Mental illness practice test A – Flashcards
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A nurse is interviewing an older adult client in an outpatient mental health clinic. Which of the following stratagies should the nurse use?
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Conduct the interview in a private area.
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A nurse is caring for a client receiving tranylcypromine. Which of the following is an appropriate menu choice for the nurse to suggest?
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Roasted Chicken
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A nurse is caring for a client receiving imipramine for depression. For which of the following adverse effects should the nurse monitor?
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Urinary retention
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A nurse is assessing a client in the emergency department. The client appears agitated, his blood pressure is 152/94 mm Hg, his heart rate is 104/min, and his pupils are dilated. The nurse should suspect intoxication with which of the following substances?
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Cocaine
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A nurse is providing teaching to a client who has a new prescription for haloperidol. Which of the following side effects should the nurse instruct the client to report to the provider?
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Shuffling gait
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A nurse is caring for a client who has alcoholic cardiomyopathy. Which of the following laboratory values should the nurse expect
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Increased creatine phosphokinase (CPK)
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During morning rounds, a nurse finds a client who has schizophrenia trembling and tearful in her bed. The client reports that a bomb was placed in her room by a family member during visiting hours. Which of the following is an appropriate action by the nurse?
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Assess the client for evidence of a perceptual disturbance.
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A nurse is facilitating a bereavement support group and observes that one member remains silent, even after attending several sessions. Which of the following strategies should the nurse use to encourage the member's participation?
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Divide the group into pairs to discuss a topic, then summarize the discussion to the group.
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A nurse is caring for a child who has conduct disorder and is behaving in a destructive manner, throwing objects, and kicking others. Which of the following therapeutic nursing interventions is the highest priority?
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Use a therapeutic holding technique.
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A nurse is developing a plan of care for a client who exhibits anger, aggression, and violent behavior on the unit. The priority nursing intervention is to
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create a large, personal space.
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A nurse is obtaining a history and physical on a client who presents to the emergency department of a mental health facility. The nurse recognizes which of the following assessment findings as being consistent with posttraumatic stress disorder (PTSD)? (Select all that apply.)
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Distressing dreams difficulty concentrating exaggerated startle response
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A nurse is reviewing the potential adverse effects of lithium with a client who began the medication 2 weeks ago. For which of the following should the nurse instruct the client to monitor and report to the provider?
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Coarse hand tremor
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A nurse is caring for a client who has schizophrenia and is prescribed risperidone. Which of the following laboratory tests should the nurse monitor?
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blood glucose
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A nurse is caring for a client who has borderline personality disorder. Which of the following is the priority goal when planning care for this client?
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The client will refrain from self-mutilation.
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A nurse is educating the parent of a child who has a new diagnosis of autism spectrum disorder. Which of the following characteristics of this disorder should the nurse include in the teaching?
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Language delay
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A nurse is providing care for a client who has bipolar disorder and is experiencing acute mania. The client's morning lithium level is 1.5 mEq/L. Which of the following additional laboratory data has the highest priority? (Click on the "Exhibit" button below for additional client information. There are three tabs that contain separate categories of data.)
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Serum sodium 125 mEq/L
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A nurse is caring for a client who has schizophrenia and is threatening to harm others on the unit. The provider prescribes haloperidol and seclusion. Which of the following should be included in the plan of care?
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Obtain baseline serum sodium level.
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A nurse is admitting a client to an inpatient unit who is in the acute stages of schizophrenia. The nurse observes the following findings: restlessness, pacing with clenched fists, eyes darting to one side, and muttering. Which of the following interventions should the nurse initiate?
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Stay with the client in a quiet setting.
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A nurse is caring for a client who is taking chlorpromazine for schizophrenia. Which of the following assessment findings indicates that the client is experiencing extrapyramidal adverse effects?
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Lip smacking and tongue rolling
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A client is experiencing a situational crisis. Which of the following findings should the nurse expect?
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The client recently lost a grandparent in a motor vehicle crash.
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A nurse is conducting a counseling session with a client who has depression. Which of the following statements by the client indicates the client is demonstrating transference?
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"I feel like you talk to me like my sister does.
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A nurse is admitting an adolescent client who has anorexia nervosa. Which of the following clinical findings should the nurse expect?
