We Better Not Miss These
A parent comes to the health clinic with their child. The parent states, “My child doesn't want to be held. They start rocking and banging their head when strangers come in the room.” Based on the parent's statements, the nurse suspects which neurodevelopmental disorder?
Intellectual developmental disability
Psychosis
Autism Spectrum Disorder
Dyslexia
ASD
A client prescribed disulfiram experiences facial flushing, a throbbing headache, nausea, and vomiting and states to the nurse that “I only drank one beer.” Which is the best response by the nurse?
A. “This is a mild side effect of the medication, and one beer shouldn’t cause the reaction.”
B. “The reaction that you experienced is an expected response with the ingestion of alcohol.”
C. “This is an idiosyncratic reaction to the medication and is an expected response to treatment.”
D. “You must have a severe allergy to disulfiram that you were not aware of and will need to stop the medication.”
“The reaction that you experienced is an expected response with the ingestion of alcohol.”
A client who has been taking clozapine for 6 weeks visits the clinic reporting fever, sore throat, and mouth sores. The nurse notifies the client’s physician because the nurse suspects what possible side effect of the medication?
Severe anemia
Neuroleptic malignant syndrome
Encephalitis
Agranulocytosis
Agranulocytosis
A client has been diagnosed with memory dysfunction associated with Alzheimer’s disease. The nurse determines that damage to the client’s brain includes deterioration of temporal lobe structures and the nerves of which area?
Basal ganglia
Limbic system
Parietal lobe
Hippocampus
Hippocampus
The nurse is sitting with a client who is crying. After a few minutes, the nurse places one hand on the client's shoulder. Which situation does the nurse use touch with for this client?
A.
To express sympathy to the client
B.
To assess the client's skin temperature and circulation status
C.
To offer comfort and support for the client
D.
To extend an offer of friendship to the client
To offer comfort and support for the client
The nurse asks a client about their mood, and the client responds using neologisms. What should the nurse document?
The client demonstrates word salad during the assessment
The client invents new words or phrases with no clear meaning
The client uses repetitive or echolalic speech patterns
The client’s speech is goal-directed and coherent
The client invents new words or phrases with no clear meaning
The nurse observes the client experiencing a panic attack in the day room in the behavioral health unit. Which is the priority action by the nurse?
A.
Stay with the client and maintain a safe environment.
B.
Take the client for a walk around the unit.
C.
Redirect the client to an activity or task.
D.
Educate the client in ways to prevent a future panic attack.
Stay with the client and maintain a safe environment.
A nurse is working with a client who is anticipating the possibility of leaving an abusive relationship. In helping the client make the decision to leave or to stay in the abusive situation, which is appropriate for the nurse to do?
Ensure that the client can effectively describe the behaviors inherent in each phase of the cycle of domestic violence.
Inform the client that if they leave the abusive situation, there is a possibility that their partner will attempt to murder them.
Assist the client in finding a new apartment and a new job so they will be safe after they leave their current situation.
Suggest that the client legally change their name and move out of state so that they will be safe from future harm.
Inform the client that if they leave the abusive situation, there is a possibility that their partner will attempt to murder them.
Answer
A novice nurse accepts a staff position at an inpatient mental health facility. Which basic-level responsibility will the nurse expect to have?
A.
Providing clinical supervision
B.
Using effective communication skills
C.
Adjusting client medications
D.
Directing program development
Using effective communication skills
An older adult reports anxiety and is prescribed diazepam by a primary care provider. The office nurse is asked to explain to the client the problematic side effects of this medication. Which instruction about this drug would be most important for the nurse to emphasize?
“You may experience minor urine incontinence from time to time.”
“You may find that you have temporary memory disturbances.”
“You need to use this medication cautiously because it can cause dependence.”
“You may feel dizzy and be prone to falls after taking this medication.”
“You may feel dizzy and be prone to falls after taking this medication.”
The nurse is sitting down with a client to begin a conversation. Which position will the nurse take to convey acceptance of the client?
A.
Leaning forward with arms on the table sitting directly across from the client
B.
Turned slightly to the side of the client with arms folded across the chest
C.
Leaning back in the chair next to the client with legs crossed at the knees
D.
Sitting upright facing the client with both feet on the floor
Sitting upright facing the client with both feet on the floor
The nurse is evaluating a client’s judgment and insight. Which question would best assess insight?
"Do you know why you were admitted to the hospital?"
"Can you add 5+3 and subtract 2?"
"Who is the current president?"
