mental health questions

PRN 1562-21.A nurse working in an acute mental health unit is caring for a client diagnosed with major
depressive disorder. Which of the following is the highest priority for the nurse?
A. Ensuring the client attends group therapy as scheduled.
B. Ensuring the client’s safety, including dose monitoring.
C. Reviewing the client’s ability to complete their self-care needs.
D. Informing the client of the medication they have been prescribed.
2. A client diagnosed with obsessive -compulsive disorder is ready for discharge. As the nurse
reviews the orders, which of the following should be an expected part of the discharge
planning?
A. An antipsychotic, such as haloperidol with group therapy
B. A benzodiazepine, such as lorazepam with family therapy
C. A mood stabilizer, such as lithium with psychoanalytic therapy
D. A SSRI, such as fluvoxamine with cognitive behavioral therapy.
3. The nurse is caring for a client with post traumatic stress disorder (PTSD). Which statement
from the client indicates the client is experiencing hypervigilance?
A. “ I am having trouble sleeping at night.”
B. “ I haven’t been able to feel emotions lately.”
C. “ I always have to be aware of my surroundings.”
D. “ Certain noises scare me.”
4. A nurse is assigned to a client diagnosed with obsessive compulsive disorder (OCD). Which
of the following nursing actions should be incorporated into the client’s care?
A. Encourage the client to avoid situations that increase anxiety.
B. Prevent the client from performing compulsive behavior.
C. Explain to the client that the compulsive behavior is excessive.
D. Allow time for the client to complete compulsive behaviors.
5. Goals and desired outcomes for an older adult client experiencing delirium caused by fever
and dehydration will focus on which of the following?
A. The client will return to premorbid levels of function.
B. The nurse will identify stressors negatively affecting the client.
C. The client will demonstrate limited motor responses to external stimuli.
D. The client will be able to exert control over responses to perceptual distortions.
6. A client diagnosed with obsessive compulsive disorder (OCD) has been prescribed
fluvoxamine. Which statement by the client shows an understanding of this medication?
A. “ I will need to avoid cheese and aged meats.”
B. “ I may experience dry mouth.”
C. “ I will need to monitor my sodium intake.”
D. “ I will need to tell my doctor if I have any suicidal thoughts.”
7. A client has been prescribed lithium for long-term maintenance of bipolar disorder diagnosis.
Which statement by the client shows an understanding of the medication?
A. “ Lab work is only needed at the start of taking the medication.”
B. “ Once I feel better, I will not need to take this medication anymore.”
C. “ There is a chance I may become addicted to this medication.”
D. “ I need to be aware of situations that may cause dehydration.”
8. During the initial interview with a client being admitted with a history of depression and
current suicidal ideation, the nurse asks if anything is happening in life to cause distressor worry.
The client responds: There’s nothing wrong. My life is perfect.” which of the following defense
mechanisms does the nurse recognize this as an example of?
A. Sublimation
B. displacement
C. Projection
D. denial
9. A veteran of the Iraq war describes that he is having intrusive thoughts including healing
missilles, screams, explosions, and feeling the same feelings of terror first experienced in
combat. The nurse would recognize these symptoms are most likely associated with which
diagnosis?
A. Obsessive compulsive disorder
B. Generalized anxiety disorder
C. Panic disorder with agoraphobia
D. Post traumatic stress disorder
10. A nurse is caring for a client who has major depressive disorder and attempted suicide.the
client tells the nurse, “ I should have died because i am no good to anyone.” Which of the
following could be the best response by the nurse?
A. “ You have a great deal to live for.”
B. “ It’s not unusual for depressed people to feel that way.”
C. “ Why do you feel you are no good to anyone?”
D. “ You’ve been feeling that your life has no meaning.”
11. A client is admitted to the hospital for abdominal pain, diarrhea, sweating,fever, tachycardia,
elevated blood pressure. Upon review the client has been taking sertraline. But the client states
they were recently switched from another medication phenelzine. Which of the following does
the nurse recognize the client is mostly likely experiencing?
