Mental Health Benchmark Prep

A nurse is planning care for a client who has depression and has made frequent suicide attempts. Which of the following statements indicates the client has a decreased risk for suicide?

"It is easier to talk about my feelings now."

3 multiple choice options

A nurse is discussing a 12-step program with a client who has alcohol use disorder and is in an acute care facility undergoing detoxification. Which of the following information should the nurse include in the teaching?

The client should obtain a sponsor before discharge for an increased chance of recovery

3 multiple choice options

A nurse on a mental health unit observes who has acute mania hit another client. Which of the following actions should the nurse take first?

Call for a team of staff members to help with the situation

3 multiple choice options

A nurse in a community health center is working with a group of clients who have PTSD. Which of the following interventions should the nurse include to reduce anxiety among the group members?

Guided imagery

3 multiple choice options

A nurse is admitting a client who has anorexia nervosa and is at 60% of their ideal body weight. Which of the following interventions should the nurse include in the plan of care?

Encourage the client to drink 125 mL of fluid each hour while awake

3 multiple choice options

A nurse is planning care for a client who is to undergo electroconvulsive therapy (ECT). Which of the following actions should the nurse include in the plan?

Monitor the client's cardiac rhythm during the procedure

3 multiple choice options

A nurse is planning care for a client who has generalized anxiety disorder. At which of the following levels of anxiety should the nurse plan to teach the client relaxation techniques?

Mild

3 multiple choice options

A nurse is talking with a group of parents who have recently experienced the death of a child. Which of the following actions should the nurse take?

Suggest forming a weekly support group for parents who have experienced the death of a child

3 multiple choice options

During a client's initial interview in a mental health inpatient setting, a nurse identifies that the client is maintaining eye contact and leaning forward. Which of the following assumptions should the nurse make based on the client's nonverbal behaviors?

The client is interested in what the nurse is saying

3 multiple choice options

A nurse is teaching the partner of a client who has bipolar disorder how to identify manifestations of acute mania. Which of the following findings should the client's partner report to the provider?

Inability to sleep

3 multiple choice options

A nurse in a provider's office is collecting a health history from the guardian of a school-age child who has been taking atomoxetine. Which of the following adverse effects reported by the guardian is the priority for the nurse to report to the provider?

Dark urine

3 multiple choice options

A nurse is performing an admission assessment on a client and notices that the client appears withdrawn and fearful. To establish a trusting nurse-client relationship, which of the following actions should the nurse take first?

Inform the client that this admission is confidential

3 multiple choice options

A nurse is assessing a client for risk factors for the development of depression. The nurse should identify that which of the following factors places the client at an increased risk for depression?

The client has COPD

3 multiple choice options

A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report?

A client was administered one-half of the prescribed dose of medication

3 multiple choice options

A nurse is caring for a group of clients. Which of the following findings is the nurse required to report?

A client who has borderline personality disorder threatened to harm their roommate

3 multiple choice options

A nurse is performing a cognitive assessment to distinguish delirium from dementia in a client whose family reports episodes of confusion. Which of the following assessment findings supports the nurse's suspicion of delirium?

Easily distracted

3 multiple choice options

A nurse in a community health center is teaching families of clients who has PTSD about expected clinical manifestations. Which of the following manifestations should the nurse include?

Experiences feelings of isolation

3 multiple choice options

A nurse is planning care for a client who has schizophrenia and reports auditory hallucinations. Which of the following interventions should the nurse include in the plan?

Promote the use of music to compete with the client's auditory hallucination

3 multiple choice options

A nurse is preparing to administer prescribed clozapine to a client. Which of the following client laboratory results should the nurse review prior to administering the clozapine?

Absolute neutrophil count

3 multiple choice options

A client who has a recent diagnosis of bipolar disorder is placed in a room with a client who has severe depression. The client who has depression reports to the nurse, "My roommate never sleeps and keeps me up, too." Which of the following actions should the nurse take?