"Can you copy this geometric shape?"
"Do you know why you were admitted to the hospital?"
The nurse is using the DSM-5-TR for a newly admitted client diagnosed with bipolar I disorder. Which information will the nurse obtain to assist with the use of this resource?
A.
Devise a plan of care for a newly admitted client
B.
Predict the client’s prognosis of treatment outcomes
C.
Document the appropriate diagnostic code in the client’s medical record
D.
Use as a guide for client assessment
Use as a guide for client assessment
The nurse working in the ED of an urban hospital notifies the manager that there are several clients with mental health disorders still present in the ED that have been there over 48 hours. Which issue related to this phenomenon does the nurse discuss with the manager?
A.
Temporary detaining orders for clients
B.
Decision to practice boarding
C.
The revolving door for clients
D.
The cost of holding clients in the ED for over 48 hours
Decision to practice boarding
The nurse is reviewing a plan of care for a child diagnosed with conduct disorder. When reviewing the care plan, the nurse should expect to see a focus on which problem?
Disturbance in personal identity
Sleep pattern disturbance
Risk for violence directed at others
Impaired verbal communication
Risk for violence directed at others
A nurse is caring for a patient who has developed dystonia after starting an antipsychotic medication. What is the nurse's priority intervention?
Administer the prescribed lorazepam PRN.
Administer diphenhydramine IM
Encourage the patient to perform range-of-motion exercises.
Notify the healthcare provider to discontinue the antipsychotic medication.
Administer diphenhydramine IM
The nurse has completed health teaching about dietary restrictions for a client taking a monoamine oxidase inhibitor. Which statement made by the client indicates that teaching is effective?
A.
“I’m glad I can eat pizza since it’s my favorite food.”
B.
“I must follow this diet or I will have severe vomiting.”
C.
“It will be difficult for me to avoid pepperoni.”
D.
“None of the foods that are restricted are part of a regular daily diet.”
“It will be difficult for me to avoid pepperoni.”
The nurse is working with a client who has a history of inflicting spousal abuse. Although the nurse does not condone domestic violence, the nurse treats the client with unconditional positive regard through which behavior?
A.
Understanding the feelings that might have led to violent behavior.
B.
Using honest emotional expression in relating to the client.
C.
Viewing the client as someone worthy of respect and assistance.
D.
Relating to the client as a spouse.
Viewing the client as someone worthy of respect and assistance.
Which of the following requires a face-to-face evaluation by a provider within one hour?
Use of chemical restraints
Initiation of seclusion or physical restraints
A client being placed on suicide precautions
Administration of an emergency sedative
Initiation of seclusion or physical restraints
A client exhibits psychomotor retardation during an interview. Which behavior is the nurse most likely to observe?
Repetitive hand wringing or tapping
Slowed physical movements and speech
Rapid, erratic gestures
Involuntary twitching or blinking
Slowed physical movements and speech
A client with PTSD suddenly appears panicked, stating that they "feel like they are back in the war zone." What is the nurse's priority intervention?
Tell the client to calm down and reassure them they are safe
Use grounding techniques to help the client reorient to the present
Encourage the client to discuss the details of the traumatic event
Offer a PRN sedative immediately
Use grounding techniques to help the client reorient to the present
Which statement made by a client being treated for a somatic disorder, supports the nurse's evaluation that the client has developed the skills necessary to achieve full recovery?
“I really want to get better and I will do whatever it takes to have that happen.”
“I've learned how to cope with the stress that triggered my past physical problems.”
“I won't ask for any diagnostic testing unless I'm really sure the pain isn't in my head.”
“I've learned that my illness causes me to exaggerate the pain I'm experiencing.”
“I've learned how to cope with the stress that triggered my past physical problems.”
A nursing supervisor reprimands an employee for being chronically late for work. If the employee handles the reprimand using the defense mechanism of displacement, which behavior by the employee will be observed?
A.
Arguing with the supervisor that the employee is usually on time
B.
Making a special effort to be on time tomorrow
C.
Telling fellow employees that the supervisor is picking on the employee
D.
Telling the unit housekeeper that the unit housekeeper’s work is sloppy
Telling the unit housekeeper that the unit housekeeper’s work is sloppy
The nurse has developed a therapeutic relationship with a client in the outpatient behavioral health clinic. Which situation is considered a breach of professional boundaries?
A.
Client asking a nurse for the nurse’s phone number
B.
The nurse refuses a gift from a client.
C.
The nurse changes the subject in response to a client’s compliment.
