1. A nurse in a community health center is working with a group of clients who have posttraumatic stress disorder. Which of the following interventions should the nurse include to

reduce anxiety among the group members?

- Response prevention

- Guided imagery *

- Aversion therapy

- Light therapy

2. 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 *

- Administer sleep medication to the client who has bipolar disorder

- Move the client who has severe depression to a private room

- Administer sleep medication to the client who has severe depression

3. A nurse is reviewing laboratory results for a client who has schizophrenia and is taking

clozapine. Which of the following values should the nurse identify as a contraindication for

receiving clozapine.

A. WBC 2500/mm3 *

B. Hbg 11.5 mg/dL

C. Platelets 150,000/mm3

D. RBC 3.5 million/mm3

4. 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?

- 17 yr old who lives with friends

- 50 yr old who has a blood alcohol level of 80 mg/dL

- 65 yr old who just received a dose of morphine

- 35 yr old who has major depressive disorder*

5. 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?

- Tell the client to talk less or risk being removed from the meeting

- Ask the group members to discuss their feelings about the client’s monopolizing behavior *

- End the group meeting and take the client aside to discuss the disruptive behavior

- Focus on other group members and ignore the client who is doing all the talking

6. A nurse in a community health center is teaching families of clients who has post-traumatic

stress disorder (PTSD) about expected clinical manifestations. Which of the following

manifestations should the nurse include?

- Repeatedly talks about the traumatic event

- Sleeps excessively

- Experiences feelings of isolation *

- Uses repetitive speech

7. A nurse is preparing to administer diazepam 7.5 mg IV bolus to a client for alcohol

withdrawal. Available is diazepam injection 5 mg/mL. How many mL should the nurse

administer?

1.5 mL

8. 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?

- Provide teaching about the use of positive coping mechanisms

- Establish screening programs to identify at risk clients *

- Refer survivors of intimate partner abuse to a legal advocacy program

- Organize rehab therapy for clients who have experiences intimate partner abuse

9. 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 is married

- Recent promotion at work

- COPD *

- Male

10. A nurse is preparing to discharge to home an older adult client who attempted suicide. The

client lives alone and has difficulty performing ADL’s. Which of the following referrals should the

nurse initiate? Select all that apply

- Occupational therapy *

- Meal delivery services *

- Speech language pathologist

- Physical therapy *

- Home health services *

11. A nurse is receiving change of shift report for four clients. Which of the following clients

should the nurse plan to see first?

- A avoidant personality disorder

- Bipolar disorder and reports being kidnapped by aliens over night

- Taking bupropion and reports having insomnia the past two nights

- Taking clozapine and reports a sore throat and chills *

12. A nurse in a mental health clinic is planning care for four clients. Which of the following

tasks should the nurse delegate to the AP?

- Discuss outpatient resources with a client who has PTSD

- Create a plan of care for a client who is experiencing alcohol withdrawal

- Explain sleep hygiene to a client who has insomnia

- Stay with a client who has anorexia nervosa for 1 hr after mealtimes *

13. A nurse on a mental health unit observes a client who has acute mania hit another client.

Which of the following actions should the nurse take first?

- Call the provider to obtain an immediate prescription for restraint

- Prepare to administer benzodiazepine IM

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

- Check the client who was hit for injuries

14. 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?

- Complete documentation about the clients states Q1H while they are in restraints

- Maintain the client in restraints for a minimum of 4 hr

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

- Request that the provider assess the client within 8H of the application of restraints

15. A nurse is teaching the guardians of a client about their adolescent child’s diagnosis of

bulimia nervosa. Which of the following statements made by the guardians indicates an

understanding of their child’s illness?

- The disease will increase our child’s risk for high blood pressure

- It is important for our child to have regular dental check ups *

- We need to weigh our child daily for several weeks, then once per week

- Bleeding during our child’s periods will increase because of the disease.

16. 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 spend extra time at work to keep from feeling depressed

- I will talk about my feelings with a close friend *

- I will be able to learn how to prevent my partner’s attacks

- I will use meditation instead of taking my antidepressant

17. 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?

- Offer the client various choice for meal selection

- Assign different nursing personnel for each shift

- Permit the client to perform daily rituals to decrease anxiety *

- Maintain an environment that has low lighting

18. A nurse in a mental health clinic is caring for a client who has PTSD after returning from

military deployment. Which of the following in the priority action for the nurse to take?

- Assist the client to identify personal areas of strength

- Encourage the client to talk about experiences during the deployment

- Stay with the client when flashbacks occur *

- Teach the client stress management techniques

19. A nurse is caring for a client who gave birth to a stillborn baby. Which of the following

statements should the nurse make?

- You probably want to hold your baby

- I’ll stay with you just in case you want to talk *

- I know how you must be feeling

- It hurts now, but things will get better soon

20. 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?

- Encourage expression of feelings

- Support the child’s attendance at an assertiveness training group

- Asist the child to perform relaxation breathing

- Reduce environmental stimuli *

21. 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 response should the

nurse make?

