A nurse has completed orientation to a locked psychiatric unit. Which statement best
demonstrates that the nurse is prepared to fulfill the professional role?
1. “I took a course in self-defense so I can take care of myself.”
2. “I will ask for support from colleagues when I need it.”
3. “I know there is a fine line between the clients and the staff.”
4. “I can maintain proper distance by engaging in therapeutic interventions.”
Answer:
A client who has been divorced for six months has recently been lying in bed most
days, unable to care for the children. This is referred to as:
1. A situational crisis.
2. A stressful situation.
3. Lack of resilience.
4. Regression.
Answer:
A nurse is caring for a client with a terminal illness. The client asks if the nurse will
pray with the client for the remission of the cancer. The nurse does not practice the
same religion and does not believe that a remission is possible at this stage of the
disease. The nurse should:
1. Gently confront the client about unrealistic expectations that the cancer is going to
regress.
2. Encourage the client to go ahead, but leave the room while the client prays.
3. Call the chaplain and set up a referral for the client’s spiritual distress.
4. Stand silently for a few moments while the client prays.
Answer:
Which of the following reflects the concepts of crisis intervention?
Standard Text: Select all that apply.
1. Includes interdisciplinary treatment
2. Restoring the individual to a sense of equilibrium
3. Used when client is unable to overcome the effects of a crisis
4. Utilized when client becomes suicidal
5. Short-term, action-oriented assistance, focused on problem-solving
Answer:
A community health nurse meets with a 15-year-old single mother to teach a
tube-feeding technique to her infant. The teen’s mother is present. The nurse notes that
the young mother is hesitant to try the feeding technique and does not ask questions.
During the feeding, the teen mother almost drops the feeding tube and is scolded by her
mother for being clumsy. Based on this initial information, which nursing diagnosis is
most appropriate?
1. Anxiety related to lack of knowledge and inexperience
2. Ineffective Family Coping related to conflicted daughter”parent relationship and
dysfunctional communication
3. Social Interaction Impaired related to paternal interference
4. Self-Esteem (Low) Situational, related to lack of experience, criticism, and role
uncertainty
Answer:
The client with binge-eating disorder reports a lack of involvement in activities, loss of
interest in self-care activities, and oversleeping. The client’s speech is filled with
despondency. What nursing diagnosis is most appropriate for this client?
1. Hopelessness
2. Anxiety
3. Social Isolation
4. Knowledge Deficit
Answer:
The charge nurse is reviewing the care plans for the clients on the unit. In several care
plans, the nurse has noted that the words noncompliant and manipulative have been
used to describe those clients with severe mental illness. The nurse plans on discussing
this with the staff at the next unit meeting. Which of the following responses will
demonstrate the charge nurse’s personal accountability to the staff?
1. “If you use these terms regularly, you will need to reassess your reasons for working
in psychiatric settings.”
2. “Does the use of these terms reflect an underlying level of stress on the unit that I
should be aware of?”
3. “While these terms might be accurate, they are not appropriate to use in a care plan.”
4. “How might these terms reflect negativity and stigma towards persons with mental
illness?”
Answer:
Which of the following is a risk factor for the development of delirium in older adults?
1. A lack of rigorous exercise that leads to decreased cerebral blood flow
2. Decreased social interaction that leads to profound isolation and psychosis
3. Administration of multiple medications that may cause drug”drug interactions or
toxicity
4. Age-related cognitive changes that make older adult clients more susceptible to
changes in mental status
Answer:
The nurse is planning care for a new patient admitted to the behavioral health unit.
Which of the following activities can the nurse expect to occur in the orientation phase
of a therapeutic nurse”client relationship?
1. Explore in-depth how the client relates to others.
2. Emphasize growth and positive aspects of the relationship.
3. Discuss with the client how to work together toward a common goal.
4. Identify dysfunctional client thoughts and emotional patterns.
Answer:
The nurse and a client are discussing the diagnosis of depression. The client asks,
“Where in my brain does the depression come from?” The nurse is aware that:
1. The occipital lobe governs perceptions of events, judging them as positive or
negative.
2. The parietal lobe has been linked to depression.
3. The limbic system is thought to be the emotional center of the brain.
4. The medulla regulates key biological and psychological activities.
Answer:
A client with a history of physical and sexual abuse by her husband is admitted to the
hospital for treatment of vaginal lacerations. While hospitalized, the client expresses
concerns to the nurse about her safety when she returns home. The first priority for the
nurse is to:
1. Offer to contact outpatient services if the client promises that she will not return
home after her discharge.
2. Encourage the client to take charge of her situation.
3. Make it clear to the client that her husband needs to see a therapist.
4. Assist the client to devise a safety or escape plan.
Answer:
The staff observes that a young male manifests oppositional behavior when he interacts
with male staff. He has recently been placed in the custody of his father, since his
mother has been deployed in the military. The client told the nurse that his mother relied
on him a lot when he lived with her. He tells the nurse that his father is always on his
case, never speaks to him without yelling, and tells him he can”t do anything right.
Identify the appropriate intervention for the client when he feels oppositional toward
the staff.
1. Provide opportunities for the client to get to know the staff.
2. Encourage the client to “take five to revive.”
3. Have the client chose the consequences for his behavior.
4. Ask the client if he is upset.
Answer:
The mental health nurse is training primary care providers about treatment options for
anxiety disorders, including pharmacologic options. The nurse knows that SSRIs are the
choice class of medications for treating anxiety disorders because they:
1. Have fewer side effects than other anti-anxiety medications.
2. Have a short half-life.
3. Are metabolized in the liver.
4. Are adrenergic blocking agents.
Answer:
A 13-year-old client was admitted for giving a younger sister a black eye and throwing
the cat out the window. Which areas of the brain could have abnormalities associated
with this behavior?
Standard Text: Select all that apply.
1. Amygdala
2. Occipital lobe
3. Frontal lobe
4. Hypothalamus
5. Hippocampus
Answer:
The therapist for an interactive therapy group has noticed some behaviors among the
members that need to be made overt. The therapist would be concerned about:
1. Expressing affection and sorrow.
2. Suggesting alternatives and denigrating each other.
3. Power struggles and attention-seeking.
4. Seeking social support and increasing conflict.
Answer:
Which of the following services are typically performed by psychiatric nurses
employed in managed care organizations?
Standard Text: Select all that apply.
1. Performing mental health assessments
2. Scheduling appointments for therapy
3. Providing stress management classes
4. Contacting medication prescribers to arrange for changes
5. Triaging initial requests for services
Answer:
The nurse educator is reviewing a student’s care plan. Which of the following nursing
diagnoses would not be appropriate to include when a patient experiences regressive
behavior during the termination phase of the nurse”client relationship?
1. Ineffective Coping
2. Self-care Deficit
3. Powerlessness
4. Knowledge Deficit
Answer:
The visiting nurse cares for an older client with rheumatoid arthritis. During a nurse’s
visit to supervise the home health aide, the client reports a flare-up in symptoms and the
pain medication is not helping. To plan continuing care for the client, it would be
important to focus on:
1. Emotional issues and depression.
2. Environmental conditions, temperature, and humidity.
3. Medication tolerance and addiction.
4. Dietary changes.
Answer: