Mental health – 2025 A nurse is caring for a client who has schizophrenia and is experiencing delusions The client states I can feel
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Mental health – 2025
A nurse is caring for a client who has schizophrenia and is experiencing delusions. The client states, “I can feel worms crawling through my vein. Which of the following types of delusions should the nurse document the client is experiencing! Delusion of reference Delusion of persecution Somatic delusion Erotomaniac delusion A nurse in an emergency department is caring for a client following a domestic dispute. The client states, “Nothing seems to go right for me and probably never will. Which of the following statements should the nurse make? a. Are you thinking about harming yourself b. You should remove yourself from this situation now.” c. We will help get you through this. You’ll be fine d. What have you done to change your situation?” A nurse is assessing a child in the emergency department. Which of the following findings places the child at greatest risk for physical abuse? a. The child has cystic fibrosis. b. The child has no siblings c. The child is homeschooled. d. The child is 10 years old A nurse is caring for a client who has bipolar disorder and is experiencing a manic episode. Which of the following actions should the nurse take? a. Dim the lights in the client’s room b. Provide detailed explanations to the client c. Administer methylphenidate to the client. d. Encourage the client to join group activities A nurse is treating a plan of care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan? a. Prepare the client for electroconvulsive therapy b. Encourage the client to participate in family therapy c. Set a weight gain goal of 22 kg (4.9 lb.) per week d. Weigh the client twice per day A nurse is caring for a client who has major depressive disorder. After discussing the treatment with his partner, the client verbally agrees to electroconvulsive therapy (ECT) but will not sign the consent form. Which of the following actions should the nurse take? a. Inform the client about the risks of refusing ECT. b. Proceed with preparation for ECT based on implied consent. c. Request that the client’s partner sign the consent form. d. Cancel the scheduled ECT procedure. A nurse is caring for an adolescent whose family has a very rigid system of rules. Which of the following characteristics should the nurse expect when observing the family? a. The older children in the family take over parenting roles for younger children. b. The family members exhibit psychosomatic manifestations. c. The communication between family members is minimal d. The family members make decisions based on compromise. A nurse manager is observing a newly licensed nurse preparing to administer an IM medication to a client who is mania and refuses the medication. Which of the following actions should the nurse manager take first? a. Assess the need for physical restraints. b. Stop the newly licensed nurse from administering the medication. c. Demonstrate how to verbally deescalate the situation d. Discuss the purpose of the medication with the client. A nurse is assessing a client who is withdrawing from heroin. Which of the following manifestations should the nurse expect? a. Hyperthermia b. Slurred speech c. Hypotension d. Bradycardia A nurse in the emergency department is admitting a client who has a history of alcohol use disorder. The client has a blood alcohol level of 0.24 g/dL. The nurse should anticipate a prescription for which of the following medications? a. Acamprosate b. Disulfiram c. Naltrexone d. Chlordiazepoxide A nurse is planning care for a client who is experiencing acute alcohol withdrawal. The nurse should anticipate that the provider will prescribe which of the following medications for the client? a. Diazepam b. Buprenorphine c. Varenicline d. Clonidine After assessing a client in a crisis situation, a nurse determines the client is safe. Which of the following actions should the nurse take first a. Involve the client in planning interventions b. Assist the client to lower his anxiety level c. Teach the client specific coping skills to handle stressful situations d. Help the client identity social support A community health nurse is providing an education program about expected age-related changes for a group of older adults. Which of the following statements by a client demonstrates an understanding of the teaching? a. should expect my libido to decrease as I age.” b. should expect an increased risk of depression as age- c. know that my risk for being the victim of a crime decreases as age.” d. “I know that I am likely to be socially isolated as l age A nurse is providing teaching for a newly licensed nurse about the constructive use of defense mechanisms. Which of the following examples should the nurse include in the teaching a. A woman who has a health concern postpones a medical appointment until after a vacation. b. A school age child whose mother died 2 years ago talks about her in present tense c. A student who is upset with her teacher writes a story about an excellent student. d. An adult who was sexually abused as a child is unable to remember the incident. A nurse is providing behavioral therapy for a client who has obsessive-compulsive disorder. The client repeatedly checks that the doors are locked at night. Which of the following Instructions should