1.A nurse on a mental health unit is assisting with the plan of care for a newly admitted client who

Mental Health 1.A nurse on a mental health unit is assisting with the plan of care for a newly admitted client who has anorexia nervosa. Which actions should the nurse include in the plan of care?Offer liquid supplements to the client *Anorexia nervosa= eating disorder following by low body weight(intense fear of gaining weight) 2.A nurse in a mental health facility is caring for a client who has schizophrenia. The client becomes violent in the day room and begins throwing objects at staff and other clients. After calling for assistance, which actions should the nurse take next?Tell the client calmly to sit down *Schizophrenia= A serious mental disorder /chronic brain disorder resulting in hallucinations, delusions, disorganized speech, trouble with thinking , and lack of motivation.

3.A nurse is caring for a group of clients on a mental health unit. Which of clients behaviors should the nurse report to the charge nurse?A client who is manic has been pacing the unit for several hours.

4.A nurse is collecting data from a client who is taking valproic acid for treatment of bipolar disorder. The nurse should identify that which findings is priority to report to the provider?Bleeding Gums *The priority finding is bleeding gums because of the risk of thrombocytopenia.If you have thrombocytopenia, you do not have enough platelets in your blood. Platelets help your blood clot.

5.A nurse is attempting to resolve an ethical dilemma that involves a client’s medical decision and his own personal values. After collecting data and identifying the problem, which actions should the nurse take next?Determine the benefits and consequences of respecting the client’s medical decisions 6.A nurse is reinforcing teaching with a client who has obsessive-compulsive disorder and performs hand hygiene to decrease anxiety. Which of the actions should the nurse take to demonstrate modeling as a behavioral intervention strategy?Demonstrating performing hand washing at appropriate time 7.A nurse is caring for a client who has antisocial personality disorder. Which action should the nurse take when caring for this client?Remind the client of consequences for unacceptable behavior 8.A nurse is assisting with the plan of care for a client who is malnourished due to alcohol use disorder. Which of the interventions should the nurse include in the plan?Restrict the client’s sodium intake *The intervention the nurse should include in the plan is to restrict the client’s sodium intake to decrease the risk of fluid retention because a client who is malnourished due to alcohol use disorder is at risk for ascites. Ascite is the buildup of fluid in you’re disease belly/abdomen, usually occurs when the liver stops working properly.

9.A nurse is collecting data from a client whose home was destroyed by a fire. Which of the responses should the nurse make first?“Are you experiencing feeling of hopelessness?” 10.A nurse is reinforcing teaching with the parent of an adolescent who has amphetamine use disorder. Which of the statements by the parent should the nurse identify as indicating an understanding of the teaching?“Dilated pupils are a sign my child is using amphetamines” *The nurse should instruct the parent to monitor the adolescent for mydriasis, or dilated pupils because this is a manifestation of amphetamine use.

11.A nurse is collecting data from a client who has agoraphobia. The nurse should identify that which of the situations will increase the client’s anxiety?Traveling in an airplane *Agoraphobia= Anxiety disorder, fear of open spaces, PTSD 12.A nurse is monitoring communication between a client who has alcohol use disorder and her partner. Which of the communication patterns of the client’s partner should the nurse identify as being effective?“ I become very angry when you get drunk” 13.A nurse is collecting data from a client who uses alcohol “to cope with stress”. Which of the questions should the nurse ask?“What daily activities are disrupted because of your alcohol consumption?” 14.A nurse is reinforcing teaching with an adolescent client who has a history of aggressive behavior. Which of the statements should the nurse make?“ Have you considered participating in a sport to help you control your aggression?” 15.A nurse on an impatient mental health unit is supervising a group of clients in the unit’s dayroom. The nurse fails to respond to the escalating, aggressive behavior of a client who eventually becomes violent and injures another client. For which of the following is the nurse liable?Negligence *The nurse is liable for negligence by failing to respond to the client’s escalating and aggressive behavior and prevent harm to other.

16.A nurse is reviewing the medical record of a client who has schizophrenia. For which of the findings should the nurse withhold the client’s medications and notify the provider?WBC count 17.A nurse on a mental health unit is caring for 4 clients who have schizophrenia. Which of the clients should the nurse see first?The client who is experiencing command hallucinations 18.A nurse is reinforcing teaching about stress management techniques with a client who has mild anxiety. Which of the statements should the nurse make?

