PN Mental Health 2023

Question 3

PN Mental Health 2023A nurse in a substance use disorder clinic is explaining the alcohol recovery process to a client’s family. Which of the following should the nurse identify as the first step toward successful recovery from alcohol use disorder?

• Agree to a prescription for an alcohol use deterrent
• Incorporate a form of spirituality into daily life
• Acknowledge an inability to control drinking
• Form a close support network

Question 5

A nurse is caring for a client who was placed in four-point restraints by the nursing staff following an episode of violent behavior. Which of the following actions should the nurse take?

• Request the provider renew the prescription in 24 hr
• Provide range-of-motion exercises to all extremities every 2 hr
• Document the client’s behavior in the medical record every 1 hr
• Keep staff interactions with the client to a minimum

Question 6

A nurse is providing information to a client about smoking cessation. Which of the following medications should the nurse include?

• Quetiapine
• Bupropion
• Aripiprazole
• Risperidone

Question 7

A nurse is reinforcing teaching with a newly licensed nurse about the Patient Self-Determination Act (PSDA). Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

• “The PSDA becomes applicable when a client reaches 65 years of age.”
• “Advance directives do not apply to clients receiving mental health care.”
• “A witness is legally required to sign a client’s living will.”
• “A client can verbally designate a durable power of attorney.”

Question 9

A nurse is reinforcing teaching with a client who has bipolar disorder and has a new prescription for lithium. To address possible adverse effects, the nurse should include that which of the following laboratory values will be monitored while the client is taking this medication?

• Uric acid
• Sodium level
• Liver enzymes
• Erythrocyte sedimentation rate

Question 10

A nurse is preparing to administer medications to a client who has schizophrenia.

History and Physical Client has hypertension, depressive disorder, and seasonal allergies.

Complete the following sentence by using the list of options. The nurse should clarify the prescription for Select ______ due to the client’s Select ______.

Options:

• lorazepam
• fluoxetine
• clozapine
• loratadine

Correct completion: The nurse should clarify the prescription for fluoxetine due to the client’s clozapine prescription (risk of increased clozapine levels and toxicity).

Question 11

A nurse is reinforcing teaching with a client who started taking haloperidol decanoate 125 mg IM 1 month ago. Which of the following statements by the client should the nurse address?

• “I check my blood pressure once a week.”
• “I haven’t had a drink of alcohol since I started taking the injections.”
• “I chew sugar-free gum several times daily.”
• “I spend several hours a day outside gardening when it’s sunny.”

Question 12

A nurse is preparing to administer sertraline 50 mg PO once daily to a client who has depressive disorder. Available is sertraline oral solution 20 mg/mL. 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.)

Correct answer: 2.5 mL

Question 13

A nurse in a mental health clinic is collecting data from a client to determine the client’s risk for suicide. Which of the following findings should the nurse identify as a risk factor for suicide? (Select all that apply)

• Access to guns in the home
• Terminal liver cancer
• Alcohol use disorder
• Currently married
• Sibling history of suicide

Question 14

A nurse is reviewing the medical record of a client who is to receive electroconvulsive therapy. The nurse should notify the provider for which of the following findings?

• Crohn’s disease
• Asthma
• Cardiac arrhythmia
• Renal colic

Question 15

A nurse is reinforcing teaching about a new prescription for haloperidol with a client who has schizophrenia. Which of the following statements by the client indicates an understanding of the teaching?

• “The medication may cause ringing in my ears.”
• “The medication may cause urinary incontinence.”
• “I may be more sensitive to the sun while taking this medication.”
• “I may experience a metallic taste while taking this medication.”

Question 16

A nurse in a mental health facility is caring for a client who has antisocial personality disorder and alcohol dependency. The nurse should encourage the client to participate in which of the following groups?

• Psychodrama
• Crisis interventionPN Mental Health 2023
• Codependency support
• Dual diagnosis treatment

Question 17

A nurse is assisting with the care of a client who has dementia. Which of the following actions should the nurse take?

