ATI Mental Health Proctored Exam With NGN Version 4 With Answers-329 Solved Questions

VERSION 4
ATI Mental Health Proctored Final Exam
A nurse is planning care for a client who has borderline personality disorder who selfmutilates. Which of the following test approaches should the nurse plan to take?
A. Restrict participation in group therapy sessions.
The nurse should encourage the client who has borderline personality disorder to participate
in group therapy sessions to encourage appropriate interaction with other clients.
B. Establish consequences for self-mutilation.
The nurse should respond to self-mutilation with a neutral affect and encourage the client to
write down feelings that occurred leading up to the incident.
C. Maintain close observation of the client.
Clients who have borderline personality disorder are at risk for self- harm during times of
increased anxiety. Maintaining close observation reduces the client's risk of injury.
D. Provide an unstructured environment.
Providing an unstructured environment for a client who has borderline personality disorder is
not an effective treatment approach because it does not provide a safe environment to protect
the client from impulsive and self-injurious behavior.
Answer: C. Maintain close observation of the client.
Clients who have borderline personality disorder are at risk for self- harm during times of
increased anxiety. Maintaining close observation reduces the client's risk of injury.
A nurse is assessing a client who has Stage 4 Alzheimer's disease. Which of the following
findings should the nurse expect?
A. The client requires assistance with eating.
The nurse should expect the client who has Stage 4 Alzheimer’s disease to still have the
ability to eat without assistance. Clients who have Alzheimer’s disease maintain this ability
until Stage 7.
B. The client independently manages personal finances.
The nurse should expect the client who has Stage 4 Alzheimer’s disease to have difficulty
performing complex tasks, such as managing personal finances.
C. The client has bladder incontinence.
The nurse should expect the client who has Stage 4 Alzheimer’s disease to be able to use the
toilet independently. Clients who have Alzheimer’s disease maintain continence until Stage 6.

D. The client is able to identify the names of family members.
The nurse should expect the client who has Stage 4 Alzheimer’s disease to recognize and
identify family members. Clients who have Alzheimer’s disease maintain this ability until
Stage 6.
Answer: D. The client is able to identify the names of family members.
The nurse should expect the client who has Stage 4 Alzheimer’s disease to recognize and
identify family members. Clients who have Alzheimer’s disease maintain this ability until
Stage 6.
A nurse is caring for a client who reports that the television set in the room is really a twoway radio and states, "voices are coming from the TV and everything we say in the room is
being recorded." Which of the following responses should the nurse make?
A. "What we say is not being recorded."
The nurse should avoid negating the client’s beliefs about the delusion. This response can
promote a defensive client response and interfere with the development of trust in the nurseclient relationship.
B. "Let's ignore the voices and talk about something else."
The nurse should ask the client directly about what the voices are saying to determine if there
is a safety risk. The nurse should also avoid validating that the voices are real, which
promotes the client’s beliefs about the delusion.
C. "That must be very frightening."
The nurse should respond to the client’s delusion in a calm and empathetic manner. By
acknowledging to the client that the delusion must be frightening, the nurse promotes the
nurse-client relationship.
D. "Why do you think the TV is a two-way radio?"
The nurse should avoid asking the client a "why" question, which promotes a defensive client
response.
Answer: C. "That must be very frightening."
The nurse should respond to the client’s delusion in a calm and empathetic manner. By
acknowledging to the client that the delusion must be frightening, the nurse promotes the
nurse-client relationship.

A nurse is planning care for a newly admitted client who has bipolar disorder and is
experiencing acute mania. Which of the following client goals should the nurse identify as
the priority?
A. Practicing problem-solving skills
The nurse should encourage the client to practice problem-solving skills during the
continuation phase of treatment; however, there is another intervention that is the priority
during the acute phase of bipolar disorder.
B. Understanding of medication regimen
The nurse should ensure that the client understands the medication regimen during the
continuation phase of treatment; however, there is another intervention that is the priority
during the acute phase of bipolar disorder.
C. Identifying indications of relapse
The nurse should teach the client to recognize indications of relapse during the continuation
phase of treatment; however, there is another intervention that is the priority during the acute
phase of bipolar disorder.
D. Maintaining adequate hydration
The nurse should identify that the priority goal is to prevent physical exhaustion, maintain
health, and meet nutritional and rest needs during the acute phase of the client’s manic
episode. The nurse should consider Maslow’s hierarchy of needs, which includes five levels
of priority when planning care for this client. The first level consists of physiological needs;
the second level consists of safety and security needs; the third level consists of love and
belonging needs; the fourth level consists of personal achievement and self-esteem needs; and
the fifth level consists of achieving full potential and the ability to problem solve and cope
with life situations. When applying Maslow’s hierarchy of needs priority-setting framework
the nurse should review physiological needs first. The nurse should then address the client’s
needs by following the remaining four hierarchical levels. It is important, however, for the
nurse to consider all contributing client factors, as higher levels of the pyramid can compete
with those at the lower levels, depending on the specific client situation. The fourth level of
Maslow’s hierarchy of needs includes usefulness, selfworth, and self-confidence in fulfilling
self-esteem needs.
Answer: D. Maintaining adequate hydration
The nurse should identify that the priority goal is to prevent physical exhaustion, maintain
health, and meet nutritional and rest needs during the acute phase of the client’s manic
episode. The nurse should consider Maslow’s hierarchy of needs, which includes five levels

of priority when planning care for this client. The first level consists of physiological needs;
the second level consists of safety and security needs; the third level consists of love and
belonging needs; the fourth level consists of personal achievement and self-esteem needs; and
the fifth level consists of achieving full potential and the ability to problem solve and cope
with life situations. When applying Maslow’s hierarchy of needs priority-setting framework
the nurse should review physiological needs first. The nurse should then address the client’s
needs by following the remaining four hierarchical levels. It is important, however, for the
nurse to consider all contributing client factors, as higher levels of the pyramid can compete
with those at the lower levels, depending on the specific client situation. The fourth level of
Maslow’s hierarchy of needs includes usefulness, selfworth, and self-confidence in fulfilling
self-esteem needs.
A nurse is preparing to administer benzodiazepine to a client with Generalized Anxiety
Disorder. The nurse should tell the client to expect with of the following adverse reactions?
A. Tinnitus
Tinnitus is not an adverse effect of benzodiazepines.
B. Bradycardia
Tachycardia, rather than bradycardia, is a potential adverse effect of benzodiazepines.
C. Halitosis
Halitosis is not an adverse effect of benzodiazepines.
D. Sedation
The nurse should tell the client to expect sedation as an adverse effect of benzodiazepines
because of the CNS depression effects.
Answer: D. Sedation
The nurse should tell the client to expect sedation as an adverse effect of benzodiazepines
because of the CNS depression effects.
A nurse in a mental health unit is planning care for a client who is receiving treatment for
self-inflicted injuries. The nurse should identify which of the following interventions as the
priority when planning care for this client?
A. Promoting and maintaining client safety
The nurse should recognize that the client who has self-inflicted injuries is at risk for further
self-harm or suicide; therefore, the client’s safety is the priority. The nurse should apply the
safety and risk reduction prioritysetting framework when planning care for this client. This

framework assigns priority to the factor or situation posing the greatest safety risk to the
client. When there are several risks to client safety, the one posing the greatest threat is the
highest priority. The nurse should use Maslow’s hierarchy of needs, the ABC priority-setting
framework, or nursing knowledge to identify which risk poses the greatest threat to the client.
B. Discussing reasons for the client's behavior
The nurse should communicate with the client to discuss reasons for the client’s behavior;
however, there is another action that is the priority.
C. Assisting the client to recognize feelings
The nurse should assist the client to recognize feelings; however, there is another action that
is the priority.
D. Teaching the client alternative coping strategies
The nurse should teach the client alternative coping strategies; however, there is another
action that is the priority.
Answer: A. Promoting and maintaining client safety
The nurse should recognize that the client who has self-inflicted injuries is at risk for further
self-harm or suicide; therefore, the client’s safety is the priority. The nurse should apply the
safety and risk reduction priority setting framework when planning care for this client. This
framework assigns priority to the factor or situation posing the greatest safety risk to the
client. When there are several risks to client safety, the one posing the greatest threat is the
highest priority. The nurse should use Maslow’s hierarchy of needs, the ABC priority-setting
framework, or nursing knowledge to identify which risk poses the greatest threat to the client.
A nurse is providing teaching to a client who has a new prescription for disulfiram for
management of alcohol dependence. Which of the following dietary choices should the nurse
instruct the client to avoid?
A. Peppermint candy
It is not necessary for the client to avoid peppermint while taking disulfiram.
B. Pure vanilla extract
The nurse should instruct the client to avoid alcohol and alcohol- containing substances, such
as pure vanilla extract, while taking disulfiram. The ingestion of alcohol while taking this
medication causes a disulfiram-alcohol reaction, which is manifested by hyperventilation,
dizziness, vomiting, and hypotension.
C. Salt