- Why do you think you deserve this punishment

- Don’t worry about being punished by God

- Let’s talk about what is upsetting you *

- You shouldn’t say things that will upset you so much

22. A nurse is performing 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?

- Slow onset

- Aphasia

- Confabulation

- Easily distracted *

23. A nurse on a med/surg unit assessing a client who sustained injuries 12H ago following a

motor vehicle crash. The client’s admission blood alcohol level was 325 mg/dL. Which of the

following findings should indicate to the nurse that the client is experiencing alcohol

withdrawal?

- Somnolence

- BP 154/96 *

- Pinpoint pupils

- Blood glucose 210

24. 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?

- Obsessive attention to detail

- Inability to sleep *

- Reports of fatigue

- Isolation from others

25. 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?

- Allowing a client to choose which unit activities to attend

- Attempting alternative therapies instead of restraints for a client who is combative

- Providing a client with accurate information about their prognosis

- Spending adequate time with a client who is verbally abusive *

26. 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

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 *

- Veracity

- Justice

- Autonomy

27. A nurse is caring for a client who is in an abusive relationship and is assisting in the

development of a safety plan. Which of the following actions is the first component of a safety

plan?

- Develop a code worse that means “time to go”

- Identify signs of escalation of violence *

- Have a predetermined place to go in the event of violence

- Keep a hidden package of necessities

28. A nurse is caring for a client who has alcoholic cardiomyopathy. Which of the following lab

findings should the nurse expect?

- Increased CPK *

- increased LDL

- Decrease fasting blood glucose

- Decreased AST

29. A nurse is assessing a client who has major depressive disorder and has been receiving

amitriptyline for 1 wk. Which of the following outcomes should the nurse expect?

- Rapid improvement in affect within 30-60 min after taking the medication

- Greater risk of attempting suicide as affect and energy improve *

- Onset of frequent, loose stools

- Development of physiologic dependence on the medication

30. 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 use the same plan of care and interventions for each client who has depression

- Each nurse will develop a separate plan of care for each client who has depression

- I will update the plan of care as the client’s manifestations of depression change *

- An AP can use the plan of care for client teaching

31. A nurse on an acute mental health facility is receiving change of shift report for four clients.

Which of the following clients should the nurse assess first?

- A client who does not recognize familiar people

- A client who cannot verbalize their needs

- A client who is awake and disoriented at night

- A client who is experiencing delusion of persecution *

32. 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?

- Include a liquid supplement with meals

- Identify the client’s trigger foods*

- Allow the client at least 1H for each meal

- Weigh the client at bedtime each day

33. 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?

- Calling family members

- Spending time alone

- Giving away possessions *

- Excessive crying

34. A nurse at a providers office is interviewing an older adult client. Which of the following

actions should the nurse plan to take?

Nurse's Notes

The client reports a history of anxiety; diagnosed with Alzheimer's disease 2

months ago. The client's partner died 6 months ago. Reports decreased

appetite, low energy levels, and insomnia for several weeks; some memory

loss.

Graphic Results

SaO2 96% on room air

Respiratory rate 20/min

Blood pressure 112/76 mm Hg (lying)

Blood pressure 104/68 mm Hg (standing)

Heart rate 68/min

Temperature 36° C (96.8° F)

Medication Administration Record

Captopril 12.5 mg by mouth three times daily

Digoxin 0.125 mg by mouth each morning

Multivitamin with iron one by mouth daily

Docusate sodium 50 mg by mouth each evening

- Use a screening tool to evaluate the client for depression *

- Ask the provider to decrease the dose of the client’s BP med

- Instruct the client to decease intake of vitamin B12

- Suggest the client go for a brisk walk 20 min before bedtime

35. A nurse is planning care for a client who is to undergo ECT. Which of the following actions should the

nurse include in the plan?

- Administer phenytoin 30 min prior to the procedure

- Instruct the client to expect a headache following the procedure

- Place the client in four point restraints prior to the procedure

- Monitor the client’s cardiac rhythm during the procedure *

36. 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 *

- Introduce the client to other clients in the day room

- Asist the client in facilitating behavioral change

- Determine coping strategies that the client has used in the past

37. 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?

- Encourage the parents to avoid discussing the death with their other children to protect their feelings

- Recommend each parent grieve in private to avoid hindering each other’s healing

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

- Advice the parents to begin counseling if they are still grieving in a few months

38. A nurse is providing teaching to the partner of a client who is in a rehab 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 avoid social events until my partner has completed treatment

- It is important for me to focus my attention on my partner’s addiction

- I will not take charge of my partner’s work responsibilities *

- I want my partner to promise to change addictive behaviors

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

following findings?

- Amenorrhea

- Lanugo

- Cold extremities

- Tooth erosion *

40. A nurse is caring for a client who is experiencing a panic attack. Which of the following

actions should the nurse take?