the nurse give the client when using thought stopping technique? a. “Ask a family member to check the locks for you at night.” b. -Snap a rubber band on your wrist when you think about checking the locks.” c. “Focus on abdominal breathing whenever you go to check the locks.” d. “Keep a journal of how often you check the locks each night.” A charge nurse is discussing the care of a client who has a substance use disorder with a staff nurse. Which of the following statements by the staff nurse should the charge nurse identify as counter transference? a. “The client is just like my brother who finally overcame his habit. b. The client needs to accept responsibility for his substance use.” c. “The client asked me to go on a date with him, but I refused.” d. The client generally shares his feelings during group therapy sessions.” A nurse in an acute care mental health facility is planning discharge care for a client who sustained a traumatic brain injury. For which of the Following needs should the nurse collaborate with a clinical psychologist? a. The client needs to find a place to live after discharge b. The client needs to begin a group therapy program prior to discharge. c. The client needs to relearn how to perform skills that require fine motor coordination d. The client needs a prescription for medication to promote nighttime sleep while in the facility A nurse is assessing a client who has Alzheimer’s disease. Which of the following findings should the nurse identity as the priority? a. The client places their shoes on the wrong feet. b. The client is unable to remember their personal history. c. The client does not recognize their partner d. The client engages in wandering A nurse is creating a plan of care for a client who has major depressive disorder. Which of the following interventions should the nurse include the plan? a. Keep a bright light on in the client’s room at night b. Identify and schedule alternative group activities for the client c. Discourage the client from expressing feelings of anger. d. Encourage physical activity for the client during the day. A nurse is creating a plan of care for a client who has schizophrenia and is experiencing command hallucinations. Which of the following Interventions should the nurse include in the plan? a. Avoid making eye contact when speaking with the client b. Maintain a low level of environmental stimuli c. Encourage increased socialization during group therapy d. Provide reassurance and comfort for the client through touch A nurse has placed a client who has become physically aggressive into seclusion. Which of the following actions should the nurse take? a. Monitor the client’s vital signs every 4 hr. b. Offer the client food and fluids every 2 nr. c. Document the client’s behavior every 15 min. d. Obtain the provider’s prescription within 60 min. A nurse is caring for a client who has bipolar disorder. The client is walking in and out of rooms, speaking inappropriately and placing Which of the following actions should the nurse take? a. Have the client return to her room to read a book b. Take the client to the day room to watch a movie with other clients c. Lead the client outside for a walk d. Tell the client there will be negative consequences for her behavior A nurse is caring for a client who states. “I have been having trouble sleeping for the last several months. Which of the following responses should the nurse make? a. You should relax by watching a television show in bed before going to sleep b. “You should take a 2 hour nap during the afternoon c. “You should avoid stressful activities prior to going to sleep d. “You should plan to exercise 2 hours before going to sleep A nurse is caring for a client who was just placed in mechanical restraints. Which of the following actions should the nurse take? a. Notify the provider about the use of restraints after the restraints are removed. b. offer the client the opportunity to use the toilet every 15 min while in restraints. c. Request that the provider provide an as-needed prescription for restraints. d. Withhold food and drink until the restraints are removed from the client A nurse is caring for a client who reports that he is angry with his partner because she thinks he is just trying to gain attention. When the nurse attempts to talk to the client, he becomes angry and tells her to leave. Which of the following defense mechanisms is the client demonstrating a. Displacement b. Rationalization c. Compensation d. Denial A nurse is providing teaching to a client who has a substance use disorder and a new prescription for methadone. Which of the following Information should the nurse include in the teaching? a. “Discontinue this medication if you develop a productive cough.” b. “You should expect this medication to cause insomnia c. “Monitor yourself for weight gain while taking this medication d. “You might experience constipation while taking this medication.” A nurse is assessing client who has bipolar disorder. Which of the following findings should the nurse identity as an indication that the chant la experiencing acute mania? a. Refuses to engage in conversation b. Reports a lack of sleep c. Isolates self from others d. Writes a detailed daily activity schedule A nurse is providing discharge teaching about manifestations of relate to the family of a client who has schizophrenia. which of the should the nurse include in the teaching? a. The client