Though certain medications require a reduction in sodium intake, it is not necessary for the
client to avoid salt while taking disulfiram.
D. Chocolate
Though certain medications require a reduction in caffeine-containing substances such as
chocolate, it is not necessary for the client to avoid chocolate while taking disulfiram.
Answer: B. Pure vanilla extract
The nurse should instruct the client to avoid alcohol and alcohol- containing substances, such
as pure vanilla extract, while taking disulfiram. The ingestion of alcohol while taking this
medication causes a disulfiram-alcohol reaction, which is manifested by hyperventilation,
dizziness, vomiting, and hypotension.
A nurse is planning care for a client with a physical dependence of Alprazolam and must
discontinue the medication. Which of the following should the nurse include in the plan?
A. Taper the medication gradually over several weeks.
The nurse should plan to taper the dosage of alprazolam gradually over several weeks,
possibly months. This gradual reduction in dosage reduces the manifestations of withdrawal.
B. Encourage participation in stimulating physical activity.
The nurse should provide the client with a calm, low-stimulation environment to decrease the
anxiety and physical manifestations that can result from alprazolam withdrawal.
C. Monitor the client for a return of anxiety for up to 72 hr following discontinuation of the
medication.
The nurse should plan to monitor the client for at least 3 weeks following discontinuation of
the medication for a return of anxiety manifestations.
D. Implement restraints and seclusion as needed.
It is not necessary to restrain or seclude the client during withdrawal from alprazolam.
Restraints are considered restrictive, and the nurse should work to promote the least
restrictive environment.
Answer: A. Taper the medication gradually over several weeks.
The nurse should plan to taper the dosage of alprazolam gradually over several weeks,
possibly months. This gradual reduction in dosage reduces the manifestations of withdrawal.
A nurse is caring for a newly admitted client who is receiving treatment for alcohol use
disorder. the client tells the nurse “I have not had a drink for 6 hours.” Which findings should
the nurse expect during alcohol withdrawals.

A. Low body temperature
The nurse should expect the client who is experiencing alcohol withdrawal to have an
elevated temperature.
B. Insomnia
The nurse should expect the client who is experiencing alcohol withdrawal to have insomnia
and restlessness.
C. Muscle flaccidity
The nurse should expect the client who is experiencing alcohol withdrawal to have muscle
tremors.
D. Bradycardia
The nurse should expect the client who is experiencing alcohol withdrawal to have
tachycardia.
Answer: B. Insomnia
The nurse should expect the client who is experiencing alcohol withdrawal to have insomnia
and restlessness.
A nurse is caring for a client who is receiving treatment for alcohol detoxification. Which of
the following medications should the nurse expect to administer during this phase of the
client's care?
A. Buprenorphine
The nurse should expect to administer buprenorphine to a client during opiate detoxification.
B. Diazepam
The nurse should expect to administer diazepam to a client during alcohol detoxification.
Anti-anxiety agents, such as chlordiazepoxide and diazepam, are long-acting CNS
depressants that are used to minimize the manifestations of alcohol withdrawal.
C. Varenicline
The nurse should expect to administer varenicline to a client who has nicotine use disorder.
D. Rimonabant
The nurse should expect to administer rimonabant to a client who has nicotine use disorder.
Answer: B. Diazepam
The nurse should expect to administer diazepam to a client during alcohol detoxification.
Anti-anxiety agents, such as chlordiazepoxide and diazepam, are long-acting CNS
depressants that are used to minimize the manifestations of alcohol withdrawal.

A nurse is speaking to a community group about the diagnosis and treatment of clients who
have Alzheimer's. The nurse should conclude that the members of the group need further
teaching when she identifies the following as manifestations of Alzheimer Disease.
A. Impaired judgment
The nurse should identify impaired judgment as a common manifestation associated with
Alzheimer Disease.
B. Sudden confusion
The nurse should clarify that the client who has Alzheimer’s disease is expected to exhibit
confusion that develops slowly over a period of months. Clients who have delirium exhibit
sudden confusion.
C. Personality change
The nurse should identify that clients who have Alzheimer’s disease are expected to exhibit
changes in personality as the disease progresses.
D. Remote memory loss
The nurse should identify recent and remote memory loss as common manifestations
associated with Alzheimer’s disease.
Answer: B. Sudden confusion
The nurse should clarify that the client who has Alzheimer’s disease is expected to exhibit
confusion that develops slowly over a period of months. Clients who have delirium exhibit
sudden confusion.
A nurse is providing teaching to a client with Generalized Anxiety Disorder and a new
prescription for Buspirone. The nurse should inform the client that which of the following
manifestations is a common adverse effect of this medication?
A. Confusion
Confusion is not an adverse effect of buspirone, though the client might experience decreased
concentration and headache.
B. Bradycardia
Tachycardia and palpitations, not bradycardia, are possible adverse effects of buspirone.
C. Dizziness
The nurse should inform the client that dizziness is a common adverse effect of buspirone.
The nurse should instruct the client to avoid driving and operating heavy machinery until the
presence of adverse effects is determined.
D. Insomnia

Drowsiness, not insomnia, is an adverse effect of buspirone.
Answer: C. Dizziness
The nurse should inform the client that dizziness is a common adverse effect of buspirone.
The nurse should instruct the client to avoid driving and operating heavy machinery until the
presence of adverse effects is determined.
A nurse is reviewing the medications of a client who has bipolar disorder and a new
prescription for lithium. The nurse should identify that it is safe to administer which of the
following medications while the client is taking lithium?
A. Ibuprofen
Ibuprofen is not safe to administer to a client who is taking lithium because it can cause
increased kidney absorption of lithium, which can lead to lithium toxicity.
B. Haloperidol
Haloperidol is not safe to administer to a client who is taking lithium because the
combination of these medications increases the client’s risk for extrapyramidal adverse
effects and tardive dyskinesia.
C. Valproic acid
Valproic acid and lithium are both indicated for the treatment of bipolar disorder. It is safe for
the nurse to administer both of these medications to the client.
D. Hydrochlorothiazide
Hydrochlorothiazide is not safe to administer to a client who is taking lithium because it
promotes sodium loss, which can lead to lithium toxicity.
Answer: C. Valproic acid
Valproic acid and lithium are both indicated for the treatment of bipolar disorder. It is safe for
the nurse to administer both of these medications to the client.
A nurse in the emergency department is caring for a toddler with a fractured arm. which of
the following finding should the nurse suspect as possible abuse?
A. The parent provides a history that is inconsistent with the child's injury. The nurse should
suspect possible abuse when the child’s injury conflicts with the history of the injury that is
reported by his parent.
B. The child is brought to the emergency department immediately following the injury.
The nurse should suspect possible abuse when there is a delay in seeking medical care
following an injury.

C. The parent requests to remain present with the child throughout treatment of the injury.
The nurse should suspect possible abuse when the parent leaves the treatment area or facility
after bringing the child in for treatment of an injury.
D. The child clings to the parent when the nurse begins to assess the injury.
The nurse should suspect possible abuse if the child displays fear of the parent.
Answer: A. The parent provides a history that is inconsistent with the child's injury. The
nurse should suspect possible abuse when the child’s injury conflicts with the history of the
injury that is reported by his parent.
A nurse is evaluating a care plan for a client who has an Antisocial Personality Disorder.
Which of the following client actions indicates he is making progress in treatments? (Select
All That Apply)
A. Assisting another client who has depression to fill out a menu.
Clients who have antisocial personality disorder tend to lack empathy for others and often
display an inability to connect with others. Assisting another client indicates the client’s
willingness to help and connect with others and demonstrates to the nurse his progress with
treatment.
B. Nominating himself to chair the client government meeting.
Clients who have antisocial personality disorder tend to see themselves as superior to others.
Providing a self-nomination for chairperson status places him in a position of power over
others; therefore, this behavior does not indicate progress with the treatment.
C. Requesting a weekend pass to go home.
Clients who have antisocial personality disorder tend to disregard rules and have a lack of
respect for authority. Requesting a weekend pass indicates the client’s willingness to follow
unit rules and demonstrates to the nurse his progress with the treatment.
D. Serving as the judge for a unit talent show.
Clients who have antisocial personality disorder tend to see themselves as superior to others.
Serving as a judge places the client in a position of power over others; therefore, this
behavior does not indicate progress with the treatment.
E. Informing the nurse that the staff provides excellent care to clients.
Clients who have antisocial personality disorder often use flattery as a form of manipulation
to promote personal gain; therefore, providing a compliment to the nursing staff does not
indicate progress with the treatment.
Answer: A. Assisting another client who has depression to fill out a menu.

Clients who have antisocial personality disorder tend to lack empathy for others and often
display an inability to connect with others. Assisting another client indicates the client’s
willingness to help and connect with others and demonstrates to the nurse his progress with
treatment.
C. Requesting a weekend pass to go home.
Clients who have antisocial personality disorder tend to disregard rules and have a lack of
respect for authority. Requesting a weekend pass indicates the client’s willingness to follow
unit rules and demonstrates to the nurse his progress with the treatment.
A nurse is providing teaching to a client who is to start taking valproic acid. Which of the
following instructions should the nurse include?
A. "You should expect the provider to gradually decrease your dosage of valproic acid."
The nurse should inform the client that the provider will initially prescribe a small dose, and
then gradually increase the dose until a maintenance dosage is achieved.
B. "You should take aspirin for pain you have while taking valproic acid." The nurse should
instruct the client to avoid aspirin while taking valproic acid because of the increased risk of
spontaneous bleeding.
C. "You should undergo thyroid function tests every 6 months while taking valproic acid."
The nurse should identify that hypothyroidism is an adverse effect of lithium rather than
valproic acid.
D. "You should have your liver function levels monitored regularly while taking valproic
acid"
The nurse should inform the client of the need to regularly monitor liver function levels due
to the risk for hepatotoxicity while taking valproic acid. It is recommended to obtain baseline
levels and then repeat every 2 months during the first 6 months of therapy.
Answer: D. "You should have your liver function levels monitored regularly while taking
valproic acid"
The nurse should inform the client of the need to regularly monitor liver function levels due
to the risk for hepatotoxicity while taking valproic acid. It is recommended to obtain baseline
levels and then repeat every 2 months during the first 6 months of therapy.
A nurse is teaching a client who has Agoraphobia about Systematic
Desensitization. Which of the following comments should the nurse include in the teaching?