D.
The nurse has a lengthy social conversation with a client on the phone.
The nurse has a lengthy social conversation with a client on the phone.
The nurse is performing a medication reconciliation for a client at a high risk for suicide. Which antidepressant drug identified by the nurse will be best in the treatment of this client and reduces the risk of lethal overdose?
A.
Tranylcypromine
B.
Tylenol
C.
Imipramine
D.
Sertraline
Sertraline
A nurse asks a client to interpret the proverb, "A rolling stone gathers no moss." What is the nurse assessing?
Short-term memory
Judgment
Abstract thinking
Orientation
Abstract thinking
A charge nurse during inservice has provided information on personality disorders to newly hired nurses. After reviewing information, the charge nurse believes education has been effective when one of the newly hired nurses states which characteristic as associated with schizoid personality disorder?
A.
“They are introverted and distant.”
B.
“They are friendly and willing to help.”
C.
"Being social and making friends"
D.
“Exuberance and grandiosity is expressed.”
“They are introverted and distant.”
A child diagnosed with autism spectrum disorder is hospitalized in an inpatient mental health unit. When developing the plan of care for this child, which will a nurse likely include?
A.
Ensuring that a variety of caregivers are available for the child
B.
Providing a consistent, structured environment with predictable routines
C.
Allowing the child frequent visits off the unit to provide stimulation
D.
Sending the child to the “time out” area if the child repeats phrases continually
Providing a consistent, structured environment with predictable routines
A client is prescribed a monoamine oxidase inhibitor (MAOI) for treatment of severe depression. Which statement made by the client indicates that there is understanding of education provided by the nurse related to dietary restrictions?
A.
“I am now allergic to foods that are high in the amino acid tyramine.”
B.
“I will avoid foods that are high in the amino acid tyramine since they can cause severe side effects”
C.
“Certain foods will cause me to have sexual dysfunction when I take this medication.”
D.
“Foods that are high in tyramine will reduce the medication’s effectiveness.”
“I will avoid foods that are high in the amino acid tyramine since they can cause severe side effects”
A client diagnosed with depression asks a nurse about possible herbal supplements. Which supplement would the nurse identify as being commonly used?
Valerian
St. John’s wort
Kava
Melatonin
St. John’s wort
The nurse is assessing a client weaning from a selective serotonin reuptake inhibitor (SSRI) to a monoamine oxidase inhibitor (MAOI) with a heart rate of 104, profuse diaphoresis, temperature 102°F (38.9°C), BP 98/58 mm Hg, and hyperreflexia. Which condition will the nurse educate the client regarding after stabilization of the current acute phase?
A.
Tardive dyskinesia
B.
Allergic reaction to the MAOI
C.
Malignant hyperthermia
D.
Serotonin syndrome
Serotonin syndrome
A 35-year-old patient was placed in seclusion due to aggressive behavior toward staff and peers. According to mental health standards, what is the maximum time the patient can remain in seclusion before requiring reassessment?
2 hours
4 hours
6 hours
8 hours
4 hours
The nurse is assessing a client’s self-concept. Which question would be most appropriate?
"Can you tell me about your body image?"
"Do you have a history of hallucinations?"
"How do you generally handle stress and anxiety?"
"Do you know where you are and what day it is?"
"Can you tell me about your body image?"
During an assessment, the nurse observes that a client is sitting in a fixed posture, maintaining a position even when asked to move. This behavior is best described as:
Psychomotor retardation
Automatisms
Waxy flexibility
Akathisia
Waxy flexibility
A client is admitted with a diagnosis of major depression and states “nothing brings me pleasure anymore.” Which behaviors will the nurse assess that correlates with the diagnosis?
A.
Depressed mood, guilt, and pressured speech
B.
Anhedonia, feelings of worthlessness, and difficulty focusing
C.
Changes in sleep pattern, fatigue, and grandiose mood
D.
Difficulty focusing, feelings of helplessness, and flight of ideas
Anhedonia, feelings of worthlessness, and difficulty focusing
A client is educated about taking disulfiram at home to help with abstaining from alcohol. Which statement made by the client indicates the education provided is effective?
A.
“I need to read product labels carefully to avoid all products containing alcohol.”
B.
“I’ll take the medication with food to avoid stomach upset.”
C.
“I will skip the dose of disulfiram on days when I am likely to drink alcohol.”
D.
“By taking this medication, it will prevent the cravings for alcohol.”