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Amenorrhea
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A nurse is planning a teaching session regarding the code of ethics for registered nurses. Which of the following should the nurse include in the teaching?
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The right to treatment ensures individualized care.
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A home health nurse is assessing an older adult client who lives alone. Which of the following findings should indicate to the nurse that the client is experiencing delirium?
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Sudden onset
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A nurse is caring for four clients in an inpatient mental health facility. Which of the following clients can give informed consent?
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A 35-year-old who has major depressive disorder.
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A nurse is assessing a client in the emergency department who is brought in by a caregiver. The caregiver states the client fell recently. The nurse observes bruises on the client's abdomen, back, and legs and suspects abuse. Which of the following actions should the nurse take first?
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Check the client for other signs and symptoms of abuse.
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A nurse in a provider's office is talking with a client who has diabetes mellitus and an HbA1c of 8.5%. The client states that she is under a lot of stress and that she doesn't want to talk about her diabetes mellitus right now. Based on these comments, the nurse should note that the client is demonstrating which of the following defense mechanisms?
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Suppression
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A nurse in a mental health facility observes a client who is experiencing panic level of anxiety. Which of the following actions should the nurse take first?
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Accompany the client to a quiet room.
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The nurse is caring for a client who has anorexia nervosa. Which of the following criteria requires hospitalization?
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Temperature of 35.6° C (96.1° F)
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A nurse is caring for a client who has a history of substance use and was involuntarily admitted to a mental health facility. When the nurse attempts to administer oral lorazepam, the client refuses to take the medication and becomes physically aggressive. Which of the following actions should the nurse take?
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Do not administer the lorazepam.
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A nurse is preparing to participate in an interdisciplinary conference for a client who has bipolar disorder. Which of the following behaviors is the highest priority for the nurse to report to the treatment team?
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Giving away possessions
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A nurse is performing an assessment on a 78-year-old client who has injuries consistent with suspected abuse. Which of the following statements indicates the greatest potential risk factor for abuse?
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"My son enjoys a couple of drinks each night to unwind."
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A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the following medications should the nurse administer?
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Chlordiazepoxide
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A nurse is preparing to discharge an older adult client, who attempted suicide, to his home where he lives alone. The client also has difficulty performing ADLs. Which of the following referrals should the nurse initiate? (Select all that apply.)
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Occupational therapy Meal delivery services Physical therapy Home health services
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A nurse is caring for a client in a mental health facility who has recently started a new prescription for valproic acid. For which of the following should the nurse monitor to determine effectiveness of the medication?
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The client has decreased episodes of pressured speech. The nurse should monitor for decreased episodes of pressured speech, insomnia, grandiose thoughts and hyperactivity for a client who has mania and is taking valproic acid.
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A nurse is caring for a client who is scheduled to undergo electroconvulsive therapy (ECT). The provider has explained the procedure to the client. Which of the following statements made by the client indicates a need for further teaching?
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This procedure can increase my risk for developing Parkinson's disease."
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A client recently diagnosed with bipolar disorder is placed in a room with a client who has severe depression. The client who has depression reports to the nurse, "That man in my room never sleeps and he keeps me up, too." Which of the following is an appropriate intervention for the nurse to take?
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Move the client who has bipolar disorder to a private room.
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A nurse is conducting a group therapy session for clients who have bipolar disorder. One of the clients begins bragging and dominating the conversation. Which of the following actions should the nurse take?
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Tell the client to calm down or he will be dismissed from the session. It is important for the nurse to provide clear expectations and set limits for the client; therefore, this is an appropriate action for the nurse to take.
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A nurse is interviewing an older adult client in an outpatient mental health clinic. Which of the following stratagies should the nurse use?
answer
Conduct the interview in a private area.
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A nurse working in an outpatient clinic is assessing a university student who says he feels restless and irritable before taking an exam. The nurse should assess the clinical findings as which of the following?
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Mild anxiety
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A nurse is caring for a client with dementia. Which of the following interventions is useful for orienting a client to reality?
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Place a large wall calendar in the client's room.
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A nurse is caring for a client receiving tranylcypromine. Which of the following is an appropriate menu choice for the nurse to suggest?
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Roasted chicken
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A nurse is developing a discharge plan for a client who has a history of gambling dependency and includes participation in a support group. The nurse should tell the client that which of the following is the purpose of attending a support group?
