Florida National University: NURSING ADULT 2 Mental Health Assessment quiz Updated 2021/2022,100% CORRECT

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Florida National University: NURSING ADULT 2 Mental Health Assessment quiz Updated 2021/2022 1. A nurse is caring for a client whose partner died 3 years ago. The client has withdrawn socially and ... has not participated in regular activities since the funeral. The nurse should identify that the client is experiencing which of the following types of grief? Anticipatory grief Exaggerated grief Chronic grief Disenfranchised grief 2. A nurse is planning to teach a group of clients about techniques to change unwanted behaviors. Which of the following techniques is the nurse using when she acts out different scenarios and has clients respond by practicing new behaviors? Operant conditioning Systematic desensitization Role playing Biofeedback 3. A nurse in acute care facility is providing teaching for the adult child of an older adult client who is admitted with a urinary tract infection and delirium. The client has been living independently at home. Which of the following statements by the adult child demonstrates the teaching has been effective? I should look into the possibility of long-term care for my father when he is discharge. I would like information about respite care for when my father is discharged. I expected that my father will no longer be confused when he is discharged. I will obtain a permanent identification bracelet for my father when he is discharged. 4. A nurse is caring for a client following a fire that destroyed her home and killed one of her children. The client is crying and does not make eye contact with the nurse. Which of the following questions should the nurse ask first? How are you feeling at this time? Is there someone I can call to be with you now? Can you tell me what you have done in the past when going through a difficult time? Have you through of harming yourself? 5. A nurse is developing a plan of care for an adolescent client who has conduct disorder. Which of the following interventions should the nurse include in the plan? Determine if the client has a history of command hallucinations. Instruct the client on thought-stopping techniques. Initiate a behavioral contract with the client. Monitor the client’s neurologic status. 6. A nurse is providing morning care for a client who has Alzheimer’s disease and has frequent outbursts of aggression. Which of the following actions should the nurse take? Limit the client’s choices. Avoid eye contact when talking with the client. Assign a different staff member to the client each day. Discourage the client from talking about the past. 7. A nurse is caring for a client who appears extremely agitated and believes that pacing the floor a specific number of times is necessary or “something terrible” will happen. Which of the following responses should the nurses make? Nothing terrible is going to happen to you. You must stop this behavior. It must be hard for you to have to pace the floor. Let’s talk about your feelings. Are you looking for sympathy? There are other ways to get attention. I understand your need to work off excess energy. Are you angry about something? 8. A nurse in an outpatient mental health is assessing a family unit that consists of grandparents, parents and several children. Which of the following tools should the nurse plan to use to assist in assessing this group of clients? Genogram Patient Health Questionnaire-9(PHQ-9) Hamilton Depression Scale Abnormal Involuntary Movement Scale (AIMS) 9. A nurse is planning care for a client who is taking benztropine to reduce extrapyramidal manifestations develop secondary to taking an antipsychotic medication. For which of the following adverse effects of benztropine should the nurse monitor? Diaphoresis Tachycardia Diarrhea Polyuria 10. A nurse is creating a plan of care for a client who has posttraumatic stress disorder (PTSD). Which of the following interventions should the nurse include in the plan? Assign the same staff to care for the client. Allow the client privacy when experiencing flashbacks. Discourage the client from expressing feelings of trauma. Address the client in an authoritative manner. 11. A nurse is leading a medication education group for several clients. A client who is sometimes violent becomes angry and begins yelling at others in the group. Which of the following actions should the nurse take? (Select all that apply) Speak to the client in an aggressive tone of voice. Move others away from the client. Offer the client a PRN dose of lorazepam. Stand directly in front of the client. Ask the client open-ended question about the behavior 12. A nurse is caring for a client who has generalized anxiety disorder and is taking buspirone. The nurse should identify that which of the following outcomes is advantage of buspirone? It will relieve the client's feeling of anxiety with 30 minutes. Gastrointestinal disturbance are rare. It does not cause physical dependence. It can be used in place of a nighttime sedative for sleep. 13. A nurse is assessing a client who has bulimia nervosa. Which of the following findings should the nurse expect? Yellow skin Dental caries Cold extremities Amenorrhea 14. A nurse is assessing a group of clients in a community health clinic. In which of the following situation should the nurse identify a requirement to report child or vulnerable adult maltreatment to an appropriate agency? (Select all that apply) A 7-year old child has a variety of old and new bruises on his back and posterior thighs. A 2-years old child has a spiral fracture of his arm, which of the parent state happened when he fell from a swing. A 10-years old child has a swollen, bruises ankle, which she reports occurred during basketball practice at school. An 80-year old client who has dementia and lives in a group home has bruises in the perineal area. A 25-year old woman has newly diagnosed hypertension and state that she is a stressed because she and her partner have been arguing about money. 