RN MENTAL HEALTH 2023

Question 8

RN MENTAL HEALTH 2023. A nurse in the student health clinic is caring for a client. Exhibit 1 (Nurses’ Notes):

2 weeks ago, 1300: Client is a 19-year-old student requesting the form to participate in a sport on the college campus. Client states the form is a waste of time because of having extreme talent in the sport, and the team would benefit from their participation; expects to be drafted to play for a national team while still in college and says team members are going to be envious of their abilities. Physical form completed.
Today: Client experienced an injury while participating in a team sport; coming to the student health clinic to be cleared before continued participation. Client states other team members are jealous of the client’s abilities and wanted them to be injured; states they are the best player the team has and the team will fail without them. States being entitled to play for a professional team and does not care what other team members think about them.

Exhibit 2 (Plan of Care):

2 weeks ago, 1300: Physical for team sport participation.
Today: Abstain from team sport participation for 1 week.

Sentence Completion: The nurse should care for the client by remaining neutral and explaining that the client is not entitled to play on a professional team.

Question 9

A nurse is caring for a client. Exhibit 1 (Nurses’ Notes):

Yesterday, 1300: A client presents to the emergency department with a family member for concerns about the client’s mental health. The client’s partner states the client has had a deterioration in memory and job performance over the last few months. The client’s partner states the client “keeps telling me their deceased grandparent is sending them messages.” The nurse notes that the client has pressured speech and motor agitation. Client pacing and restless.
1500: Client becoming more aggressive and agitated. Provider notified.
1800: The client is admitted to the inpatient psychiatric unit for an acute schizophrenic episode.
Today, 1000: The client reports a dry mouth and “blurry vision.” The client states, “I just feel terrible.”

Exhibit 2 (Provider Prescriptions):

1500: Lorazepam 1 mg PO three times per day PRN anxiety or agitation; Haloperidol 3 mg PO three times per day.

(Vital Signs) Exhibit 3:

Yesterday, 1300: BP 100/70 mm Hg, HR 98/min, RR 18/min, Temp 37°C (98.6°F).
Today, 1000: BP 98/68 mm Hg, HR 124/min, RR 22/min, Temp 39.5°C (103.1°F).

Sentence Completion: The nurse identifies the client’s heart rate and temperature can indicate a life-threatening reaction to the client’s scheduled medication.

Question 10

A nurse is preparing to administer methylphenidate 25 mg PO to a school-age child who has ADHD. Available is methylphenidate 10 mg/5 mL liquid. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

12.5 mL

Question 11

A nurse is caring for a client who has schizophrenia and is preparing for discharge. The nurse is providing discharge teaching to the client. Which of the following information should the nurse include when educating the client about relapse prevention? Select all that apply.

Go for a walk to decrease anxiety during times of increased stress.
Notify your provider within 48 hr of manifestations of a relapse.
Report any adverse effects of the medication to the provider immediately.
Take a dose of the medication as soon as delusions or hallucinations begin.
Ask a trusted person to watch for manifestations of illness.
Limit alcohol consumption to no more than two drinks per week.

Question 12

A nurse is caring for a client who has cocaine use disorder. Which of the following manifestations should the nurse expect the client to have during withdrawal?

Fatigue
Seizures
Hand tremors
Rapid speech. RN MENTAL HEALTH 2023

Question 13

A charge nurse in an emergency department is assigning tasks. Which of the following tasks should the nurse delegate to an assistive personnel?

Insert an NG tube for a client who has acetaminophen toxicity.
Inform a client who has schizophrenia about available community services.
Transfer a client who has delirium from a bed to a wheelchair.
Obtain a list of current medications from a client who is experiencing a manic episode.

Question 14

A nurse is caring for a client who has dementia and is experiencing disorientation. Which of the following actions should the nurse take?

Avoid having a structured schedule.
Approach the client from the front.
Remove clocks from the room.
Give detailed explanations.

Question 15

A nurse in an outpatient mental health clinic is assessing a new client. Which of the following findings should the nurse immediately report to the provider?

The client is experiencing command hallucinations.
The client is experiencing anosognosia.
The client is exhibiting concrete thinking.
The client is exhibiting a blunted affect.