A. Neurologic malignant syndrome
B. Withdrawal from phenelzine
C. Serotonin syndrome
D. Overdose of sertraline
12. Which statement by a client experiencing severe anxiety may indicate the possibility of
obsessive compulsive disorder (OCD)?
A. “ I have to keep checking to see where my keys are.”
B. “ I’m afraid to go out alone in public.”
C. “ I keep seeing the accident over and over.”
D. My arms feel weak
13. A client with depression is taking a tricyclic antidepressant. He states, “ I don’t want to keep
taking these pills. Now I get dizzy when I stand up.” Which would be the most appropriate
nursing response?
A. “ Orthostatic hypertension is a side effect of the medication. Before standing, rise slowly
from a lying to sitting position first.”
B. “ Dizziness is a concerning side effect. I will inform the physician of your decision .”
C. “ I will take your blood pressure and make sure there is nothing else going on.”
D. “ I would think feeling dizzy is better than feeling depressed.”
14. A nurse is caring for an elderly client. Which of the following would be a sign of change in
mentation and possible delirium from a urinary tract infection.
A. The client is climbing out of bed repeatedly and stating she must get to the bank.
B. The client is refusing to bathe.
C. The client refuses to get out of bed and wants to sleep all day.
D. The client has an elevated body temperature.
15. A client diagnosed with major depressive disorder is telling the nurse, “ My life doesn’t have
any happiness in it anymore. I used to care about going out with friends, and now I don’t even
care if they don’t invite me.” The nurse recognizes this as an example of which of the following?
A. Anergia
B. Anhedonia
C. Euphoria
D. Affect flattening
16. A nurse is caring for a client prescribed alprazolam for panic disorder. Which statement by
the client shows an understanding of the medication?
A. “ I’ll need to watch my diet and avoid things like cheese.”
B. “ I won’t be able to have eggs anymore.”
C. “ I have to watch my sodium intake.”
D. “ I know not to drink wine or beer.”
17. A client has been prescribed phenelzine for the diagnosis of major depressive disorder. The
client shows an understanding of the dietary needs by selecting which of the following meal
choices?
A. A grilled chicken breast with corn on the cob and sweet tea.
B. A pepperoni pizza with chicken wings and diet soda.
C. An avocado salad with aged cheese and a glass of wine.
D. A slice of chocolate cake with a glass of milk.
18. A nurse receives a laboratory result of a lithium level of 1.8 mEq/L. How would the nurse
interpret this lab value?
A. It is within therapeutic limits.
B. It is below therapeutic limits.
C. It is above therapeutic limits.
D. A redraw will need to be completed as this is an error.
19. While assessing a client the nurse notes that she is complaining of feeling nauseous and
having loose stools. Her hands are shaking and she is talking quickly. Which of the following
does the nurse identify these symptoms can be associated with?
A. Opioid Abuse
B. Depression
C. Paranoia
D. anxiety
20. A nurse is admitting an older client who has a suspected cognitive disorder. Which of the
following tools should be included as part of the admission assessment?
A. Brief Patient Health Questionnaire (Brief PHQ)
B. Mental Status Examination (MSE)
C. Abnormal Involuntary Movement Scale (AIMS)
D. Scale for Assessment of Negative Symptom (SSNS)
21. A nurse is preparing to administer phenytoin oral suspension 300 mg PO. Available is
phenytoin oral suspension 125 mg/5mL. How many mL should the nurse administer? (Round
answer to the nearest whole number. Do not use a trailing zero.)
22. 0.75 g =___________mg?
23. A nurse is caring for a client who is given a prescription for lorazepam. While reviewing the
client’s medical record, which part of the client’s history would raise a concern for this
prescription?
A. A history of a control seizure disorder
B. A history of post-traumatic stress disorder
C. A history of alcohol abuse
D. A history of auditory hallucinations
24. A client diagnosed with major depressive disorder is started on citalopram. The client tells
the nurse, “ I have some old medications from another doctor called selegiline. Can I just take
them together to see if having both works better for me?” The nurse would want to ensure the
client understands which of the following?