15. A nurse is reviewing a laboratory report of a client who is taking olanzapine. Which of the following laboratory values should the nurse report to the provider? Fasting blood glucose 140 mg/dL Hematocrit 44% Thyroid-stimulating hormone 4.1 uU/ml BUN 19 mg/dL 16. A nurse is caring for a client who has a schizophrenia an exhibiting violent behavior. After staff members place the client in restraints, which of the following action should the nurse take? Document the client’s behavior hourly. Release the restraints when the client goes to sleep. Offer toileting to the client every 4 hour. Request that the provider see the client within 1 hour. 17. A nurse is providing information to a client who is seeking voluntary admission to a mental health facility. Which of the following information should the nurse include? You cannot leave until you provider discharges you. You will give up your right to refuse treatment upon admission. You will still need to give informed consent for treatment after admission. Your provider will notify your employer of your admission. 18. A nurse is caring for an adult client who has involuntarily admitted following a suicide attempt. The nurses receives a call from the client’s spoused asking for the status report. Which of the following response should the nurse make? I can give you a list of your supposed medications because he attempted suicide. Because you are married, you have the right to request a copy of your spouse’s medical record. I cannot discuss your spouse health information with you without his consent. Because your spouse was involuntary admitted for treatment his provider an answer your questions. 19. A nurse is caring for a client who has bipolar disorder and is taking carbamazepine. The nurse should monitor to the client for which of the following adverse effects? Ataxia Drooling Goiter Muscle weakness 20. A nurse in an acute mental health facility is assessing a nearly admitted client who has schizophrenia. Which of the following finding should the nurse identify as the priority to assess further? Command hallucinations Waxy flexibility Somatic delusions Derealization 21. A nurse is assessing for a substance use disorder. The client exhibits yawning, pupillary dilation, rhinorrhea, and reports muscle cramps. The nurse should suspect that the client is withdrawing from which of the following substance? Alcohol Heroin Cannabis Cocaine 22. A nurse in an emergency department is caring for a school-age child who has laceration and bruises inflicted by his mother. The client's father states, “My wife was fired today and came home really angry. I don't think this will ever happen again.” Which of the following responses should the nurse make? Your wife should not be allowed to take out her stress on your child. Why do you think this will not happen again? It's up to you as the father to report this incident to the authorities. Your child will be privately interview about the incident 23. A home health nurse is providing education for the family of a client who has dementia. Which of the following intervention should the nurse recommended? Place a soft rug in front of the client's chair. Set the clients water heater at 140 F. Encourage the client to take a 1-hour nap in the afternoon. Limit fluid intake after the clients evening meal. 24. A home health nurse is caring for a new client who has hoarding disorder that involves food. Which of the following actions should the nurse take first? Encourage the client to verbalize their feelings about hoarding. Refer the client to a support group for hoarding disorder. Discuss the health risk associated with hoarding a food. Assist the client with completing the Hoarding Scale Self-Report. 25. A nurse is caring for an adolescent client who has anorexia nervosa. The client states, “Have I done any permanent damage to my body?” Which of the following response should the nurse make? You should ask your provider that questions. I wouldn’t worry about any permanent damage you might have caused right now. Why do you feel like you have damaged your body? You’re afraid you have caused physical injury to yourself? 26. A nurse in an acute care mental health facility is caring for a client who has generalized anxiety disorder and suddenly begins pacing, wringing her hands, and reporting numbness tingling in her fingers. Which of the following action should the nurse take? Prepare to administer donepezil to decrease the client’s anxiety. Use aversion therapy to decrease the client’s anxiety Distract the client by sending her to a group meeting in the community room. Walk with the client while setting physical limits on behavior. 27. A nurse is caring for a client Who is experiencing mania and is placed in seclusion due to escalating behavior. Which of the following actions should the nurse take? Request that the provider assess the client within 8 hr. Discontinue the seclusion if the clients request it. Check the client’s physical needs every 15 minutes while in seclusion. Request a PRN Prescription for future seclusion. 28. A nurse is providing teaching to a client who has bipolar disorder and has been taking lithium for 4 months. The client’s serum lithium levels are within the therapeutic range. Which of the following instructions should the nurse include to promote the maintenance of the therapeutic lithium level? Limit outdoor exercise during hot weather Reduce dietary intake of sodium by avoiding salty foods. Double your next lithium dose if a dose is skipped or forgotten. Take a daily diuretic if ankle swelling occurs. 