develops an inability to concentrate. b. The client increases participation in social activities. c. The client exhibits an inflated sense of self d. The client begins more than usual A nurse is assessing a client who has post-traumatic stress disorder. Which of the following findings should the nurse expect the apply) a. Blames others for own mistakes b. Difficulty falling or staying asleep c. Talks excessively d. Holds persistent negative beliefs about self e. Has difficulty concentrating on set tasks A nurse is speaking to a former high school friend. The friend states. “heard one of our high school teachers was admitted to your hospital. Is everything okay? Which of the following responses should the nurse make? a. “I can only discuss the status of a client with the client’s family: b. “I cannot discuss the care of anyone who might be hospitalized in our facility” c. “I think that you should contact the high school for information about her d. “I recommend you contact the hospital to see if she has been admitted.” A nurse is caring for a client who has severe depression and is scheduled to receive electroconvulsive therapy. The nurse should recognize that the client will receive succinylcholine to prevent which of the following adverse effects? a. Muscle distress b. Aspiration c. Elevated blood pressure d. Decreased heart rate A nurse is caring for a school age child who has conduct disorder and is in physical restraints after becoming physically aggressive toward other clients on the unit. Which of the following actions should the nurse take? a. Arrange an in person evaluation by the child provider within 2 hr. of initiating restraints b. As the provider to renew the prescription for the restraints every 24 hr. c. Monitor the child’s sign every 15 min d. Keep the restraints on for a minimum of 1 hr. A nurse is caring for a client who is undergoing electroconvulsive therapy. Which of the following tasks should the nurse delegate to an assistive personnel? a. Check the client’s condition after the procedure. b. Assist the client to ambulate for the first time following the procedure. c. Give the client atropine 30 min before the procedure. d. Witness the client’s signature on the consent for the procedure. A nurse is assisting with obtaining informed consent for a client who has been declared legally incompetent. Which of the following actions should the nurse take? a. Contact the facility social worker to obtain the consent b. Explain implied consent to the client’s Family c. Ask the charge nurse to obtain informed consent d. Request that the client’s guardian sign the content A nurse in the emergency department is caring for a client who reports feeling sad, worthless, and hopeless 9 months after the death of her son. Which of the following actions should the nurse take first? a. Ask the client if she has thought about harming herself. b. Discuss the client’s coping skills. c. Encourage the client to attend a grief support group d. Request a mental health consult for the client A nurse in an inpatient facility is caring for a client who has an anxiety disorder. Which of the following actions should the nurse take while the client is experiencing an acute panic attack? a. Encourage the client to watch television as a distraction b. Administer a dose of alprazolam to the client. c. Encourage the client to describe their feelings in a journal d. Administer a dose of atomoxetine to the client A nurse is evaluating the medication response of a client who takes naltrexone for the treatment of alcohol use disorder. The nurse should identify that which of the following is a therapeutic effect of this medication? a. Reduces substance craving b. Block’s aldehyde dehydrogenase c. Prevents the anxiety of abstinence d. Decreases the likelihood of seizures A nurse is caring for a client who has bipolar disorder and is refusing to take prescribed medications. Which of the following ethical principles is the nurse displaying when he supports the client’s refusal of medications? a. Autonomy b. Beneficence c. Veracity d. Justice A nurse in the emergency department is assessing a client who has major depressive disorder. Which of the following actions should the nurse take? (Click on the “Exhibit” button for additional information about the client. There are three tabs that contain separate categories of data.) a. Prepare the client for electroconvulsive therapy. b. Ask the client if she has eaten foods containing tyramine. c. Administer dantrolene IV bolus to the client. d. Give regular insulin subcutaneously to the client. A nurse is caring for a client who has been placed in restraints. Which of the following actions should the nurse take? a. Request a PRN client prescription for restraints from the provider. b. Observe the client’s behavior once every 15 min. c. Document the client’s behavior hourly on a flow sheet. d. Remove the restraint when the client calmly follows commands. A nurse is developing a plan of care for a school-age child who has autism spectrum disorder. Which of the following interventions should the nurse include in the plan? a. Discourage the child from making eye contact with caregivers. b. Allow flexibility in the child’s daily schedule. c. Use a reward system for appropriate behavior d. Assign the child to a room with another child of the same age A nurse is assessing a client who has bipolar disorder and is transitioning from hypomania to mania. Which