A. Regardless, it will still take several weeks before noticing any changes.
B. Mixing those medications together could have serious interactions. Such as a
hypertensive crisis.
C. There will need to be dietary review to prevent complications from tyramine.
D. Monitoring blood pressure closely would be required.
25. A client recently diagnosed with acute stress disorder (ASD) asks the nurse how this
diagnosis is different from post-traumatic stress disorder (PTSD). Which of the following is the
best response?
A. “ Whereas PTSD is caused by a traumatic event; acute stress disorder is not.”
B. “ The major difference between the disorders is the time frame from which the traumatic
event occured.”
C. “ Only a diagnosis of PTSD will experience nightmares.
D. “ Only a diagnosis of acute stress disorder will experience flashbacks.”
26. Following a failed suicide attempt, the client tells the nurse, “ I’m going to try this again, and
next time I’ll choose a no-fail method.” Which is the most appropriate response by the nurse?
A. “ You are safe here, and we will keep you here to make sure nothing happens to you.”
B. “ It ‘s lucky your roommate found you when she did.”
C. “ I don’t understand. You have so much to live for.”
D. “ What are you planning to do?”
27. A nursing student is learning about the differences between bipolar disorders. When asked
to explain the main differences between bipolar I and bipolar II, the student shows
understanding by explaining which of the following?
A. “There are different medications used to treat the disorders.”
B. “ Each disorder has a different duration and type of mania.”
C. “ Bipolar II has anxiety symptoms that must be displayed.”
D. “ Bipolar I does not experience mood swings, just mania.”
28. A client in a manic phase has not been eating during mealtime because they have been
unable to sit still for the designated time period as they are constantly pacing around the dining
room. What would be a possible meal option for the client to help ensure they are meeting their
dietary needs?
A. The client needs to learn to manage their excessive energy and eat with the rest of the
clients.
B. Offer the client a high-calorie protein drink instead of a sit-down meal.
C. Have the client sit separately in their room with minimal distractions.
D. Request a doctor ‘s order for a nasogastric tube placement for feeding.
29. A nurse is caring for a client experiencing panic level anxiety . the nurse understands which
of the following nursing actions should be considered a priority?
A. Guide the client through relaxation techniques.
B. Stay with the client and reduce the stimuli in the room.
C. Ask the family member what the trigger for the anxiety was.
D. Allow the client to remain alone to recollect themselves.
30. During an admission a veteran diagnosed with post-traumatic stress disorder (PTSD)
states, “ Sometimes I just drink until I can’t feel anything anymore.” What should be considered
for this client?
A. The client needs to go through detoxification before treatment.
B. The client needs to be educated about the negative impacts of excessive alcohol use.
C. The client needs to be further evaluated for a possible substance abuse disorder.
D. The client is coping in a positive manner.
31. A 36-year-old teacher with a history of anxiety is admitted to the emergency room. The
nurse understands common symptoms of panic level anxiety will include which of the following?
A. Feeling pain, hunger and confusion
B. Feeling sad, tired, and expressions of minimal emotion
C. Feeling impending doom, chest tightness, and hypertension
D. Feeling overwhelmed and “butterflies” in my stomach.
32. A client is in seclusion after striking a staff member. While speaking with the nurse. The
client states. “ They shouldn’t have provoked me.” Which of the following defense mechanism
does the nurse identify the comment as reflecting?
A. Denial
B. rationalization
C. Humor
D. Sublimation
33. An older client with Alzheimer’s disease lives with family and goes to daycare on weekdays.
The nurse at the center observed poor hygiene and discussed this observation with the
caregiver, the client’s adult child. The caregiver became defensive and said, “ It takes all my
time and energy to take care of my mother. She is awake all night. Last night she fell down the
stairs.” Which nursing intervention takes the highest priority in this case?