29. A nurse is assessing a client who is experiencing mild anxiety. Which of the following finding should the nurse expect? Selective inattention Urinary frequency Sharpened perceptions Voice tremors 30. A nurse in an emergency department is preparing to discharge a client who has severe hypertension and requires detoxification for alcohol use disorder. The nurse should recommend a referral to which of the following resources? A residential rehabilitation program. Intensive outpatient therapy Alcoholics Anonymous A halfway house 31. A nurse is checking laboratory values for a hospitalized young adult client who has bipolar disorder and is taking lithium which of the following values is the priority for the nurse to report to the provider? Lithium level 0.8 mEq/L Serum creatinine 2.1 mg/dL Serum sodium 141 mEq/L T3 180 ng/dL 32. A nurse is discussing resources with the case manager of a client who has schizophrenia and heart failure. Which of the following resources should the nurse recommend to address the client’s behavioral health and medical needs? Patient-center medical home (PCMH) Assertive community treatment (ACT) Community mental Health Center Psychiatric home care 33. A nurse is performing a mental status examination of a client. Which of the following question should the nurse ask the client to assess their cognition? What did you have for dinner last night? Do you hear voices speaking to you? Do you ever think about harming yourself? What do you do to relieve stress? 34. A Hospice nurse is talking with the family of a client who recently died from cancer following a series of chemotherapy treatments. Which of the following defense mechanism is the family member using? Dissociation Rationalization Repression Displacement 35. A charge nurse on a mental health unit is discussing legal issues with a newly licensed nurse. Which of the following statements should the charge nurse include? A client loses the right to refuse prescribed medication when they are admitted involuntarily. Clients admitted involuntarily are considered to be incompetent to provide informed consent A provider can write a prescription for restraint to use on a client on an as-needed basis If a client threatens to seriously harm someone the provider should notify that person of the threat. 36. A nurse is discussing therapeutic communication with a group of newly licensed nurses. Which the following phrases should a nurse use as an example of offering general leads? Do I understand you correctly? And after that? I found it hard to believe I will sit with you for a while 37. A nurse is preparing to administer methylphenidate 30 mg PO to a school age child who has ADHD. Available is methylphenidate oral solution 10 mg/5ml. How many mL should the nurse administer? (Round the answered to the nearest whole number. Use a leading zero if it applies. Do not use a Trailing zero.) 15 38. A nurse is planning care to assist a client with a smoking cessation. Which of the following medications Should the nurse expect the provider to prescribe? Bupropion Chlorodiazepoxide Disulfiram Methadone 39. A nurse is performing an admission assessment for a client who appears withdrawn and fearful. Which of the following actions should the nurse take first? Inform the client that this admission is confidential Determine coping strategies that the client has used in the past. Assist the client in facilitating a change in behavior Introduce the client to other clients in the day room 40. A chart nurse is planning an in-service for a group of newly licensed nurse about the use of restraints. Which of the following information should the nurse include? Record the client’s behavior every 15 min while in restraints. Secured the restrain to the client’s bed rail using a slip knot. Raising all four bedrails to keep a client in bed is not considered a restraint. The nurse should assess a restrained client once every 2 hours 41. A nurse is assigning task to a licensed practical nurse and an assistive personal (AP) Which of the following task should the nurse delegate to the AP? Witness the client's signature on an informed consent for electroconvulsive therapy. Remain witha client who has anorexia nervosa following a meal. Determine there is for suicide of a client who has attempted self-injury. Complete the CAGE questionnaire with a client who has been admitted for observation 42. A nurse is caring for a client who has depressive disorder and recently started taking a selective serotonin reuptake inhibitor. For which of the following findings should the nurse monitor to identify serotonin syndrome. Decreased deep-tendon reflexes Hyperpyrexia Bradycardia Orthostatic hypotension 43. A nurse is counseling a client who has alcohol use disorder and has chosen to enter a treatment program. The client states “I need to find a program that won’t interfere with my job.” The nurse should identify which of the following community resources has being the least restrictive? Outpatient treatment program Residential rehabilitation program Partial hospitalization program Detoxification program 44. A nurse in an emergency department is assessing an older adult client who was brought in by a family member. The family member reports that the client has had a change in behavior over the past 2 days. The nurse should identify that which of the following findings is an indication that the client has delirium. (Select all that apply) Change in level of consciousness decrease attention span Akathisia Hallucinations Aphasia 45. A nurse in a mental health clinic is