A. "You will watch from a secure location as your therapist goes to public spaces." The nurse
should recognize that encouraging the client to watch as the therapist acts as a role model in
anxiety-provoking situations is an example of modeling, not systematic desensitization.
B. "You will start your therapy by staying in a public space until your anxiety decreases."
The nurse should recognize that sudden exposure of the client to the undesirable stimulus is
an example of flooding, not systematic desensitization.
C. "You will be instructed to say 'Stop!' out loud when you become anxious in public spaces."
The nurse should recognize that saying "Stop!" to interrupt a negative thought is an example
of thought stopping, not systematic desensitization.
D. "You will slowly be exposed to increasing levels of public spaces."
The nurse should inform the client that, using systematic desensitization, she will be
gradually exposed to the feared situation under controlled conditions until she learns to
overcome the anxious response.
Answer: D. "You will slowly be exposed to increasing levels of public spaces."
The nurse should inform the client that, using systematic desensitization, she will be
gradually exposed to the feared situation under controlled conditions until she learns to
overcome the anxious response.
A nurse is planning a staff education session about the administration of antidepressant
medications to older adult clients. Which of the following information should the nurse
include in the teaching?
A. Older adult clients require a lower initial dose of antidepressant medication than adult
clients.
The nurse should recognize that older adult clients are recommended to start at half the adult
dose for antidepressant medications. This is due to altered rates of absorption and the
increased risk for adverse effects.
B. Older adult clients should not receive antidepressant medication.
The nurse should identify that antidepressant medications are commonly prescribed for older
adult clients; however, adjustments are needed due to the clients' altered rates of absorption.
C. Older adult clients achieve the therapeutic effects of antidepressant medications more
quickly than adult clients.
The nurse should identify that older adult clients have a decreased rate of absorption,
distribution, and metabolism, resulting in a delay in achieving therapeutic effects. It can take
about 1 month of treatment for the older adult client to achieve therapeutic effects.

D. Older adult clients have a decreased risk for adverse effects from antidepressant
medication.
The nurse should identify that older adult clients have an increased risk for adverse effects
due to a decreased rate of excretion.
Answer: A. Older adult clients require a lower initial dose of antidepressant medication than
adult clients.
The nurse should recognize that older adult clients are recommended to start at half the adult
dose for antidepressant medications. This is due to altered rates of absorption and the
increased risk for adverse effects.
A nurse in an acute mental health facility is reviewing the medication records for a group of
clients. The nurse should expect a prescription for memantine for a client who has which of
the following diagnoses?
A. Postpartum depression
The nurse should recognize that memantine, an N-methyl-D-aspartate
(NMDA) receptor agonist, is not indicated for the treatment of depression.
B. Schizophrenia
The nurse should recognize that memantine, an NMDA receptor agonist, is not indicated for
the treatment of schizophrenia.
C. Obesity
The nurse should recognize that memantine, an NMDA receptor agonist, is not indicated for
the treatment of obesity.
D. Severe Alzheimer's disease
The nurse should expect a prescription for memantine for a client who has moderate to severe
Alzheimer’s disease. Memantine, an NMDA receptor agonist, is shown to slow the
progression of manifestations and to improve cognitive function.
Answer: D. Severe Alzheimer's disease
The nurse should expect a prescription for memantine for a client who has moderate to severe
Alzheimer’s disease. Memantine, an NMDA receptor agonist, is shown to slow the
progression of manifestations and to improve cognitive function.
A nurse is assessing a client who has Binge-Eating Disorder. Which of the following findings
should the nurse expect?
A. Amenorrhea

Clients who have binge-eating disorder often have an increased BMI; therefore, amenorrhea
resulting from a low body weight is not expected.
B. Abdominal pain
The nurse should expect the client who has binge-eating disorder to report problems with
abdominal pain. This is due to the gastrointestinal dilation that occurs as a result of eating
excessive volumes of food.
C. Restricted caloric intake
Clients who have binge-eating disorder often have an increased BMI resulting from eating
excessive volumes of food.
D. Frequent use of laxatives
Clients who have binge-eating disorder have repeated episodes of binging without the use of
compensatory behaviors, such as the use of laxatives.
Answer: B. Abdominal pain
The nurse should expect the client who has binge-eating disorder to report problems with
abdominal pain. This is due to the gastrointestinal dilation that occurs as a result of eating
excessive volumes of food.
A nurse on an acute care unit is providing postoperative care for an elderly patient who
developed Delirium. Which of the following actions should the nurse take?
A. Request a prescription for an antianxiety medication.
The nurse should request a prescription for an antianxiety medication for a client who
develops delirium. Administration of a PRN antianxiety medication can decrease her anxiety
and agitation.
B. Provide the client with a stimulating activity prior to bedtime.
The nurse should maintain a low-stimulation environment for the client to decrease
disorientation due to overstimulation.
C. Keep the lights in the client's room dim at night.
The nurse should keep the client’s room well-lit. Adequate lighting can help her to remain
oriented to place upon waking at night and will provide for safety if she becomes ambulatory.
D. Encourage the client to make decisions about her daily routine.
The nurse should provide the client with a consistent routine and limit her need to make
decisions. These actions will decrease disorientation and anxiety.
Answer: A. Request a prescription for an antianxiety medication.

The nurse should request a prescription for an antianxiety medication for a client who
develops delirium. Administration of a PRN antianxiety medication can decrease her anxiety
and agitation.
A nurse assessing a client who has Conduct Disorder. Which of the following findings should
the nurse expect?
A. Fearfulness of authority figures
Clients who have conduct disorder exhibit a lack of respect for authority figures and might
attempt to initiate a fight with or intimidate others.
B. Flat affect
Clients who have conduct disorder are easily angered and do not have a flat affect.
C. Preoccupation with enforcing rules
Clients who have conduct disorder exhibit a lack of respect for rules.
D. Aggressive behavior toward others
The nurse should expect the client who has conduct disorder to exhibit aggression toward
others and impulsively violate others' rights.
Answer: D. Aggressive behavior toward others
The nurse should expect the client who has conduct disorder to exhibit aggression toward
others and impulsively violate others' rights.
A nurse in an acute care facility is leading a staff discussion about the legal implications of
involuntary admissions. Which of the following should the nurse include?
A. A client who is involuntarily admitted must take prescribed medications.
Clients who are involuntarily admitted retain the legal right to refuse medications.
B. An involuntary admission of a client is limited to 2 weeks.
Clients who are involuntarily admitted might be required to remain in the facility for up to 60
days. After this time a legal review of the case is required to determine if continued
involuntary treatment is required.
C. A client who is involuntarily admitted can leave the facility against medical advice.
Clients who are involuntarily admitted retain certain rights; however, they are unable to leave
the health care facility against medical advice. If a client who is involuntarily admitted feels
that the admission is unjustified, the client can file a legal petition requesting a review of the
admission.

D. An involuntary admission is justified if the client is a danger to others. A client who is a
danger to others or to himself qualifies for an involuntary admission. The inability to meet
basic needs due to the need for mental health treatment is also a justification for an
involuntary admission.
Answer: D. An involuntary admission is justified if the client is a danger to others. A client
who is a danger to others or to himself qualifies for an involuntary admission. The inability to
meet basic needs due to the need for mental health treatment is also a justification for an
involuntary admission.
A nurse is caring for a client who has Schizophrenia. The nurse notices that the client is
pacing up and down the hall very rapidly and muttering in an angry manner. Which of the
following actions should the nurse take first?
A. Apply mechanical restraints to the client.
The nurse might have to place the client in restraints to prevent harm to others and allow the
client to calm down; however, the nurse should use a less restrictive intervention first.
B. Administer PRN haloperidol IM to the client.
The nurse might have to administer PRN haloperidol to calm the client; however, the nurse
should use a less restrictive intervention first.
C. Approach the client in a nonthreatening manner.
The first action the nurse should take is to approach the client calmly, in a nonthreatening
manner, to create a nonthreatening environment. The nurse should apply the least restrictive
priority-setting framework when caring for this client. This framework assigns priority to
nursing interventions that are least restrictive to the client, as long as those interventions do
not jeopardize client safety. Least restrictive interventions promote client safety without using
restraints. The nurse should only use physical or chemical restraints when the safety of the
client, staff, or others is at risk.
D. Place the client in seclusion.
The nurse might have to place the client in seclusion to prevent harm to others and allow the
client to calm down; however, the nurse should use a less restrictive intervention first.
Answer: C. Approach the client in a nonthreatening manner.
The first action the nurse should take is to approach the client calmly, in a nonthreatening
manner, to create a nonthreatening environment. The nurse should apply the least restrictive
priority-setting framework when caring for this client. This framework assigns priority to
nursing interventions that are least restrictive to the client, as long as those interventions do