“You should listen to music when you feel stress” 19.A nurse is caring for a client who is undergoing outpatient electroconvulsive therapy (ECT) to treat rapid-cycling bipolar disorder. Following the procedure, which of the actions should the nurse take?Administer oxygen to the client *In preparation for ECT, an anesthesiologist administers succinylcholine to the client, which paralyzes respiratory muscle. After the procedure, clients require oxygen administration until their respiratory status is stable 20.A nurse is caring for a client who has psychiatric somatic symptom disorder. Which of the actions should the nurse take?Encourage the client to examine how his illness behavior affects his family 21.A nurse is caring for a client who recently lost his child in a motor vehicle crash. The client is expressing feelings of hopelessness. Which of the questions is the most important for the nurse to ask?“ have you ever had any thoughts of harming yourself ?” 22.A nurse is caring for a client who has dementia. Which of the actions should the nurse take?

STAND IN FRONT OF THE CLIENT WHEN SPEAKING

23.A nurse is collecting data from a client who is experiencing oxycodone toxicity. Which of the medications should the nurse anticipate the provider to prescribe?Naloxone *The nurse should identify that naloxone is an opioid antagonist that is administered to treat the effects of opioid toxicity.

24.A nurse is assisting with the admission of a client who has an eating disorder. During data collection, which of the findings should the nurse identify as manifestations of bulimia nervosa?(Select all that apply.) Tooth erosion Hand calluses Hypokalemia

• Tooth erosion and Hand calluses= a manifestation of bulimia nervosa that result from self-

induced vomiting;Hypokalemia = a manifestation of bulimia nervosa that result from self- induced vomiting or excessive diuretic and laxative use.

25.A nurse is caring for a client who is taking lithium and reports persistent nausea and vomiting for

• days. Which of the following laboratory values should the nurse report to the provider?

Sodium 132 mEq/L 26.A nurse is collecting data from a client who has delirium. The nurse should identify which of the condition as a predisposing factor for delirium?Hepatic failure 27.A nurse is caring for a client who state, “This has been the worst day of my life”. Which of the responses should the nurse make?“Tell me about your day”

28.A nurse is assisting with the admission of a client to an acute care mental health facility . Which of the activities should the nurse plan for the working phase of the therapeutic relation?Evaluate the client’s progress toward meeting his goals 29.A nurse is caring for 4 clients who are displaying the use of defense mechanisms. Which of the clients should the nurse identify as using maladaptive defense mechanism?A client who has multiple sclerosis stops taking her medication and says her diagnosis is wrong *Denying the presence of an illness is a maladaptive use of defense mechanism 30.A nurse is participating in group therapy for clients who have major depressive disorder. Which of the topics should the nurse include in the orientation phase of group therapy?Confidentiality *The nurse should establish the expectations of confidentiality during the orientation phase of group therapy.

31.A nurse is assisting in the morning hygiene care of a client who is cognitively impaired. Which of the statements should the nurse make?“ Let me help you get your toothbrush” 32.A nurse is caring for a client who has schizophrenia and a prescription for haloperidol. The nurse should identify that which of the findings indicates a potential need for a PRN dose of benztropine?Shuffling gait *The nurse should identify that shuffling gait can be indicative of the presence of pseudoparkinsonism, which can be treated with a dose of benztropine.

33.A nurse is caring for a client who states that she does not want to go to physical therapy after having a below-the-knee amputation. Which of the responses should the nurse make?“What are your feelings about going to physical therapy?” 34.A nurse is contributing to the plan of care for a client who has anxiety disorder. Which of the interventions should the nurse recommend be included in the plan?Help the client to identify situations that trigger his anxiety 35.A nurse is collecting data from a client who is experiencing severe anxiety. Which of the manifestations should the nurse expect?Sighing *The nurse should identify that a client who has severe anxiety can display respiratory manifestations, including sighing, constriction of the chest, and dyspnea.

36.A nurse is collecting data from a client who is experiencing alcohol withdrawal. Which of the findings should the nurse anticipate?Elevated blood pressure