assessing a client who has dependent personality disorder. Which of the following findings should the nurse expect? Obsesses over details Avoid self-responsibility Becomes anxious in social situation Expresses emotions theatricality 46. A nurse in a mental health clinic received a phone call from a client who has mental health disorder and lives at home. The client reports they cannot afford to refill their prescription for an antipsychotic medication and request assistance. Which of the following members of the client’s health care team children nurse notify? Primary care provider Therapist Case manager Peer support specialist 47. A nurse is assessing a client who has bipolar disorder and is experiencing mania. Which of the following findings is the priority for the nurse to report to the provider? The client is slept for hour last night The client refused to take a shower The client ate half of the provided snack The client refused to drink fluids. 48. A nurse is creating a plan of care for a newly admitted client who has anorexia nervosa. Which of the following interventions should the nurse include? Allow the client to eat in their room for the first week Obtain the clients vital signs once each day Weigh the client daily after first voiding Allow the client to terminate their daily calorie intake. 49. A nurse is a community program for playing who experienced partner violence is planning secondary prevention strategies. Which of the following interventions should the nurse plan to include? Coordinating community resources for a hospitalized client. Arranging for a group of new mothers to meet weekly in order to encourage long-term social support. Teaching a class about risk to a group of young adults Referring a former client who is now living in a safe situation to a legal advocacy organization. 50. A nurse is planning care for a client who is withdrawing from alcohol. Which of the following medication should the nurse plan to administer during the acute phase of alcohol withdrawal? Varenicline Diazepam Disulfiram Acamprosate 51. A nurse is providing dietary to a client who has a prescription for tranylcypromine. The nurse should instruct the client to avoid which of the following foods while taking this medication? Cream cheese Grapefruit Avocados Fresh salmon 52. A nurse is teaching a client about biofeedback therapy. Which of the following clients statement indicates an understanding of the teaching? This therapy will help me use specific body postures to achieve balance this therapy will improve my range of motion This therapy will help me to concentrate on soothing images This therapy will help me recognize change in my blood pressure 53. A nurse in a mental health facility is caring for a client who has frequent episodes of aggressive and violent behavior. The nurse should identify which of the following findings as indication that the client is at risk for imminent violence? (Select all that apply) Uses profanity to express emotions. Displays oculogyric crisis Clenches an unclenches the jaw Maintains intense eye contact Pace the floor 54. A nurse is planning care for a client following a suicide attempt. Which of the following interventions should the nurse include in the plan? Check on the client every 30 minutes while they are in their room Request that a family member bring personal hygiene Items from home Provide the client with plastic eating utensils keep the client’s door closed at night. 55. A nurse is assisting in obtaining informed consent from a client who is scheduled for vagus nerve stimulation. Which of the following actions should the nurse take to act as client advocate? Explain the benefits of the procedure to the client Describe alternatives to the procedure to the client Ensure the client signs the form voluntarily Inform the client of the purpose of vagus nerve stimulation 56. A nurse on a mental health unit is conducting at one-on-one session with a client who suddenly become silent. Which of the following response should the nurse make? Apparently, you no longer wish to talk with me. Have I made you angry? I've notice you have become quiet. Please share with me what you are thinking. What caused you to get quiet all of a sudden. Do you want to talk today? You should talk during this time. It will make you feel better. 57. A charge nurse is conducting an in-service for a group of newly licensed nurse about risk factor for child maltreatment. Which of the following example should the nurse include in the teaching? A child who has acute bronchiolitis A child who has born with a cleft lip and palate A parent who grew up as part of an extended family A parent who has high self-esteem 58. A nurse is caring for a client who is experiencing a manic episode. Which of the following action should the nurse take first? Provide supervised physical activities Maintain a calm attitude with the client Decrease environmental stimuli Encourage the client to rest each hour 59. A nurse is caring for a client who has Schizophrenia and is experiencing frequent delusions. Which of the following strategies should the nurse use when caring for the client? Identify the client’s feelings underlying the delusions Tell the client that the delusion is not real Reinforce the delusions to gain the clients cooperation Help the client to ignore events that trigger delusions 60. A nurse in an acute care mental health facility is preparing a client for discharge. Which of the following task should the nurse include in the termination phase of the nurse-client relationship? Plan short-term goals Discuss confidentiality Make appropriate referrals Clarify responsibilities of the nurse and the client . [Show More]

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