate?

The nurse is caring for a client with a poor appetite. The nurse notes that the client is consuming less than 10% of meals and does not snack in between meals. Which of the following is NOT an appropriate intervention? Select all that apply.

Which nursing intervention would be most appropriate for the following care plan? Altered Nutrition: Less than body requirements, related to an unwillingness to eat, as evidenced by severe weight loss greater than 10%.

A nurse is assigned to care for a client with bulimia nervosa and assists the client to order a meal. Which of the following actions is important for the nurse to take regarding mealtime?

After being admitted as an inpatient for treatment of substance abuse, a client becomes confused and disoriented and is demonstrating tachycardia, sweating, and tremor. Which nursing intervention is most appropriate for management of this client?

A client has orders for lorazepam administration, seizure precautions, and a banana bag. The nurse recognizes that this client is at risk for which of the following conditions?

A nurse arrives at work in the psychiatric unit and is given the assignments for the day. The nurse has a client who is experiencing delirium tremens after alcohol withdrawal and needs medication, a client who will be undergoing ECT later that day, a client with obsessive-compulsive disorder who has not had breakfast yet, and a client who needs to go to eating disorder group therapy. Which client should the nurse see first?

A client is undergoing acute alcohol withdrawal and is experiencing delirium tremens. Which nursing diagnosis would most likely be associated with this condition?

The nurse is caring for a client admitted for alcohol addiction. Which of the following questions is the priority at this time?

While working with a client who is experiencing acute alcohol withdrawal, a nurse performs an assessment by asking the client to drink a glass of water. Which best explains the significance of this test?

A client is admitted to the floor from the ER for Ulcerative Colitis complicated with infection. The client is slurring their words and stumbling. The nurse notes empty mini vodka bottles in the client belonging bag. The client reports that they drink every day and asks the nurse to get them more vodka. What is the nurse’s priority at this time?

The nurse is working in the emergency department caring for a client with delirium tremens and severe alcohol withdrawal. Which question is the priority?

The nurse is caring for a client who presents to the ER with complaints of a fall with a laceration to the right arm. The client is slurring their speech. All vital signs are within normal limits. Which substance should be suspected in this client?

The nurse is caring for a client who is an alcoholic with a history of seizures while going through withdrawals. The nurse is setting up the room and implementing seizure precautions. Which of the following does the nurse ensure is included in the client’s plan of care?

A nurse is caring for a client who lost her father to cancer last year. The client is demonstrating dysfunctional grief in that she has intense feelings of guilt over the situation. Which of the following factors would increase a person’s risk of developing dysfunctional grief?

A client is suffering from feelings of loss after experiencing a miscarriage. Which action of the nurse would best support this client in working through her grief?

A nurse is helping a family whose loved one died thirty minutes ago. The family exhibits sadness and crying. What kind of grief is the family experiencing?

Which best describes disenfranchised grief?

Which of the following situations best describes acute grief?

A 58-year-old client is feeling sadness and loss after his mother died. Which best describes the difference between grief and depression?

The parents of a 2-year-old child who died of leukemia are experiencing intense grief in the months following the death. Which of the following is a factor that would affect how these parents experience grief?

A 35-year-old client is undergoing a lower limb amputation after a crushing injury. Which best describes how the nurse can support the client’s anticipated grief during this time?

The parents of a 1-year-old child who has been adopted from Ethiopia ask the nurse about the child’s feelings of grief. The mother tells the nurse, “I do not think the understands the loss at one year old.” Which response from the nurse is correct?

A nurse is caring for a woman whose mother died six months ago and who is grieving over the loss. The nurse assesses the woman for any signs of complicated grief patterns. Based on the nurse’s understanding of this condition, the nurse knows to look for what signs that indicate complicated grief? Select all that apply.

The nurse is caring for a 14-year-old client. The client’s mother informs the nurse that the client told her that he wants to kill himself. What is the priority?

The nurse is leading group therapy in a behavioral health unit. Which client concerns the nurse the most?

A client with suicidal ideation is undergoing dialectical behavior therapy. The nurse should educate the client to expect which type of treatment?

Signs of suicidal intent or planning include which of the following? Select all that apply.

A client with a history of severe depression and anxiety is in the hospital after attempting suicide. Which evidence would most likely be seen that indicates a crisis in a person with a mental illness? Select all that apply.

A client with depression has been taken to the emergency department by a friend after making statements that he was contemplating suicide. The provider has ordered that the client be admitted for inpatient treatment but the client refuses. Which of the following best explains the client’s rights in this situation?

Which of the following are risk factors for suicide? Select all that apply.

The provider has finished seeing four clients in the emergency room. The nurse should first assess the client with which condition?

A psych nurse is floated to the emergency room to help with the number of psych clients that are being triaged. The psych nurse knows to see the client with which of the following first?

A nurse is caring for an older adult who is experiencing wasting and malnutrition as a result of dementia. The client’s daughter asks the nurse about giving her mother a nutritional shake. Which response from the nurse is accurate?

A client with dementia has forgotten how to perform basic tasks. The nurse knows that which theory is demonstrated by the loss of these abilities?