Move the client who has bipolar disorder to a private room

3 multiple choice options

A nurse is planning discharge teaching with a family member of a client who has a new diagnosis of depression. Which of the following information about relapse should the nurse include?

Early identification of changes, such as decreased social involvement, is important

A nurse is planning care for a client who has made repeated physical threats toward others on the unit. Although the client does not want to leave the unit, the nurse requests the provider to transfer the client to a unit that is equipped to manage violent behavior. Which of the following ethical principles should the nurse apply in this situation?

Nonmaleficence

3 multiple choice options

A nurse on an acute mental health facility is receiving a change-of-shift report for four clients. Which of the following clients should the nurse assess first?

A client who is experiencing delusions of persecution

3 multiple choice options

A school nurse is assessing a school-age child who experienced the traumatic loss of a parent 8 months ago. Which of the following findings should the nurse identify as an indication that the child is experiencing PTSD?

Lack of interest in an upcoming holiday

3 multiple choice options

A nurse is caring for a child who has conduct disorder and is behaving in a destructive manner, throwing objects, and kicking others. Which of the following therapeutic nursing interventions is the priority?

Reduce environmental stimuli

3 multiple choice options

A nurse is caring for an older adult client who is experiencing delirium. Which of the following interventions should the nurse include in the client's plan of care?

Permit the client to perform daily rituals to decrease anxiety

3 multiple choice options

A nurse on a mental health unit is caring for a group of clients. Which of the following actions by the nurse is an example of the ethical principle of justice?

Spending adequate time with a client who is verbally abusive

3 multiple choice options

A nurse in the emergency department is caring for a client who has alcohol toxicity and is unresponsive. Which of the following interventions should the nurse take?

Gather supplies for endotracheal intubation

3 multiple choice options

A nurse is assessing a client who has borderline personality disorder. Which of the following findings should the nurse expect?

Emotional lability

3 multiple choice options

A nurse is caring for an older adult client who begins to cry and states, "I knew God would punish me and I deserve this horrible sickness!" Which of the following responses should the nurse make?

"Let's talk about what is upsetting you."

3 multiple choice options

A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan of care?

Offer the client high-calorie finger foods frequently

3 multiple choice options

A nurse in a clinic is assessing a client whose partner died 4 months ago. Which of the following statements indicates that the client is at risk for complicated grief?

"I feel so empty without my wife that it's hard to get up every morning."

3 multiple choice options

A nurse is teaching a newly licensed nurse about nursing care plans for clients who have depressive disorders. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

"I will update the plan of care as a client's manifestations of depression change."

3 multiple choice options

A nurse is establishing a therapeutic relationship with a client who has antisocial personality disorder. Which of the following strategies should the nurse use when communicating with this client?

Set realistic limits on the client's behavior

3 multiple choice options

A nurse is caring for a group of clients. Which of the following findings should the nurse report?

A client who is taking lamotrigine and has developed a rash

3 multiple choice options

A nurse is planning prevention strategies for partner violence in the community. Which of the following strategies should the nurse include as a method of secondary prevention?

Establish screening programs to identify at-risk clients

3 multiple choice options

A nurse in a community health center is counseling a family of two parents and two children. Which of the following statements by a family member indicates manipulative behavior?

"If you do my homework for me, I won't bother you for the rest of the day."

3 multiple choice options

A nurse in a mental health facility is caring for a client who requires the use of restraints. Which of the following actions should the nurse take when caring for the client?

Ensure a staff member checks on the client every 15 min

3 multiple choice options

A nurse is caring for a male client who has schizophrenia and is taking clozapine. Which of the following client findings should the nurse identify as a contraindication for receiving clozapine?

WBC count 2,500 (5,000-10,000)

3 multiple choice options

A nurse in an inpatient mental health facility is caring for a client. The client begins pacing with their fists clenched and is verbally abusing the staff. Which of the following actions should the nurse take?

Ensure security personnel are available in the background to assist if the client's behavior escalates

3 multiple choice options

A nurse is assessing a client who recently used cocaine. Which of the following findings should the nurse expect?