not jeopardize client safety. Least restrictive interventions promote client safety without using
restraints. The nurse should only use physical or chemical restraints when the safety of the
client, staff, or others is at risk.
A nurse is reviewing the medical record of a client who has a new prescription for a
benzodiazepine. For which of the following findings should the nurse question the provider's
prescriptions?
A. A skeletal muscle injury
Benzodiazepines have muscle relaxant properties and can relieve muscle spasms; therefore, a
skeletal muscle injury is not a contraindication for receiving benzodiazepines.
B. History of status epilepticus
Benzodiazepines can raise the seizure threshold and prevent seizures; therefore, a history of
status epilepticus is not a contraindication for receiving benzodiazepines.
C. Hypotension
The nurse should question the provider’s prescription for a benzodiazepine for a client who
has hypotension. Benzodiazepines can cause severe hypotension and increase the client’s risk
for cardiac arrest.
D. Insomnia
Benzodiazepines induce sleep for clients who have a sleep disorder; therefore, insomnia is
not a contraindication for receiving benzodiazepines.
Answer: C. Hypotension
The nurse should question the provider’s prescription for a benzodiazepine for a client who
has hypotension. Benzodiazepines can cause severe hypotension and increase the client’s risk
for cardiac arrest.
A nurse is providing teaching to the parents of a school-age child who has attention deficit
hyperactivity disorder (ADHD). Which of the following instructions should the nurse include
in the teaching?
A. "Ignore your child's attention-seeking behaviors that are not dangerous."
The nurse should instruct the parents about the use of planned ignoring.
This technique ignores attention-seeking behaviors that are not dangerous to the child or
others. If the child learns that the behavior will not elicit the desired response, then the
behavior should decrease.
B. "Administer ADHD medications within 30 minutes of your child's bedtime."

The nurse should instruct the parents to administer medications in the morning to decrease
insomnia, which is a common adverse effect of ADHD medications.
C. "Continue with an activity as planned even if your child becomes frustrated." The nurse
should instruct the parents about the use of restructuring. This technique adjusts or changes
an activity based on the child’s level of frustration.
D. "Expect your child to gain weight after starting ADHD medications."
The nurse should instruct the parents that a decreased appetite and weight loss are common
adverse effects of ADHD medications.
Answer: A. "Ignore your child's attention-seeking behaviors that are not dangerous."
The nurse should instruct the parents about the use of planned ignoring.
This technique ignores attention-seeking behaviors that are not dangerous to the child or
others. If the child learns that the behavior will not elicit the desired response, then the
behavior should decrease.
The nurse is interviewing a client who has Anorexia Nervosa. Which if the following findings
should the nurse expect?
A. Poor personal hygiene habits
The nurse should not expect the client who has anorexia nervosa to have poor personal
hygiene habits. Clients who have anorexia nervosa often exhibit compulsive behaviors, such
as frequent hand washing, and are preoccupied with their appearance.
B. Strenuous exercise regimen
The nurse should expect the client who has anorexia nervosa to report a strenuous exercise
regimen. The client might participate in excessive physical activity due to the perceived need
to burn calories and lose weight.
C. Grandiose behaviors
The nurse should expect clients who have anorexia nervosa to have poor self-esteem and
negative feelings about themselves.
D. Intense fear of death
The nurse should expect the client who has anorexia nervosa to have an intense fear of
gaining weight. Clients who have anorexia nervosa exhibit behaviors that have negative
health consequences in order to prevent weight gain.
Answer: B. Strenuous exercise regimen

The nurse should expect the client who has anorexia nervosa to report a strenuous exercise
regimen. The client might participate in excessive physical activity due to the perceived need
to burn calories and lose weight.
A nurse is caring for a client who has depression, the clients states, "I am too tired and
depressed to attend group therapy today." Which of the following responses should the nurse
make?
A. "Attending group therapy, even if you're tired, is an important part of your treatment."
The nurse provides a therapeutic response by giving the client information to make an
informed decision. Group therapy is beneficial to the client who has depression by promoting
peer support and reducing social isolation.
B. "That's okay if you're too tired to attend group therapy today, but you will have to go
tomorrow."
The nurse should recognize that a lack of energy is expected for a client who has depression.
There is no indication that the client will have more energy for group therapy in the future.
The nurse should also respect the client’s autonomy and avoid giving a directive about
required participation.
C. "It is normal to feel tired when you're feeling depressed. The others in group therapy also
feel this way."
The nurse should avoid minimizing the client’s feelings by making a generalization about her
status in relation to others.
D. "I agree with your decision to wait for participation in group therapy until you begin to
feel better."
The nurse should avoid giving approval to the client’s decision, which promotes the need for
her to please the nurse. The nurse should also encourage her to participate in group therapy to
promote improvement of her depression.
Answer: A. "Attending group therapy, even if you're tired, is an important part of your
treatment."
The nurse provides a therapeutic response by giving the client information to make an
informed decision. Group therapy is beneficial to the client who has depression by promoting
peer support and reducing social isolation.
A nurse is performing an admission assessment for a client who has restricting type Anorexia
Nervosa. The nurse should expect which of the following findings?

A. Decreased caloric intake
The nurse should expect the client who has restricting type anorexia nervosa to have a
restricted and decreased caloric intake due to the client’s intense fear of weight gain.
B. Recurrent binging
Recurrent binging is an expected finding of binge-eating/purging type anorexia nervosa.
Clients who have restricting type anorexia nervosa are not expected to exhibit bulimic
manifestations, such as binge eating.
C. Compensatory vomiting
Compensatory vomiting is an expected finding of binge-eating/purging type anorexia
nervosa. Clients who have restricting type anorexia nervosa are not expected to exhibit
bulimic manifestations, such as compensatory vomiting.
D. Loss of appetite
Loss of appetite is not an expected finding of a client who has anorexia nervosa. Clients who
have restrictive type anorexia nervosa maintain an appetite; however, they have inadequate
intake due to fear of gaining weight.
Answer: A. Decreased caloric intake
The nurse should expect the client who has restricting type anorexia nervosa to have a
restricted and decreased caloric intake due to the client’s intense fear of weight gain.
A nurse in a substance abuse treatment facility is reviewing the medication records for a
group of clients. The nurse should expect to administer Methadone for a client who has a
substance use disorder for which of the following addictions?
A. Amphetamines
The nurse should recognize that the administration of methadone is not indicated for the
treatment of amphetamine use disorder.
B. Opiates
The nurse should recognize that the administration of methadone is indicated for the
treatment of opiate use disorder. Opiates include opium, morphine, codeine, methadone, and
heroin. Methadone is given as a substitute to prevent cravings and severe manifestations of
opiate withdrawal.
C. Barbiturates
The nurse should recognize that the administration of methadone is not indicated for the
treatment of barbiturate use disorder.
D. Hallucinogenics

The nurse should recognize that the administration of methadone is not indicated for the
treatment of hallucinogen use disorder.
Answer: B. Opiates
The nurse should recognize that the administration of methadone is indicated for the
treatment of opiate use disorder. Opiates include opium, morphine, codeine, methadone, and
heroin. Methadone is given as a substitute to prevent cravings and severe manifestations of
opiate withdrawal.
A nurse is caring for a client who has just received a terminal diagnosis of cancer. Which of
the following initial reactions should the nurse expect?
A. Bargaining
The nurse should expect the client to exhibit bargaining during the grief process; however,
there is another response that is expected first.
B. Depression
The nurse should expect the client to exhibit depression during the grief process; however,
there is another response that is expected first.
C. Denial
The nurse should expect the client to initially deny the reality of the diagnosis. This is a
protective reaction that serves to protect the client from psychological pain.
D. Anger
The nurse should expect the client to exhibit anger during the grief process; however, there is
another response that is expected first.
Answer: C. Denial
The nurse should expect the client to initially deny the reality of the diagnosis. This is a
protective reaction that serves to protect the client from psychological pain.
A nurse is caring for a client with Alzheimer Disease and becomes agitated while refusing
morning hygiene care. Which of the following actions should the nurse take?
A. Talk to the client from two arm-lengths away.
The nurse should talk calmly and quietly to the client to decrease her agitation. The nurse
should remain one to two arm-lengths away to provide her with a sense of personal space and
maintain safety if she becomes aggressive.
B. Obtain assistance to restrain the client for safety.

