NCLEX Mental Health

Mental Health
1. The home care nurse is visiting an older client whose

spouse died 6 months ago. Which behavior by the client
indicates ineffective coping?
1. Neglecting personal grooming
2. Looking at old snapshots of family
3. Participating in a senior citizens' program
4. Visiting their spouse's grave once a month
1. Neglecting personal grooming
2. A client with a diagnosis of major depression who has

attempted suicide says to the nurse, "I should have died.
I've always been a failure. Nothing ever goes right for me."
Which response demonstrates therapeutic communication?
1. "You have everything to live for."
2. "Why do you see yourself as a failure?"
3. "Feeling like this is all part of being depressed."
4. "You've been feeling like a failure for a while?"
4. "You've been feeling like a failure for a while?"
3. When the mental health nurse visits a client at home, the

client states, "I haven't slept at all the last couple of nights."
Which response by the nurse illustrates a therapeutic
communication response to this client?
1. "I see."
2. "Really?"
3. "You're having difficulty sleeping?"
4. "Sometimes, I have trouble sleeping too."
3. "You're having difficulty sleeping?"
4. A client experiencing disturbed thought processes believes

that his food is being poisoned. Which communication
technique should the nurse use to encourage the client to
eat?
1. Using open-ended questions and silence
2. Sharing personal preference regarding food choices
3. Documenting reasons why the client does not want to eat
4. Offering opinions about the necessity of adequate
nutrition
1. Using open-ended questions and silence
5. A client admitted to a mental health unit for treatment of

psychotic behavior spends hours at the locked exit door
shouting, "Let me out. There's nothing wrong with me. I
don't belong here." What defense mechanism is the client
implementing?
1. Denial
2. Projection
3. Regression
4. Rationalization
1. Denial
6. A client diagnosed with terminal cancer says to the nurse,

"I'm going to die, and I wish my family would stop hoping
for a cure! I get so angry when they carry on like this. After
all, I'm the one who's dying." Which response by the nurse
is therapeutic?
1. "Have you shared your feelings with your family?"
2. "I think we should talk more about your anger with your
family."
3. "You're feeling angry that your family continues to hope
for you to be cured?"

4. "You are probably very depressed, which is
understandable with such a diagnosis."
3. "You're feeling angry that your family continues to hope for you to be cured?"
7. On review of the client's record, the nurse notes that the

mental health admission was voluntary. Based on this
information, the nurse anticipates which client behavior?
1. Fearfulness regarding treatment measures.
2. Anger and aggressiveness directed toward others.
3. An understanding of the pathology and symptoms of the
diagnosis.
4. A willingness to participate in the planning of the care
and treatment plan.
4. A willingness to participate in the planning of the care and treatment plan.
8. When reviewing the admission assessment, the nurse notes

that a client was admitted to the mental health unit
involuntarily. Based on this type of admission, the nurse
should provide which intervention for this client?
1. Monitor closely for harm to self or others.
2. Assist in completing an application for admission.
3. Supply the client with written information about their
mental illness.
4. Provide an opportunity for the family to discuss why
they felt the admission was needed.
1. Monitor closely for harm to self or others.
9. The nurse is preparing a client for the termination phase of

the nurse-client relationship. The nurse prepares to
implement which nursing task that is most appropriate for
this phase?
1. Planning short-term goals
2. Making appropriate referrals
3. Developing realistic solutions
4. Identifying expected outcomes
2. Making appropriate referrals
10.
The nurse in the mental health unit recognizes which
as being therapeutic communication techniques? Select all
that apply.
1. Restating
2. Listening
3. Asking the client, "Why?"
4. Maintaining neutral responses
5. Providing acknowledgment and feedback
6. Giving advice and approval or disapproval
o 1. Restating
o 2. Listening
o 4. Maintaining neutral responses
o 5. Providing acknowledgment and feedback
11.
A client being seen in the emergency department
immediately after being sexually assaulted appears calm
and controlled. The nurse analyzes this behavior as
indicating which defense mechanism?
1. Denial
2. Projection
3. Rationalization
4. Intellectualization
1. Denial
12.
A client's unresolved feelings related to loss would
be most likely observed during which phase of the
therapeutic nurse-client relationship?
1. Trusting
2. Working
3. Orientation
4. Termination
4. Termination
13.
The nurse is working with a client who despite making
a heroic effort was unable to rescue a neighbor trapped in a
house fire. Which client-focused action should the nurse
engage in during the working phase of the nurse-client
relationship?
1. Exploring the client's ability to function
2. Exploring the client's potential for self-harm
3. Inquiring about the client's perception or appraisal of
why the rescue was unsuccessful
4. Inquiring about and examining the client's feelings for
any that may block adaptive coping
4. Inquiring about and examining the client's feelings for any that may block adaptive
coping
14.
The nurse employed in a mental health unit of a
hospital is the leader of a group psychotherapy session.
What is the nurse's role during the termination stage of
group development?
1. Acknowledging that the group has identified goals
2. Encouraging the accomplishment of the group's work
3. Acknowledging the contributions of each group member
4. Encouraging members to become acquainted with one

another
3. Acknowledging the contributions of each group member
15.
Which are characteristics of the termination stage of
group development? Select all that apply.
1. The group evaluates the experience.
2. The real work of the group is accomplished.
3. Group interaction involves superficial conversation.
4. Group members become acquainted with each other.
5. Some structuring of group norms, roles, and
responsibilities takes place.
6. The group explores members' feelings about the group
and the impending separation.
o 1. The group evaluates the experience.
o 6. The group explores members' feelings about the group and the impending
separation.
16.
When a client is admitted to an inpatient mental health
unit with the diagnosis of anorexia nervosa, a cognitive
behavioral approach is used as part of the treatment plan.
The nurse understands that which is the purpose of this
approach?
1. Providing a supportive environment
2. Examining intrapsychic conflicts and past issues
3. Emphasizing social interaction with clients who
withdraw
4. Helping the client to examine dysfunctional thoughts and
beliefs
4. Helping the client to examine dysfunctional thoughts and beliefs
17.
The nurse understands that which best describes
Gestalt therapy?
1. It emphasizes self-expression, self-exploration, and selfawareness in the present.
2. It promotes the individual's comfort in the group, which
then transfers to other relationships.
3. The therapist focuses on how irrational beliefs and
thoughts contribute to psychological distress.
4. The therapist's goal is to help others express their
feelings toward one another during group sessions.
1. It emphasizes self-expression, self-exploration, and self-awareness in the present.
18.
A client is preparing to attend a Gamblers Anonymous
meeting for the first time. The nurse should tell the client
that which is the first step in this 12-step program?
1. Admitting to having a problem
2. Substituting other activities for gambling
3. Stating that the gambling will be stopped
4. Discontinuing relationships with people who gamble
1. Admitting to having a problem
19.
Which describes the primary focus of milieu therapy?
1. A form of behavior modification therapy
2. A cognitive approach to changing behavior
3. A living, learning, or working environment
4. A behavioral approach to changing behavior
3. A living, learning, or working environment
20.
While being treated, a client is introduced to short
periods of exposure to the phobic object while in a relaxed
state. What term is used to describe this form of behavior
modification?
1. Milieu therapy
2. Aversion therapy
3. Self-control therapy
4. Systematic desensitization
21.
A client is planning to attend Overeaters Anonymous.
Which statement by the client indicates a need for
additional information regarding this self-help group?
1. "The leader is a nurse or psychiatrist."
2. "The members provide support to each other."
3. "People who have a similar problem are able to help
others."
4. "It is designed to serve people who have a common
problem."
1. "The leader is a nurse or psychiatrist."
22.
What is the most appropriate nursing action to help
manage a manic client who is monopolizing a group
therapy session?
1. Ask the client to leave the group for this session only.
2. Refer the client to another group that includes other
manic clients.
3. Tell the client to stop monopolizing in a firm but
compassionate manner.
4. Thank the client for the input, but inform the client that
now others need a chance to contribute.
4. Thank the client for the input, but inform the client that now others need a chance to
contribute.
23.
Which type of therapeutic approach has the
characteristic that all team members are seen as equally
important in helping clients meet their goals?
1. Milieu therapy
2. Interpersonal therapy
3. Behavior modification
4. Rational emotive therapy
1. Milieu therapy
24.
A client says to the nurse, "The federal guards were
sent to kill me." What is the best nursing response to the
client's concern?
1. "I don't believe this is true."
2. "The guards are not out to kill you."
3. "Do you feel afraid that people are trying to hurt you?"
4. "What makes you think the guards were sent to hurt
you?"
3. "Do you feel afraid that people are trying to hurt you?"
25.
A client diagnosed with delirium becomes disoriented
and confused at night. Which intervention should the nurse
implement initially?
1. Move the client next to the nurse's station.
2. Use an indirect light source and turn off the television.
3. Keep the television and a soft light on during the night.
4. Play soft music during the night, and maintain a well-lit
room.
2. Use an indirect light source and turn off the television.
26.
A client is admitted to the mental health unit with a
diagnosis of depression. The nurse should develop a plan of
care for the client that includes which intervention?

1. Encouraging quiet reading and writing for the first few
days
2. Identification of physical activities that will provide
exercise
3. No socializing activities, until the client asks to
participate in milieu
4. A structured program of activities in which the client can
participate
4. A structured program of activities in which the client can participate
27.
When planning the discharge of a client with chronic
anxiety, the nurse directs the goals at promoting a safe
environment at home. Which is the most
appropriate maintenance goal?
1. Suppressing feelings of anxiety
2. Identifying anxiety-producing situations
3. Continued contact with a crisis counselor
4. Eliminating all anxiety from daily situations
2. Identifying anxiety-producing situations
28.
A client is unwilling to go out of the house for fear of
"making a fool of myself in public." Because of this fear,
the client remains homebound. Based on these data, which
mental health disorder is the client experiencing?
1. Agoraphobia
2. Social phobia
3. Claustrophobia
4. Hypochondriasis
2. Social phobia
29.
The nurse is conducting a group therapy session.
During the session, a client diagnosed with mania
consistently disrupts the group's interactions. Which
intervention should the nurse initially implement?
1. Setting limits on the client's behavior
2. Asking the client to leave the group session
3. Asking another nurse to escort the client out of the group
session
4. Telling the client that they will not be able to attend any
future group sessions
1. Setting limits on the client's behavior
30.
A client is admitted to a medical nursing unit with a
diagnosis of acute blindness after being involved in a hitand-run accident. When diagnostic testing cannot identify
any organic reason why this client cannot see, a mental
health consult is prescribed. Which condition will be the
focus of this consult?
1. Psychosis
2. Repression
3. Conversion disorder
4. Dissociative disorder
3. Conversion disorder
31.
A manic client begins to make sexual advance towards
visitors in the dayroom. When the nurse firmly states that
this is inappropriate and will not be allowed, the client
becomes verbally abusive and threatens physical violence
to the nurse. Based on the analysis of this situation, which
intervention should the nurse implement?
1. Place the client in seclusion for 30 minutes.
2. Tell the client that the behavior is inappropriate.

3. Escort the client to their room, with the assistance of
other staff.
4. Tell the client that their telephone privileges are revoked
for 24 hours.
3. Escort the client to their room, with the assistance of other staff.
32.
Which nursing interventions are appropriate for a
hospitalized client with mania who is exhibiting
manipulative behavior? Select all that apply.
1. Communicate expected behaviors to the client.
2. Ensure that the client knows that they are not in charge
of the nursing unit.
3. Assist the client in identifying ways of setting limits on
personal behaviors.
4. Follow through about the consequences of behavior in a
nonpunitive manner.
5. Enforce rules by informing the client that they will not
be allowed to attend therapy groups.
6. Have the client state the consequences for behaving in
ways that are viewed as unacceptable.
o 1. Communicate expected behaviors to the client.
o 3. Assist the client in identifying ways of setting limits on personal behaviors.
o 4. Follow through about the consequences of behavior in a nonpunitive manner.
o 6. Have the client state the consequences for behaving in ways that are viewed as
unacceptable.
33.
The nurse observes that a client is pacing, agitated,
and presenting aggressive gestures. The client's speech
pattern is rapid, and affect is belligerent. Based on these
observations, what is the nurse's immediate priority of

care?
1. Provide safety for the client and other clients on the unit.
2. Provide the clients on the unit with a sense of comfort
and safety.
3. Assist the staff in caring for the client in a controlled
environment.
4. Offer the client a less stimulating area to calm down in
and gain control.
1. Provide safety for the client and other clients on the unit.
34.
The nurse is preparing a client with a history of
command hallucinations for discharge by providing
instructions on interventions for managing hallucinations
and anxiety. Which statement in response to these
instructions suggests to the nurse that the client understands
the instructions?
1. "My medications aren't likely to make me anxious."
2. "I'll go to support group and talk so that I don't hurt
anyone."
3. "It's not likely that I'll get anxious or hear things if I get
enough sleep and eat well."
4. "When I begin to hallucinate, I'll call my therapist and
talk about what I should do."
4. "When I begin to hallucinate, I'll call my therapist and talk about what I should do."
35.
The nurse is caring for a client diagnosed with
catatonic stupor who is lying on the bed in a fetal position.
What is the most appropriate nursing intervention?
1. Ask direct questions to encourage talking.
2. Leave the client alone so as to minimize external stimuli.
3. Sit beside the client in silence with occasional openended questions.

4. Take the client into the dayroom with other clients so
that they can help watch him.
3. Sit beside the client in silence with occasional open-ended questions.
36.
The nurse is caring for a client who is experiencing
disturbed thought processes as a result of paranoia. In
formulating nursing interventions with the members of the
health care team, what best instruction should the nurse
provide to the staff?
1. Increase socialization of the client with peers.
2. Avoid laughing or whispering in front of the client.
3. Begin to educate the client about social supports in the
community.
4. Have the client sign a release of information to
appropriate parties for assessment purposes.
2. Avoid laughing or whispering in front of the client.
37.
The nurse is planning activities for a client diagnosed
with bipolar disorder with aggressive social behavior.
Which activity would be most appropriate for this client?
1. Chess
2. Writing
3. Ping pong
4. Basketball
2. Writing
38.
The home health nurse visits a client at home and
determines that the client is dependent on drugs. During the
assessment, which action should the nurse take to plan
appropriate nursing care?