A. Inform the caregiver more about the effects of Alzheimer’s disease.
B. Secure additional safety measures for the mother’s evening and night care.
C. Support the caregiver to drive the loss of the mother’s ability to function.
D. Demonstrate to the family how to give physical care more effectively and efficiently.
34. A client recently diagnosed with post- traumatic stress disorder (PTSD), describes moments
where he feels as though he is completely reliving the experience. Even smelling gunpowder.
Which statements by the nurse shows an understanding of the symptoms the client is
experiencing?
A. “ Hypervigilance can occur, where your senses are heightened, and are more
situationally aware with PTSD.”
B. “ It is uncommon to have these experiences: we should let the doctor know.”
C. “ It sounds as though you are experiencing an intense nightmare regarding the
memories.”
D. “ A flashback is when you relieve the experiences and include all of the senses, as it
sounds you experienced.”
35. A nurse is caring for a 55-year-old male client newly diagnosed with post-traumatic stress
disorder (PTSD). The nurse knows as part of the disorder to anticipate which of the following
possible symptoms?
A. Pain without a medical cause
B. Counting and re-checking of objects
C. Nightmares and hallucinations.
D. Trouble maintaining boundaries
36. A client experiencing acute mania approaches the nurse, waving a newspaper, saying , “ I
must make a phone call right this second. I need to call a store while their sale is going on. I
need to order ten dresses and four pairs of shoes. “ Which of the following would be the most
appropriate intervention for the nurse to implement?
A. Explain the phone is available during certain hours, and the client must wait.
B. Suggest to the client a family member can do the shopping for them.
C. Allow the client to use the phone to make the purchases.
D. Redirect the client’s energy by inviting them to sit and look through a magazine with the
nurse.
37. The daughter of a client with dementia has been her primary caregiver. The daughter
expresses to the nurse. “ At times, it is so overwhelming I feel I do not have a life anymore.”
Which response by the nurse would be most appropriate?
A. “ Are you saying you don’t want to care for your mother anymore?”
B. “ I know it is really hard. It takes a lot of work, and you are doing such a good job.”
C. “ Your mother really appreciates what you do for her. You are the best one to care for
her.”
D. “ There is a local caregiver support group. How do you think you would feel talking with
others in the same situation?”
38. While caring for a client admitted with depression the client states. “ Everything is going to
be just fine now.” Which of the following would be the most appropriate nursing response?
A. ‘’ I’ m glad you have a positive outlook on life.”
B. “ You’re right. The medications are starting to work.”
C. “ When you say ‘everything is going to be fine’. Can you tell me what that means?”
D. “ You seem to be feeling better.”
39. On discharge, a client is receiving a new prescription for donepezil. Which statement by the
family would show an understanding of the medication?
A. “ Donepezil is a sedative used for short term treatment of insomnia.”
B. “ Donepezil is a treatment used in all stages of Alzheimer’s disease.”
C. “ Donepezil is an antipsychotic used to treat neurocognitive disorders.”
D. “ Donepezil is an anti-anxiety medication used to treat dementia.”
40. A client weighs 125 lbs. What is the client’s weight in kg? (Record the answer to the nearest
tenth, one decimal place. Do not use a trailing zero.)
41. A nurse is admitting a client experiencing chronic stress. Which of the following findings
should the nurse expect?
A. The client is experiencing low blood pressure
B. The client has been getting sick frequently
C. The client states they have large amounts of energy
D. The client is experiencing a greater awareness of their situation
42. When assessing a client’s plan for suicide, which aspect has the highest priority?
A. The client’s financial and educational status
B. The availability of means and lethality of the selected method
C. The client’s insight into suicidal motivation
D. The quality and availability of the client’s social supports
43. A client is asking about stress reduction techniques which they could use daily. Which
response by the nurse would best represent a technique the client could use?
A. “ It will be important to have your doctor write a prescription for assistance.”
B. “ You can find multiple guided deep breathing exercises on the internet.”
C. “ If it were me , I would try all of them before making a choice.”
D. “ Only physical activity on a daily basis has shown to decrease a person’s stress.”
44. A client with major depressive disorder has been admitted to the in-patient psychiatric unit.
Which displayed behavior would indicate the need for a follow -up of a suicide assessment?