The nurse should identify that the client’s refusal of care is not a justification for restraints.
The nurse should apply restraints only if her behavior becomes a threat to her safety or the
safety of others.
C. Firmly state to the client that morning care will be performed.
The nurse should recognize that the client has a right to refuse care. Telling her that care will
be performed, despite refusal, can increase her anxiety and agitation.
D. Call the provider to request a prescription for an antipsychotic medication. The nurse
should recognize that antipsychotic medications are used only with extreme caution due to
the increased risk of death for clients who have Alzheimer’s disease. Antipsychotic
medications are not indicated for the treatment of agitation.
Answer: A. Talk to the client from two arm-lengths away.
The nurse should talk calmly and quietly to the client to decrease her agitation. The nurse
should remain one to two arm-lengths away to provide her with a sense of personal space and
maintain safety if she becomes aggressive.
A nurse is assessing a client who takes Phenelzine for the treatment of Depression. Which of
the following finding should the nurse report to the provider?
A. Elevated blood pressure
The nurse should identify that the greatest risk to the client is an elevated blood pressure,
which increases his risk for a hypertensive crisis that can result from taking an MAOI, such
as phenelzine. The nurse should apply the safety and risk reduction priority-setting
framework when assessing this client. This framework assigns priority to the factor or
situation posing the greatest safety risk to the client. When there are several risks to client
safety, the one posing the greatest threat is the highest priority. The nurse should use
Maslow’s hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to
identify which risk poses the greatest threat to the client.
B. Weight gain
The nurse should identify weight gain as a common adverse effect of an MAOI, such as
phenelzine. The nurse should report the adverse effect to the provider; however, there is
another finding that is a greater risk to the client than weight gain.
C. Muscle twitching
The nurse should identify muscle twitching as a common adverse effect of an MAOI, such as
phenelzine. The nurse should report the adverse effect to the provider; however, there is
another finding that is a greater risk to the client than muscle twitching.

D. 2+ peripheral edema
The nurse should identify peripheral edema as a common adverse effect of an MAOI, such as
phenelzine. The nurse should report the adverse effect to the provider; however, there is
another finding that is a greater risk to the client than peripheral edema.
Answer: A. Elevated blood pressure
The nurse should identify that the greatest risk to the client is an elevated blood pressure,
which increases his risk for a hypertensive crisis that can result from taking an MAOI, such
as phenelzine. The nurse should apply the safety and risk reduction priority-setting
framework when assessing this client. This framework assigns priority to the factor or
situation posing the greatest safety risk to the client. When there are several risks to client
safety, the one posing the greatest threat is the highest priority. The nurse should use
Maslow’s hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to
identify which risk poses the greatest threat to the client.
A nurse is assessing a client who experienced a sexual assault 6 months ago. Which of the
following findings should the nurse report to the provider as an indication of rape-trauma
syndrome?
A. Flat affect
The nurse should expect the client who has rape-trauma syndrome to experience mood
swings and intense emotions.
B. Refusal to accept help from others
The nurse should expect the client who has rape-trauma syndrome to exhibit dependence
toward others.
C. Report of intense guilt
The nurse should expect the client who has rape-trauma syndrome to experience guilt about
the sexual assault. These feelings of guilt can delay the healing process and produce a
sustained and maladaptive response.
D. Denial of the sexual assault
The nurse should expect a client to have denial immediately following a sexual assault;
however, this is not a characteristic of rape-trauma syndrome.
Answer: C. Report of intense guilt
The nurse should expect the client who has rape-trauma syndrome to experience guilt about
the sexual assault. These feelings of guilt can delay the healing process and produce a
sustained and maladaptive response.

A nurse in interviewing an older adult client about possible anger abuse by her caregiver.
Which of the following techniques should the nurse use?
A. Avoid directly asking the client if she has been abused.
The nurse should ask the client directly about possible abuse to identify the client’s physical,
emotional, and safety needs.
B. Use a confrontational approach.
The nurse should avoid a confrontational approach, which can raise the client’s defensive
barriers and potentially block further communication.
C. Maintain a nonjudgmental tone.
The nurse should use a nonjudgmental tone to promote trust and communication.
D. Avoid being in the room alone with the client.
The nurse should conduct the interview in private to provide a calm and safe environment.
Answer: C. Maintain a nonjudgmental tone.
The nurse should use a nonjudgmental tone to promote trust and communication.
A nurse is providing teaching for a family of a client who has Alzheimer Disease about
Donepezil. Which of the following statements should the nurse include in the teaching?
A. "Donepezil can improve cognitive functioning during the earlier stages of the disease."
The nurse should inform the family that donepezil is used to treat the manifestations of mild
to severe Alzheimer’s disease. Although donepezil does not prevent the progression of
Alzheimer’s disease, it is intended to prolong the client's ability to function in the early stages
of the disease.
B. "Donepezil cures the disease process if it is started upon first recognition of dementia."
The nurse should inform the family that donepezil is used to treat the manifestations of mild
to severe Alzheimer’s disease; however, donepezil does not prevent the progression of
Alzheimer’s disease.
C. "Donepezil provides long-term reversal of memory loss in the last phase of the disease."
The nurse should inform the family that donepezil is used to treat the manifestations of mild
to severe Alzheimer’s disease. Though donepezil can provide mild improvements in memory,
it does not reverse memory loss. Improvements in the client’s memory are usually short-term.
D. "Donepezil accelerates the breakdown of acetylcholine within the client's brain."

The nurse should inform the family that donepezil is used to treat the manifestations of mild
to severe Alzheimer’s disease. Donepezil works by preventing the breakdown of
acetylcholine within the client’s brain, increasing its availability at cholinergic synapses.
Answer: A. "Donepezil can improve cognitive functioning during the earlier stages of the
disease."
The nurse should inform the family that donepezil is used to treat the manifestations of mild
to severe Alzheimer’s disease. Although donepezil does not prevent the progression of
Alzheimer’s disease, it is intended to prolong the client's ability to function in the early stages
of the disease.
A nurse is obtaining a client's medical history prior to scheduling them for ECT. Which of the
following findings should the nurse identify as a potential complication for the procedure?
A. Severe depression
A client can receive ECT for treatment of severe depression.
B. Cardiac arrhythmia
A client who has cardiac arrhythmias needs further evaluation. The nurse should identify that
the greatest risk for death due to ECT is related to cardiac complications.
C. Bipolar disorder
A client can receive ECT for treatment of bipolar disorder.
D. Parkinson's disease
A client can receive ECT for treatment of Parkinson's disease.
Answer: B. Cardiac arrhythmia
A client who has cardiac arrhythmias needs further evaluation. The nurse should identify that
the greatest risk for death due to ECT is related to cardiac complications.
A nurse is planning care for a client who had Bipolar Disorder and is experiencing a Manic
Episode. Which of the following interventions should the nurse include in a plan of care?
A. Discourage the client from taking naps during the day.
The nurse should encourage the client to take naps and frequent rest periods during the day to
avoid physical exhaustion due to mania.
B. Allow the client to choose which clothing to wear each day.
The nurse should closely supervise the client’s choice of clothing to maintain her dignity and
promote positive self-esteem during a manic episode.
C. Encourage the client to participate in group therapy.

The nurse should encourage one-on-one therapy during the manic phase. Group therapy can
cause anxiety and agitation in the client.
D. Provide the client frequently with high-calorie finger-foods.
The nurse should provide the client with frequent, high-calorie snacks and meals during a
manic episode to provide the calorie replacement needed due to excessive physical energy
and activity. Providing finger foods increases the client’s intake by making it easier to eat
when mania makes it difficult for her to sit down and concentrate on a meal.
Answer: D. Provide the client frequently with high-calorie finger-foods.
The nurse should provide the client with frequent, high-calorie snacks and meals during a
manic episode to provide the calorie replacement needed due to excessive physical energy
and activity. Providing finger foods increases the client’s intake by making it easier to eat
when mania makes it difficult for her to sit down and concentrate on a meal.
A nurse in an acute mental health facility is caring for a client who is experiencing an Acute
Manic Episode. Which of the following actions is the nurse's priority?
A. Maintain the client's contact with her family.
The nurse should assist all acute care clients in maintaining contact with family during
treatment; however, there is another action that is the priority.
B. Discourage the client's use of vulgar language.
The nurse should discourage behaviors that disrupt the therapeutic milieu; however, there is
another action that is the priority.
C. Protect the client from impulsive behavior.
The nurse should protect the client who is manic from impulsive behavior that puts the client
at risk for self-harm. The nurse should apply the safety and risk reduction priority-setting
framework. This framework assigns priority to the factor or situation posing the greatest
safety risk to the client. When there are several risks to client safety, the one posing the
greatest threat is the highest priority. The nurse should use Maslow’s hierarchy of needs, the
ABC priority-setting framework, or nursing knowledge to identify which risk poses the
greatest threat to the client.
D. Redirect excessive energy to creative tasks.
The nurse should redirect the client’s energy into a calming and constructive activity;
however, there is another action that is the priority.
Answer: C. Protect the client from impulsive behavior.

The nurse should protect the client who is manic from impulsive behavior that puts the client
at risk for self-harm. The nurse should apply the safety and risk reduction priority-setting
framework. This framework assigns priority to the factor or situation posing the greatest
safety risk to the client. When there are several risks to client safety, the one posing the
greatest threat is the highest priority. The nurse should use Maslow’s hierarchy of needs, the
ABC priority-setting framework, or nursing knowledge to identify which risk poses the
greatest threat to the client.
A nurse in an acute mental health facility is planning care for a client who has obsessivecompulsive disorder (OCD). Which of the following actions should the nurse include in the
plan?
A. Encourage the client to focus on personal hygiene.
Clients who have OCD are often obsessive about personal hygiene and might perform
ritualistic behaviors related to handwashing and grooming. The nurse should plan
interventions to limit and control these obsessive thoughts.
B. Limit the hours the client sleeps each day.
Clients who have OCD often have difficulty sleeping due to obsessive thoughts and ritualistic
behaviors. The nurse should plan interventions to promote sleep.
C. Instruct the client to practice thought stopping.
The nurse should teach the client who has OCD to use thought stopping. By saying "stop" out
loud, the client can learn to interrupt obsessive thoughts.
D. Make negative statements about the client's behavior.
Clients who have OCD often feel shame and humiliation about their obsessive thoughts and
ritualistic behavior. The nurse should plan interventions to decrease feelings of shame and
increase feelings of self worth.
Answer: C. Instruct the client to practice thought stopping.
The nurse should teach the client who has OCD to use thought stopping. By saying "stop" out
loud, the client can learn to interrupt obsessive thoughts.
A nurse is caring for a client who has alcohol use disorder.Following alcohol withdrawal,
which of the following medications should the nurse expect to administer to the client during
maintenance?
A. Methadone
The nurse should expect to administer methadone to the client who has opioid withdrawal.