• Provide the client with a dark environment for sleeping.
• Make a personal introduction to the client at each interaction.
• Give the client a list of foods to choose from for dinner.
• Repeat orientation questions until the client gives a correct response.

Question 18

A nurse is collecting data from a client who has anorexia nervosa. Which of the following findings should the nurse expect? (Select all that apply.)

• Tooth erosion
• Diarrhea
• Hypotension
• Lanugo
• Cold extremities

Question 19

A nurse is collecting data from an older adult client who was admitted with heart failure. The nurse should report which of the following findings to the provider as an indication of delirium?

• Demonstrates obsessive behaviors
• Consistent state of depression
• Family report of gradual memory loss
• Fluctuating level of orientation

Question 20

A nurse is collecting data from a client who has antisocial personality disorder. Which of the following findings should the nurse expect? (Select all that apply.)

• Manipulative behaviors
• Lack of empathy
• Preoccupation with details
• Splitting
• Anxiousness

Question 21

A nurse is collecting data for a health history from a client who has antisocial personality disorder. Which of the following clinical findings is associated with this disorder?

• Exploitive of others
• Withdrawn behaviors
• Excessively anxious
• Blunted affect

Question 22 (Scenario-based: ED admission)

Nurse’s Notes 0205 Client brought to the ED by police after being found wandering on the street. Client able to provide identity to police but not able to identify place or time. Family notified.

Client confused and agitated. Appearance is disheveled. Mucous membranes dry. Lungs clear and equal, heart rhythm regular.

During data collection, client states, “Can you ask that person to leave my room?” Client is pointing to an empty chair.

Vital Signs Temperature 38.6°C (101.5°F) Heart rate 104/min Respiratory rate 18/min Blood pressure 158/96 mm Hg Oxygen saturation 96% on room air

Correct findings requiring immediate follow-up:

• Temperature 38.6°C (101.5°F)
• Client hallucinations (pointing to empty chair)
• Dehydration (dry mucous membranes, poor intake)

Question 23

The nurse has reviewed the nurse’s notes, provider’s note, and laboratory results.

Provider’s Note Diagnosis: delirium secondary to urinary tract infection and dehydration

For each client finding, specify if consistent with delirium or Alzheimer’s disease:PN Mental Health 2023

• Agitation → Delirium
• Hallucinations → Delirium
• Fluctuating levels of consciousness → Delirium
• Sudden onset of confusion → Delirium

Question 24

Complete the following sentence by using the list of options.

The client is most likely experiencing _______.

Options:

• Alzheimer’s disease
• Delirium
• Substance use disorder

Correct completion: The client is most likely experiencing delirium.

Question 25 (Fill-in-the-blank style)

Complete the following sentence by using the lists of options.

The client is most likely experiencing delirium as evidenced by:

• Sudden onset of confusion
• Past medical history (not primary evidence)
• Laboratory results (supportive but secondary)

Correct evidence: Sudden onset of confusion

Question 26 (Scenario continuation)

Nurse’s Notes Client admitted to medical-surgical unit. Peripheral IV initiated. Client agitated, attempting to pull out IV, yelling “I am leaving now!”

Laboratory Results Serum toxicology screen: Alcohol 50 mg/dL (mild intoxication range)

Potential Provider Prescriptions

• Administer 0.9% sodium chloride 125 mL/hr by continuous IV infusion → Expected
• Administer lorazepam → Expected
• Administer oxygen → Unexpected (not indicated)
• Administer flumazenil → Unexpected (used for benzodiazepine overdose, not alcohol intoxication)

Question 27 (Scenario continuation)

Provider’s Note Diagnosis: delirium secondary to UTI and dehydration. Will transfer client to medical-surgical unit.

Potential Provider Prescriptions

• Administer 0.9% sodium chloride 125 mL/hr by continuous IV infusion → Expected
• Initiate 1:1 supervision → Expected
• Administer acyclovir → Unexpected (antiviral, not indicated)
• Administer lorazepam → Expected

Question 29

A nurse is caring for a newly admitted client who has obsessive-compulsive disorder. Which of the following actions should the nurse take first?