A. The client’s family members cancelled their scheduled visit.
B. The client has chosen not to attend group therapy.
C. The client appears to be happy and peaceful, which is a change from previous days.
D. The client has eaten less than 50% of their food
45. The nurse practitioner orders gentamycin 55 mg IM every 8 hours. On hand is gentamycin
80 mg/2mL. How many mL will the nurse administer each dose? (Round answer to the nearest
tenth. One decimal place. Use a leading zero if it applies. Do not use a trailing zero)
46. While being treated for a deliberate overdose attempt the client says to the nurse. “ My
boyfriend broke up with me. We have been together forever. I just love him so much. I don’t
know how I’m supposed to live without him.” Which is the best response by the nurse?
A. “ It seems as though you are very sad about your loss.”
B. “ Don’t worry there are other fish in the sea.”
C. “ Why do you think he broke up with you?”
D. “ In time, you will be able to move past this pain.”
47. A client has been prescribed buspirone for a new diagnosis of generalized anxiety disorder
(GAD). Which statement by the client indicates an understanding of the medication?
A. “ I will only need to take this when I feel anxious.”
B. “ I should begin to feel better in a few days.”
C. “ I will let my physician know if I become addicted.”
D. “ I will need to take this medication for a while before I see how well it works for me.”
48. The provider orders ondansetron 8 mg by mouth (PO) to be given three times a day. On
hand is ondansetron elixir 4 mg/5mL. How many mL will the nurse administer each dose?
(Round the answer to the nearest whole number. Do not use a trailing zero.)
49. The client, a veteran of the war in Iraq, is diagnosed with post-traumatic stress disorder
(PTSD). His psychiatrist has recently recommended he begin eye-movement desensitization
and reprocessing (EMDR) therapy. Which statement by the client shows an understanding of
the therapy?
A. “ I will be able t o share my experiences with others who have the same disorder.”
B. “ I will use skills such as mindfulness to evaluate emotional situations.”
C. “ By using this therapy, I will be able to experience the memory differently.”
D. “ By using this therapy, I will be able to replace cognitive distortion with a true statement.”
50. A nurse caring for a client with Alzheimer’s disease who has been hospitalized for the
treatment of pneumonia. During the night shift, the client is found climbing into another client’s
bed, who becomes upset and frightened. Which of the following actions would be most
appropriate for the nurse to make?
A. Assist the client to the correct room.
B. Place the client in restraints.
C. Remind the client they are in the hospital.
D. Move the client to a room at the end of the hall.
51. Two days ago a client was admitted to the in-patient psychiatric unit with a diagnosis of
post-traumatic stress disorder (PTSD). He continues to have sleep problems and trouble with
concentration. He has expressed increasing anger toward another client who reminds him of a
former employer. Which of the following would the nurse recognize as the highest priority
nursing concern is?
A. Experiencing nightmares.
B. Having a self-care deficit.
C. The risk for evidence.
D. Demonstrating ineffective coping.
52. A 29-year-old female client has recently been diagnosed with bipolar disorder and has been
prescribed valproic acid. What teaching must be provided to the client regarding the
medication?
A. “ Every month, you will need to be weighed.”
B. “ You will need to monitor your sodium intake while on medication.”
C. “ There is a chance of developing a dependency on the medication.”
D. “ You will need to ensure you are using preventive measures when sexually active.”
53. 1 Ounce = ___________________ mL ?
54. Nurses often work with clients who are experiencing traumatic experiences. Working with
these clients can leave the nurses with compassion fatigue. Which of the following would be
considered symptoms of compassion fatigue? ( Select all that apply.)
A. Depression
B. Insomnia
C. Pessimism
D. Joyfulness
E. Motivation
55. A nurse is caring for an older adult client who has dementia and handles anxiety by
confabulating. The nurse should recognize confabulation when the client does which of the
following?