Question 16

A nurse is caring for a client who has alcohol use disorder. Which of the following statements made by the client indicates the client has a support system?

“My friends frequently drink alcohol, so I do not see them anymore.”
“My boss fired me due to my frequent absence.”
“I take care of my parent who has Wernicke-Korsakoff syndrome.”
“I have a sibling who attends Al-Anon.”

Question 17

A nurse in an emergency department is caring for a client following an assault. Which of the following actions should the nurse take first?

Determine if the client is experiencing thoughts of self-harm.
Provide information to the client about local support groups.
Ask the client how they have dealt with stress in the past.
Schedule a follow up visit with the client’s primary provider.

Question 18

A nurse is planning care for a client who has acute delirium. Which of the following instructions should the nurse include in the plan?

Refute the client’s perception of visual hallucinations.
Assign the client to a different caregiver each shift.
Reinforce the client’s orientation with a calendar.
Teach the client assertive techniques.

Question 19

A nurse in a provider’s office is assessing a client who has dementia. Which of the following findings should the nurse expect? RN MENTAL HEALTH 2023

Difficulty finding words
Clang associations
Traumatic flashbacks
Revenge seeking behavior

Question 26

A nurse is assessing a client who has antisocial personality disorder. Which of the following findings should the nurse expect?

Submissive behavior
Disregard for others
Clinging behaviors
Perfectionism

Question 27

A nurse is caring for a client who has dementia. Which of the following interventions should the nurse include in the plan of care?

Give the client a few directions at a time.
Quiz the client about orientation.
Limit the client’s number of choices.
Use confrontation to manage the client’s behavior.

Question 28

A nurse is assessing a client who has borderline personality disorder. Which of the following behaviors should the nurse expect?

Inflated view of their importance
Exhibits a pattern of unstable relationships
Feeling inferior compared to their peers
Lacks confidence in their own abilities

Question 29

A nurse is discussing guidelines for a client who has dementia with their family. Which of the following information should the nurse include in the teaching?

Use zippers for clothing.
Use written signs to label rooms.
Avoid exposing the client to the morning light.
Offer finger foods.

Question 30

A nurse is evaluating a client’s adherence to their treatment plan for generalized anxiety disorder. Which of the following statements by the client indicates compliance with the plan of care?

“I began taking a kava herbal supplement at bedtime.”
“I stopped attending my support group after my first session.”
“I have been jogging one mile when I get home from work.”
“I take an additional dosage of my medication when I am having a bad day.”

Question 31

A nurse is caring for a client who has severe major depressive disorder. The client states, “I no longer have the desire to finish school.” Which of the following actions should the nurse take?

Acknowledge the client’s feelings without reinforcing a change in their life goals.
Tell the client to stop worrying about school for now.
Assure the client that their current feelings are temporary.
Inform the client that goals are to focus on here-and-now issues, not the future.

Question 32

A nurse is providing teaching to a client who has anxiety and a new prescription for lorazepam. Which of the following potential adverse effects should the nurse include?

Elevated blood pressure
Muscle aches
Dizziness
Increases urine output

Question 33

A nurse is providing teaching to a client who has a new prescription for lithium. Which of the following statements by the client indicates an understanding of the teaching?

“I should drink at least 2 liters of fluid a day.”
“I should follow a low-sodium diet.”
“Constipation is an indication of medication toxicity.”
“Weight loss is an expected side effect of this medication.”

Question 34

A nurse is teaching a client who has bulimia nervosa about their plan of care. Which of the following diagnostic tests should the nurse mention in the teaching?

Erythrocyte sedimentation rate
Creatine phosphokinase
Electroencephalography
Complete blood count

Question 35

A nurse is supervising a group of staff members on a mental health unit. Which of the following actions require the nurse to complete an incident report?

An assistive personnel tells the provider that a client is making other clients feel unsafe.
An assistive personnel provides 1:1 monitoring for a client who is reporting thoughts of self-harm.
An assistive personnel applies physical restraints on a client who is aggressive.
An assistive personnel reapplies a soft limb restraint on a client after assisting them to the bathroom.