B. Disulfiram
The nurse should expect to administer disulfiram as a deterrent to prevent future use of
alcohol. The nurse must ensure that the client has not had any alcohol intake for at least 12 hr
prior to administration.
C. Chlordiazepoxide
The nurse should expect to administer chlordiazepoxide during alcohol withdrawal.
Chloridiazepoxide is not a medication used to help with maintenance.
D. Naloxone
The nurse should expect to administer naloxone to the client who is experiencing a narcotic
overdose.
Answer: B. Disulfiram
The nurse should expect to administer disulfiram as a deterrent to prevent future use of
alcohol. The nurse must ensure that the client has not had any alcohol intake for at least 12 hr
prior to administration.
A nurse is caring for a client who attends family counseling with his partner and their
children. The client tells the nurse he isn't going to attend any further sessions and states, "I
don't have time for all this talking." Which of the following responses should the nurse make?
A. "It must be difficult for you to talk about family problems."
The nurse’s response indicates empathy for the client’s feelings and is an example of the
therapeutic communication technique of verbalizing what the client implied. With this
technique, the nurse helps him focus on the actual reason for not wanting to continue family
therapy.
B. "You should continue attending the family counseling sessions until the therapist tells you
to stop."
The nurse’s response is an example of the nurse giving advice, which is nontherapeutic and a
possible block to further communication.
C. "If you continue to go to family counseling, I'm sure you'll be able to resolve your family
problems soon."
The nurse’s response is an example of false reassurance. The client’s continued participation
is not an indication that problems will be resolved.
D. "I think you need to continue family therapy if your partner and children want to receive
further counseling."

The nurse’s response is an example of the nurse giving advice, which is nontherapeutic and a
possible block to further communication.
Answer: A. "It must be difficult for you to talk about family problems."
The nurse’s response indicates empathy for the client’s feelings and is an example of the
therapeutic communication technique of verbalizing what the client implied. With this
technique, the nurse helps him focus on the actual reason for not wanting to continue family
therapy.
A nurse in an acute substance is assessing a client who received treatment in the Emergency
Department for a Heroin Overdose. Which of the following findings should the nurse
anticipate during Heroin Withdrawal?
A. Excessive sleeping
The nurse should expect the client to have insomnia during heroin withdrawal.
B. Muscle aches
The nurse should expect the client to have muscle aches during heroin withdrawal. The nurse
should expect this and other manifestations of withdrawal to begin within 6 to 8 hr following
the last dose of heroin.
C. Pupillary constriction
The nurse should expect the client to have pupillary dilation during heroin withdrawal.
D. Absent bowel sounds
The nurse should expect the client to have diarrhea during heroin withdrawal.
Answer: B. Muscle aches
The nurse should expect the client to have muscle aches during heroin withdrawal. The nurse
should expect this and other manifestations of withdrawal to begin within 6 to 8 hr following
the last dose of heroin.
A nurse in an emergency room is assessing a client who has cocaine intoxication. Which of
the following findings should the nurse expect?
A. Low blood pressure
The nurse should expect a client who has cocaine intoxication to have an elevated blood
pressure.
B. Dilated pupils
Dilated pupils are associated with the use of cocaine.
C. Conjunctival redness

The nurse should expect a client who has cannabis intoxication to have conjunctival redness.
D. Decreased body temperature
The nurse should expect a client who has cocaine intoxication to have an elevated body
temperature.
Answer: B. Dilated pupils
Dilated pupils are associated with the use of cocaine.
A nurse is admitting a client who has antisocial personality disorder to an acute care unit. The
client is admitted under court order following the theft and destruction of a car. Which of the
following behaviors should the nurse expect the client to display?
A. Relief about finally receiving care for a problem for which he was previously afraid to ask
for help
A client who has antisocial personality disorder exhibits a pattern of irresponsible behavior
that lacks morals and ethics and brings the client into conflict with society. The client views
this behavior as justified and does not perceive the need for help.
B. Anger with the nursing staff for hospitalizing him against his will.
A client who has antisocial personality disorder exhibits a low frustration level and can
quickly become angry and aggressive when the situation goes against his will or desires.
C. Withdrawal from others due to shame over his recent actions
Clients with antisocial behavior do not view their own behavior objectively and rarely
experience any anxiety or guilt over their actions.
D. Remorse for stealing and destroying the car
Clients who have antisocial behavior usually display a sense of entitlement and rarely express
any remorse for their illegal or unethical actions.
Answer: B. Anger with the nursing staff for hospitalizing him against his will.
A client who has antisocial personality disorder exhibits a low frustration level and can
quickly become angry and aggressive when the situation goes against his will or desires.
A nurse is developing a plan of care with a client who has Anorexia Nervosa. The nurse
should identify that which of the following actions is contraindicated for this client?
A. Explaining that tube feedings are necessary if the client refuses oral intake The nurse
should inform the client that he might require tube feedings to provide adequate nutritional
intake if oral intake is inadequate. This intervention is not intended to be punitive but to
ensure the client’s safety.

B. Weighing the client each day prior to any oral intake
The nurse should weigh the client each day prior to any oral intake to obtain accurate data
and to monitor his progress toward weight gain goals.
C. Permitting the client to spend some quiet time alone after each meal The nurse should
directly observe the client for a minimum of 1 hr following meals. This intervention prevents
the client from purging or discarding hidden food. Therefore, permitting the client to have
alone time following meals is contraindicated for his plan of care.
D. Refraining from commenting about the client's eating during meal times The nurse should
encourage conversation during meals to promote a pleasurable eating environment; however,
the nurse should avoid the topics of eating and food, which can increase the client’s level of
anxiety.
Answer: C. Permitting the client to spend some quiet time alone after each meal The nurse
should directly observe the client for a minimum of 1 hr following meals. This intervention
prevents the client from purging or discarding hidden food. Therefore, permitting the client to
have alone time following meals is contraindicated for his plan of care.
A nurse in the Emergency Department is assessing a client who has Heroin Intoxication.
Which of the following findings should the nurse expect?
A. Seizure activity
Heroin is an opioid, which can result in impaired coordination rather than seizure activity.
B. Respiratory depression
Heroin is an opioid; therefore, the nurse should expect the client who has heroin intoxication
to exhibit respiratory depression.
C. Hypersensitivity to pain
Heroin is an opioid, which can result in pain reduction rather than a hypersensitivity to pain.
D. Increased mental alertness
Heroin is an opioid, which can result in drowsiness and sedation rather than increased mental
alertness.
Answer: B. Respiratory depression
Heroin is an opioid; therefore, the nurse should expect the client who has heroin intoxication
to exhibit respiratory depression.
A nurse is caring for a client who has Alzheimer Disease and a new prescription for
Donepezil. Which of the following actions should the nurse take?

A. Monitor the client's liver function while taking this medication.
The nurse should monitor the liver function for a client who is taking the cholinesterase
inhibitor tacrine; however, donepezil is a medication in this category that is not hepatotoxic.
B. Increase the dosage of this medication every 72 hr.
The nurse should expect the provider to gradually increase the client’s dosage until a
therapeutic effect is achieved; however, an increase is not expected until the client has been
taking the medication for 4 to 6 weeks.
C. Offer the client a PRN NSAID while taking this medication.
The nurse should inform the client of the risk for gastrointestinal bleeding while taking this
medication. Taking donepezil concurrently with an NSAID increases this risk.
D. Administer the medication at bedtime.
Donepezil is used to treat the manifestations of mild to moderate Alzheimer’s disease. The
nurse should administer this medication at bedtime to reduce the risk for injury due to
bradycardia and syncope.
Answer: D. Administer the medication at bedtime.
Donepezil is used to treat the manifestations of mild to moderate Alzheimer’s disease. The
nurse should administer this medication at bedtime to reduce the risk for injury due to
bradycardia and syncope.
A nurse is caring for a client who has major depressive disorder and is severely withdrawn.
Which of the following techniques should the nurse use to facilitate communication with the
client?
A. Continue to talk if the client does not provide an immediate verbal response. The nurse
should allow the client additional time to respond. Clients who are severely withdrawn might
take longer to comprehend what is being said and formulate a response.
B. Use platitudes when talking with the client.
The nurse should avoid the use of platitudes because this technique minimizes the client’s
feelings and promotes feelings of worthlessness in clients who are severely withdrawn.
C. Ask the client direct questions.
The nurse should avoid asking direct questions to a client who is severely withdrawn because
this technique can raise his level of anxiety.
D. Speak to the client using simple and concrete terminology. The nurse should use simple
and concrete terminology when communicating with this client. The client who is severely