• Discuss the benefits of relaxation exercises with the client
• Administer an antianxiety medication
• Explain the use of response prevention to the client
• Calculate the client’s score on the Hamilton Rating Scale for Anxiety

Question 30

A nurse in a mental health facility is collecting a blood specimen from a client. The client is hallucinating and states, “That looks like a snake, and I won’t let it take all of my blood.” Which of the following responses should the nurse make?

• “I don’t see a snake, but that must be scary for you.”
• “Your provider requires this blood specimen.”
• “I’m using a syringe to obtain your blood, not a snake.”
• “You must be mistaken. Snakes cannot be in the clinic.”

Question 31

A nurse is caring for a group of clients in a pediatric clinic. Which of the following clients is at highest risk for physical abuse?

• A preschooler who is reluctant to share
• A toddler who has cystic fibrosis
• An adolescent who is preparing to leave home for college
• A school-age child who wants to go away to summer camp

Question 32

A nurse is collecting data from a client who experienced physical abuse as a child. Which of the following findings should the nurse identify as a risk factor for the client to become a perpetrator of child abuse?

• Involved in community activities
• Absence of impulsive behaviorsPN Mental Health 2023
• Submissive personality
• Low tolerance for frustration

Question 33

A nurse is caring for a client who becomes extremely agitated and asks if they can go to a separate room to be alone for an hour. The nurse should document which of the following de-escalation techniques in the client’s medical record?

• Diversion
• Therapeutic hold
• Restraint
• Timeout

Question 34

A nurse is collecting data from a client who has bulimia nervosa. Which of the following findings should the nurse expect?

• Lanugo
• Hypomagnesemia
• Hypokalemia
• Muscle wasting

Question 35

A nurse is caring for a client who has an anxiety disorder. The client transforms their anxiety into physical manifestations. The nurse should recognize that the client is exhibiting which of the following manifestations?

• Sublimation
• Somatization
• Reaction formation
• Intellectualization

Question 36

A nurse is reinforcing teaching with a newly licensed nurse about client confidentiality. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

• The provider must give consent to discuss health information with the client’s family.
• A client retains the legal right to privacy of health information even after the client’s death.
• A provider may speak to a client’s employer regarding a substance use disorder.
• I can discuss a client’s information with staff who are providing care to the client.

Question 37

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

• Limit the client’s need to make decisions.
• Keep the client’s room dark at night.
• Provide a high-stimulation environment for the client.
• Discourage visitation from the client’s family.

Question 38

A nurse is reinforcing behavior management techniques with the parent of a school-age child who has conduct disorder. Which of the following statements by the parent indicates an understanding of the reinforcement technique?

• I should re-engage my child in an appropriate activity.
• I should move closer to my child when they are agitated.
• I should ignore attention-seeking behavior.
• I should use role-playing to enhance new behaviors at home.

Question 39

A nurse is caring for a client who is receiving acute care for the treatment of a substance use disorder. Which of the following actions by the nurse demonstrates the ethical principle of veracity?

• Maintaining the client’s confidentiality about a substance use disorder
• Reinforcing information on the potential adverse effects of a medication with the client
• Encouraging the client to attend a daily exercise program on the unit
• Respecting the client’s right to refuse to attend a group therapy session

Question 40

A nurse is contributing to the plan of care for a client who has a new prescription for lithium. Which of the following interventions should the nurse recommend?

• Decrease the client’s dietary potassium.
• Administer the medication with meals.
• Increase the client’s daily caloric intake.
• Monitor the client for hypoglycemia.

Question 45

The nurse is continuing to assist with the care of the client. Complete the following sentence by using the lists of options. The nurse should [Select…] due to [Select…].

• offer the client multiple options for meals
• anticipate the client’s needs
• weigh the client daily

Due to:

• the client’s risk of malnutrition
• the client’s decreased ability to communicate
• the client’s desire for independence

Question 47

A nurse is assisting with the plan of care for a group of clients at a mental health facility. Which of the following clients should the nurse plan to see first?