Hypertension

3 multiple choice options

While observing group therapy, a nurse recognizes that a client is behaving in a way suggestive of dependent personality disorder. Which of the following behaviors is consistent with this condition?

The client needs excessive external input to make everyday decisions

3 multiple choice options

A nurse is planning discharge teaching for a client who has severe schizoaffective disorder. The nurse should identify that which of the following treatment options can offer interdisciplinary services for the client at home?

Assertive community treatment

3 multiple choice options

A nurse is educating the parent of a child who has a new diagnosis of autism spectrum disorder. Which of the following manifestations of this disorder should the nurse include in the teaching?

Language delay

3 multiple choice options

A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse document as a negative symptom of this disorder?

Anhedonia

3 multiple choice options

A nurse on a med-surg unit is assessing a client who sustained injuries 12 hr ago following a MVC. The client's admission blood alcohol level was 325 (0-50). Which of the following findings should indicate to the nurse that the client is experiencing alcohol withdrawal?

Blood pressure 154/96

3 multiple choice options

A nurse is caring for a child who is taking methylphenidate. The nurse should monitor the child for which of the following findings as an adverse effect of methylphenidate?

Tachycardia

3 multiple choice options

A nurse is caring for an older adult client who has dementia and has wandered into the day room looking for their deceased partner. Which of the following actions should the nurse take?

Talk with the client about activities they enjoyed with their partner

3 multiple choice options

A nurse is teaching a group of newly licensed nurses about the use of mechanical restraints. Which of the following information should the nurse include in the teaching?

Apply restraints when other means of managing the client's behavior have failed

3 multiple choice options

A nurse is preparing to participate in an interdisciplinary conference for a client who has bipolar disorder. Which of the following behaviors is the priority for the nurse to report to the treatment team?

Giving away possessions

3 multiple choice options

A nurse is teaching a client who has a depressive disorder about fluoxetine. Which of the following information should the nurse include in the teaching?

"You might experience difficulties with sexual functioning while taking this medication."

3 multiple choice options

A nurse is caring for a client whose child has a terminal illness. The client requests information about how to deal with the upcoming loss. Which of the following statements should the nurse make?

"It is not uncommon to feel angry toward yourself or others."

3 multiple choice options

A nurse is admitting a client who has major depressive disorder and a new prescription for tranylcypromine. Which of the following over-the-counter medications that the client reports taking should alert the nurse to a potential adverse reaction?

Phenylephrine

3 multiple choice options

A nurse is caring for a client who has schizophrenia and began taking a conventional antipsychotic medication yesterday. Which of the following findings indicates the nurse should administer benztropine 2 mg IM?

Shuffling gait

3 multiple choice options

A nurse is reviewing the electronic medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings is the priority for the nurse to notify the provider?

The client reports an inability to breathe easily

3 multiple choice options

A nurse is reviewing the medication administration record for a client who is experiencing adverse effects of chlorpromazine. The nurse should administer benztropine to relieve which of the following adverse effects?

Acute dystonia

3 multiple choice options

A nurse is caring for a client in a mental health facility. The nurse overhears another staff member make derogatory comments to the client. Which of the following actions should the nurse take?

Report the occurrence to the charge nurse

3 multiple choice options

A client who has a diagnosis of depression is attending group therapy. During the group meeting, the nurse asks each member to identify one goal for the day. When it is the client's turn, they do not respond. Which of the following actions should the nurse take before repeating the request to the client?

Allow the client time to formulate an answer

3 multiple choice options

A nurse is caring for a client who has antisocial personality disorder and is receiving behavioral therapy through operant conditioning. Which of the following client behaviors indicates effectiveness of the therapy?

Refrains from manipulating others to earn dining room privileges

3 multiple choice options

A nurse observes a client on a mental health unit pushing on the locked unit door. Which of the following statements should the nurse make?

"It appears as though you would like to open the door."

3 multiple choice options

A nurse is providing teaching to the partner of a client who is in a rehabilitation program for alcohol use disorder. The nurse should identify that which of the following statements by the client's partner indicates an understanding of the teaching?