1. Ask the client why he started taking illegal drugs.
2. Ask the client about the amount of drug use and its
effect.
3. Ask the client how long he thought that he could take
drugs without someone finding out.
4. Not ask any questions for fear that the client is in denial
and will throw the nurse out of the home.
2. Ask the client about the amount of drug use and its effect.
39.
Which interventions are most appropriate for caring
for a client in alcohol withdrawal? Select all that apply.
1. Monitor vital signs.
2. Maintain NPO status.
3. Provide a safe environment.
4. Address hallucinations therapeutically.
5. Provide stimulation in the environment.
6. Provide reality orientation as appropriate.
o 1. Monitor vital signs.
o 3. Provide a safe environment.
o 4. Address hallucinations therapeutically.
o 6. Provide reality orientation as appropriate.
40.
The nurse determines that the wife of an alcoholic
client is benefiting from attending an Al-Anon group if the
nurse hears the wife make which statement?
1. "I no longer feel that I deserve the beatings my husband
inflicts on me."
2. "My attendance at the meetings has helped me to see that
I provoke my husband's violence."
3. "I enjoy attending the meetings because they get me out

of the house and away from my husband."
4. "I can tolerate my husband's destructive behaviors now
that I know they are common with alcoholics."
1. "I no longer feel that I deserve the beatings my husband inflicts on me."
41.
A hospitalized client with a history of alcohol abuse
tells the nurse, "I am leaving now. I have to go. I don't want
any more treatment. I have things that I have to do right
away." The client has not been discharged and is scheduled
for an important diagnostic test to be performed in 1 hour.
After the nurse discusses the client's concerns with the
client, the client dresses and begins to walk out of the
hospital room. What action should the nurse take?
1. Call the nursing supervisor.
2. Call security to block all exit areas.
3. Restrain the client until the health care provider (HCP)
can be reached.
4. Tell the client that the client cannot return to this hospital
again if the client leaves now.
42.
The nurse is preparing to perform an admission
assessment on a client with a diagnosis of bulimia nervosa.
Which assessment findings does the nurse expect to
note? Select all that apply.
1. Dental decay
2. Moist oily skin
3. Loss of tooth enamel
4. Electrolyte imbalances
5. Body weight well below ideal range
o 1. Dental decay
o 3. Loss of tooth enamel
o 4. Electrolyte imbalances
43.
The nurse is caring for a female client who was
admitted to the mental health unit recently for anorexia
nervosa. The nurse enters the client's room and notes that
the client is engaged in rigorous push-ups. Which nursing
action is most appropriate?
1. Interrupt the client and weigh her immediately.
2. Interrupt the client and offer to take her for a walk.
3. Allow the client to complete her exercise program.
4. Tell the client that she is not allowed to exercise
rigorously.
2. Interrupt the client and offer to take her for a walk.
44.
A client with a diagnosis of anorexia nervosa, who is
in a state of starvation, is in a two-bed room. A newly
admitted client will be assigned to this client's room. Which
client would be the best choice as a roommate for the client
with anorexia nervosa?
1. A client with pneumonia
2. A client undergoing diagnostic tests
3. A client who thrives on managing others
4. A client who could benefit from the client's assistance at
mealtime
2. A client undergoing diagnostic tests
45.
The nurse is monitoring a hospitalized client who
abuses alcohol. Which findings should alert the nurse to the
potential for alcohol withdrawal delirium?
1. Hypotension, ataxia, hunger

2. Stupor, lethargy, muscular rigidity
3. Hypotension, coarse hand tremors, lethargy
4. Hypertension, changes in level of consciousness,
hallucinations
4. Hypertension, changes in level of consciousness, hallucinations
46.
The spouse of a client admitted to the mental health
unit for alcohol withdrawal says to the nurse, "I should get
out of this bad situation." What is the most helpful
response by the nurse?
1. "Why don't you tell your wife about this?"
2. "What do you find difficult about this situation?"
3. "This is not the best time to make that decision."
4. "I agree with you. You should get out of this situation."
2. "What do you find difficult about this situation?"
47.
A client with anorexia nervosa is a member of a
predischarge support group. The client verbalizes that she
would like to buy some new clothes, but her finances are
limited. Group members have brought some used clothes to
the client to replace the client's old clothes. The client
believes that the new clothes were much too tight and has
reduced her calorie intake to 800 calories daily. How
should the nurse evaluate this behavior?
1. Normal behavior
2. Evidence of the client's disturbed body image
3. Regression as the client is moving toward the community
4. Indicative of the client's ambivalence about hospital
discharge
2. Evidence of the client's disturbed body image
48.
The nurse in the emergency department is caring for a
young female victim of sexual assault. The client's physical
assessment is complete, and physical evidence has been
collected. The nurse notes that the client is withdrawn,
confused, and at times physically immobile. How should
the nurse interpret these behaviors?
1. Signs of depression
2. Normal reactions to a devastating event
3. Evidence that the client is a high suicide risk
4. Indicative of the need for hospital admission
2. Normal reactions to a devastating event
49.
The nurse is reviewing the assessment data of a client
admitted to the mental health unit. The nurse notes that the
admission nurse documented that the client is experiencing
anxiety as a result of a situational crisis. The nurse
determines that this type of crisis could be caused by which
event?
1. Witnessing a murder
2. The death of a loved one
3. A fire that destroyed the client's home
4. A recent rape episode experienced by the client
2. The death of a loved one
50.
The nurse is conducting an initial assessment on a
client in crisis. When assessing the client's perception of the
precipitating event that led to the crisis, what is the most
appropriate question?
1. "With whom do you live?"
2. "Who is available to help you?"

3. "What leads you to seek help now?"
4. "What do you usually do to feel better?"
3. "What leads you to seek help now?"
51.
The nurse is developing a plan of care for a client in a
crisis state. When developing the plan, the nurse should
consider which factor?
1. A crisis state indicates that the client has a mental illness.
2. A crisis state indicates that the client has an emotional
illness.
3. Presenting symptoms in a crisis situation are similar for
all clients experiencing a crisis.
4. A client's response to a crisis is individualized and what
constitutes a crisis for one client may not constitute a crisis
for another client.
4. A client's response to a crisis is individualized and what constitutes a crisis for one
client may not constitute a crisis for another client.
52.
The nurse observes that a client with a potential for
violence is agitated, pacing up and down the hallway, and is
making aggressive and belligerent gestures at other clients.
Which statement would be most appropriate to make to
this client?
1. "You need to stop that behavior now."
2. "You will need to be placed in seclusion."
3. "You seem restless; tell me what is happening."
4. "You will need to be restrained if you do not change your
behavior."
3. "You seem restless; tell me what is happening."
53.
A depressed client on an inpatient unit says to the
nurse, "My family would be better off without me." What is
the nurse's best response?
1. "Have you talked to your family about this?"
2. "Everyone feels this way when they are depressed."
3. "You will feel better once your medication begins to
work."
4. "You sound very upset. Are you thinking of hurting
yourself?"
4. "You sound very upset. Are you thinking of hurting yourself?"
54.
The nurse has been observing a client closely who has
been displaying aggressive behaviors. The nurse observes
that the behavior displayed by the client is escalating.
Which nursing intervention is least helpful to this client at
this time?
1. Initiate confinement measures.
2. Acknowledge the client's behavior.
3. Assist the client to an area that is quiet.
4. Maintain a safe distance from the client.
1. Initiate confinement measures.
55.
Which behavior observed by the nurse indicates a
suspicion that a depressed adolescent client may be
suicidal?
1. The adolescent gives away a DVD and a cherished
autographed picture of a performer.
2. The adolescent runs out of the therapy group, swearing at
the group leader, and runs to her room.
3. The adolescent becomes angry while speaking on the
telephone and slams down the receiver.
4. The adolescent gets angry with her roommate when the

roommate borrows the client's clothes without asking.
1. The adolescent gives away a DVD and a cherished autographed picture of a performer.
56.
The police arrive at the emergency department with a
client who has lacerated both wrists. What is
the initial nursing action?
1. Administer an antianxiety agent.
2. Examine and treat the wound sites.
3. Secure and record a detailed history.
4. Encourage and assist the client to ventilate feelings.
2. Examine and treat the wound sites.
57.
A moderately depressed client who was hospitalized 2
days ago suddenly begins smiling and reporting that the
crisis is over. The client says to the nurse, "I'm finally
cured." How should the nurse interpret this behavior as a
cue to modify the treatment plan?
1. Suggesting a reduction of medication
2. Allowing increased "in-room" activities
3. Increasing the level of suicide precautions
4. Allowing the client off-unit privileges as needed
3. Increasing the level of suicide precautions
58.
The nurse is planning care for a client being admitted
to the nursing unit who attempted suicide.
Which priority nursing intervention should the nurse
include in the plan of care?
1. One-to-one suicide precautions
2. Suicide precautions with 30-minute checks
3. Checking the whereabouts of the client every 15 minutes

4. Asking the client to report suicidal thoughts immediately
1. One-to-one suicide precautions
59.
The emergency department nurse is caring for an adult
client who is a victim of family violence.
Which priority instruction should be included in the
discharge instructions?
1. Information regarding shelters
2. Instructions regarding calling the police
3. Instructions regarding self-defense classes
4. Explaining the importance of leaving the violent
situation
1. Information regarding shelters
60.
A female victim of a sexual assault is being seen in the
crisis center. The client states that she still feels "as though
the rape just happened yesterday," even though it has been
a few months since the incident. What is the most
appropriate nursing response?
1. "You need to try to be realistic. The rape did not just
occur."
2. "It will take some time to get over these feelings about
your rape."
3. "Tell me more about the incident that causes you to feel
like the rape just occurred."
4. "What do you think that you can do to alleviate some of
your fears about being raped again?"
3. "Tell me more about the incident that causes you to feel like the rape just occurred."
61.
A client is admitted to the mental health unit after an
attempted suicide by hanging. The nurse can best ensure
client safety by which action?
1. Requesting that a peer remain with the client at all times
2. Removing the client's clothing and placing the client in a
hospital gown
3. Assigning a staff member to the client who will remain
with the client at all times
4. Admitting the client to a seclusion room where all
potentially dangerous articles are removed
3. Assigning a staff member to the client who will remain with the client at all times
62.
A client is admitted with a recent history of severe
anxiety following a home invasion and robbery. During the
initial assessment interview, which statement by the client
would indicate to the nurse the possible diagnosis of
posttraumatic stress disorder? Select all that apply.
1. "I'm afraid of spiders."
2. "I keep reliving the robbery."
3. "I see his face everywhere I go."
4. "I don't want anything to eat now."
5. "I might have died over a few dollars in my pocket."
6. "I have to wash my hands over and over again many
times."
o 2. "I keep reliving the robbery."
o 3. "I see his face everywhere I go."
o 5. "I might have died over a few dollars in my pocket."
63.
The emergency department nurse is caring for a client
who has been identified as a victim of physical abuse. In
planning care for the client, which is the priority nursing

action?
1. Adhering to the mandatory abuse-reporting laws
2. Notifying the case worker of the family situation
3. Removing the client from any immediate danger
4. Obtaining treatment for the abusing family member
3. Removing the client from any immediate danger
64.
The nurse assesses a client with the admitting
diagnosis of bipolar affective disorder, mania. Which client
symptoms require the nurse's immediate action?
1. Incessant talking and sexual innuendoes
2. Grandiose delusions and poor concentration
3. Outlandish behaviors and inappropriate dress
4. Nonstop physical activity and poor nutritional intake
65.
The nurse is performing an assessment on a client with
dementia. Which data gathered during the assessment
indicates a manifestation associated with dementia?
1. Uses confabulation
2. Improvement in sleeping
3. Absence of sundown syndrome
4. Presence of personal hygienic care
1. Uses confabulation
66.
The nurse is caring for a client with anorexia nervosa.
Which behavior is characteristic of this disorder and
reflects anxiety management?
1. Engaging in immoral acts
2. Always reinforcing self-approval
3. Observing rigid rules and regulations

4. Having the need always to make the right decision
67.
A depressed client verbalizes feelings of low selfesteem and self-worth typified by statements such as "I'm
such a failure. I can't do anything right." How should the
nurse plan on responding to the client's statement?
1. Reassure the client that things will get better.
2. Tell the client that this is not true and that we all have a
purpose in life.
3. Identify recent behaviors or accomplishments that
demonstrate the client's skills.
4. Remain with the client and sit in silence; this will
encourage the client to verbalize feelings.
3. Identify recent behaviors or accomplishments that demonstrate the client's skills.
68.
A client with diabetes mellitus is told that amputation
of the leg is necessary to sustain life. The client is very
upset and tells the nurse, "This is all my health care
provider's fault. I have done everything I've been asked to
do!" Which nursing interpretation is best for this situation?
1. An expected coping mechanism
2. An ineffective coping mechanism
3. A need to notify the hospital lawyer
4. An expression of guilt on the part of the client
69.
A client experiencing a great deal of stress and anxiety
is being taught to use self-control therapy. Which statement
by the client indicates a need for further teaching about
the therapy?
1. "This form of therapy can be applied to new situations."
2. "An advantage of this technique is that change is likely
to last."
3. "Talking to oneself is a basic component of this form of
therapy."
4. "This form of therapy provides a negative reinforcement
when the stimulus is produced."
4. "This form of therapy provides a negative reinforcement when the stimulus is
produced."
70.
The nurse is caring for a client who is at risk for
suicide. What is the priority nursing action for this client?
1. Provide authority, action, and participation.
2. Display an attitude of detachment, confrontation, and
efficiency.
3. Demonstrate confidence in the client's ability to deal
with stressors.
4. Provide hope and reassurance that the problems will
resolve themselves.
1. Provide authority, action, and participation.
71.
A client comes to the emergency department after an
assault and is extremely agitated, trembling, and
hyperventilating. What is the priority nursing action for
this client?
1. Begin to teach relaxation techniques.
2. Encourage the client to discuss the assault.
3. Remain with the client until the anxiety decreases.
4. Place the client in a quiet room alone to decrease
stimulation.
72.
The nurse is developing a plan of care for a client who
was experiencing anxiety after the loss of a job. The client
is now verbalizing concerns regarding the ability to meet
role expectations and financial obligations. What is
the priority problem for this client?
1. Anxiety
2. Unrealistic outlook
3. Lack of ability to cope effectively
4. Disturbances in thoughts and ideas
3. Lack of ability to cope effectively
73.
The nurse has developed a plan of care for a client
diagnosed with anorexia nervosa. Which client problem
would the nurse select as the priority in the plan of care?
1. Disrupted appearance because of weight
2. Inability to feed self because of weakness
3. Pain because of an inflamed gastric mucosa
4. Nutritional imbalance because of lack of intake
4. Nutritional imbalance because of lack of intake
74.
Which statement made by an unlicensed assistive
personnel (UAP) indicates to the registered nurse that the
UAP understands the concepts related to suicide?
1. "Discussing suicide with a client is not harmful."
2. "Those clients who talk about suicide never do it."
3. "Depressed clients are the only persons who commit
suicide."
4. "When a person talks about making suicide threats, the
only thing the person wants is attention from family and

friends."
1. "Discussing suicide with a client is not harmful."
75.
Which client is most at risk for committing suicide?
1. A 75-year-old client with metastatic cancer
2. A 71-year-old client with a cardiac disorder
3. A 24-year-old client who just had an argument with her
roommate
4. A 30-year-old newly divorced client who states she has
custody of the children
1. A 75-year-old client with metastatic cancer
76.
A nursing instructor teaches a group of nursing
students about violence in the family. Which statement by a
student indicates a need for further teaching?
1. "Abusers use fear and intimidation."
2. "Abusers usually have poor self-esteem."
3. "Abusers often are jealous or self-centered."
4. "Abuse occurs more often in low-income families."
4. "Abuse occurs more often in low-income families."
77.
A client is being prepared for electroconvulsive
therapy (ECT). The nurse's plan of care for the day before
ECT includes ensuring that the client follows which
guideline?
1. Does not smoke at all
2. Receives no visitors and participates in limited unit
activities
3. Reports to the clinic for blood draws and an
electrocardiogram (ECG)
4. Is placed on nothing by mouth (NPO) status for 16 to 24

hours before the ECT
3. Reports to the clinic for blood draws and an electrocardiogram (ECG)
78.
A nursing student is assisting with the care of a client
with a chronic mental illness. The nurse informs the student
that a behavior modification approach (operant
conditioning) will be used in treatment for the client.
Which statement by the student indicates a need for
further information about the therapy?
1. "It uses positive reinforcement."
2. "It uses negative reinforcement."
3. "It increases social behaviors in the client."
4. "It increases the level of self-care in the client."
2. "It uses negative reinforcement."
79.
The nurse is performing an admission assessment on a
client at high risk for suicide. The nurse should prepare to
ask the client which assessment question to elicit data
related to this risk?
1. "What are you feeling right now?"
2. "Do you have a plan to commit suicide?"
3. "How many times have you attempted suicide in the
past?"
4. "Why were your attempts at suicide unsuccessful in the
past?"
2. "Do you have a plan to commit suicide?"
80.
The nurse in the mental health unit is performing an
assessment in a client who has a history of multiple somatic
complaints involving several organ systems. Diagnostic
studies revealed no organic pathology. The care plan

developed for this client will reflect that the client is
experiencing which disorder?
1. Depression
2. Schizophrenia
3. Somatization disorder
4. Obsessive-compulsive disorder
81.
A mental health nurse in a psychiatric unit is meeting
with a client who has a long history of acting out and
violent behavior. The client also is known to have abused
drugs on numerous occasions. During the session the client
says to the nurse, "I'm feeling much better now, and I'm
ready to go straight." Which response by the nurse would
be therapeutic?
1. "You have said this many times before!"
2. "Tell me what makes you feel that you are ready."
3. "I have not seen any changes in you to believe that you
are ready to go straight."
4. "I'm so glad to hear you talking this way. I will let your
health care provider know."
2. "Tell me what makes you feel that you are ready."
82.
A client with a diagnosis of depression has been
meeting with the mental health nurse for therapy sessions
for the past 6 weeks. During the session the client says to
the nurse, "I lost my job this week, and I'm going to be
evicted from my apartment if I can't pay my bill. The only
person that I have is my daughter, but I don't want to
burden her with my problems." Which response by the
nurse would be therapeutic?