A nurse is providing home care to a client with dementia. The nurse knows that which of the following is the primary goal for the client?

The nurse is caring for a client with Alzheimer’s disease. The client takes galantamine as a new medication. Which of the following element of the client’s history would alert the nurse to discuss this with the provider?

A nurse is assisting a client with dementia to take a shower. Which interventions would be most appropriate to maximize safety? Select all that apply.

Which medical condition has been shown to cause dementia in some adults?

The nurse is interviewing a client going to the operating room for a total hip replacement. During the interview, the client is unable to state their name or birthdate. The client takes medication for dementia. The nurse would expect which of the following when obtaining the informed consent? Select all that apply.

A client has overdosed on amitriptyline. Which of the following antidotes will the nurse anticipate giving?

The nurse is caring for a client who was on an SSRI for depression. The SSRI was ineffective, so the provider has switched the client to a tricyclic antidepressnat (TCA). Which of the following is a priority to be completed prior to initiation of TCA therapy?

A client reports feeling profoundly depressed and states that he came to the hospital because he feels like he wants to end his life. Which medication is appropriate for this client?

The nurse is teaching a client about which foods to avoid while taking phenelzine sulfate. Which of the following foods should be avoided? Select all that apply.

The nurse is caring for a client who is starting to take citalopram for depression. The nurse would be most concerned when the client states which of the following?

The nurse is assessing a client who takes sertraline for depression. The client has stated that “the medication seems to be working.” The nurse knows that this medication works in which of the following ways?

A client who has had type 1 diabetes for 15 years was recently diagnosed with depression. The provider writes a prescription for the client to start taking antidepressant medications. Which of the following types of antidepressant medications should be avoided among clients who have diabetes?

The nurse is caring for a client with depression who takes a selective serotonin reuptake inhibitor. The nurse knows these types of drugs include which of the following? Select all that apply.

A nurse is caring for a client who was diagnosed with depression and anxiety three years ago. The client currently has prescriptions for four different medications for control of symptoms. Which nursing intervention is most appropriate to reduce the risks associated with taking many different medications in this situation?

A patient is being seen for treatment of depression after suffering from chronic back pain. The physician has prescribed duloxetine. The patient asks the nurse, “What kind of side effects does this medicine cause?” Which response from the nurse is correct?

The nurse is reviewing a client’s lab results. Which result for lithium would the nurse correctly note as therapeutic?

The nurse is caring for a client who complains of an upset stomach when taking lithium. Which of the following is appropriate for the nurse instruct the client to do?

A client has overdosed on a benzodiazepine. The nurse has given the client flumazenil as the antidote, and begins to monitor for which type of reaction from the effects of the antidote?

A client with bipolar disorder has been prescribed carbamazepine. Which lab value should the nurse anticipate monitoring?

The nurse is caring for a client with Alzheimer’s disease who is taking quetiapine. A family member asks the nurse, “What is the benefit to taking this drug?” Which of the following responses from the nurse is correct? Select all that apply.

The nurse is caring for a client with Alzheimer’s disease. The client takes galantamine as a new medication. Which of the following element of the client’s history would alert the nurse to discuss this with the provider?

The nurse is caring for a client who is scheduled to take phenobarbital. The nurse knows that this type of medication is indicated for which condition?

A nurse is working with a client who takes zolpidem (Ambien) every night before going to bed. Which of the following should the nurse teach this client about long-term use of this drug? Select all that apply.

The provider has written an order for Xanax 250 mg prn one time for sleep. What aspect of the order needs to be addressed?

A nurse is caring for a client who requires moderate sedation for a procedure. With this type of sedation, the nurse would expect which of the following client responses?

A nurse is working with a client at the care clinic who has arrived for a routine physical exam. The nurse is reviewing the client’s medications with him and notes that he takes zolpidem. Which best describes the condition treated by this drug?

The nurse is caring for a client who is receiving thiopental. Which of the following types of medication is this?

The nurse is receiving report from the ED on a client with ETOH. The nurse giving report informs the receiving nurse that the client was found to possess phenobarbital pills. Why is the nurse concerned?

The nurse is going to administer midazolam to a client for moderate sedation. Which of the following vital signs does this drug affect? Select all that apply.

A nurse is caring for a client with post-traumatic stress disorder who has been suffering from insomnia. Which of the following directions could the nurse give that would most likely be related to sleep hygiene for this client?

A nurse is caring for a client with insomnia. Which of the following would be an appropriate care plan goal for this client? Select all that apply.

A client is diagnosed with neuroleptic malignant syndrome. Which of the following events has the client likely experienced?

A client is brought into the emergency room by a family member. The client states she is being followed by people who are trying to kill her. The nurse reviews the client’s medications and notes that the client is likely to have schizophrenia based on which medication?

Which of the following medications would be classified as an antipsychotic medication?

A 29-year-old client is being seen for a diagnosis of schizophrenia. The physician has ordered an atypical antipsychotic medication for disease management. Which best describes how this type of medication works?

The nurse is caring for a client with dystonia. What is the priority nursing intervention for this client?