A. Displays repetitive behaviors.
B. Reminisces about the past.
C. Makes up stories when he is unable to remember actual events.
D. Refuses to leave home to see a provider.
56. A nurse working on an in-patient psychiatric unit observes a client diagnosed with
obsessive-compulsive disorder (OCD) rearranging the magazines in the dayroom. The nurse
understands this action is primarily meant to do with which of the following?
A. Ensure a structured and orderly environment.
B. Show the other clients how to stay organized.
C. Temporarily reduce the anxiety the client is feeling.
D. Show the nursing staff they can handle emotions.
57. While learning about depressive disorders, a client understands the difference between
major depression disorder and persistent depressive disorder when they can state which of the
following?
A. “ Major depression is more serious than persistent depressive disorder.”
B. “ Persistent depressive disorder is a chronic form of depression lasting more than two
years.”
C. Persistent depressive disorder is more common than major depression.”
D. “ Major depression impairs a person’s ability to function, but persistent depressive
disorder does not.”
58. A nurse is caring for a client diagnosed with bipolarI disorder and currently in a manic state.
Which of the following symptoms would the nurse expect to observe? ( Select all that apply.)
A. Inflated self-esteem
B. An increased need for sleep
C. Increase in risky behavior
D. Flight of ideas
E. Limited verbal communication
59. A client is scheduled for a series of diagnostic tests due to a reported history of smoking,
recent weight loss, constant cough, and reports of becoming easily fatigued. The client states, “
There’s absolutely nothing wrong with me; I just have a stubborn chest cold,” which of the
following defense mechanisms does the nurse recognize the client may be using?
A. Displacement
B. Denial
C. Humor
D. projection
60. A client with bipolar disorder has just been started on valproic acid. As part of the client’s
monitoring the nurse is aware of which of the following?
A. Baseline blood glucose testing will be required.
B. The client will need to report any seizure activity.
C. Potassium intake will need to be carefully monitored.
D. Baseline laboratory work for liver function tests will be needed.
61. While discussing with a client newly diagnosed with obsessive-compulsive disorder (OCD)
the client asks, “ what are considered to be common compulsions?” Which of the following
would be the best response by the nurse?
A. “ Often the compulsions are centered around illness and death.”
B. “ We really haven’t seen any compulsions to be common.”
C. “ common compulsions can include hand -washing and checking a door multiple times to
make sure it is locked.”
D. “ Each person will have their own unique compulsion.”
62.. A family member of a client recently diagnosed with obsessive -compulsive disorder (OCD)
asked the nurse to explain the difference between an obsession and a compulsion. The best
response would be which of the following?
A. “ Compulsions and obsessions include an action and thought, but they are motivated by
different desires.”
B. “ We are still learning to understand how the brain processes obsessions and
compulsions.”
C. “ Obsessions are repetitive thoughts uncontrolled by the client, and compulsions are the
behaviors alone that are typically associated with obsessive thought.”
D. Obsessions and compulsions are really the same things, both of which the client has no
control over.”
63. A client diagnosed with bipolar disorder has recently been started on lamotrigine as part of
their medication regimen. Which of the following would be an essential teaching point to include
regarding the medication?
A. “ You will need to monitor your sodium intake closely while on this medication.”
B. “ If you experience a rash , you should notify your physician.”
C. “ You will need to monitor your weight while taking this medication.”
D. “ It is important for you not to become pregnant while taking this medication.”
64. 1 Tablespoon =
mL?
65. The use of restraint or seclusion is a last resort when other least restrictive measures have
failed. What are some reasons that would justify the use of restraints or seclusion ? (Select all
that apply.)