- Orient the client to person, place and time

- Assist the client with deep breathing exercises *

- Calm the client by using therapeutic touch

- Have the client sit alone in a quiet room

41. A nurse in a mental health facility is caring for a client who has schizophrenia. Which of the

following findings places the client at the greatest risk for self-directed injury or injuring others?

- Inability to communicate with others

- Feelings of absence of self-worth

- Lack of motivation to perform daily tasks

- Command hallucinations *

42. A nurse in an ER is caring for a female 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?

- She works so hard at ballet. Will she be able to perform?

- She won’t let me take the trash from her room. I’m concerned about what she has in there *

- She told me she was tired, so I did her chores for her today

- She is happier with her appearance now that she’s lost some weight

43. 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?

- Community mental health center

- Mental health day program

- Partial hospitalization program

- Assertive community treatment *

44. A school nurse is assessing a school age child who experienced the traumatic loss of a

parent 8 mo ago. Which of the following findings should the nurse identify as an indication that

the child is experiencing PTSD?

- Clinging behaviors directed toward a teaching

- Increased time spent sleeping

- Intense focus on school work

- Lack of interest in an upcoming holiday *

45. A nurse is counseling an adolescent who has anorexia nervosa and reports excessive laxative

use and a fear or gaining weight. The client states, “I’m so fat I can’t even stand to look at

myself.” Which of the following therapeutic response demonstrates the nurse’s use of

summarizing?

- You’ve discussed several concerns about your weight. Let’s go back and talk about your belief

that you are fat

- You’re saying that you think you are fat and are using laxatives because you are afraid of

gaining weight *

- You don’t want to look at yourself because you think you are fat

- You and I can work together to overcome your fears of gaining weight

46. 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?

- Encourage the client to participate in group therapy

- Instruct the client to avoid napping during the day

- Offer the client high-calorie finger foods frequently

- Decrease the client’s daily fiber intake

47. A nurse is planning care for a client who has generalized anxiety disorder. At which of

following levels of anxiety should the nurse plan to teach the client relaxation techniques?

- Panic

- Moderate

- Severe

- Mild

48. A nurse is admitting a client who has major depressive disorder and a new prescription for

tranylcypromine. Which of the following OTC meds that the client reports taking should alert

the nurse to potential adverse reaction?

- Lansoprazole

- Naproxen

- Magnesium hydroxide

- Phenylephrine *

49. A nurse in an ER is caring for four clients. Which of the following clients is the nurse required

to report as potential victim of abuse?

- School age child who has bruises on the knees

- Older adult client who is bedbound and had stage IV pressure ulcer *

- An adolescent who has vaginal candida infection

- Young adult who is pregnant and has a sprained ankle

50. A charge nurse on a mental health unit is discussing client rights with a newly licensed

nurse. Which of the following statements should the charge nurse make?

- Clients can’t refuse to take meds if they are admitted involuntarily

- You can notify a client’s family if they are admitted involuntarily

- Clients who are admitted involuntarily maintain the right to give informed consent for

procedures *

- You can remove a client’s privileges if they are admitted involuntarily and refuse to attend

therapy sessions

51. A nurse is assisting a client who has terminal illness adjust to progressive loss of

independence. Which of the following statements by the client indicates acceptance of her

illness?

- I am going to order a wheelchair for when I’m unable to walk *

- I am going to stop paying my bills since I won’t be around much longer

- I wish you would go take care of somebody who actually needs you

- I am sure I’m going to be able to continue to care for myself without help

52. 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 program will help the client accept responsibility for the disorder

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

- The client will need to identify individuals who have contributed to the disorder

- The program will need a prescription from the client’s provider prior to attendance

53. A nurse is education 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?

- Fear of abandonment

- Motor and verbal tics

- Hostile behavior

- Language delay *

54. 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 *

- You will feel more comfortable after you’ve been here for a while

- It is okay to not want to be here

- You really shouldn’t be pushing on the door

55. 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?

- Document the client’s behavior Q8H

- Limit the client’s fluid intake to 50 mL/Hr

- Renew the prescription for the client Q4H *

- Toilet the client 4H

56. 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?

- weight gain

- tinnitus

- Tachycardia *

- Increased salivation

57. 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 relapse should the nurse include?

- Additional acute episodes of depression are unlikely following inpatient care

- Early identification of changes such as decreased social involvement is important *

- Medication compliance will prevent further need for inpatient hospitalization

- It is helpful to regularly reinforce to the client that things will get better

58. 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?

- Blurred vision

- Orthostatic hypotension

- Dry mouth

- Acute dystonia *

59. A nurse is assessing a client who is experiencing opioid withdrawal. Which of the following

manifestations should the nurse except?

- Sedation

- Rhinorrhea *

- Bradycardia

- Hypothermia

60. 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?

- An adolescent family member who questions parental authority

- A family with three generations in the same household

- Older children who are responsible for their younger siblings *

- Two adults and their children from prior relationships in the same household