1. "Why did you lose your job?"
2. "There are homeless shelters available, and we will get
you into one if you are evicted from your apartment."
3. "If you get evicted from your apartment, we will commit
you to the hospital, so you will have a place to eat and
sleep."
4. "Let's talk about contacting your daughter. Wouldn't you
want to know if your daughter was having difficulty and try
to help her if you could?"
4. "Let's talk about contacting your daughter. Wouldn't you want to know if your daughter
was having difficulty and try to help her if you could?"
83.
During a therapy session with a client with paranoid
disorder, the client says to the nurse, "You look so nice
today. I love how you do your hair, and I love that perfume
you're wearing." Which response by the nurse would be
therapeutic?
1. "Your comment is inappropriate."
2. "Thank you for noticing. I just bought this new
perfume."
3. "My hair has been a mess. I really needed to have it
done."
4. "We are not here to discuss how I look or smell. We are
here to talk about you."
4. "We are not here to discuss how I look or smell. We are here to talk about you."
84.
The nurse in the mental health unit is assigned to care
for a female client with a diagnosis of acute depression. In
communicating with the client, which statement would be
appropriate for the nurse to make?
1. "You look lovely today."

2. "You're wearing a new blouse."
3. "Don't worryeveryone gets depressed once in a while."
4. "You will feel better when your medication starts to
work."
2. "You're wearing a new blouse."
85.
The nurse is planning care for a client with bipolar
disorder who is experiencing psychomotor agitation. Which
activity should the nurse plan for this client?
1. Reading letters and books in a quiet environment
2. Providing an activity such as checkers for the client
3. Involving the client in a card game with other clients on
the unit
4. Including the client in a clay-molding class that is
scheduled for today
4. Including the client in a clay-molding class that is scheduled for today
86.
The nurse is developing a plan of care for a client with
depression whose food intake is poor. The nurse should
include which interventions in the plan of care? Select all
that apply.
1. Assist the client in selecting foods from the food menu.
2. Offer high-calorie fluids throughout the day and evening.
3. Allow the client to eat alone in the room if the client
requests to do so.
4. Offer small high-calorie, high-protein snacks during the
day and evening.
5. Select the foods for the client to be sure that the client
eats a balanced diet.
o 1. Assist the client in selecting foods from the food menu.

o 2. Offer high-calorie fluids throughout the day and evening.
o 4. Offer small high-calorie, high-protein snacks during the day and evening.
87.
The nurse is monitoring a client with a diagnosis of
schizophrenia. The nurse notes that the client's emotional
responses to situations occurring throughout the day are
incongruent with the tone of the situation. The nurse should
document the findings using which description of the
client's behavioral response?
1. Flat affect
2. Bizarre affect
3. Blunted affect
4. Inappropriate affect
4. Inappropriate affect
88.
A mental health nurse notes that a client with
schizophrenia is exhibiting an immobile facial expression
and a blank look. Which should the nurse document in the
client's record?
1. The client has a flat affect.
2. The client has an inappropriate affect.
3. The client is exhibiting bizarre behavior.
4. The client's emotional responses exhibit a blunted affect.
1. The client has a flat affect.
89.
The nurse is developing a plan of care for the client
with a diagnosis of paranoia and should include which
interventions in the plan of care? Select all that apply.
1. Provide a warm approach to the client.
2. Ask permission before touching the client.
3. Eliminate physical contact with the client.

4. Defuse any anger or verbal attacks with a nondefensive
stance.
5. Use simple and clear language when communicating
with the client.
o 2. Ask permission before touching the client.
o 3. Eliminate physical contact with the client.
o 4. Defuse any anger or verbal attacks with a nondefensive stance.
o 5. Use simple and clear language when communicating with the client.
90.
The nurse is preparing a client for electroconvulsive
therapy (ECT), which is scheduled for the next morning.
Which interventions would be included in the
preprocedural plan? Select all that apply.
1. Obtain an informed consent.
2. Have the client void before the procedure.
3. Remove dentures and contact lenses before the
procedure.
4. Withhold food and fluids for 6 hours before the
treatment.
5. Administer tap water enemas on the evening before the
procedure.
o 1. Obtain an informed consent.
o 2. Have the client void before the procedure.
o 3. Remove dentures and contact lenses before the procedure.
o 4. Withhold food and fluids for 6 hours before the treatment.
91.
A hospitalized client is receiving clozapine (Clozaril)
for the treatment of a schizophrenic disorder. The nurse
determines that the client may be having an adverse
reaction to the medication if abnormalities are noted on
which laboratory study?
1. Platelet count
2. Cholesterol level
3. Blood urea nitrogen
4. White blood cell (WBC) count
4. White blood cell (WBC) count
92.
A client has been prescribed disulfiram (Antabuse).
Before giving the client the first dose of this medication,
what should the psychiatric home health nurse determine?
1. If there is a history of hyperthyroidism
2. When the last full meal was consumed
3. If there is a history of diabetes insipidus
4. When the last alcoholic drink was consumed
4. When the last alcoholic drink was consumed
93.
A home care nurse making an initial home visit notes
that a client is taking donepezil hydrochloride (Aricept).
The nurse questions the client's spouse about a history of
which disorder that is treated with this medication?
1. Dementia
2. Schizophrenia
3. Seizure disorder
1. Dementia
94.
The nurse is caring for a client with a diagnosis of
agoraphobia. When communicating with the client about
the disorder, the nurse should expect the client to describe
which behavior?
1. A fear of dirt and germs
2. A fear of leaving the house
3. A fear of speaking in public
4. A fear of riding in elevators
2. A fear of leaving the house
95.
A client recently admitted to the hospital in the manic
phase of bipolar disorder is dehydrated, unkempt, taking
antipsychotic medications, and complaining of abdominal
fullness and discomfort. The nurse determines that which
intervention is most appropriate for these complaints?
1. Teach self-grooming skills.
2. Reward cleanliness with unit privileges.
3. Monitor the adequacy of the antipsychotic dosage.
4. Encourage frequent fluid intake and a high-fiber diet.
4. Encourage frequent fluid intake and a high-fiber diet.
96.
A homebound client confidentially discusses suicidal
plans with the visiting nurse. Based on professional duty to
observe confidentiality, which statement bestdescribes the
nurse's obligation to the client?
1. The nurse must have the client go to the local mental
health center daily for counseling.
2. The nurse must ask the client not to reveal suicidal plans
if the information needs to be kept confidential.
3. The nurse cannot tell anyone what the client said and
must strictly adhere to the professional duty for
confidentiality.
4. The nurse must override the duty to observe
confidentiality and notify the client's health care provider
(HCP) about the suicidal ideation.
4. The nurse must override the duty to observe confidentiality and notify the client's
health care provider (HCP) about the suicidal ideation.
97.
The mental health nurse is reviewing the discharge
plan for a hospitalized client. In reviewing the plan, the
nurse recognizes that which is the most prominent problem
in the management of a client with a mental health problem
in the community?
1. The community's opposition
2. The client's noncompliance with medication therapy
3. The associated increased incidence of social problems
4. The family's reaction to keeping the client in the
community
2. The client's noncompliance with medication therapy
98.
During a home visit, the nurse suspects that a young
daughter of the client is bulimic. The nurse bases this
suspicion on which primary characteristic of bulimia?
1. Refusing to eat and excessive exercising
2. Eating only vegetables and fruits and fasting
3. Hoarding of food and difficulty controlling food intake
4. Eating a lot of food in a short period of time and misuse
of laxatives
4. Eating a lot of food in a short period of time and misuse of laxatives
99.
The mental health nurse is talking to a client who has
been diagnosed with posttraumatic stress disorder. During
the conversation, the nurse notes that the client is exhibiting

a paranoid stare and that he begins to pace and fidget. What
is the appropriate nursing intervention?
1. Allow the client to pace.
2. Escort the client to a quiet room.
3. Change the conversation to a less threatening subject.
4. Share the observation with the client and help the client
to recognize his feelings.
4. Share the observation with the client and help the client to recognize his feelings.
100. The nurse is reviewing the record of a client admitted

to the mental health unit. The nurse notes documentation
that the client experiences flashbacks. What diagnosis
should the nurse expect to be documented for this client?
1. Anxiety
2. Agoraphobia
3. Schizophrenia
4. Posttraumatic stress disorder (PTSD)
101. The nurse is admitting a client with a diagnosis of

posttraumatic stress disorder to the mental health unit. The
client is confused and disoriented. During the assessment,
what is the nurse's primary goal for this client?
1. Explain the unit rules.
2. Orient the client to the unit.
3. Stabilize the client's psychiatric needs.
4. Accept the client and make the client feel safe.
4. Accept the client and make the client feel safe.
102. The nurse in the mental health unit is having a

conversation with a client diagnosed with posttraumatic
stress disorder. The client seems upset and looks anxious.
What is the appropriate nursing statement the nurse should
make to the client?
1. "Don't worry so much."
2. "I can see that you are upset."
3. "Everything is going to be all right."
4. "Why are you having so much trouble controlling your
anxiety?"
2. "I can see that you are upset."
103. A client with depression is scheduled to receive three

sessions of electroconvulsive therapy (ECT). The client
asks the nurse about the length of time it will take for
improvement in the condition. The nurse should tell the
client he or she will see improvement approximately how
long after the three treatments?
1. 1 week
2. 3 weeks
3. 4 weeks
4. 8 weeks
1. 1 week
104. A client has been diagnosed with major depression.

The nurse notes that the client is not eating adequately and
at times refuses to eat. What should the nurse plan to do to
meet the client's nutritional needs?
1. Force foods and fluids.
2. Provide small, frequent meals.
3. Provide snacks and meals as requested.
4. Tell the client that social activities will be restricted

unless food intake is increased.
2. Provide small, frequent meals.
105. The health care provider has prescribed medication

therapy for a client with an alcohol abuse problem to assist
in the maintenance of sobriety. The nurse reviews the
client's record and expects to note that which medication
has been prescribed?
1. Clonidine (Catapres)
2. Disulfiram (Antabuse)
3. Pyridoxine hydrochloride (vitamin B6)
4. Chlordiazepoxide hydrochloride (Librium)
2. Disulfiram (Antabuse)
106. The mental health nurse is caring for a client with a

social phobia. The nurse tells the client that a music therapy
session has been scheduled as part of the treatment plan.
The client tells the nurse that she cannot sing and refuses to
attend. What is the appropriate nursing response?
1. "You must go. You have no choice."
2. "Why don't you want to attend? What is the real reason?"
3. "The health care provider has prescribed this therapy for
you."
4. "You don't have to sing at the session. You can listen and
enjoy the music."
4. "You don't have to sing at the session. You can listen and enjoy the music."
107. The nurse is monitoring a client who has been placed

in restraints because of violent behavior. When should the
nurse determine that it will be safe to remove the restraints?
1. Administered medication has taken effect.

2. The client verbalizes the reasons for the violent behavior.
3. The client apologizes and tells the nurse that it will never
happen again.
4. No acts of aggression have been observed within 1 hour
after the release of two of the extremity restraints.
4. No acts of aggression have been observed within 1 hour after the release of two of the
extremity restraints.
108. The mental health nurse is conducting a group therapy

session and is monitoring a client with a diagnosis of
agoraphobia who has been attending the sessions for
several months. The nurse notes that the client is
cooperative, sharing with peers, and making appropriate
suggestions during group discussions. How should the
nurse interpret this behavior?
1. Manipulation
2. Improvement
3. Attention seeking
4. Desire to be accepted
2. Improvement
109. The nurse is preparing a client for electroconvulsive

therapy (ECT). The family of the client asks the nurse
about this treatment. The nurse responds, knowing that
which statements are accurate regarding this
treatment? Select all that apply.
1. The average series involves 6 to 12 treatments.
2. Some confusion may be noted after the procedure.
3. Memory loss will occur but will resolve with time.
4. This treatment is a permanent cure to the condition.

5. This treatment is tried before the use of medications.
o 1. The average series involves 6 to 12 treatments.
o 2. Some confusion may be noted after the procedure.
o 3. Memory loss will occur but will resolve with time.
110. The nurse is planning a stress management seminar for

clients in an ambulatory care setting. Which concept should
the nurse plan to include in the content of the seminar?
1. Biofeedback has the advantage of using no equipment at
all.
2. Guided imagery is a helpful technique but requires video
equipment for its use.
3. Confrontation is a useful method for solving potentially
stressful conflicts with others.
4. Progressive muscle relaxation techniques are useful for
easing tension from many causes.
4. Progressive muscle relaxation techniques are useful for easing tension from many
causes.
111. A 15-year-old client who is pregnant and unwed tells

the nurse, "My life was unbearable before I met Johnny.
My mother beats me up every day, and my dad has been
sleeping with me since I was 10 years old!" Which
response is appropriate for the nurse to make?
1. "Why didn't you just report your parents for abuse?"
2. "What are you saying? Your parents abused you so you
got pregnant?"
3. "Sounds like you decided to have a baby so you'd have
someone for yourself."
4. "It seems that you needed help to separate from your

family. Do you feel you are ready to have a baby with
Johnny?"
4. "It seems that you needed help to separate from your family. Do you feel you are ready
to have a baby with Johnny?"
112. A 10-year-old girl who has been referred for

evaluation for drawing sexually explicit scenes in her
textbooks says to the psychiatric nurse, "I just felt like it."
Which response is therapeutic for the nurse to make in
order to assess abuse-related symptoms?
1. "Well, a picture paints a thousand words."
2. "You just felt like destroying your textbooks?"
3. "Your parents and teachers are very concerned about
your drawings."
4. "I am concerned about you. Are you now or have you
ever been abused?"
4. "I am concerned about you. Are you now or have you ever been abused?"
113. During a nursing interview, a client says, "My

daughter was murdered in her New York apartment, and her
estranged husband called to tell me. I can't help wondering
if he killed her, but the police have eliminated him as a
suspect." Which statement is a therapeutic nursing
response?
1. "I agree. What do you want to bet he did it?"
2. "Have you shared your concerns with the police?"
3. "I don't think that you should blame yourself one little
bit."
4. "It feels terrible to lose a daughter. I'd have suspicions
about him, too."
2. "Have you shared your concerns with the police?"
114. The nurse is assessing a client in the coronary care

unit (CCU) who seems to fluctuate in his ability to focus
during the day. On the basis of this assessment, which
client problem should the nurse suspect?
1. Dementia as a result of isolation
2. Acute confusion as a result of CCU psychosis
3. Dementia as a result of substance intoxication
4. Interruption in the family as a result of alcohol
withdrawal
2. Acute confusion as a result of CCU psychosis
115. A client with diabetes mellitus is told that amputation

of the leg is necessary to sustain life. The client is very
upset and tells the nurse, "This is all the health care
provider's fault. I have done everything that he has asked
me to do!" How should the nurse interpret the client's
statement?
2. An ineffective coping mechanism
3. A need to notify the hospital lawyer
4. An expression of guilt on the part of the client
116. The nurse is planning to formulate a psychotherapy