A. The client is an immediate threat to themselves or others.
B. The client requests seclusion.
C. There is a shortage of nurses on the unit.
D. The client refuses to participate in group therapy
E. The client has been involuntarily admitted for treatment.
66. A nurse working in an outpatient has been completing the initial intake interview. Which of
the following clients has an increased risk of suicide? (Select all that apply)
A. A client who has been selected for a promotion.
B. A client with a family history of suicide.
C. A client diagnosed with cancer who is in remission.
D. A client who has abused a child.
E. A client who is having legal problems.
67. The nurse is preparing to discharge an 86-year-old client diagnosed with Alzheimer’s
disease. The nurse is reinforcing discharge education with the client’s family, who will be caring
for her. Which intervention would be beneficial for this client’s family?
A. Discourage wandering by installing complex locks or locks placed at the top of doors
where the client cannot readily reach them.
B. For situations In which the client becomes upset, Instruct her family to seclude her in her
room for an hour, being sure to turn off the television or other stimulating sounds.
C. Recognize that the client can no longer successfully interact with others; provide a
darkened quiet room for her to spend her time.
D. Hire an off-duty police officer to watch the home in case she tries to wander away.
68. A client diagnosed with a neurocognitive disorder is disoriented, unsteady and wanders.
Which is the priority nursing concern?
A. The risk of having a disturbed thought process
B. The risk of experiencing a self-care deficit
C. The risk of injury
D. The risk of demonstrating an altered healthcare maintenance
69. A client with vascular dementia is experiencing agnosia. She sits at her dining table looking
at her food but does not pick utensils and try to eat. Which intervention is most appropriate for
the nurse to try first?
A. Send the food back to the kitchen and try something else.
B. Help the client by feeding her.
C. Hand the fork to the client and say, “ Use this fork to eat your meatloaf.”
D. Tell the client, “ It’s time to start eating. Those potatoes look good.”
70. A client with suicidal impullses has been admitted to the in-patient psychiatric unit with
suicide precautions ordered. Which measures should be incorporated into the plan of care for
the safety of the client.(Select all that apply)
A. Ensure there is no metal or glass on meal trays.
B. Assign the client a private room with door closed .
C. Remove all potentially harmful objects from the client’s possession.
D. Monitor the client only when they are awake or engaged in activities.
E. Encourage client to speak to nurse if increased suicidal thoughts occur.
71. A 70-year-old client is admitted to the locked psychiatric unit diagnosed with delirium. Later
in the day, he tries to get out of the locked unit several times. He yells.” I have to leave and get
to my barber. I see him every Wednesday. Let me out.” which of the following would be the most
therapeutic response by the nurse?
A. You need to come and take a shower before you get the haircut.”
B. “ Please stop banging on the door. Your room is right over there.”
C. The door is locked so that you don’t leave and get hurt.”
D. “ It’s Monday and you’re in the hospital, I’m your nurse.”
72. Which statement by the client would warrant further investigation regarding the risk for
suicide?
A. “ I ‘m glad these medications have improved my mood.”
B. “ Everything is going to be okay now.”
C. “ My family has been a major support.”
D. “ I reviewed my living will this year.”
73. While assessing a 78-year-old client diagnosed with dementia, the nurse observes the client
has slow responses and difficulty finding the right words. What is the nurse ‘s best initial action?
A. Suggest words the client may be trying to remember.
B. Ask the client, “ Are you having problems saying what you mean?”
C. Use silence to allow the client an opportunity to compose responses.
D. Discontinue the assessment to prevent further frustration to the client.
74. A client with a history of post-traumatic stress disorder (PTSD) is pacing and yelling at the
staff in their room. As the nurse approaching to communicate with the client, which of the
following would be the best approach?
A. Remain calm, use a neutral tone when speaking and maintain a safe distance.
B. Use an authoritative approach with a stern voice for providing directions.
C. Allow the client to continue to express themselves without interfering.
D. Remain calm, using a gentle voice and therapeutic touch to guide the client.
75. A nurse is caring for a client who has dementia. When performing a Mini-Mental Status
Examination(MMSE), the nurse should include which of the following data? ( Select all that
apply.)
A. The ability to show attention
B. Current coping skills
C. Immediate recall ability
D. Level of orientation
E. Nutritional status