withdrawn has impaired comprehension and difficulty concentrating; therefore, this technique
facilitates communication.
Answer: D. Speak to the client using simple and concrete terminology. The nurse should use
simple and concrete terminology when communicating with this client. The client who is
severely withdrawn has impaired comprehension and difficulty concentrating; therefore, this
technique facilitates communication.
A nurse is caring for a client who has Wernicke-Korsakoff Syndrome due to Alcohol Use
Disorder. Which of the following findings should the nurse expect?
A. Increased arousal
The nurse should expect the client who has Wernicke-Korsakoff syndrome to exhibit
somnolence and stupor rather than increased arousal.
B. Arrhythmias
The nurse should expect the client who has cardiomyopathy due to alcohol use to have
arrhythmias. Cardiac manifestations are not expected findings of Wernicke-Korsakoff
syndrome.
C. Confusion
The nurse should expect the client who has Wernicke-Korsakoff syndrome to exhibit
neurological and cognitive manifestations due to thiamine deficiency. Confusion, stupor,
diplopia, and memory loss are expected findings of this disorder.
D. Esophageal pain
The nurse should expect the client who has esophagitis due to alcohol use to have esophageal
pain. Gastrointestinal manifestations are not expected findings with Wernicke-Korsakoff
syndrome.
Answer: C. Confusion
The nurse should expect the client who has Wernicke-Korsakoff syndrome to exhibit
neurological and cognitive manifestations due to thiamine deficiency. Confusion, stupor,
diplopia, and memory loss are expected findings of this disorder.
A nurse is teaching a client who has schizophrenia about her new prescription for risperidone.
Which of the following statements should the nurse include in the teaching?
A. “You should continue this medication if you develop muscle rigidity”.
B. “You will experience weight loss while taking this medication.”
C. “You will notice your symptoms improve within 24 hours of taking this medication.”

D. “You should increase your consumption of complex carbohydrates.”
Answer: A. “You should continue this medication if you develop muscle rigidity”.
A nurse is admitting a client who has generalized anxiety disorder. Which of the following
actions should the nurse plan to take first?
A. Provide the client with a quiet environment
B. Determine how the client handles stress.
C. Teach the client to use guided imagery.
D. Ask the client to identify her strengths
Answer: A. Provide the client with a quiet environment
A nurse is conducting an admission interview with a client who is experiencing mania. Which
of the following should the nurse report to the provider?
A. States that he hasn’t bathed in 2 days
B. Reports eating twice in the past two weeks.
C. Makes inappropriate sexual comments.
D. Speaks in rhyming sentences.
Answer: B. Reports eating twice in the past two weeks.
A nurse is planning care for a client who has obsessive-compulsive disorder. Which of the
following recommendation should the nurse include in the clients plan of care?
A. Validation therapy
B. Thought stopping
C. Operant conditioning
D. Reality orientation therapy
Answer: B. Thought stopping
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. Encourage the client to join group activities
B. Dim the lights in the clients room
C. Provide detailed explanations to the client
D. Administer methylphenidate
Answer: B. Dim the lights in the clients room

A nurse is leading a crisis intervention group for adolescents who witnessed the suicide of a
classmate. Which of the following actions should the nurse take first.
A. Initiate referrals
B. Review community resources
C. Identify prior coping skills
D. Discuss the importance of confidentiality
Answer: C. Identify prior coping skills
A nurse overhears a client saying, "I am a spy, a spy for the FBI. I am an I, an eye for an eye
in the sky. Sky is up high." The nurse should document the client's statement as which of the
following speech alterations?
A. Echolalia
B. Word salad
C. Neologism
D. Clang association
Answer: D. Clang association
An older adult client is brought to the mental health clinic by her daughter. The daughter
reports that her mother is not eating and seems 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. Everyone gets depressed from time to time.
B. You shouldn't worry about this because depressive disorder is easily treated.
C. Older adults are usually diagnosed with depressive disorder as they age.
D. Tell me the reasons you think your mother is depressed.
Answer: D. Tell me the reasons you think your mother is depressed.
A nurse is planning care for an adolescent who has autism spectrum disorder. Which of the
following outcomes should the nurse include in the plan care?
A. Meets own needs without manipulating others.
B. Initiates social interactions with caregivers.
C. Changes behavior as a result of peer pressure.
D. Acknowledges his delusions are not real.

Answer: B. Initiates social interactions with caregivers.
A nurse is providing behavior 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. Snap a rubber band on your wrist when you think about checking the locks.
B. Ask a family member to check the locks for you at night.
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.
Answer: A. 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.
A nurse is caring for a client who is starting treatment for substance use disorder. Which of
the following actions indicate the nurse is practicing the ethical principle of nonmaleficence?
A. Provide the client with quality care regardless of their ability to pay for treatment.
B. Educating the client about legal rights concerning treatment.
C. Withholding the prescribed medication that is causing adverse effects for the client.
D. Being truthful with the client about the manifestations of with drawl.
Answer: C. Withholding the prescribed medication that is causing adverse effects for the
client.
A nurse in a group home facility is caring for a client who is developmentally disabled. The
client has been stealing belongings from other clients. Which of the following techniques
should the nurse use?
A. Crisis intervention to decrease anxiety.
B. Aversion therapy to provide distraction
C. Positive reinforcement to increase desired behavior.
D. Systematic desensitization to extinguish the behavior.
Answer: C. Positive reinforcement to increase desired behavior.
A nurse is caring for a client who is experiencing a panic attack.
Which of the following actions should the nurse take?
A. Ask the client to discuss precipitating events
B. Speaks to the client in a high-pitched voice.

C. Place the client in seclusion
D. Have the client breathe into a paper bag.
Answer: D. Have the client breathe into a paper bag.
The nurse is caring for a client following a physical assault. The client states "I don’t
remember what happened to me." The nurse should recognize that the client is using which of
the following defense mechanisms?
A. Repression
B. Displacement
C. Rationalization
D. Denial
Answer: A. Repression
A nurse is caring for a client who has anorexia nervosa. Which of the following findings
require immediate intervention by the nurse?
A. +2 edema of the lower extremities
B. BUN 21 mg/dL
C. Lanugo covering the body
D. Blood pH 7.60
Answer: D. Blood pH 7.60
A nurse is caring for a client in a mental health facility. The client is agitated and threatens to
harm herself and others. Which of the following is the priority intervention?
A. Place the client in restraints
B. Administer an anti-anxiety medication to the client
C. Put the client in seclusion
D. Set limits on the client's behavior
Answer: D. Set limits on the client's behavior
Dosage Calculation Question.
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. Ask the clients family to encourage the client to receive ECT
B. Inform the client that ECT does not require a consent.
C. Document the client's refusal of the treatment in the medical record.
D. Tell the client he cannot refuse the treatment because he was involuntarily committed.
Answer: C. Document the client's refusal of the treatment in the medical record.
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. Request a mental health consult for the client.
B. Ask the client if she has thought about harming herself.
C. Encourage the client to attend a grief support group.
D. Discuss the clients coping skills.
Answer: D. Discuss the clients coping skills.
A nurse is caring for a client who has borderline personality disorder and has been engaging
in self-mutilation. The nurse should encourage the client to participate in which of the
following groups.
A. Dual diagnosis treatment group
B. Dialectical treatment group
C. Desensitization therapy
D. Co-dependents support group.
Answer: B. Dialectical treatment group
The nurse is reviewing the medication administration record of a client who has
schizophrenia. The nurse should plan to initiate the Abnormal Involuntary Movement Scale
to monitor for adverse effects of which of the following medications.?
A. Amantadine
B. Diphenhydramine
C. Benztropine
D. Haloperidol
Answer: D. Haloperidol

A nurse is counseling a client following the death of a clients partner 8 months ago. Which of
the following client statements indicates maladaptive grieving?
A. I am so sorry for the times I was angry with my partner.
B. I find myself thinking about my partner often.
C. I still don't feel up to returning to work.
D. I like looking at his personal items in the closet.
Answer: C. I still don't feel up to returning to work.
A nurse is caring for a client who has borderline personality disorder. Which of the following
outcomes should the nurse include in the treatment plan?
A. The client will report a decrease in hallucinations.
B. The client will communicate needs
C. The client will verbalize improved mood
D. The client will attend to personal hygiene.
Answer: C. The client will verbalize improved mood
A nurse is caring for a client who is prescribed massage therapy to treat panic disorder. The
client states "I can't stand to be touched by another person." Which of the following responses
should the nurse make?
A. Why don’t you like to be touched by others
B. Don’t worry about it. Your anxiety will lessen once the massage begins.
C. I will tell your provider you would like a treatment other than a massage.
D. I will request that the massage therapist wear gloves during your treatment.
Answer: C. I will tell your provider you would like a treatment other than a massage.
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 in the plan?
A. Encourage physical activity for the client during the day
B. Discourage the client from expressing feelings of anger
C. Keep a bright light on in the client's room at night.
D. Identify and schedule alternative group activities for the client.
Answer: A. Encourage physical activity for the client during the day