group. Several clients are interested in attending the
session. The nurse plans the group, knowing that which is
the maximum number of group members that can be
included?
1. 3
2. 8
3. 14
4. 16
2. 8
117. A nurse assists a client with a diagnosis of obsessivecompulsive disorder (OCD) in his preparations for bedtime.
One hour later the client calls the nurse and says that he is
feeling anxious; he asks the nurse to sit and talk for a while.
Which is the appropriate initial nursing action?
1. Sit and talk with the client.
2. Ask the unlicensed assistive personnel to sit with the
client.
3. Administer the prescribed as-needed antianxiety
medication.
4. Tell the client that it is time for sleep and that you will
talk with him tomorrow.
1. Sit and talk with the client.
118. A nurse is planning care for a group of clients on a

mental health unit. The nurse notes that most of the
assigned clients require interventions commonly used to
treat anxiety disorders. Such antianxiety interventions
would be appropriate for which clients? Select all that
apply.
1. A client with panic disorder
2. Generalized anxiety disorder
3. A client with multiple personality disorder
4. A client with posttraumatic stress disorder (PTSD)
5. A client with obsessive-compulsive disorder (OCD)
o 1. A client with panic disorder

o 2. Generalized anxiety disorder
o 4. A client with posttraumatic stress disorder (PTSD)
o 5. A client with obsessive-compulsive disorder (OCD)
119. A nurse is preparing to admit a client with a diagnosis

of obsessive-compulsive disorder (OCD) to the mental
health unit. The nurse would expect to note which
behaviors in the client?
1. Suspicious and hostile
2. Flexible and adaptable
3. Frightened and delusional
4. Rigidness in thought and inflexibility
4. Rigidness in thought and inflexibility
120. A nurse is performing an assessment on a client

admitted to the mental health unit. The client tells the nurse
that she cannot leave home without checking numerous
times that the iron and coffee pot have been shut off. The
client states that this activity makes her late for many
functions and that she misses engagements on occasion
because of it. The nurse would expect to note which
anxiety disorder documented in the client's record?
1. A phobia
2. Generalized anxiety disorder
4. Obsessive-compulsive disorder (OCD)
4. Obsessive-compulsive disorder (OCD)
121. A nurse is performing an assessment on a client

admitted to the mental health unit. The nurse notes that the
client's diagnosis is documented as obsessive-compulsive
disorder. The nurse plans care knowing that the client
is most likely to experience which type of compulsive
behavior?
1. Fears
2. Actions
3. Illusions
4. Thoughts
2. Actions
122. A mental health nurse asks a nurse orientee to describe

the underlying pathophysiology associated with acts of
compulsion, such as repeated hand washing, performed by
clients with obsessive-compulsive disorder (OCD). The
nurse determines that the orientee understands this disorder
if the orientee identifies which characteristic of the client?
1. Unaware that the client is performing the ritual
2. Consciously attempting to punish the self or others
3. Unconsciously controlling unpleasant thoughts or
feelings
4. Responding to "the voices" telling the client to perform
rituals
3. Unconsciously controlling unpleasant thoughts or feelings
123. A nurse is performing an assessment on a client being

admitted to the mental health unit. During the interview, the
nurse discovers that the client suffered a severe emotional
trauma 1 month earlier and is now experiencing paralysis
of the right arm. Which is the initial nursing action?
1. Refer the client to a psychiatrist.

2. Encourage the client to move and use the arm.
3. Assess the client for organic causes of the paralysis.
4. Encourage the client to talk about his or her feelings.
3. Assess the client for organic causes of the paralysis.
124. A nurse is developing a plan of care for a client

admitted to the mental health unit with a diagnosis of
obsessive-compulsive disorder (OCD). What is the
nurse's first priority in the plan of care?
1. Monitor for repetitive behavior.
2. Demand active participation in care.
3. Educate the client about self-care needs.
4. Establish a trusting nurse-client relationship.
4. Establish a trusting nurse-client relationship.
125. A nurse is preparing to develop a care plan for a client

admitted to the mental health unit with a diagnosis of
obsessive-compulsive disorder (OCD). The nurse should
plan to include which component as a priority in the
nursing plan of care?
1. The medical diagnosis of the client
2. Individualized goals and objectives
3. Attendance at group therapy sessions
4. Self-care measures to improve hygiene
2. Individualized goals and objectives
126. A nurse is reviewing the assessment findings

documented in the chart of a client who is newly admitted
to the mental health unit. The nurse notes that the client has
experienced emotional turmoil and is exhibiting signs and
symptoms that usually result from a loss of physical

functioning, although no such loss can be confirmed
medically. The nurse interprets these findings as indicating
which condition?
1. Depression
3. Posttraumatic stress disorder
127. The home health nurse visits an older adult client who
has recently lost her husband. The client says, "No one
cares about me anymore. All the people I loved are dead."
Which is the appropriate response?
1. "Right! Why not just pack it in'?"
2. "That seems rather unlikely to me."
3. "I don't believe that, and neither do you."
4. "You must be feeling all alone at this point."
4. "You must be feeling all alone at this point."
128. A depressed client who appeared sullen, distraught,

and hopeless a few days ago now suddenly appears calm,
relaxed, and more energetic. Which is the
nurse's best initialaction with regard to the client's altered
demeanor?
1. Continue to assess the client's behaviors and document
clearly in the chart.
2. Report to the health care provider that the client is
adapting to the unit and is feeling safe.
3. Notify the health team of these observations and alert
them to the suspicion that the client is contemplating
suicide.
4. Engage the client in one-to-one supervision, share with
the client the observations that have been assessed, and ask
whether the client is thinking about suicide.
4. Engage the client in one-to-one supervision, share with the client the observations that
have been assessed, and ask whether the client is thinking about suicide.
129. The nurse is performing an assessment on a 16-yearold female client who has been diagnosed with anorexia
nervosa. Which statement, if made by the client, would the
nurse identify as necessitating further assessment on
a priority basis?
1. "I check my weight every day without fail."
2. "I've been told that I am 10% below ideal body weight."
3. "I exercise 3 to 4 hours every day to keep my slim
figure."
4. "My best friend was in the hospital with this disease a
year ago."
3. "I exercise 3 to 4 hours every day to keep my slim figure."
130. A nurse is assessing a client in crisis and is

determining the potential for self-harm. Which assessment
data would indicate that the client is at very high risk for
suicide?
1. The client is impulsive.
2. The client is disorganized.
3. The client has a history of suicide attempts.
4. The client has an immediate plan for a suicide attempt.
4. The client has an immediate plan for a suicide attempt.
131. The nurse is planning to instruct a mental health client

and his or her family about the importance of medication
compliance. The nurse should plan for which interventions
that are associated with increased compliance? Select all
that apply.
1. Giving all medications just once per day
2. Including the family in the medication planning process
3. Working with the psychiatrist to find the right
medication at the right dose
4. Providing the client with the injectable, long-acting form
of the medication if available
5. Working with the psychiatrist to find the medication that
provides the least side effects for the client
o 2. Including the family in the medication planning process
o 3. Working with the psychiatrist to find the right medication at the right dose
o 4. Providing the client with the injectable, long-acting form of the medication if
available
o 5. Working with the psychiatrist to find the medication that provides the least side
effects for the client
132. The nurse is planning care for a client who has been
hospitalized for violent behavior and is at risk for harming
others. Which intervention could potentially present a
danger to the client, health care providers, and others on the
nursing unit?
1. Facing the client when providing care
2. Assigning the client to a room at the end of the hall
3. Ensuring that a security officer is within the immediate
area
4. Keeping the door to the client's room open when

providing care to the client
2. Assigning the client to a room at the end of the hall
133. A nurse who is caring for a client with severe

depression is planning activities for the client. The nurse
goes to the activity room and finds a puzzle; a
checkerboard game; a paint-by-number picture; and
crayons, colored pencils, and paper for drawing. Which
activity would be most appropriate for this client?
1. Drawing
2. Playing checkers
3. Painting by numbers
4. Putting a puzzle together
1. Drawing
134. The nurse is developing a plan of care for a client who

is scheduled to have electroconvulsive therapy (ECT).
Which problem is a priority for this client?
1. Fear
2. Anxiety
3. Risk for aspiration
4. Worry about body image
3. Risk for aspiration
135. A female client in a manic state emerges from her

hospital room. She is topless and is making sexual remarks
and gestures toward the staff and other clients. Which is
the best initial nursing action?
1. Ignore the client.
2. Tell the client to go back to her room.
3. Escort the client to her room and assist her in getting

dressed.
4. Tell the other clients to go into the nursing unit day room
immediately.
3. Escort the client to her room and assist her in getting dressed.
136. A nurse is monitoring a group therapy session. During

this session the members are identifying tasks and
boundaries. The nurse determines that these activities are
characteristic of which stage of group development?
1. Forming
2. Storming
3. Norming
4. Performing
1. Forming
137. When planning discharge care for a client with bipolar

disorder, the nurse determines theneed for further
teaching when the client makes which statement?
1. "I hope I am going to like my new counselor."
2. "I sure hope I will still be productive at work."
3. "I am going to keep a close check on any stress in my
life."
4. "I will take the medicine until I am sure I am feeling well
enough to handle my problems again."
4. "I will take the medicine until I am sure I am feeling well enough to handle my
problems again."
138. A client has consented to participate in Alcoholics

Anonymous (AA) community groups after discharge from
the hospital. The nurse is monitoring the client's response to
the substance abuse sessions. Which statement by the

client best reflects the development of an effective coping
response style and effective processing of information for
self-use?
1. "I know I'm ready to be discharged. I feel like I can say
no' and leave a group of friends if they are drinking. No
problem."
2. "I'll keep all my appointments and go to all my AA
groups; I'll do everything I'm supposed to. Nothing will go
wrong that way."
3. "I'm looking forward to leaving here. I will miss all of
you. So, I'm happy and I'm sad, I'm excited, and I'm scared.
I know that I have to work hard to be strong and that
everyone isn't going to be as helpful as you people."
4. "This group has really helped a lot. I know it will be
different when I go home. But I'm sure that my family and
friends will all help me like the people in this group have....
They'll all help me.... I know they will.... They won't let me
go back to old ways."
3. "I'm looking forward to leaving here. I will miss all of you. So, I'm happy and I'm sad,
I'm excited, and I'm scared. I know that I have to work hard to be strong and that
everyone isn't going to be as helpful as you people."
139. A client who is on lithium carbonate will be

discharged at the end of the week. In formulating a
discharge teaching plan, the nurse should include which
precaution?
1. Avoid soy sauce, wine, and aged cheese.
2. Have the blood lithium level checked every 2 weeks.
3. Take the medication only as prescribed because it can
become addicting.
4. Check with the psychiatrist before using any over-thecounter medications.

4. Check with the psychiatrist before using any over-the-counter medications.
140. The home health nurse visits an agoraphobic client

who experiences panic attacks. Which statement by the
client would indicate a therapeutic response to behavioral
and pharmacological treatment?
1. "I took an extra pill for anxiety and got through the
funeral fairly well."
2. "Taking my anxiety pills before I leave has helped me to
cross the bridge and go to work every morning."
3. "I went to the movies with my family and stayed through
the whole film by sitting in a seat along the aisle."
4. "I have noticed that I'm becoming anxious, and I worry
that if I don't take my anxiety pill just before it's due, I'll go
crazy, so I get it ready to take to calm down."
3. "I went to the movies with my family and stayed through the whole film by sitting in a
seat along the aisle."
141. The psychiatric home care nurse visits a client with a

phobia who experiences panic attacks. The nurse teaches
the client to use paradoxical intention and employs which
method to teach the client this form of therapy?
1. Having the client confront the anxiety-provoking
stimulus and providing support during the episode
2. Instructing the client to do what the client fears and, if
possible, to exaggerate the outcome of this exposure to the
point of humor
3. Presenting the anxiety-provoking stimulus without any
preparation of the client and having him or her remain
exposed until the anxiety subsides

4. Using progressive relaxation toward the client's
individual anxiety hierarchy, increasing the level of
difficulty, and pairing relaxation with the gradual exposure
to reduce his or her anxiety
2. Instructing the client to do what the client fears and, if possible, to exaggerate the
outcome of this exposure to the point of humor
142. A client tentatively diagnosed with a borderline

personality disorder says to the nurse, "I don't know why I
got my tattoo; it was for me. OK? Sometimes I do these
things to get my parents mad, and sometimes I do them
because I'm bored. That's what happened the night I
crashed the family car. I wasn't drunk or suicidal or
anything like the police thought. It was just for kicks!"
Which is the appropriate nursing response?
1. "Next time, pick less dangerous and expensive ways to
explode."
2. "What can you do to stop your behavior when it gets to
that point the next time?"
3. "It's a good thing that you don't abuse substances or you
might be dead because of your reckless disregard."
4. "It is scary when you feel out of control with such
feelings of emptiness and anger that you can't stop
yourself."
4. "It is scary when you feel out of control with such feelings of emptiness and anger that
you can't stop yourself."
143. The nurse is reviewing the medical record of a client

who received electroconvulsive therapy (ECT) in the past.
Which assessment data would indicate to the nurse the
presence of long-term retrograde amnesia in the client?

1. The client has memory loss for 2 days after the
procedure.
2. After the procedure, the client has difficulty recalling
newly learned information.
3. The client had difficulty remembering information
learned for 4 months before ECT.
4. The client has difficulty recalling newly learned
information for 2 weeks following the procedure.
3. The client had difficulty remembering information learned for 4 months before ECT.
144. The mother of a teenage client with an anxiety

disorder is concerned about her daughter's progress on
discharge. She states that her daughter stashes food, eats all
the foods that make her hyperactive, and hangs out with the
"wrong crowd." In helping the mother prepare for her
daughter's discharge, what instruction should the nurse
provide?
1. Restrict the daughter's socializing time with her friends.
2. Restrict the amount of chocolate and caffeine products in
the home.
3. Keep her daughter out of school until she can adjust to
the school environment.
4. Consider taking time off from work to help her daughter
readjust to the home environment.
2. Restrict the amount of chocolate and caffeine products in the home.
145. The nurse is reviewing the record of a client scheduled

for electroconvulsive therapy (ECT). Which medical
diagnosis, if noted on the client's record, would indicate a
need to contact the health care provider scheduled to
perform the ECT?

1. Diabetes mellitus
2. Hyperthyroidism
3. Peripheral vascular disease
4. Recent myocardial infarction
4. Recent myocardial infarction
146. A woman who is a victim of family violence is now

engaged in group therapy sessions. She begins yelling at
another client during the therapy session and screams, "I
can't listen to this. You people are no different from the
ones at home." The client stands up and tips the chair over
backward. What is the nurse's immediate action?
1. Inform the yelling client that she must leave the group.
2. Call security personnel to come to the group therapy
session.
3. Explore the other client's responses to the woman's
yelling behavior.
4. Firmly reinforce group rules to the woman, stating that
aggressive yelling is not acceptable in the group.
4. Firmly reinforce group rules to the woman, stating that aggressive yelling is not
acceptable in the group.
147. A client hospitalized in the mental health unit with

depression is preparing to be discharged to outpatient
status. The nurse is discussing termination and follow-up
plans with the client. Which client statement
would most concern the nurse about the client's discharge
and indicate the need for follow-up treatment?
1. "I want to say thank you. I think I've worked hard and
you, too. I know I'm not finished yet. I need to come back
for appointments. I'm glad. I don't think I could leave

totally on my own."
2. "This has been the hardest trip here for me, but I have
made progress in learning how to communicate, especially
with my family. I'm ready to go. I feel I'm ready this
time...more than the last!"
3. "I really tried to listen to what people said in the group
this time. Sometimes it was hard, but I tried to listen. I
think we really helped each other. I think I've learned to
listen better rather than my jumping too quickly into
something."
4. "I think I really couldn't have worked that job even if the
man had given me the time he should have during the
interview. It's just as well. I really didn't want a job where I
had to work such long hours. But I had good reason to get
depressed and end up here. But it all worked out. I really
didn't want that job anyway."
4. "I think I really couldn't have worked that job even if the man had given me the time
he should have during the interview. It's just as well. I really didn't want a job where I had
to work such long hours. But I had good reason to get depressed and end up here. But it
all worked out. I really didn't want that job anyway."
148. During a support group session for battered women, a

client says, "I was abused by my father and then my
husband, so I finally stabbed my husband when he came
after me, but no one on the jury believed me "cause my
husband, the big shot,' can lie to anyone and be believed."
If no one in the group responds, which statement is the
therapeutic response by the nurse?
1. "A pretty horrible experience for you to undergo. Does
anyone in the group want to respond?"
2. "Yes. Everyone here was ill-used and abused, but what
makes you think that this is a reason to stab someone?"