“I need to read product labels carefully to avoid all products containing alcohol.”
A hospitalized client who has been taking an antipsychotic medication for 2 weeks begins pacing and walking throughout the unit. The client tells the nurse, “I cannot sit still.” The nurse documents this finding using what term?
Akinesia
Dystonia
Pseudoparkinsonism
Akathisia
Akathisia
A client who has a major depressive episode tells a nurse that, for the past 2 weeks, the client has been hearing voices and at times thinks that they are being followed. History reveals that the client had these alternating symptoms before. The client also has experienced time with neither of these symptoms and has been able to function adequately. The nurse interprets these findings as suggesting which condition?
A.
Paranoid schizophrenia
B.
Schizoaffective disorder
C.
Undifferentiated schizophrenia
D.
Brief psychotic disorder
Schizoaffective disorder
A client with antisocial personality disorder is requesting to use the phone to call the client's spouse, even though it is against the unit rules. The client states, "It is just this once, and my spouse will be so hurt if I don't call." Which is the most appropriate response by the nurse?
A.
"You may not use the phone to call your spouse."
B.
"Only to help your spouse, you can call this time."
C.
"I will get in trouble with my supervisor if I let you call."
D.
"You cannot call because you need to focus on your recovery.”
"You may not use the phone to call your spouse."
A group of nursing students is reviewing information about delirium and dementia. The students demonstrate a need for additional review when they identify which as characteristics of dementia?
A.
Possible hallucinations
B.
Fluctuating changes within a 24-hour period
C.
Normal psychomotor activity
D.
Globally impaired cognition
Fluctuating changes within a 24-hour period
A client presents with tangential thinking during a mental health assessment. Which behavior would the nurse expect?
The client continuously changes topics and never returns to the original point
The client repeats words and phrases without logical connection
The client’s speech includes made-up words
The client’s thinking is goal-directed and logical
The client continuously changes topics and never returns to the original point
A nurse is describing histrionic personality disorder to a group of new nurses. Which term would the nurse most likely use?
A.
Attention-seeking
B.
Psychopath
C.
Sociopath
D.
Lacking empathy
Attention-seeking
A patient on antipsychotic therapy is exhibiting pseudoparkinsonism, including tremors, bradykinesia, and a shuffling gait. What medication should the nurse anticipate administering?
Haloperidol (Haldol)
Propranolol (Inderal)
Benztropine (Cogentin)
Lithium (Eskalith)
Benztropine (Cogentin)
A nurse is preparing to assess a middle-aged client who was brought to the emergency department by the spouse. The spouse reports that the client has been “extremely depressed lately.” When assessing this client, which assessment would be the priority?
A.
Changes in sleeping patterns
B.
Thoughts of self-harm
C.
Appetite changes
D.
Level of fatigue
Thoughts of self-harm
A preadolescent client has been considered a neighborhood bully for several years. Peers avoid them, and the parent says, “I cannot believe a thing my child tells me.” Recently, the client was observed shooting at several dogs with a pellet gun and setting fire to a vacant lot for the first time. A nurse would assess these behaviors as being most consistent with which disorder?
A.
Conduct disorder
B.
Oppositional defiant disorder
C.
Pyromania
D.
Defiance of authority
Conduct disorder
A patient is sharing their fears about surgery, and the nurse responds, "Many other patients go through this without any issues, so you shouldn’t be worried." This response is an example of:
Belittling feelings
Offering self
Focusing
Clarifying
Belittling feelings
The nurse is evaluating several clients with a diagnosis of schizophrenia. Which client will be assessed as having the worst potential outcomes?
A client who has a first cousin with bipolar I disorder
B.
An adolescent client with alogia, anhedonia, and a flat or blunted affect
C.
A client with an exacerbation of hallucinations and delusion 2 years after diagnosis
D.
An older adult client with an onset of positive symptoms at age 35
An adolescent client with alogia, anhedonia, and a flat or blunted affect
A nurse is assessing a client’s concentration. Which of the following is the most appropriate method?
Asking the client to spell "world" backward
Asking the client to name the current president
Asking the client to interpret a proverb
Asking the client about their childhood memories
Asking the client to spell "world" backward
A client is brought to the emergency department after witnessing a traumatic car accident four days ago. They report flashbacks, nightmares, and hypervigilance. Which diagnosis is most appropriate?
Posttraumatic stress disorder (PTSD)
Acute stress disorder (ASD)
Adjustment disorder
Generalized anxiety disorder
Acute stress disorder (ASD)