Question 42

A nurse is caring for a client who is at risk for alcohol withdrawal. Click to highlight the manifestations of alcohol withdrawal that would require immediate follow-up by the nurse. To deselect a finding, click on the finding again.

Impaired cognition
Insomnia
Seizures
Increased blood pressure
Increased heart rate
Diaphoresis
Lack of appetite
Vomiting
Tremulousness
Malaise

Question 43

A nurse is planning care for a client who has alcohol use disorder. For each potential provider’s prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

Complete blood count and basic metabolic profile: Anticipated
Propranolol 40 mg PO twice a day: Anticipated
Schedule electroconvulsive therapy (ECT): Contraindicated
Nutritional consult: Anticipated
Diazepam 10 mg PO three times a day: Anticipated
Perform Alcohol Use Disorders Identification Test (AUDIT): Contraindicated
Methadone 40 mg PO daily: Contraindicated
Group therapy: Anticipated

Question 44

Complete the following sentence by using the lists of options.

The nurse should first administer propranolol followed by request a nutrition consultation.

Question 45

A nurse is evaluating the client’s response to treatment. Select the 4 findings that indicate the client is progressing with their plan of care.

Vital signs
Client resolves to limit alcohol consumption
Cognition
Participation in group therapy
Movement through the stages of grief
Appetite

Question 46

A nurse is caring for a client who reports difficulty coping with several recent stressors. Which of the following responses should the nurse make?

“Everything will be okay if you give it some time.”
“Tell me about your support system.”
“You should find a therapist who can help you.”
“Why are you having difficulty coping?”

Question 47

A nurse in an alcohol treatment facility is caring for a client who states, “My job is so stressful that the only way I can cope is to drink.” The nurse should recognize that the client is displaying which of the following defense mechanisms?

Rationalization
Repression
Intellectualization
Introjection

Question 48

A nurse in a long-term care facility is caring for a client who has dementia and reports difficulty falling asleep at night. Which of the following actions should the nurse take to promote adequate rest?

Schedule the client for a morning group fitness class at the facility.
Allow the client several hours in the afternoon to take a nap.
Walk around the hallway with the client an hour before bedtime.
Limit the client to no more than four caffeinated beverages a day.

Question 49

A nurse is caring for a client who has a substance use disorder. The client states, “The state took my child away after my overdose. I don’t want to go on living without them.” Which of the following therapeutic responses should the nurse make?

“We can ask the physician to prescribe a sedative.”
“If you attend counseling, you will get your child back.”
“Have you thought about harming yourself?”
“Can a family member try to obtain temporary custody of your child?”

Question 50

A nurse is leading a group therapy session. A client with a history of violence suddenly stands up and appears angry. Which of the following actions should the nurse take?

Ask the client to describe how they are feeling.
Stand directly in front of the client when speaking to them.
Place the client in mechanical restraints.
Use therapeutic touch when addressing the client.

Question 53 of 70

A nurse is reviewing the medical records for a group of clients prior to administering the clients’ medications. For which of the following clients should the nurse withhold the prescribed medication and notify the provider?

A client who is taking nortriptyline and reports nausea and dry mouth
A client who is taking venlafaxine and exhibits frequent yawning and weight loss
A client who is taking fluoxetine and exhibits muscle rigidity and tachycardia
A client who is taking olanzapine and reports frequent urination

Question 54 of 70

A nurse is assisting a provider in obtaining informed consent from a client who has depressive disorder and is scheduled to have electroconvulsive therapy (ECT). The signature of the nurse on the consent form indicates which of the following?

The nurse has witnessed the client’s signature on the form.
The nurse has assessed the client’s knowledge of alternative treatments.
The nurse has provided information about the benefits of ECT.
The nurse has discussed the risks of ECT with the client.

Question 55 of 70

A nurse is assessing a client following treatment for serotonin syndrome caused by an antidepressant medication. Which of the following findings indicates the treatment has been effective?

Altered mental status
Decrease in blood pressure
Hyperpryexia
Muscle rigidity

Question 56 of 70

A nurse is developing a plan of care for a school-age child who has ADHD. Which of the following interventions should the nurse include in the plan?