3. "Your story is very much like every woman's here. I
think you had other options besides violence, don't you?"
4. "Seems as if you went from one abusing man to another.
Do you really think you're here because your husband is a
good liar and a big shot'?"
1. "A pretty horrible experience for you to undergo. Does anyone in the group want to
respond?"
149. The nurse is caring for a client with Alzheimer's

disease who is having difficulty recognizing objects that are
well known, including people. The nurse determines that
the client is experiencing which problem?
1. Ataxia
2. Agnosia
3. Apraxia
4. Aphasia
2. Agnosia
150. A client with schizophrenia says to the nurse, "Will

you protect me from the Grand Duchess?" and points to an
older client who is sitting reading a book. Which statement
is the therapeutic response by the nurse?
1. "Where is she? I'll talk to her."
2. "I can see no Grand Duchess. You will need to trust me
on that."
3. "You will be safe here. Your thinking will be clearer after
your medication starts to work."
4. "The Grand Duchess, huh? Well, I'm the Queen, and I
will order her to stay away from you."
3. "You will be safe here. Your thinking will be clearer after your medication starts to
work."
151. The night nurse reported to the nurse manager that a

client was admitted to the mental health unit after attacking
his father with an iron for interrupting him at his computer.
During nursing rounds, this client interrupts the nurse
manager and says, "I need to get out of here, so I can work
on my computer project to save the world!" Which
statement is a therapeutic response by the nurse manager?
1. "I will be able to talk with you in 15 minutes after I
complete nursing rounds."
2. "You have a project to save the world? I'd really like to
hear about that after I finish rounds."
3. "Well, sit right down and eat your breakfast. You're not
going to save the world on an empty stomach."
4. "You hurt your father because of these thoughts, and you
won't leave here until you can control yourself better."
1. "I will be able to talk with you in 15 minutes after I complete nursing rounds."
152. The nurse is performing a mental status examination

on a client, and the client states, "Glass breaks if you throw
stones or shoot at it with a gun. My cousin shoots guns at
the police all the time at target practice. People who live in
glass houses shouldn't throw stones." Which interpretation
by the nurse is appropriate?
1. Speech is incoherent and tangential.
2. Speech is illogical and loosely associated.
3. Speech is distractible and contains flight of ideas.
4. Speech is pressured and contains clang associations.
2. Speech is illogical and loosely associated.
153. The nurse is caring for a client with schizophrenia

who states, "I decided not to take my medication because I
realize that it really can't help me. Only I can help me."
Which nursing response would be therapeutic?
1. "Only you can help?"
2. "You decided not to take your medication?"
3. "If you can make this wise observation, you probably
don't need your medication any longer."
4. "Your health care provider wants you to continue with
this medication because it is helping you. Do you recall
needing to be hospitalized because you stopped your
medication?"
4. "Your health care provider wants you to continue with this medication because it is
helping you. Do you recall needing to be hospitalized because you stopped your
medication?"
154. A nursing student is asked to identify suicide methods

that are referred to as soft methods. The nursing instructor
determines that the student understands the subject if he or
she states that which is a soft method?
1. Hanging
2. Using a gun
3. Inhaling natural gas
4. Jumping off a bridge
3. Inhaling natural gas
155. The nurse in a mental health clinic is reviewing the

records of the clients to be seen that day. The nurse
determines that which client is at highest risk for suicide?
1. An African-American male lawyer who is 47 years old
and recently divorced
2. A 25-year-old housewife who is married to a widower

and has one 2-year-old son and a 3-year-old stepdaughter
3. A single parent who failed the general equivalency
diploma examination and whose six children are on
scholarship in graduate and medical schools
4. An 18-year-old alcohol- and drug-abusing youth who
must tell his parents that he failed to pass an examination
required for graduation from high school
4. An 18-year-old alcohol- and drug-abusing youth who must tell his parents that he
failed to pass an examination required for graduation from high school
156. The spouse of an alcoholic client is attending a

support group and says to the group members, "It's all very
well for everyone to label me an enabler, but if I didn't call
him in sick at work, he'd lose his job. Where would we be
then?" Which statement by the nurse co-leader would be
therapeutic?
1. "Does anyone in the group want to respond to that?"
2. "So you only call him in sick because you are worried
about money?"
3. "Do you know that enabling creates codependency? Isn't
viewing his failure as yours significant?"
4. "Do you need a house to fall on you to understand this
disease? Can someone else deal with this client's
statements?"
3. "Do you know that enabling creates codependency? Isn't viewing his failure as yours
significant?"
157. A heroin-addicted client who is taking methadone

hydrochloride (Dolophine) discontinues the methadone
without consulting the health care provider. The client says
to the nurse, "I thought I didn't need the methadone after 1

year. I had a job and was even saving money. I can't believe
I ruined everything." Which statement by the nurse is
therapeutic?
1. "It sounds as if everything you do is either all-or-none."
2. "Your counselor called and asked for you, so it would
seem that everything isn't ruined yet."
3. "The methadone program is now refusing you, and your
boss fired you, so you're at square one, so to speak."
4. "It does sound as if you need to work on repair, but now
you will need to be more alert to your signs of being
vulnerable to slipping off your treatment program."
4. "It does sound as if you need to work on repair, but now you will need to be more alert
to your signs of being vulnerable to slipping off your treatment program."
158. An alcohol-troubled client says, "The 12 Steps of

Alcoholics Anonymous (AA) freak me out. I had to go for a
drink after 1 hour with those people; they're fanatics!"
Which statement by the nurse would be therapeutic?
1. "It sounds as if you look for any reason to drink!"
2. "I agree. AA is definitely not for you if you find it is a
trigger to restart drinking."
3. "You think AA is for fanatics? You know, I just don't
understand how you can judge individuals who are sober."
4. "Not all strategies for remaining sober are the best for
everyone. It seems that you don't view yourself as having
the same problem as others in the group."
4. "Not all strategies for remaining sober are the best for everyone. It seems that you don't
view yourself as having the same problem as others in the group."
159. A 37-year-old client who is recovering from

benzodiazepine dependence says, "I think I've walked
under a black cloud. I've lost so many people. First, my
brother dies of the big C; then my husband leaves me for a
20-year-old bimbo. I wish I had a Xanax right now." Which
statement by the nurse would be therapeutic?
1. "The big Cit must have been a terrible loss for you
when your brother died."
2. "Did you ever stop to think that your spouse might have
gotten fed up with your using Xanax so much?"
3. "It sounds as if you feel that all of this has just happened
to you. I wonder what part you played in events?"
4. "Can you tell me what you think the Xanax can do for
you? Are there other things you used to do that might help
you just as well?"
4. "Can you tell me what you think the Xanax can do for you? Are there other things you
used to do that might help you just as well?"
160. The husband of an alcohol-troubled wife says, "If

anyone had said I'd be henpecked, I'd have called them a
liar, but now I realize that I'm codependent." Which
1. "Did you know that more people identify with just what
you are saying?"
2. "Which of the features that describe codependence
caused you to sit up and take notice?"
3. "Can you tell me more about that? You see yourself as
being codependent with your wife?"
4. "Have you discussed your feelings with your wife? What
does your wife think about what you've said?"
3. "Can you tell me more about that? You see yourself as being codependent with your
wife?"
161. A 45-year-old client states that he used to drink a

cocktail nightly after work and also had a drink with his
meal. Now he has two drinks before dinner and two or
three more drinks during his meal. As the client continues
to describe his alcohol intake, the nurse discovers that he
also has added a couple of drinks at night to help him sleep.
Which is the most accurate assessment of his alcohol
consumption?
1. Tolerance
2. Addiction
3. Adjustment
4. Heavy social drinking
1. Tolerance
162. A battered wife says, "My husband never beat me up,

so I didn't think he was abusive even after he lost all our
money through bad deals, bullying me into his schemes,
gambling, womanizing, and now not holding a real job with
benefits. I still let him refinance our mortgage, take money
out of the bank, and put the house in his name." Which
statement by the nurse is therapeutic?
1. "When did you do that? How could you be so gullible?"
2. "Most emotionally battered spouses begin to heal once
they start to identify their husbands' behaviors."
3. "How is it that a man who doesn't earn the chief
supporting income can maneuver someone like he has?"
4. "So you realize that there are many ways to erode
someone's self-confidence and independence? Can you
share with me some ways that you feel you can cope with
this abuse?"
4. "So you realize that there are many ways to erode someone's self-confidence and
independence? Can you share with me some ways that you feel you can cope with this
abuse?"
163. An 80-year-old resident in a long-term care facility

prepares to walk out into a rainstorm after saying, "My
father is waiting to take me for a ride." Which is the
appropriate response by the nurse?
1. "I need to place you in restraints."
2. "I need you to sign a form before leaving."
3. "How old are you? Your father must no longer be living."
4. "I'm glad you told me that. Let's have a cup of coffee,
and you can tell me about your father."
4. "I'm glad you told me that. Let's have a cup of coffee, and you can tell me about your
father."
164. A client who is exhibiting psychotic behaviors is

admitted to the psychiatric unit. In developing a plan of
care, the nurse should identify which as the priority client
problem?
1. Disturbed thought processes
2. Lack of knowledge about the behavior
3. Inability to care for self with bathing procedures
4. Altered nutrition: inadequate consumption of food
1. Disturbed thought processes
165. The nurse is developing a daily care program for a

depressed client who was just admitted to the mental health
unit. Which is the best approach when planning activities
for this client?
1. Plan nothing until the client asks to participate in milieu.

2. Encourage the client to play solitaire while providing a
deck of cards.
3. Provide a structured daily program of activities and
encourage the client to participate.
4. Offer the client a menu of daily activities and insist that
the client participate in all of them.
3. Provide a structured daily program of activities and encourage the client to participate.
166. A client with a history of panic disorder comes to the

emergency department and states to the nurse: "Please help
meI think I'm having a heart attack." What is
the priority nursing action?
1. Assess the client's vital signs.
2. Identify the client's activity during the pain.
3. Assess for signs related to a panic disorder.
4. Determine the client's use of relaxation techniques.
1. Assess the client's vital signs.
167. The nurse reviews the assessment data of a client

admitted to the hospital with a diagnosis of anxiety. The
nurse should assign priority to which assessment finding?
1. Tearful, self-isolated
2. Affect bland, withdrawn
3. Fist clenched, pounding table, fearful
4. Temperature 98.4 F; respirations 18 breaths/min
3. Fist clenched, pounding table, fearful
168. A home care nurse suspects that a client's spouse is

experiencing caregiver strain. Which nursing action will
assist in supporting the nurse's suspicion?
1. Obtaining feedback from the client about the coping

abilities of the caregiver
2. Gathering subjective and objective assessment from the
caregiver and the client
3. Making a referral to the home care agency social worker
to complete the assessment
4. Waiting until the caregiver expresses concern about the
significant responsibility in caring for the client
2. Gathering subjective and objective assessment from the caregiver and the client
169. A client who has a history of being sexually assaulted

is admitted to a psychiatric unit for self-mutilation. She is
found sucking her thumb while rocking in her bed and does
not respond to verbal communication. The nurse should
recognize that this behavior demonstrates which coping
mechanism?
1. Fantasy
2. Regression
3. Displacement
4. Compensation
2. Regression
170. A client is being evaluated for possible antisocial

personality disorder. Which behavior is expected of a client
with this disorder?
1. Asking for reassurance
2. Hypervigilance around others
3. Disregard for the rights of others
4. Always wanting to spend time with others
3. Disregard for the rights of others
171. The client with a diagnosis of dependent personality

disorder is most likely to have problems coping with which
issue?
1. Trust
2. Socialization
3. Making decisions
4. Self-centeredness
3. Making decisions
172. Which piece of subjective data obtained during

assessment of a severely anxious client would indicate the
possibility of posttraumatic stress disorder?
1. "I'm afraid to go outside."
2. "I keep reliving the abuse."
3. "I am afraid to drive on the freeway."
4. "I keep washing my hands over and over."
2. "I keep reliving the abuse."
173. A client admitted to the hospital at the beginning of

the nursing shift with a diagnosis of alcohol dependence
tells the nurse that she had her last drink 6 hours ago. The
nurse expects which finding based on knowledge of time
for appearance of withdrawal symptoms?
1. The danger time has passed.
2. The next hour could be critical.
3. Signs may appear during the present shift.
4. Withdrawal will occur after the shift is over.
3. Signs may appear during the present shift.
174. Thiamine supplementation and other nutritional

vitamin support measures are prescribed for clients who
have been using alcohol to prevent or decrease the risk of

which complication?
1. Cirrhosis
2. Delirium tremens
3. Esophageal varices
4. Wernicke-Korsakoff syndrome
4. Wernicke-Korsakoff syndrome
175. Which mental health professional is responsible for

the milieu in an inpatient psychiatric setting?
1. Nurse
2. Psychiatrist
3. Psychologist
4. Social worker
1. Nurse
176. Which best describes the purpose of behavioral

therapy?
1. Fosters positive behavioral change
2. Develops structure and organizes time
3. Creates insight into maladaptive behavior
4. Decreases stress through relaxation training
1. Fosters positive behavioral change
177. The client experiencing a great deal of stress and

anxiety is being taught to use self-control therapy. Which
statement by the client indicates a need for further
teaching about the therapy?
1. "This form of therapy can be applied to new situations."
2. "An advantage of this technique is that change is likely
to last."
3. "Talking to oneself is a basic component of this form of

therapy."
4. "It provides a negative reinforcement when the stimulus
is produced."
4. "It provides a negative reinforcement when the stimulus is produced."
178. Laboratory work is prescribed for a client who has

been experiencing delusions. When the nurse approaches
the client to obtain a specimen of blood, the client begins to
shout, "You're all vampires. Let me out of here!" Which is
the appropriate nursing response?
1. "What makes you think that I am a vampire?"
2. "I'll leave and come back later for your blood."
3. "I am not going to hurt you; I am going to help you."
4. "It must be frightening to think that others want to hurt
you."
4. "It must be frightening to think that others want to hurt you."
179. A supervisor reprimands the nurse in charge of the

nursing unit because the charge nurse has not adhered to
the unit budget. Later that afternoon the charge nurse
accuses the nursing staff of wasting supplies. What type of
behavior is this an example of?
1. Denial
2. Repression
3. Suppression
4. Displacement
4. Displacement
180. A client comes to the emergency department following

an assault and is extremely agitated, trembling, and
hyperventilating. What is the appropriate initial nursing

action?
stimulation.
181. A client comes to the emergency department following

an assault and is extremely agitated, trembling, and
hyperventilating. What is the appropriate initial nursing
action?
stimulation.
182. A woman comes into the emergency department

following an assault. She presents with hyperventilation,
pacing, rapid speech, and headache. Which level of anxiety
should the nurse assess that the client is experiencing?
1. Panic
2. Severe
3. Moderate
4. Psychotic
2. Severe
183. A nurse is developing a plan of care for the client who

is upset following the loss of a job. The client is verbalizing
concerns regarding the ability to meet financial obligations.
Which is the appropriate client problem?
1. Anxiety
2. Confusion about social roles
3. Inability to meet role expectations
4. Impairment of interactions among family members
3. Inability to meet role expectations
184. A client arrives in the emergency department in a

crisis state. The client demonstrates signs of profound
anxiety and is unable to focus on anything but the object of
the crisis and the effect on self. Which item should the
initial nursing assessment focus on?
1. The object of the crisis
2. The client's coping mechanisms
3. The presence of support systems
4. The physical condition of the client
4. The physical condition of the client
185. A clinic nurse is monitoring a client with anorexia

nervosa. Which statement, if made by a client, should
indicate to the nurse that treatment has been effective?
1. "I'll eat until I don't feel hungry."
2. "I no longer have a weight problem."
3. "I don't want to starve myself anymore."
4. "My friends and I went out to lunch today."
4. "My friends and I went out to lunch today."
186. A client with a history of anxiety appears to be in the

second phase of crisis response. The nurse prepares for the
possibility that which will occur?
1. The client will show the initial signs that coping methods
are failing.
2. The client will employ new coping methods that will
resolve the problem.
3. The client will experience severe anxiety as a result of
failed coping methods.
4. The client will begin to implement coping methods that
have been successful in the past.
2. The client will employ new coping methods that will resolve the problem.
187. Which is the primary goal of crisis intervention

therapy?
1. Introduce new, effective coping methods to the client.
2 .Assess the client in order to identify the causative
stressors.
3. Establish a sustainable therapeutic nurse-client
relationship.
4. Assist the client in returning to the level of pre-crisis
functioning.
4. Assist the client in returning to the level of pre-crisis functioning.
188. Which statement, if made by a client who has recently

experienced an emotional crisis, ismost likely to assure the
nurse that she has returned to her pre-crisis level of
functioning?
1. "My husband tells me that I'm back to my old cheerful
self."
2. "When I find myself getting stressed, I immediately use
the relaxation techniques I've learned."