of the following findings should the nurse expect? a. at affect b. Withdrawal c. Anger d. Anhedonia A nurse is teaching a client who has a new prescription for disulfiram. Which of the following statements by the client indicates an understanding of the teaching? a. “I can wear my cologne on special occasions b. When I bake my favorite cookies, I can use pure vanilla extract for c. tract for flavoring d. If I cut myself, I can clean the wound with isopropyl alcohol e. “I can continue to eat aged cheeses and chocolate A nurse in an alcohol rehabilitation facility is creating a discharge plan for a client who has alcohol use disorder. Which of the following recommendations should the nurse include in the plan? a. Request a discharge prescription for buprenorphine for the client. b. Refer the client to a self-help group. c. Contact a close relative of the client to discuss the discharge plan d. Teach the client to practice systematic desensitization A nurse is assessing a client who is taking chlorpromazine. The client’s dosage was decreased 3 months ago to reduce adverse effects. Which of the following findings should the nurse identify as an indication that the reduced dosage of chlorpromazine is effective? a. Improved gait b. Decreased ringing in the ears c. Increased heart rate d. Decreased salivation A nurse is caring for a client who has a binge eating disorder. Which of the following actions should the nurse take? a. Plan a menu with the client. b. Weigh the client every other day. c. Remain with the client for 1 hr. after meals. d. Offer snacks when the client is hungry. A nurse is teaching a client who has a new prescription for phenelzine to treat depression. The nurse instructs the client to avoid foods with tyramine to prevent which of the following? a. Serotonin syndrome b. Hypertensive crisis c. Urinary retention d. Cardiac toxicity A nurse is caring for a client who was involuntarily committed and is scheduled to receive electroconvulsive therapy (ECT). The client refuses the treatment and will not discuss why with the health care team. Which of the following actions should the nurse take? a. Tell the client he cannot refuse the treatment because he was involuntarily committed b. Ask the client’s family to encourage the client to receive ECT. c. Inform the client that ECT does not require client content d. Document the client’s refusal of the treatment in the medical record A nurse is caring for a client who is experiencing manifestations of alcohol withdrawal. Which of the following medications should the nurse plan to administer a. Methadone b. Clozapine c. Bupropion d. Lorazepam A nurse is interviewing a client who was recently sexually assaulted. The client cannot recall the attack. The nurse should identity that the client is using which of the following defense mechanisms? a. Reaction formation b. Suppression c. Repression d. Sublimation A nurse is providing teaching about disulfiram to a client who has a history of alcohol use disorder. Which of the following instructions should the nurse include in the teaching? (Select all that apply) a. you will need to take the medication once daily b. you will receive treatment in an inpatient setting c. You can expect to develop a physical dependence to the medication d. You should avoid mouthwash that contains alcohol e. You should avoid drinking carbonated beverages while taking the medication A nurse is assessing the boundaries of a client’s family. One of the family members says to the client, “I know exactly what you’re thinking righ now.” The nurse should recognize that the family member is displaying which of the following types of family boundaries? a. Clear b. Enmeshed c. Inconsistent d. Rigid A nurse is teaching the family of a client who has Alzheimer’s disease about safety interventions for nighttime wandering. Which of the following interventions should the nurse include a. Place the client’s mattress on the floor b. Encourage the client to take naps during the day. c. Place rubber backed throw rugs on tile floors. d. Install locks at the bottom of the exit doors. A nurse in an acute care mental health facility is receiving morning report for a group of clients. Which of the following ellents should the nurse plan to assess first? a. A client who has posttraumatic stress disorder and is reported to have experienced a flashback during the night b. A client who has generalized anxiety disorder and reports being frightened about an upcoming dental appointment c. A client who is depressed and occasionally expresses suicidal thoughts but whose mood is reported to have improved this morning d. A client who was recently admitted, has severe negative manifestations of schizophrenia, and is refusing to get up for breakfast A nurse is interviewing a client who reports ongoing feelings of depression after the death of his sibling 9 months ago. Which of the following actions should the nurse take a. Caution the client against feeling angry at the sibling b. Recommend that the client participate in more solitary activities c. Explain to the client that the duration of grief is highly variable and can last for years. d. Encourage the client to avoid discussing the events surrounding the sibling’s death A nurse in a mental health facility is interviewing a newly admitted client who is related to the nurse’s neighbor. The nurse should identify that which of the following must occur when establishing a therapeutic