• a client who has dementia and is experiencing sundowners
• a client who has schizophrenia and is reporting command hallucinations
• a client who has borderline personality disorder and reports chronic feelings of emptiness
• a client who has mydriasis and is experiencing opioid withdrawals

Question 48

A nurse is contributing to the plan of care for a client who has a new prescription for lithium. Which of the following interventions should the nurse recommend?PN Mental Health 2023

• Monitor the client for hypoglycemia.
• Increase the client’s calcium intake.
• Administer the medication with meals.
• Limit the client’s sodium intake.

Question 49

A nurse is collecting data from an adolescent client. Which of the following findings should the nurse identify as a risk factor for anorexia nervosa?

• High parental expectations
• Residence in an urban area
• Active in a book club
• Anxious temperament

Question 50

A nurse in a mental health unit is gathering data from a client. Which of the following findings should the nurse identify as a factor associated with schizophrenia?

• Maternal age over 35
• Low socioeconomic status
• Having a summer birthday
• History of alcohol use disorder

Question 51

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

• Request a consult with recreational therapy.
• Lower the window shade in the client’s room.
• Obtain a PRN prescription for a vest restraint.
• Place the client in a room close to the nurses’ station.

Question 52

A nurse is collecting data from a client who has schizophrenia. Which of the following client statements indicates that the client is experiencing a command hallucination?

• “Are you planning to kill me?”
• “The voices told me to quit eating the food here.”
• “Can you see these spiders crawling all over me?”
• “The aliens are going to abduct me tonight.”

Question 53

A nurse is assisting with teaching a group of older adult clients about behavioral expectations. Which of the following actions should the nurse take to help eliminate barriers to learning?

• Schedule the teaching sessions for a long time to promote participation.
• Assist the clients with establishing long-term goals.
• Use “I” statements rather than “you” statements.
• Ensure the teaching sessions occur right before bedtime.

Question 54

A client is becoming increasingly agitated, anxious, and tense. The nurse notes a clenched jaw and a change in the pitch of the client’s voice. Which of the following interventions should the nurse implement first?

• Take the client to the seclusion room.
• Place the client in restraints.
• Obtain a prescription for haloperidol.
• Verbally de-escalate the client.

Question 55 of 60

A nurse is caring for a client who has depression and reports only sleeping a few hours each night. Which of the following instructions should the nurse give the client to promote sleep?

• You should take a nap after lunch.
• You should drink a glass of wine 1 hour before you go to bed.
• You should limit yourself to two caffeinated beverages per day.
• You should eat a meal just prior to bedtime.

Question 56 of 60

A nurse is caring for a client who has depressive disorder following the recent death of their partner. Which of the following responses should the nurse make?

• Tell me what your relationship with your partner was like.PN Mental Health 2023
• I remember how depressed I was after my friend died.
• Everyone feels depressed during the grieving process.
• You should start participating in your usual activities.

Question 57 of 60

A nurse is contributing to the plan of care for a client who is to start therapy with fluoxetine. Which of the following is an expected outcome for this client?

• Absence of seizures
• Decreased hallucinations
• Reduction in hand tremors
• Improved mood

Question 58 of 60

A nurse is assisting with reminiscence therapy for a group of older adult clients. Which of the following strategies should the nurse implement?

• Playing board games with other clients to enhance cognition
• Making a unit calendar to promote orientation
• Discussing childhood memories during group therapy
• Encouraging thought-stopping to block undesirable thoughts

Question 59 of 60

A nurse is collecting data from a client who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect?

• Bradycardia
• Hypokinesis
• Diarrhea
• Meiosis

Question 60 of 60

A nurse is caring for an adolescent who was recently sexually assaulted. Which of the following statements by the adolescent’s guardian represents the presence of a positive support system?

• I anticipate that my child will feel some self-blame.
• I will have to do all I can to monitor my child’s relationships.
• I should encourage my child to focus solely on the future.
• I can encourage my child to think about what they did that allowed this event to happen.