3. "My boss tells me that I'm being considered for a
promotion and a raise."
4. "I have a different perspective on life now. I'm more
confident of my ability to handle any problem."
3. "My boss tells me that I'm being considered for a promotion and a raise."
189. A homeless shelter has sustained severe damage as a

result of a fire, and most of the structure and people's
belongings were destroyed. Ten of the individuals who are
being displaced have a history of chronic mental illness.
The mental health team coordinating
support initially should focus their efforts on which action?
1. Assessing the clients' need for supportive therapy
2. Evaluating the clients for signs of stress overload
3. Providing the clients with shelter, clothing, and food
4. Planning means for the clients to receive their
medications
3. Providing the clients with shelter, clothing, and food
190. A small rural community has experienced a hurricane

that has destroyed 65% of the homes and businesses in the
area. Community mental health teams recognize that in the
immediate post-disaster period, the most effective means
of identifying individuals experiencing difficulty coping
psychologically with the disaster is to take which action?
1. Establish a centrally located mental health disaster
center.
2. Ask for referrals from local health care providers and
clergy.
3. Station mental health professionals at established
assistance centers.
4. Distribute fliers identifying the availability of
psychological counseling.
3. Station mental health professionals at established assistance centers.
191. The nurse is preparing a care plan for a client

exhibiting negative symptoms of schizophrenia. Which are
indicative of negative symptoms? Select all that apply.
1. Short attention span
2. Delusional thoughts
3. Inappropriate body movements
4. Loose associations of thought
5. Limited ability to communicate verbally
o 1. Short attention span
o 5. Limited ability to communicate verbally
192. The nurse caring for a client diagnosed with

schizophrenia should include which interventions into the
plan of care to assist in managing the client's concrete
thinking?
1. Provide the client with written instructions regarding the
routine of the unit.
2. Present verbal instructions regarding expectations in
single, simple commands.
3. Assess the client's understanding of instructions by
requiring restatement of expectations.
4. Incorporate family members in determining the
emotional and physical needs of the client.
2. Present verbal instructions regarding expectations in single, simple commands.
193. The nurse understands that schizophrenia hinders a

client's cognitive ability to appropriately process data from
external stimuli. This dysfunctional processing can result in
which problem?
1. Catatonia
2. Hallucinations
3. Magical thinking
4. Delusional beliefs
4. Delusional beliefs
194. During the admission assessment process, the nurse

observes that a client with paranoid schizophrenia has
multiple dental caries and mouth ulcers. The client denies
oral pain or difficulty eating and does not present any
concern over the nurse's finding. The nurse recognizes the
client's response as most likely the result of which client
factor?
1. Apathy
2. Impaired pain perception
3. Distrust of authority figures
4. Poor verbal communication skills
2. Impaired pain perception
195. A client who is watching television in the dayroom

shares with the nurse that he has begun seeing his mother
being assaulted on the television screen. Which is the
nurse's initial intervention?
1. Turn off the television.
2. Walk with the client around the unit.
3. Discuss the possible hallucinatory triggers.
4. Help him call his mother so he can speak with her.
1. Turn off the television.
196. The nurse is planning relapse prevention information

for a client with schizophrenia who is being discharged.
The nurse understands that it is important to ensure
which primaryintervention in the plan whenever possible?
1. Including the client's support system in the teaching
2. Facilitating weekly maintenance therapy for the client
3. Having the client restate discharge goals and strategies
4. Stressing the importance of client compliance with the
medication plan
1. Including the client's support system in the teaching
197. A depressed client verbalizes feelings of low selfesteem and self-worth typified by statements such as, "I'm
such a failure. I can't do anything right." Which is the best
nursing response?
1. Tell the client that this is not true, that we all have a
purpose in life.
2. Identify recent behaviors or accomplishments that
demonstrate the client's skills.
3. Reassure the client that you know how the client is
feeling and that things will get better.
4. Remain with the client and sit in silence. This will
encourage the client to verbalize feelings.
2. Identify recent behaviors or accomplishments that demonstrate the client's skills.
198. The history assessment of a client diagnosed with

schizophrenia confirms a routine that includes smoking two
packs of cigarettes and drinking 10 cups of coffee daily.
The nurse recognizes that which is the greatest risk for
injury these behaviors present for this client?

1. Developing lung cancer and/or other respiratory
disorders
2. Withdrawal symptoms triggering a stress-induced relapse
3. Diminishing the effectiveness of psychotropic
medication
4. Developing gastrointestinal disorders, including bleeding
ulcers
3. Diminishing the effectiveness of psychotropic medication
199. The nurse should identify which best goal for a client
experiencing hallucinations?
1. Support the client through the hallucination in a caring,
therapeutic manner.
2. Provide the client with insight as to why he is
experiencing the hallucination.
3. Facilitate the client's awareness that the hallucination is
not the reality of the world.
4. Help the client understand that he can learn to ignore the
hallucination through appropriate coping mechanisms.
3. Facilitate the client's awareness that the hallucination is not the reality of the world.
200. The parents of a young adult have expressed concerns

about the cognitive and emotional changes they have noted
in their child. The nurse recognizes which assessment and
diagnostic data as associated with the diagnosis of
schizophrenia? Select all that apply.
1 .A birthday of March 30
2. A loss of interest in hobbies
3. A suicide attempt 6 months ago
4. Adopted by family at age 14 months
5. Brain scan shows increased blood flow to the frontal

lobes
6. Magnetic resonance imaging shows temporal lobe
atrophy
o 1 .A birthday of March 30
o 2. A loss of interest in hobbies
o 3. A suicide attempt 6 months ago
o 6. Magnetic resonance imaging shows temporal lobe atrophy
201. The nurse reviewing a client's diagnostic results

recognizes that which is a possible positive indication for a
diagnosis of schizophrenia?
1. Abnormally high blood flow to the frontal lobes
2. Atrophy of both the limbic structures and cerebellum
3. Abnormally small fissures on the surface of the brain
4. Atrophy of the lateral and/or third ventricles of the brain
4. Atrophy of the lateral and/or third ventricles of the brain
202. The nurse should provide which information to the

parents of a teenager about their child's new diagnosis of
schizophrenia?
1. Their child will very likely experience difficulty in
school.
2. The prognosis for their child is good because he is so
young.
3. Their child likely has an imbalance of the chemical
dopamine.
4. With medication, their child is not likely to experience
relapses.
3. Their child likely has an imbalance of the chemical dopamine.
203. The nurse should include which information in the

medication teaching plan for a client diagnosed with
schizophrenia?
1. Coffee, tea, and soda consumption should be limited.
2. If the client is compliant, the relapse of symptoms will
never occur.
3. Psychotropic medications may cause mild cardiovascular
symptoms.
4. Most schizophrenic clients are able to taper off their
medications eventually.
1. Coffee, tea, and soda consumption should be limited.
204. Which statement made by a severely depressed client

requires the nurse's immediate attention?
1. "Feeling better really isn't important to me anymore."
2. "No one can really understand what I've had to deal
with."
3. "I really don't like the way that new depression pill
makes me feel."
4. "I've not been the least bit interested in socializing since
my divorce."
1. "Feeling better really isn't important to me anymore."
205. The nurse is developing a discharge plan for the

family of a client diagnosed with a mood disorder. The
nurse should plan to include which priority information to
the family?
1. Signs that the client may be considering suicide
2. Brain anomalies that are responsible for this disorder
3. The importance benzodiazepines play in the management

of this disorder
4. The possibility that the client will experience
medication-induced tinnitus
1. Signs that the client may be considering suicide
206. Which are characteristics of seasonal affective

disorder (SAD)? Select all that apply.
1. Affects males more often than females
2. Stimulates a craving for carbohydrates
3. Is related to abnormal melatonin metabolism
4. Usually results in debilitating symptomatology
5. Improves during the spring and summer months
6. Is a result of alterations in the available amounts of
sunlight
o 2. Stimulates a craving for carbohydrates
o 3. Is related to abnormal melatonin metabolism
o 5. Improves during the spring and summer months
o 6. Is a result of alterations in the available amounts of sunlight
207. When assessing a client's possible physical

dependency on alcohol, the nurse should ask
which priority question?
1. "Are you drinking more than you did 5 years ago?"
2. "How do you feel when you haven't had a drink all day?"
3. "Does your drinking ever cause you problems with your
family?"
4. "Do you ever feel that you really need a drink to calm
your nerves?"
2. "How do you feel when you haven't had a drink all day?"
208. Which are the most likely characteristics of an alcohol

abuser? Select all that apply.
1. Male
2. Single
3. Suicidal at least once
4. Abusing drugs as well as alcohol
5. Employed in a minimal wage job
6. Been through detoxification at least twice
o 1. Male
o 3. Suicidal at least once
o 4. Abusing drugs as well as alcohol
209. The nurse is providing a health promotion session to a

group of teenagers and is discussing the abuse of
barbiturates. The nurse should provide which information
to the teenagers?
1. Commonly results in a rush of energy
2. Is the cause of many drug overdose deaths
3. Results in only psychological dependency
4. Brings about an increase in blood pressure (BP)
2. Is the cause of many drug overdose deaths
210. Which is a common outcome that results from the

effect of methamphetamine abuse on the vascular system?
1. Poor wound healing
2. Thrombophlebitis
3. Hypotension
4. Emboli
1. Poor wound healing
211. An adolescent has been prescribed an amphetamine to

help manage a diagnosis of attention deficient hyperactivity
disorder. To best minimize the risk of abuse and/or
overdose, the nurse expects that the medication will be
administered via which method?
1. Sublingual tablets
2. Rectal suppository
3. Intradermal patch
4. Weekly intramuscular injections
3. Intradermal patch
212. A client who has a history of opiate abuse asks the

nurse, "Why do I crave this stuff so much?" The nurse
responds, knowing that the client's craving is a result of
which factor?
1. Lack of naturally occurring endorphins
2. Development of tolerance for the drug
3. Client's psychological dependency on opiates
4. Typical abuse pattern for central nervous system (CNS)
depressants
1. Lack of naturally occurring endorphins
213. When admitting a client to the mental health unit who

has a history of hallucinogenic drug use, the nurse should
be prepared to manage which occurrences unique to abuse
of this classification of drugs?
1. Flashbacks
2. Amotivational syndrome
3. Enhanced physical strength

4. Absence of pain perception
1. Flashbacks
214. When discussing an individual's tendency to substance

abuse, the nurse should identify which as
a primary biological factor?
1. Male gender
2. Family history
3. Ethnic background
4. Risk-taking personality
2. Family history
215. During the termination phase of the nurse-client

relationship, the clinic nurse observes that the client has
made several sarcastic remarks and has an angry affect.
Which is the most appropriate interpretation of the client's
behavior?
1. The client needs to be admitted to the hospital.
2. The client needs to be referred to the psychiatrist as soon
as possible.
3. The client requires further treatment and is not ready to
be discharged.
4. The client is displaying typical behaviors that can occur
during termination.
4. The client is displaying typical behaviors that can occur during termination.
216. A home health nurse is talking to the spouse of a client

who is taking an antidepressant. The spouse says, "Now
that my husband is responding to the antidepressant, the
suicidal risk is over and you can stop making these home
visits." After analyzing this statement, which is the

appropriate nursing response?
1. "I need to continue with my visits. Your comment
reflects a lack of knowledge that this disease runs in
families."
2. "I agree with you. Clients who want to kill themselves
are suicidal for only a limited time. No one can feel selfdestructive forever."
3. "I agree with you. The suicidal threats were really
attention seeking. Continuing to visit would reinforce your
husband's use of manipulation."
4. "I need to continue with my visits. Most suicides occur
within 3 months after improvement begins, because the
client now has the energy to carry out the suicidal
intentions."
4. "I need to continue with my visits. Most suicides occur within 3 months after
improvement begins, because the client now has the energy to carry out the suicidal
intentions."
217. A client comes into the emergency department in a

severe state of anxiety after a car crash. Which is the
appropriate nursing intervention?
1. Remain with the client.
2. Put the client in a quiet room.
3. Teach the client deep breathing.
4. Encourage the client to talk about her feelings and
concerns.
1. Remain with the client.
218. The nurse assesses a client with an admitting diagnosis

of bipolar affective disorder, mania. Which symptom
presented by the client would require the

nurse's immediate intervention?
1. Outlandish behaviors and inappropriate dress
3. Grandiose delusions of being a royal descendent of King
Arthur
4. Constant, incessant talking that includes sexual
innuendoes and teasing the staff
219. The nurse is performing an assessment on a client with

dementia. Which would be a manifestation associated with
dementia?
1. Confabulation
2. Improvement in sleeping
3. Absence of sundown syndrome
4. Presence of personal hygienic care
1. Confabulation
220. A client is admitted to the hospital with a diagnosis of

major depression, severe, single episode. The nurse
assesses the client and notes that the client has poor
nutritional intake. Which is the appropriate nursing
intervention?
1. Weigh the client three times per week before breakfast.
2. Explain to the client the importance of a good nutritional
intake.
3. Report the nutritional concern to the psychiatrist and
obtain a nutritional consultation as soon as possible.
4. Schedule brief nursing interactions with the client during
several meals in which small portions are offered.
4. Schedule brief nursing interactions with the client during several meals in which small
portions are offered.
221. A client with a diagnosis of major depression,

recurrent, with psychotic features, is admitted to the mental
health unit. To create a safe environment for the client, the
nurse most importantly devises a plan of care that deals
specifically with which problem?
1. Nutrition
2. Self-care needs
3. Disturbed thinking
4. Knowledge about the disorder
3. Disturbed thinking
222. The nurse is caring for a client with anorexia nervosa.