"I will not take charge of my partner's work responsibilities."

3 multiple choice options

A nurse is delegating client care tasks to a LPN and an assistive personnel. Which of the following tasks should the nurse assign to the LPN?

Change the dressing of a client who has borderline personality disorder and superficial self-inflicted wounds

3 multiple choice options

A nurse is creating a plan of care for a client who has been placed in seclusion after threatening to harm others on the unit. Which of the following interventions should the nurse include in the plan?

Renew the prescription for the client every 4 hr

3 multiple choice options

A nurse in an emergency department is caring for an adolescent who has a diagnosis of bulimia nervosa and had a fainting episode during a ballet performance. Which of the following statements by the parent acknowledges the client's diagnosis?

"They won't let me take the trash from their room. I'm concerned about what they have in there."

3 multiple choice options

A nurse is communicating with a client in an inpatient mental health facility. Which of the following actions by the nurse demonstrates the use of active listening?

Attention to body language

3 multiple choice options

A nurse is caring for a client who has schizophrenia and is experiencing psychosis. The nurse should identify that which of the following findings indicates a potential psychiatric emergency?

The client reports command hallucinations

3 multiple choice options

A nurse is assessing a client who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect?

Rhinorrhea

3 multiple choice options

A nurse is assessing a client who has bulimia nervosa. The nurse should expect which of the following findings?

Tooth erosion

3 multiple choice options

A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take?

Assist the client with deep-breathing exercises

3 multiple choice options

A nurse is caring for a client who has alcoholic cardiomyopathy. Which of the following laboratory findings should the nurse expect?

Increased creatine phosphokinase (CPK)

3 multiple choice options

A nurse on a mental health unit is admitting a client who is anxious and tells the nurse, "I hear voices telling me what to do." Which of the following actions should the nurse take?

Ask the client what the voices are saying

3 multiple choice options

A nurse is reviewing the medical record of a client who has anorexia nervosa. Which of the following findings should the nurse identify as an indication the client requires hospitalization?

Total body fat 8.7%

3 multiple choice options

A nurse is planning care for a newly admitted client who has bipolar disorder and is experiencing mania. Which of the following is the priority action by the nurse?

Provide frequent high-calorie snacks

3 multiple choice options

A nurse is caring for a client who has borderline personality disorder. Which of the following goals is the priority when planning care for this client?

The client will refrain from self-mutilation

3 multiple choice options

A nurse is planning care for a 7-year-old child who has ADHD. Which of the following interventions should the nurse identify as the priority?

Remove unnecessary equipment from the child's surroundings

3 multiple choice options

A nurse in a mental health clinic is planning care for a client who has a new prescription for olanzapine. Which of the following interventions should the nurse identify as the priority?

Instruct the client to avoid driving during initial therapy

3 multiple choice options

A nurse in a mental health clinic is caring for a client who has bipolar disorder and reports that they stopped taking lithium 2 weeks ago. The nurse should recognize which of the following as an expected adverse effect that might have caused the client to stop taking the medication?

Hand tremors

3 multiple choice options

During morning rounds, a nurse finds a client who has schizophrenia trembling and tearful in their bed. The client reports that a bomb was placed in their room by a family member during visiting hours. Which of the following actions should the nurse take?

Assess the client for evidence of a perceptual disturbance

3 multiple choice options

A nurse is assessing a family's dynamics during a counseling session. The nurse should recognize which of the following findings as an indication of a boundary issue?

Older children who are responsible for their younger siblings

3 multiple choice options

A charge nurse is preparing an educational session for a group of newly licensed nurses to review client rights under the law. Which of the following statements should the nurse make?

"In the event a client threatens harm to others, medications can be administered without consent."

3 multiple choice options

A nurse is teaching coping strategies to a client who is experiencing depression related to partner violence. Which of the following statements by the client indicates an understanding of the teaching?

"I will talk about my feelings with a close friend."