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Provide assurance that others have a similar problem.
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A nurse is caring for a client receiving imipramine for depression. For which of the following adverse effects should the nurse monitor?
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Imipramine, a tricyclic antidepressant, can cause urinary retention from anticholinergic effects.
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A nurse is assessing a client in the emergency department. The client appears agitated, his blood pressure is 152/94 mm Hg, his heart rate is 104/min, and his pupils are dilated. The nurse should suspect intoxication with which of the following substances?
answer
Cocaine
question
A nurse is providing teaching to a client who has a new prescription for haloperidol. Which of the following side effects should the nurse instruct the client to report to the provider?
answer
Shuffling gait
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A nurse is caring for a client who has alcoholic cardiomyopathy. Which of the following laboratory values should the nurse expect?
answer
Increased creatine phosphokinase (CPK)
question
During morning rounds, a nurse finds a client who has schizophrenia trembling and tearful in her bed. The client reports that a bomb was placed in her room by a family member during visiting hours. Which of the following is an appropriate action by the nurse?
answer
Assess the client for evidence of a perceptual disturbance.
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A nurse is meeting with a client being discharged from a substance use disorder treatment program. Which of the following client statements indicates the client is planning to make a lifestyle change?
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"I will change my route going home from work so I don't pass my favorite bar."
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A nurse working in a clinic is assessing a client whose partner died 4 months ago. Which of the following statements indicates the client is at risk for complicated grief?
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"I feel so empty without my wife; it's hard to get up every morning."
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A nurse is caring for a client who has schizophrenia. The treatment plan is for the client to increase his autonomy from his parents. Prior to discharge, the nurse should plan to
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schedule a family conference.
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A nurse is obtaining a health history during a client's admission to a mental health facility. The client begins to talk on her cell phone. When the client finishes talking, she reports to the nurse "That was the president, I leave in the morning on my new mission." Which of the following is an appropriate response?
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"How long have you been having conversations with the president?"
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A nurse is providing teaching to a client who is to be discharged from an inpatient detoxification program and plans to attend Alcoholics Anonymous. Which of the following statements by the client indicates an understanding of the teaching?
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I will use peer support to maintain my abstinence."
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While observing group therapy, a nurse recognizes that a client is behaving in a way suggestive of dependent personality disorder. Which of the following behaviors is consistent with this condition?
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The client needs excessive external input to make everyday decisions.
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A nurse is leading a group therapy session when a client becomes agitated and yells, "Listening to all of you is making me worse!" Which of the following is an appropriate response?
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"You sound angry and frustrated. Tell us more about how you are feeling?"
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A nurse is planning to teach a group of parents about healthy adolescent behavior. Which of the following information should the nurse include?
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Exhibits a realistic self-concept
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A nurse is facilitating a bereavement support group and observes that one member remains silent, even after attending several sessions. Which of the following strategies should the nurse use to encourage the member's participation?
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Divide the group into pairs to discuss a topic, then summarize the discussion to the group.
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When admitting a client to an inpatient mental health facility, a nurse notices that the client seems withdrawn and appears fearful. To establish a trusting nurse-client relationship, the nurse should first
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inform the client that her admission will be confidential.
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A nurse is caring for a child who has conduct disorder and is behaving in a destructive manner, throwing objects, and kicking others. Which of the following therapeutic nursing interventions is the highest priority?
answer
Use a therapeutic holding technique.
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A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse identify as a negative symptom of this disorder?
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Flat affect
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A nurse is caring for a client who is deaf and is scheduled to have electroconvulsive therapy (ECT). The provider needs to explain the procedure to the client in order to obtain informed consent. Which of the following actions should the nurse take?
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Request a professional interpreter to translate.
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A nurse is communicating with a client in an inpatient mental health facility. Which of the following demonstrates the use of active listening?
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Attention to body language
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A nurse is developing a plan of care for a client who exhibits anger, aggression, and violent behavior on the unit. The priority nursing intervention is to
answer
create a large, personal space.
question
A nurse is obtaining a history and physical on a client who presents to the emergency department of a mental health facility. The nurse recognizes which of the following assessment findings as being consistent with posttraumatic stress disorder (PTSD)? (Select all that apply.)
answer
Distressing dreams Difficulty concentrating