The nurse is monitoring the behavior of the client and
understands that the client with anorexia nervosa manages
anxiety by which action?
1. Engaging in immoral acts
2. Always reinforcing self-approval
4. Having the need always to make the right decision
223. The nurse has been working with a victim of rape in a

clinic setting for the past 4 weeks. Which would be
unrealistic as a short-term initial goal for this client?
1. Physical wounds will heal.
2. The client will participate in the treatment plan.
3. The client will verbalize feelings about the event.
4.The client will resolve feelings of fear and anxiety related
to the rape trauma.
4.The client will resolve feelings of fear and anxiety related to the rape trauma.
224. Which is the best approach for the nurse to use in

crisis counseling?
1. Reassuring
2. Passive listening
3. Explore early life experiences
4. Active, with focus on the current situation
4. Active, with focus on the current situation
225. A client comes to the clinic after losing all of his

personal belongings in a hurricane. The nurse notes that the
client is coping ineffectively with the situation. Which is
the least realistic goal for this client?
1. The client will develop adaptive coping patterns.
2. The client will identify a realistic perception of stressors.
3. The client will stop blaming himself for the lack of
insurance.
4. The client will express and share feelings regarding the
present crisis.
3. The client will stop blaming himself for the lack of insurance.
226. The nursing care plan indicates a problem of selfdirected violence and the risk for suicide,related to suicidal
ideations with a plan. An expected outcome of this plan of
care would be that the client does which?
1. Displays less anxiety and agitation
2. Establishes a relationship with staff and peers
3. Develops adequate coping and problem-solving skills
4. Denies suicidal ideation and identifies options to deal
with stressors
4. Denies suicidal ideation and identifies options to deal with stressors
227. A client is admitted to the mental health unit with a

problem related to grieving, because of the loss of a spouse.
The client progresses well and is approaching discharge.
Which is an appropriate outcome for the client?
1. The client reports three additional coping strategies.
2. The client verbalizes stages of grief and plans to attend a
community grief group.
3. The client verbalizes connections between significant
losses and low self-esteem.
4. The client verbalizes decreased desire for self-harm and
discusses two alternatives to suicide.
2. The client verbalizes stages of grief and plans to attend a community grief group.
228. A client who has been hospitalized with a paranoid

disorder refuses to turn off the lights in the room at night
and states, "My roommate will steal me blind." Which is
the appropriate response by the nurse?
1. "Why do you believe this?"
2. "Tell me more about the details of your belief."
3. "I hear what you are saying, but I don't share your
belief."
4. "If you want a pass for tomorrow evening's movie, you'd
better turn that light off this minute."
3. "I hear what you are saying, but I don't share your belief."
229. A client who has just received a diagnosis of asthma

says to the nurse, "This condition is just another nail in my
coffin." Which response by the nurse is therapeutic?
1. "Do you think that having asthma will kill you?"
2. "You seem very distressed over learning you have

asthma."
3. "I'm not going to work with you if you can't view this as
a challenge rather than a nail in your coffin.'"
4. "Asthma is a very treatable condition. It is important to
properly administer your medications. Let's practice with
your inhalant."
2. "You seem very distressed over learning you have asthma."
230. A 63-year-old woman whose husband died 2 months

ago says to the visiting nurse, "My daughter came over
yesterday to help me move my husband's things out of our
bedroom, and I was so angry with her for moving his
slippers from where he always kept them under his side of
our bed. She doesn't know how much I'm hurting." Which
1. "I know just how you feel because I lost my husband last
summer."
2. "It's OK to grieve and be angry with your daughter and
anyone else for a time."
3. "You need to focus on the many good years you both
enjoyed together and move on."
4. "Although it's a troubling time for you, try to focus on
your children and grandchildren."
2. "It's OK to grieve and be angry with your daughter and anyone else for a time."
231. An older client says to the home care nurse, "I can't
believe that my wife died yesterday. I keep expecting to see
her everywhere I go in this house, ready to plan our
activities for the day." Which is the therapeutic nursing
response?
1. "It must be hard to accept that she has passed away."

2. "Are you saying that she made all the social plans for
you?"
3. "Focus on the fact that her suffering is over and that she
had a good life with you."
4. "Try to focus on the fact that you have three wonderful
children and that you and your wife loved one another for
years."
1. "It must be hard to accept that she has passed away."
232. A hospitalized client with a diagnosis of schizophrenia

who is experiencing delusions says to the nurse, "I know
that the doctor is talking to the top man in the mob to get
rid of me." Which response should the nurse make to the
client?
1. "I don't believe this is true."
2. "The doctor is not talking to the mob."
3. "What makes you think the doctor wants to get rid of
you?"
4. "I don't know anything about the top man in the mob. Do
you feel afraid that people are trying to hurt you?"
4. "I don't know anything about the top man in the mob. Do you feel afraid that people
are trying to hurt you?"
233. A nurse is gathering data from a client with a phobia.

The client tells the nurse that he consistently avoids
attending community functions because he fears that he
will be asked to speak publicly to the members. On the
basis of this information, the nurse determines that the
client is experiencing which condition?
1. Nyctophobia
2. Social phobia
3. Agoraphobia
4. Claustrophobia
2. Social phobia
234. The nurse is monitoring a woman with a diagnosis of

depression. Which behavior, if observed by the nurse,
indicates that suicide precautions should be implemented
for this client?
1. The woman refuses to attend group therapy.
2. The woman asks to meet with a lawyer to take care of
unfinished business.
3. The woman has an argument with her significant other
during visiting hours.
4. The woman swears at her roommate because she takes
too much time in the bathroom.
2. The woman asks to meet with a lawyer to take care of unfinished business.
235. A client is found to have rape trauma syndrome. The

nurse plans care for the client knowing that which occurs in
this condition?
1. More than one assault
2. Re-experiencing recollections of the trauma
3. Actively initiating situations in which sex is forced
4. Imagining the use of foreign objects in a sexual situation
2. Re-experiencing recollections of the trauma
236. A nurse working in the day care center is told that a

child with autism will be attending the center. The nurse
collaborates with the staff of the day care center to plan
activities that will meet the child's needs. Which should
have the priority consideration in planning activities for

the child?
1. Safety with activities
2. Familiarity with all activities
3. Activities providing verbal stimulation
4. Social interactions with other children
1. Safety with activities
237. A nurse is assigned to care for a chemically dependent

client who has the potential for violent episodes. In
planning to care for the client, which action by the nurse
should receive priority?
1. Speaks slowly to the client
2. Projects an attitude of calmness
3. Bargains to prevent the violent episodes
4. Moves quietly when approaching the client
2. Projects an attitude of calmness
238. A nurse has been caring for a client with a diagnosis of

depression. The client says to the nurse, "I wish you would
just be my friend." Which is the appropriate response by
the nurse?
1. "I am your friend."
2. "Our relationship is a therapeutic and helping one."
3. "I can't be your friend. I'm the nurse, and you're the
client."
4. "You have plenty of friends. You don't need me to be
your friend, too."
2. "Our relationship is a therapeutic and helping one."
239. A nurse is developing a care plan that will include

goals that will help the client achieve an optimal level of
functioning and appropriate resource utilization. When the
nurse enters the client's room, the client asks the nurse,
"Could you ask the health care provider (HCP) to let me
have a pass for the weekend?" Which response is
appropriate that assists the client in achieving these goals?
1. "When your HCP comes in, I will ask for a pass for the
weekend."
2. "When the HCP arrives on the unit, I will let them know
that you have a question."
3. "You can't have a pass for the weekend. You are not
ready, and I'm sure that your HCP will say no."
4." I will call the HCP and find out if you can have a pass
so that you can make your arrangements."
2. "When the HCP arrives on the unit, I will let them know that you have a question."
240. Which subject should the nurse address in preparing

for the orientation phase of the therapeutic relationship?
1. Facilitating behavioral change
2. Promoting self-esteem in the client
3. Promoting problem solving skills in the client
4. Establishing the parameters of the relationship
4. Establishing the parameters of the relationship
241. A nurse who is reviewing the record of a client

admitted to the mental health unit notes that the client was
admitted by voluntary status. Which statement describes
voluntary status?
1. The admission was mandated by court order.
2. The admission was made without the client's consent.
3. The client has the right to demand and obtain release

from the hospital.
4. The client was committed by a group of designated
mental health professionals.
3. The client has the right to demand and obtain release from the hospital.
242. A nurse is collecting data on a client diagnosed with

mild depression. The client says to the nurse, "I haven't had
an appetite at all for the last few weeks." Which best
response should the nurse make?
1. "The last few weeks?"
2. "You haven't had an appetite at all?"
3. "When the medication begins to work, you will begin to
feel better."
4. "Think about everything that you have been through. It
will take time for your appetite to improve."
2. "You haven't had an appetite at all?"
243. A nurse in the emergency department is preparing to

care for a client who has just been sexually assaulted.
Which client behavior demonstrates denial?
1. The client is calm and quiet.
2. The client is blaming her sister for the incident.
3. The client is justifying unacceptable self-behaviors.
4. The client is verbalizing generalizations about the
incident.
1. The client is calm and quiet.
244. The day nurses in a psychiatric unit are receiving

report from the night shift. While this is occurring, a client
approaches the nurses' station, becomes very loud and
offensive, and demands to be seen by the health care

provider (HCP) immediately. Which is the appropriate
nursing intervention?
1. Inform the client that the behavior is unacceptable.
2. Tell the client to wait in his or her room until report is
over.
3. Tell the client that the HCP will be called as soon as
report is completed.
4. Offer to assist the client to an examination room until the
HCP is notified.
4. Offer to assist the client to an examination room until the HCP is notified.
245. A nurse is developing a plan of care for a client with a

psychotic disorder who is experiencing altered thoughts
that include the belief food is being poisoned. Which
strategy should the nurse plan to implement that will
encourage the client to discuss feelings?
1. Use open-ended questions and silence.
2. Focus on the components of adequate nutrition.
3. Focus on the fact that the client's beliefs are untrue.
4. Instruct the client about the need for adequate nutrition.
1. Use open-ended questions and silence.
246. A mental health nurse has been meeting with a client

on a weekly basis and over the past several weeks, the
client has been consistently 15 minutes late. Which nursing
action is appropriate regarding the client's lateness for the
scheduled meetings?
1. Ignore the behavior.
2. Tell the client that the meetings will be terminated.
3. Ask the client if something is going on that the client
may have difficulty handling.

4. Because the client is consistently late, begin to arrive 15
minutes later than the scheduled time also.
3. Ask the client if something is going on that the client may have difficulty handling.
247. A mental health nurse who has been meeting with a

client with a diagnosis of post-traumatic stress disorder is
in the termination phase of the nurse-client relationship.
The nurse notes that the client has been quiet and
withdrawn. Which interpretation should the nurse make
about the client's behavior?
1. An indication of the need for antidepressants
2. An inability of the client to terminate from the nurse
3. A normal behavior that can occur during termination
4. An indication of the need for additional therapy sessions
3. A normal behavior that can occur during termination
248. A nurse is preparing for the arrival of a new client at a

drug abusers' residential treatment center and prepares to
explain to the client that the emphasis of the center is on
group and social interaction, and that rules and expectations
are mediated by peer pressure. Which is the most
likely focus of therapy of this residential center?
1. Milieu therapy
2. Aversion conditioning
4. Cognitive-behavioral therapy
1. Milieu therapy
249. A client with a phobia will be treated for the condition

using a behavior modification technique known as
systematic desensitization. Which describes the

components of this form of therapy?
1. The client will take medication daily to control the
condition.
2. The client will talk to himself or herself to control
actions more effectively.
3. The client will be introduced to short periods of exposure
to the phobic object while in a relaxed state.
4. The client will meet with others with the same problem
in a support group that focuses on the client's phobia.
3. The client will be introduced to short periods of exposure to the phobic object while in
a relaxed state.
250. A nurse is conducting a group therapy session when a

client who has shared with the group at a previous session
that she isolates herself when she feels depressed, suddenly
gets up to leave. Which is the appropriate nursing action?
1. Tell the client that it is not safe to leave.
2. Encourage the client to stay, and ask the client what she
is feeling.
3. Tell the client that if she leaves she cannot return to this
therapy group.
4. Lock the door so that the client cannot leave at this
potentially vulnerable time.
2. Encourage the client to stay, and ask the client what she is feeling.
251. A nurse is helping to conduct a group therapy session.

During the session, a client threatens to act out physically
and states that he will punch another member of the group.
Which is the appropriate initial nursing action?
1. Tell the client that he must leave immediately.
2. Call security to come to the session immediately.

3. Tell the client that if he hits another client, he will be
restrained and placed in seclusion.
4. Tell the client that he can talk about his anger but cannot
act on it in during the group session.
4. Tell the client that he can talk about his anger but cannot act on it in during the group
session.
252. A nurse is preparing a plan of care for a client with an

autistic disorder. A behavior modification approach
(operant conditioning) is being used to improve
communication. Which should the nurse include in the plan
of care?
1. Avoid providing rewards to the client.
2. Promote complete independence in the client.
3. Reward the client when a desired behavior is performed.
4. Provide consistent negative reinforcement to promote
appropriate behaviors.
3. Reward the client when a desired behavior is performed.
253. A nursing student is conducting a clinical conference

and is describing the characteristics associated with milieu
therapy. Which statement indicates an understanding of the
focus of this form of therapy?
1. "Milieu therapy provides a cognitive approach to
changing behavior."
2. "A living, learning, or working environment is the focus
of milieu therapy."
3. "Milieu therapy provides a behavior modification
approach type of therapy."
4. "A behavioral approach to changing behavior is the focus

of milieu therapy."
2. "A living, learning, or working environment is the focus of milieu therapy."
254. A nurse working in an urgent care center is

interviewing a woman with vague somatic complaints. The
client states that she was raped a few weeks ago but still
feels "as if it just happened to me." Which therapeutic
response should the nurse make to the client?
1. "It is very, very hard to get over these types of feelings
after being raped."
2. "What do you think you should do to reduce the
likelihood that you will be raped again?"
3. "Tell me more about what happened, and what causes
you to feel like the rape just occurred."
4. "It's hard, but try to keep a sense of perspective. After all,
it's been a while since the rape occurred."
3. "Tell me more about what happened, and what causes you to feel like the rape just
occurred."
255. A nurse is developing a plan of care for a client at high

risk for suicide who was just admitted to the psychiatric
unit. The focus of the plan is to promote a safe and
therapeutic environment. Which intervention should the
nurse include in the plan of care?
1. Place the client in a private room.
2. Establish a therapeutic relationship.
3. Assign a leadership task to the client.
4. Maintain a distance of 10 inches at all times.
2. Establish a therapeutic relationship.
256. A client admitted to the mental health unit with

depression states to the nurse, "My life has been such a
failure. Nothing I do turns out right." Which therapeutic
response should the nurse make?
1. "You are certainly entitled to your own opinion."
2. "I know just how you feel. I have those days myself once
in a while."
3. "I disagree with you; we all have some value and
accomplishments in life."
4. "You seem very discouraged. Can you think of anything
recently that went as you planned?"
4. "You seem very discouraged. Can you think of anything recently that went as you
planned?"
257. A client is admitted to the psychiatric unit with a

diagnosis of bipolar affective disorder and mania. The
nurse should prioritize that which symptoms or behaviors
require immediate intervention?
1. Grandiose delusions of being a czar of Russia
2. Constant physical activity and poor oral intake
3. Constant, incessant talking, with sexual innuendoes
4. Outlandish behaviors and wearing odd and eccentric
clothing
2. Constant physical activity and poor oral intake
258. A nurse is working with a client who is delusional.