Administer olanzapine.
Encourage thought stopping techniques.
Provide a stimulating environment.
Institute consequences for deliberate behaviors.

Question 57 of 70

A nurse is caring for a client who is newly admitted for the treatment of anorexia nervosa. Which of the following actions should the nurse plan to take?

Stay with the client for 15 min following meals.
Discuss food-related topics with the client during meals.
Weigh the client every day for the first week of acute care.
Schedule the client for a daily exercise program.

Question 58 of 70

A nurse at a community health center is preparing a presentation on alcohol use disorder. Which of the following risk factors should the nurse include in the presentation?

Low socioeconomic status
History of maternal infection during pregnancy
High self-esteem
Genetic predisposition

Question 59 of 70

A nurse is assessing a client who has post-traumatic stress disorder. Which of the following findings should the nurse expect? (Select all that apply.)

Difficulty falling or staying asleep
Holds persistent negative beliefs about self
Blames others for own mistakes
Has difficulty concentrating on set tasks
Talks excessively

Question 60 of 70

A nurse is caring for a client who has been placed in restraints. Which of the following actions should the nurse take? RN MENTAL HEALTH 2023

Observe the client’s behavior once every 15 min.
Request a PRN client prescription for restraints from the provider.
Remove the restraint when the client calmly follows commands.
Document the client’s behavior hourly on a flow-sheet.

Question 61 of 70

A nurse is performing a home visit on a client who has Alzheimer’s disease and their partner. The partner states, “I wish I had some time to myself and run errands, but I need to be here all the time.” Which of the following referrals should the nurse recommend to the client’s partner?

Respite care
Palliative care
Occupational therapy
Hospice care RN MENTAL HEALTH 2023

Question 64

A nurse is teaching the family of a client who has Alzheimer’s disease about safety interventions for nighttime wandering. Which of the following interventions should the nurse include?

Place the client’s mattress on the floor.
Encourage the client to take naps during the day.
Install locks at the bottom of the exit doors.
Place rubber-backed throw rugs on tile floors.

Question 65

A nurse is assessing a client who has paranoid personality disorder. Which of the following findings should the nurse expect?

Believes that others are deceiving her
Demonstrates detachment from others
Takes advantage of others for her own benefit
Shows exaggerated expression of emotions

Question 66

A nurse is reviewing the medical record of a client who has a new prescription for selegiline transdermal. Which of the following findings should the nurse identify as a contraindication for administration of this medication to the client? RN MENTAL HEALTH 2023

Has a history of gastric reflux
Takes St. John’s Wort daily
Drinks a glass of orange juice daily
Has a history of cholelithiasis

Question 67

A nurse is teaching a client about the use of cognitive reframing for stress management. Which of the following statements by the client indicates an understanding of the teaching?

“I will focus on a mental image while concentrating on my breathing.”
“I will progressively relax each of my muscle groups when feeling stressed.”
“I will learn how to voluntarily control my blood pressure and heart rate.”
“I will practice replacing negative thoughts with positive self-statements.”

Question 68

A nurse is assessing a client who has Alzheimer’s disease. Which of the following findings should the nurse identify as the priority?

The client does not recognize their partner.
The client is unable to remember their personal history.
The client places their shoes on the wrong feet.
The client engages in wandering.

Question 69

A charge nurse on a mental health unit is preparing an in-service about client rights for staff members. Which of the following information should the nurse include?

Clients can refuse to attend group therapy.
Clients who are involuntarily committed do not maintain access to legal counsel.
Client withdrawal of prior consent must be done in writing.
Clients who have a severe mental illness cannot request a psychiatric advance directive.

Question 70

A nurse is planning care for a school-aged child who has autism spectrum disorder and is nonverbal. Which of the following interventions should the nurse include in the plan of care?

Administer haloperidol to the child as prescribed.
Instruct the child’s guardian on the use of implosion therapy.
Provide positive reinforcement when the child uses eye contact.
Administer tranquilizing medications if the child becomes frustrated.

MENTAL HEALTH, Nursing questions, RN MENTAL HEALTH 2023

Isaura K

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