3 multiple choice options

A nurse is admitting a client who has schizophrenia to an acute care setting. When the nurse questions the client regarding their admission, the client states, "I'm red, in the head, and I'm going to bed!" The nurse should document the client's speech pattern as which of the following?

Clang association

3 multiple choice options

A nurse is obtaining a mental health history from an older adult client. Which of the following actions should the nurse plan to take?

Interview the client in a private setting

3 multiple choice options

A nurse is counseling an adolescent who has anorexia nervosa and reports excessive laxative use and a fear of gaining weight. The client states, "I'm so fat I can't even stand to look at myself." Which of the following therapeutic responses demonstrates the nurse's use of summarizing?

"You're saying that you think you are fat and are using laxatives because you are afraid of gaining weight."

3 multiple choice options

A community health nurse is planning an education program about depressive disorders. Which of the following factors should the nurse include as increasing the risk for depression?

Substance use disorder

3 multiple choice options

A nurse is updating the plan of care for a client who has bulimia nervosa and is 5% above their ideal body weight. Which of the following interventions should the nurse include in the plan?

Identify the client's trigger foods

3 multiple choice options

A nurse is planning care for a client who is experiencing acute mania. Which of the following interventions should the nurse include in the plan to promote sleep?

Encourage frequent rest periods throughout the day

3 multiple choice options

A nurse is caring for a client who is experiencing a situational crisis. Which of the following findings should the nurse expect?

The client recently lost a grandparent in a motor vehicle crash

3 multiple choice options

A home health nurse is assessing an older adult client whose sibling is the primary caregiver. Which of the following findings should the nurse identify as a possible indicator of neglect?

Inappropriate dress

3 multiple choice options

A nurse is facilitating a community meeting for acute care clients. One client is constantly talking and using the majority of the group's time. Which of the following interventions should the nurse implement?

Ask group members to discuss their feelings about this client's monopolizing behavior

3 multiple choice options

A nurse in the emergency department is caring for four clients. Which of the following clients is the nurse required to report as a potential victim of abuse?

An older adult client who is bedbound and has a stage IV pressure ulcer

3 multiple choice options

A nurse is admitting a client who has alcohol use disorder. Which of the following statements by the client indicates that the client is using denial as a defense mechanism?

"I am able to go to work every day, so I don't have a problem."

3 multiple choice options

A nurse is caring for four clients in an emergency department. The nurse should identify that which of the following clients can give informed consent?

A 35-year-old client who has major depressive disorder

3 multiple choice options

A nurse is assisting a client who has a terminal illness with adjusting to progressive loss of independence. Which of the following statements by the client indicates acceptance of their illness?

"I am going to order a wheelchair for when I'm unable to walk."

3 multiple choice options

A nurse is planning care for a client who has thoughts of suicide. Which of the following goals should the nurse include in the client's plan of care?

The client agrees to notify a staff member of thoughts of self-harm

3 multiple choice options

A nurse enters a client's room and observes that the client is agitated and pacing rapidly. The client looks at the nurse and says, "Back off. Leave me alone." Which of the following statements should the nurse make?

"I will give you space if you calm down. Tell me what is causing you to feel so tense."

3 multiple choice options

A nurse is assessing a client who has anorexia nervosa. The nurse should expect the client to display which of the following characteristics?

Possesses feelings of decreased self-worth

3 multiple choice options

A nurse is assessing a client who is experiencing moderate-level anxiety. Which of the following findings should the nurse expect?

The client has difficulty concentrating

3 multiple choice options

A nurse in an emergency department is caring for a female client who has ecchymosis of the trunk and face. The client reports that her partner hit her, causing the injuries. When offered information about shelters for intimate partner violence, the client declines, stating, "I could never leave my husband because of my kids." Which of the following responses should the nurse make?

"The next time this occurs, what might you do to ensure your safety?"

3 multiple choice options

A nurse is performing a mental status assessment on an older adult client who has dementia. Which of the following questions should the nurse ask to assess the client's remote memory?

"What year did you graduate from high school?"

3 multiple choice options