nurse-client relationship? a. The nurse seeks to spend extra time specifically with the client each day, b. The nurse maintains confidentiality unless the client’s safety is compromised. c. The client regards the nurse as a friend d. The client sees the nurse as an authority figure A nurse is assessing a client during a follow-up visit at a behavioral health clinic. The client reports that they have not been taking the prescribed antipsychotic medication on a regular basis. Which of the following actions should the nurse take to improve medication adherence! a. Tell the client they will be admitted to an inpatient care facility if they do not take the medication b. Discuss the provider’s goals for the client’s care, c. Request the provider prescribe a second antipsychotic medication to the client. d. Ask the client if the medication is causing adverse effects A nurse is assessing a client who has a family history of Alzheimer’s disease. The nurse should identify which of the following findings as an additional risk factor for dementia? a. Hypoglycemia b. Recurrent urinary tract infections c. Head injury d. Asthma A nurse is obtaining a medical history from a client who is requesting a prescription for bupropion for smoking cessation. Which of the following assessment findings in the client’s history should the nurse report to the provider? a. Hypothyroidism b. Recent head injury c. Hepatitis B infection d. Knee arthroplasty 1 month ago A nurse is planning emergency care for a client who has major depressive disorder and serotonin syndrome. Which of the following actions should the nurse plan to take a. Prepare to administer atropine for a low heart rate b. Administer naloxone to reverse respiratory depression c. Place the client in a prone position to prevent dizziness d. Use a tepid water bath to lower body temperature A nurse in a mental health facility is making plans for a client’s discharge. Which of the following interdisciplinary team members should the nurse contact to assist the client with housing placement?. a. Occupational therapist b. Social worker c. Clinical nurse specialist d. Recreational therapist A nurse is assessing a client who has depression and takes phenelzine. The client reports eating pepperoni pizza while out on pass during lunchtime. Which of the following assessments should the nurse perform? a. Blood pressure b. Bowel sounds c. Oxygen saturation d. Pupil response A nurse is assessing a client who recently started antidepressant therapy for the treatment of major depressive disorder. Which of the following findings indicates the client is at an increased risk for suicide a. Unkempt appearance b. Hypersomnia c. Increased energy d. Psychomotor retardation A nurse is caring for a client who has an anxiety disorder and is scheduled for a procedure. The client informs the nurse that they do not want to have the procedure. Which of the following actions should the nurse take? a. Encourage the client to have the procedure. b. Obtain consent from the client’s family member c. Inform the client that they have the legal right to refuse treatment at any time d. Request another nurse to review the procedure with the client. A nurse is reviewing the medical record of a client who has anorexia nervosa. Which of the following findings should the nurse report to the provider? (Click on the “Exhibit” button for additional Information about the client. There are three tabs that contain separate categories of data.) a. Heart rhythm b. Edema c. Temperature d. Intake A nurse is caring for a client who recently experienced the unexpected death of his child. Which of the following actions should the nurse take first? a. Identify the client’s support system b. Request a prescription for alprazolam for the client. c. Initiate a referral for the client to receive individual counseling d. Ask the client if he is thinking about self-harm A nurse is planning care for a client who demonstrates prolonged depression related to the loss of her partner 6 months ago. Which of the following actions should the nurse take? a. Discourage the client from reliving the events surrounding her loss. b. Explain that it can take a year or more to learn to live with a loss. c. Direct the client to maintain an unstructured daily routine. d. Suggest that the client avoid social interactions that remind her of her partner A nurse is speaking with a client. Which of the following responses by the nurse demonstrates the communication technique of reflection? a. “You feel upset when this happens b. “I would like to sit with you for a while.” c. “Let’s work together to try to solve your problem d. “Can you tell me what is happening now?” A nurse is assessing a client who is experiencing alcohol withdrawal. For which of the following findings should the nurse anticipate administration of lorazepam? a. Bradycardia b. Hypertension c. Afebrile d. Stupor An older adult client is brought to the mental health clinic by her daughter. The daughter reports that her mother is not eating and see uninterested in routine activities. The daughter states, “I’m so worried that my mother is depressed.” Which of the following responses should the nurse make a. older adults are usually diagnosed with depressive disorder as they age b. You shouldn’t worry about this, because depressive disorder is easily treated.” c. Tell me the reasons you think your mother is depressed. d. “Everyone gets depressed from tim