The client says to the nurse, "The leaders of a religious cult
are being sent to assassinate me." Which is
the best response by the nurse?
1. "I don't believe that what you are telling me is true."
2. "There are no religious cults in this area that are going to
kill you."
3. "What makes you think that cult members are being sent
to hurt you?"
4. "I don't know about a religious cult. Are you afraid that
people are trying to hurt you?"
4. "I don't know about a religious cult. Are you afraid that people are trying to hurt you?"
259. A woman is seen in the emergency department in a

severe state of anxiety following assault and battery. Which
nursing action should the nurse place highest priority on
taking at this time?
1. Remaining with the client
2. Teaching the client deep-breathing techniques
3. Encouraging the client to talk about her feelings
4. Putting the client in a quiet room, away from other
clients
1. Remaining with the client
260. A mental health nurse is assigned to care for a client

with a diagnosis of acute schizophrenia. The nurse should
use which approach when planning care for this client?
1. Allow the client to set the goals for the plan of care.
2. Let the client act out initially, and use the quiet room and
restraints as needed.
3. Provide assistance with grooming and nutrition until the
client's thinking has cleared.
4. Repeatedly point out inconsistencies in the client's
communication during initial treatment.
3. Provide assistance with grooming and nutrition until the client's thinking has cleared.
261. A mental health nurse is assigned to care for a client

with a diagnosis of acute schizophrenia. The nurse should
use which approach when planning care for this client?
1. Allow the client to set the goals for the plan of care.
2. Let the client act out initially, and use the quiet room and
restraints as needed.
3. Provide assistance with grooming and nutrition until the
client's thinking has cleared.
4. Repeatedly point out inconsistencies in the client's
communication during initial treatment.
3. Provide assistance with grooming and nutrition until the client's thinking has cleared.
262. A nurse is talking with a client who is actively

hallucinating. The client is fearful that the voices will direct
him to kill himself or will hurt him directly. Which
therapeutic statement should the nurse make at this time?
1. "I can hear the voices too, but they are telling you to go
to bed now."
2. "I know whose voices you are hearing and told them not
to hurt you."
3. "I know you believe they are going to cause you harm,
but it's not true."
4. "I don't hear them, but it must be frightening to hear
voices that others can't hear."
4. "I don't hear them, but it must be frightening to hear voices that others can't hear."
263. A client tentatively diagnosed with a borderline

personality is admitted to the psychiatric unit for control of
symptoms. Based on an understanding of personality
disorders, the nurse should determine that which problem is
the priority?
1. Isolating self
2. Inability to cope
3. Low self-esteem
4. Risk for self-harm
4. Risk for self-harm
264. A client admitted to the inpatient unit is being

considered for electroconvulsive therapy (ECT). The client
is calm, but the client's daughter is hypervigilant and
anxious. The daughter says to the nurse, "My mother's
brain will be shocked with electricity. How can the doctor
even think about doing this to her?" Which response by the
nurse is therapeutic?
1. "I think you need to speak directly to the psychiatrist."
2. "Maybe you'll feel better if you see the ECT room and
speak to the staff."
3. "Your mother has decided to have this treatment. You
should support her."
4. "It sounds as though you are very concerned about the
procedure. Let's discuss the procedure."
4. "It sounds as though you are very concerned about the procedure. Let's discuss the
procedure."
265. A nurse is assigned to a client who is psychotic,

pacing, agitated, and using aggressive gestures and rapid
speech. The nurse should determine that which action is
the priority of care at this time?
1. Providing safety for the client and other clients on the
unit
2. Offering the client a less stimulated area in which to
calm down and gain control
3. Assisting in caring for the client in a controlled

environment, such as a quiet room
4. Providing the other clients on the unit with a sense of
comfort and safety by isolating the client
1. Providing safety for the client and other clients on the unit
266. A client diagnosed with catatonic stupor is lying on

the bed, hidden under the sheets, in a fetal position. Which
appropriate action should the nurse should take?
1. Ask direct questions to encourage talking.
2. Leave the client alone but check on her every 30
minutes.
3. Sit beside the client in silence, with occasional openended questions.
4. Take the client into the dayroom with other clients for
added supervision.
3. Sit beside the client in silence, with occasional open-ended questions.
267. A client who has sustained severe injuries in a

motorcycle crash was diagnosed with intensive care unit
(ICU) psychosis. Which indicates to the nurse that the
client's status is improving?
1. Increases the number of hours slept at one time and is
increasingly alert
2. Appears to be delirious but has stopped trying to pull out
the nasogastric tube
3. Tells his wife, "I feel better, but the doctors want to give
me a lethal injection."
4. Keeps his eyes fixed on the nurses while they are
working in the room but has stable vital signs
1. Increases the number of hours slept at one time and is increasingly alert
268. A nurse caring for a client recently admitted to the

hospital for anorexia nervosa enters the client's room and
finds her in the middle of performing rapid exercises.
Which action should be the priority?
1. Interrupt the client, and offer to take her for a walk.
2. Allow the client to complete her exercise program.
3. Ignore the behavior, and return when the client is
finished.
4. Tell the client that she is not allowed to exercise
rigorously.
1. Interrupt the client, and offer to take her for a walk.
269. A postsurgical client with a history of heavy alcohol

intake has returned to the nursing unit. Which
signs/symptoms of delirium tremens (DTs) should the nurse
plan to continuously assess for?
1. Coarse hand tremor, agitation, hallucinations, and
hypotension
2. Hypotension, ataxia, muscular rigidity, and tactile
hallucinations
3. Hypotension, stupor, agitation, headache, and auditory
hallucinations
4. Fever, hypertension, changes in level of consciousness,
and hallucinations
4. Fever, hypertension, changes in level of consciousness, and hallucinations
270. A nurse working in a detoxification unit is admitting a

client for alcohol withdrawal. The client's spouse states, "I
don't know why I don't get out of this rotten situation."
Which is the therapeutic response by the nurse?

1. "This is not a good time to make that decision."
2. "What would your spouse think about your decision?"
3. "What aspects of this situation are the most difficult for
you?"
4. "You seem to have a good grip on this situation. You
probably should get out."
3. "What aspects of this situation are the most difficult for you?"
271. A nurse should monitor a client with a history of

opioid abuse for which signs and symptoms associated with
opioid withdrawal?
1. Tachycardia, mild hypertension and fever, sweating,
nausea, vomiting, and marked tremor
2. Increased appetite, irritability, anxiety, restlessness,
anxiety, and altered concentration
3. Increased pulse and blood pressure, low-grade fever,
yawning, restlessness, anxiety, craving, diarrhea, and
mydriasis
4. Depression, high drug craving, fatigue with altered sleep
(insomnia or hypersomnia), hypertension, agitation, and
paranoia
3. Increased pulse and blood pressure, low-grade fever, yawning, restlessness, anxiety,
craving, diarrhea, and mydriasis
272. A nurse is working with a client who shows signs of

benzodiazepine withdrawal. The nurse should suspect that
the client has suddenly discontinued taking which
prescribed medication?
1. Sertraline (Zoloft)
2. Fluoxetine (Prozac)
3. Diazepam (Valium)
4. Haloperidol (Haldol)
3. Diazepam (Valium)
273. A nurse is admitting a client who is in a state of

starvation because of anorexia nervosa. Which roommate
choice is least appropriate for this client?
2. A client who had back surgery
3. A client with a fractured pelvis
4. A client who has had a myocardial infarction
274. A hospitalized client with a history of alcohol abuse

tells the nurse, "I am leaving now. I don't want help. I have
other things to attend to that are more important." The
nurse attempts to discuss the client's concerns, but the
client dresses and begins to walk out of the hospital room.
Which action should the nurse take at this time?
2. Call security to block the exits to the nursing unit.
3. Restrain the client, and call the health care provider
(HCP).
4. Tell the client that readmission is not possible after
leaving against medical advice (AMA).
275. A nurse should monitor the client with a history of

heroin addiction for which signs/symptoms of heroin
withdrawal?
1. Constipation, insomnia, and hallucinations
2. Staggering gait, slurred speech, and violent outbursts

3. Nausea, vomiting, diarrhea, muscle aches, and
diaphoresis
4. Decreased heart rate and blood pressure and dry nose,
mouth, and skin
3. Nausea, vomiting, diarrhea, muscle aches, and diaphoresis
276. A nurse is interviewing a client in crisis to assess the

risk for self-harm. The nurse interprets that the client
is most at risk for suicide if which is assessed?
1. Client exhibits impulsive behavior.
2. Client exhibits disorganized behavior.
3. Client has a history of suicide attempts.
4. Client has an immediate plan for a suicide attempt.
4. Client has an immediate plan for a suicide attempt.
277. A client with a potential for violence is exhibiting

aggressive gestures, making belligerent comments to the
other clients, and is continuously pacing in the hallway.
Which comment by the nurse would be therapeutic at this
time?
1. "What is causing you to become agitated?"
2. "Why are you intent on upsetting the other clients?"
3. "Please stop so I don't have to put you in seclusion."
4. "You are going to be restrained if you do not change your
behavior."
1. "What is causing you to become agitated?"
278. A nurse is having a conversation with a depressed

client on an inpatient psychiatric unit. The client says to the
nurse, "Things would be so much better for everyone if I
just weren't around." Which appropriate response should

the nurse make at this time?
1. "You sound very unhappy. Are you thinking of harming
yourself?"
2. "Have you talked to anyone specifically about what is
bothering you?"
3. "Those feelings will go away when your medication
really takes effect."
4. "I know what you mean; everyone gets that way when
they are depressed."
1. "You sound very unhappy. Are you thinking of harming yourself?"
279. A nurse should interpret that which comment by a

client whose husband uses violence against her is consistent
with the presence of low self-esteem commonly found with
battered wife syndrome?
1. "I'm lucky to be married to a man who really loves me
the way that he does."
2. "I told him that this is his last chance. If it happens again,
I'm leaving for good."
3. "I stay because there's enough in it for me. I don't have to
work full time this way."
4. "Things would be fine at home if I just could do better.
He has a lot of pressures on him at work."
4. "Things would be fine at home if I just could do better. He has a lot of pressures on
him at work."
280. A nurse is caring for an older client whose husband

died approximately 6 weeks ago. The client says, "There's
no one left to care about me. Everyone that I have loved is
now gone." Which response should the nurse make to the
client?
1. "That doesn't sound like the real you talking!"
2. "I'm sure you have someone if you think hard enough."
3. "It sounds as though you are feeling all alone right now."
4. "I don't believe that, and I really don't think you do
either."
3. "It sounds as though you are feeling all alone right now."
281. A client has been admitted to the inpatient psychiatric

unit because the client has displayed violent behavior and is
at risk for potentially harming others. What should the
nurse avoid doing when caring for this client?
1. Admitting the client to a room near the nurses' station
2. Facing the client while speaking and providing nursing
care
3. Arranging for a security officer to be available in the
general area
4. Closing the door to the client's room when giving care to
the client
4. Closing the door to the client's room when giving care to the client
282. A client who has attempted suicide by overdosing with

a very large number of antidepressant pills has been
admitted to the psychiatric unit. Which is
the priority nursing action at this time?
1. Stay with the client at all times.
2. Request that a friend of the client remain with the client
at all times.
3. Have the client put on a hospital gown, and remove the
client's clothing from the room.
4. Suggest placing the client in a seclusion room where all

potentially dangerous articles have been removed.
1. Stay with the client at all times.
283. A client admitted to the mental health unit with major

depression 3 days ago could hardly get out of bed without
coaxing and needed constant encouragement to get dressed
and participate in unit activities. Today the client appears in
the dayroom dressed and well groomed, without any
guidance from the staff. The client appears to be calm and
relaxed, yet more energetic than before. Which initial
action should the nurse take after noting this client's
behavior?
1. Continue to monitor the client's behavior from a
distance.
2. Document that the client is adapting to the unit and is
feeling safe.
3. Notify the staff of these observations at the team
meeting, which will begin in 3 hours.
4. Speak to the client personally about the nurse's
observations, and ask if the client is thinking about suicide.
4. Speak to the client personally about the nurse's observations, and ask if the client is
thinking about suicide.
284. A nurse is preparing a client for discharge who was

hospitalized following a suicide attempt. The nurse
evaluates that the client could benefit from further
development of coping strategies if the client was
overheard making which statement before discharge?
1. "I know now that I can't be all things to all people all the
time."
2. "It is important for me to take my medications just as

prescribed."
3. "It's been good to learn better ways to deal with the
stresses in my life."
4. "I know that I won't become depressed again after the
treatment I received here."
4. "I know that I won't become depressed again after the treatment I received here."
285. A client who attempted suicide by hanging is brought

to the emergency department by emergency medical
services. Which is the immediate nursing action?
1. Take the client's vital signs.
2. Assess the client's respiratory status and for the presence
of neck injuries.
3. Perform a focused assessment, paying particular
attention to the client's neurological status.
4. Call the mental health crisis team and notify them that a
client who attempted suicide is being admitted to the
hospital.
2. Assess the client's respiratory status and for the presence of neck injuries.
286. An acutely depressed client is receiving cognitivebehavioral therapy. The nurse is developing a plan of care
for the client and includes interventions that focus on this
type of therapy. Which interventions should the nurse
include? Select all that apply.
1. Assisting the client to identify and test negative cognition
2. Assisting the client to participate in the treatment process
3. Assisting the client to develop alternative thinking
patterns
4. Assisting the client to rehearse new cognitive and
behavioral responses
5. Assisting the client with the administration of
antidepressant medications
6. Assisting the client's family to participate in group
therapy on a regular basis
o 1. Assisting the client to identify and test negative cognition
o 2. Assisting the client to participate in the treatment process
o 3. Assisting the client to develop alternative thinking patterns
o 4. Assisting the client to rehearse new cognitive and behavioral responses
287. Which should a nurse closely monitor when caring for

a hospitalized client diagnosed with bulimia
nervosa? Select all that apply.
1. Electrolyte levels
2. Exercise patterns
3. Intake and output
4. Pupillary response
5. Deep tendon reflexes
6. Elimination patterns
o 1. Electrolyte levels
o 3. Intake and output
o
6. Elimination patterns

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Mental Health

1. The home care nurse is visiting an older client whose

2. A client with a diagnosis of major depression who has

3. When the mental health nurse visits a client at home, the

4. A client experiencing disturbed thought processes believes

5. A client admitted to a mental health unit for treatment of

6. A client diagnosed with terminal cancer says to the nurse,

for you to be cured?"

7. On review of the client's record, the nurse notes that the

8. When reviewing the admission assessment, the nurse notes

9. The nurse is preparing a client for the termination phase of

4. Encouraging members to become acquainted with one

care for the client that includes which intervention?

2. Tell the client that the behavior is inappropriate.

observations, what is the nurse's immediate priority of

3. Sit beside the client in silence with occasional openended questions.

appropriate nursing care?

3. "I enjoy attending the meetings because they get me out

1. Hypotension, ataxia, hunger

2. Evidence of the client's disturbed body image

2. "Who is available to help you?"

4. The adolescent gets angry with her roommate when the

3. Checking the whereabouts of the client every 15 minutes

planning care for the client, which is the priority nursing

3. Observing rigid rules and regulations

3. Remain with the client until the anxiety decreases.

only thing the person wants is attention from family and

4. Is placed on nothing by mouth (NPO) status for 16 to 24

studies revealed no organic pathology. The care plan

nurse would be therapeutic?

1. "You look lovely today."

o 1. Assist the client in selecting foods from the food menu.

3. Eliminate physical contact with the client.

the conversation, the nurse notes that the client is exhibiting

100. The nurse is reviewing the record of a client admitted

101. The nurse is admitting a client with a diagnosis of

102. The nurse in the mental health unit is having a

103. A client with depression is scheduled to receive three

104. A client has been diagnosed with major depression.

4. Tell the client that social activities will be restricted

105. The health care provider has prescribed medication

106. The mental health nurse is caring for a client with a

107. The nurse is monitoring a client who has been placed

1. Administered medication has taken effect.

108. The mental health nurse is conducting a group therapy

109. The nurse is preparing a client for electroconvulsive

4. This treatment is a permanent cure to the condition.

110. The nurse is planning a stress management seminar for

111. A 15-year-old client who is pregnant and unwed tells

4. "It seems that you needed help to separate from your

112. A 10-year-old girl who has been referred for

113. During a nursing interview, a client says, "My

2. "Have you shared your concerns with the police?"

114. The nurse is assessing a client in the coronary care

115. A client with diabetes mellitus is told that amputation

116. The nurse is planning to formulate a psychotherapy

118. A nurse is planning care for a group of clients on a

o 1. A client with panic disorder

119. A nurse is preparing to admit a client with a diagnosis

120. A nurse is performing an assessment on a client

121. A nurse is performing an assessment on a client

122. A mental health nurse asks a nurse orientee to describe

123. A nurse is performing an assessment on a client being