A nurse is providing counseling for a family that consists of two parents and their two
adolescent children. Which of the following family members should the nurse identify as
acting in the role as the monopolizer?
A. The mother who expresses hostility toward her spouse.
B. The adolescent son who refuses to share personal feelings.
C. The father who intervenes whenever the siblings argue.
D. The adolescent daughter who attempts to dominate the conversation.
Answer: D. The adolescent daughter who attempts to dominate the conversation.
A nurse is developing a teaching plan for the family of an older adult client who is to receive
transcranial magnetic stimulation. Which of the following information should the nurse
include in the teaching plan?
A. The client might have a headache after treatment.
B. The client will experience seizure during treatment.
C. The client will require intubation after treatment.
D. The client is at risk for aspiration during treatment.
Answer: A. The client might have a headache after treatment.
A nurse is providing teaching about disulfiram to a client who has a history of alcohol use.
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 should avoid using mouthwash that contains alcohol”
D. “you should avoid drinking carbonated beverages while taking the medication”
E. “you can expect to develop a physical dependence to the medication”
Answer: A. “You will need to take the medication once daily”
C. “You should avoid using mouthwash that contains alcohol”
A nurse is caring for a client who is in the manic phase of bipolar disorder. Which of the
following actions should the nurse take?
A. Avoid power struggles by remaining neutral
B. Allow the client to set limits for his behavior
C. Provide in-depth explanation of nursing expectations

D. Encourage the client to participate in group activities
Answer: A. Avoid power struggles by remaining neutral
A nurse is assessing a young adult female client for schizophrenia. Which of the following
findings should the nurse identify as a risk factor for this condition?
A. Environmental stress
B. Gender
C. Depression
D. Birth order
Answer: D. Birth order
A nurse is providing discharge teaching about manifestations of relapse to the family of a
client who has schizophrenia. Which of the following information should the nurse include in
the teaching?
A. The client exhibits an inflated sense of self
B. The client develops an inability to concentrate
C. The client increases participation in social activities
D. The client begins sleeping more than usual
Answer: B. The client develops an inability to concentrate
A nurse is assessing a client who is restless and constantly mutters to himself. Which of the
following findings should lead the nurse to suspect delirium?
A. The client is unable to recognize objects.
B. The client manifestations developed suddenly
C. The client has a flat affect
D. The client’s speech is slow and repetitious
Answer: B. The client manifestations developed suddenly
A nurse is caring for a client in an inpatient mental health facility. The client tells the nurse
that the government is reading her mail. Which of the following responses should the nurse
make?
A. “ You know that’s not true, because it is against the law for others to read your mail”
B. “All of your letters come sealed, so that seems unlikely”
C. “It must be frightened to think that someone is reading your mail”

D. “Why do you think the government wants to read your mail?”
Answer: C. “It must be frightened to think that someone is reading your mail”
A nurse is assessing a client who has neuroleptic malignant syndrome. Which of the
following clinical findings should the nurse expect?
A. Heart rate 48/min
B. Temperature 40 C (104 F)
C. WBC 3,000/mm3
D. Hypotonicity
Answer: B. Temperature 40 C (104 F)
A nurse is reviewing the medical record of a client who is taking clozapine. For which of the
following findings should the nurse withhold the medication and notify the provider? (Click
on the “Exhibit” button for additional information about the client. There are three tabs that
contain separate categories of data.)
A. WBC count
B. Blood glucose level
C. Report of photosensitivity
D. Heart Rate
Answer: A. WBC count
A nurse is caring for a client who has personality disorder and is using transference to cope.
Which of the following behaviors should the nurse expect?
A. Talking negatively about other staff members
B. Expressing frustration regarding unit rules
C. Reacting to the nurse as though she were his mother
D. Refusing to participate in group activities
Answer: C. Reacting to the nurse as though she were his mother
A nurse in a mental health facility is caring for a newly admitted client. Which of the
following resources should the nurse recommend to help the client adapt to the health care
setting?
A. A community meeting
B. A medication group

C. A self-help meeting
D. A symptom-management group
Answer: A. A community meeting
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. Request that the client’s guardian sign the consent
B. Ask the charge nurse to obtain informed consent
C. Contact the facility social worker to obtain the consent
D. Explain implied consent to the client’s family
Answer: A. Request that the client’s guardian sign the consent
A nurse is caring for a client who has cocaine use disorder. Which of the following
manifestations should the nurse expect the client to have during withdrawal?
A. Hand tremors
B. Rapid speech
C. Fatigue
D. Seizures
Answer: C. Fatigue
A nurse is providing teaching about disorder management for a client who has posttraumatic
stress disorder (PTSD). Which of the following statements should the nurse include in the
teaching?
A. “Avoiding stimuli that trigger memories of the trauma can help you overcome your
PTSD”
B. “Talking about the traumatic experience is recommended”
C. “Response prevention is an effective treatment for PTSD”
D. “You should try to limit the number of hours that you sleep each day”
Answer: B. “Talking about the traumatic experience is recommended”
A nurse is assessing a client who has bipolar disorder and is taking lamtropine. Which of the
following findings is the nurse’s priority?
A. Thyroid-stimulating hormone (TSH) 4.0 microunits/mL
B. Alanine transaminase (ALT) 20 IU/L

C. Skin rash
D. Epistaxis
Answer: C. Skin rash
A nurse is caring for a client who has schizophrenia and displays severe negative symptoms
of the disorder. Which of the following actions should the nurse take?
A. Manage the client’s loud, rambling, and incoherent communication patterns
B. Direct the client to perform her own daily hygiene and grooming tasks
C. Assist the client to identify somatic and thought-broadcasting delusions
D. Use medication to decrease frequency of auditory and visual hallucination.
Answer: B. Direct the client to perform her own daily hygiene and grooming tasks
A nurse is beginning a therapeutic relationship with a client. The nurse should plan to
accomplish which of the following tasks during the working phase?
A. Inform the client about confidentiality rights
B. Establish boundaries between the nurse and the client
C. Set short and long-term objectives for the future
D. Evaluate progress toward predetermined goals
Answer: D. Evaluate progress toward predetermined goals
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. Clinical nurse specialist
B. Recreational therapist
C. Occupational therapist
D. Social worker
Answer: D. Social worker
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 mechanism is the client
demonstrating?
A. Denial

B. Displacement
C. Compensation
D. Rationalization
Answer: B. Displacement
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 countertransference?
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 generally shares his feelings during group therapy session”
D. “The client asked me to go on a date with him, but I refuse”
Answer: A. “The client is just like my brother who finally overcame his habit”
A nurse is caring for a client who is admitted to a mental health facility after attempting
suicide. Which of the following actions should the nurse take first?
A. Establish a rapport to foster trust
B. Implement continuous one-to-one observation
C. Ask the client to sign a no-suicide contract
D. Encourage the client to participate in group therapy
Answer: B. Implement continuous one-to-one observation
A nurse is providing teaching for a newly licensed nurse about the constructive use of defense
mechanism. Which of the following examples should the nurse include in the teaching?
A. A student who is upset with her teacher writes a story about an excellent student
B. A school-age child whose mother died 2 years ago talks about her in present tense.
C. A woman who has health concern postpones a medical appointment until after a vacation.
D. An adult who was sexually abused as a child is unable to remember the incident
Answer: A. A student who is upset with her teacher writes a story about an excellent student
A nurse in an inpatient mental health facility is assessing a client who has schizophrenia and
is taking haloperidol. Which of the following clinical findings is the nurse’s priority?
A. High fever
B. Urinary hesitancy

C. Insomnia
D. Headache
Answer: A. High fever
A nurse is planning care for a client who has a recent diagnosis of antisocial personality
disorder. Which of the following outcomes should the nurse include in the care plan?
A. The client recognizes the importance of others
B. The client conforms to social norms regarding clothing choices
C. The client reduces self-dramatization
D. The client treats others with respect
Answer: A. The client recognizes the importance of others
A nurse is planning care for a newly admitted client who has anorexia nervosa. Which of the
following interventions should the nurse include in the plan?
A. Negotiate with the client how much weight she should gain each week.
B. Decrease the client’s daily intake of fiber
C. Weight the client weekly for the first month
D. Notify the client about designated time for meals
Answer: D. Notify the client about designated time for meals
A client is fearful of driving and enters a behavioral therapy program to help him overcome
his anxiety. Using systematic desensitization, he is able to drive down a familiar street
without experience a panic attack. The nurse should recognize that to continue positive
results, the client should participate in which of the following?
A. Therapist modeling
B. Positive reinforcement
C. Frequent practice
D. Biofeedback
Answer: C. Frequent practice
A nurse in the emergency department is counseling a client who reports experiencing intimate
partner violence. Which of the following actions should the nurse take?
A. Request permission from the client to take photographs of the injuries
B. Offer to help the client escape form the partner the next time violence occurs

C. Determine what the client did to trigger the violent incident
D. Tell the client that staying with the partner shows a lack of judgment
Answer: A. Request permission from the client to take photographs of the injuries
A nurse is caring for a client who has prescription for phenelzine. The nurse should instruct
the client to avoid which of the following over-thecounter medications?
A. Ranitidine
B. Pseudoephedrine
C. Ibuprofen
D. Docusate sodium
Answer: B. Pseudoephedrine
A nurse is caring for a client who is experiencing active auditory hallucinations. Which of the
following actions should the nurse take?
A. Avoid asking direct questions about the client’s experience
B. Convey sympathy for the client’s experience
C. Tell her client her experience is not real
D. Focus the client on reality-based activities
Answer: D. Focus the client on reality-based activities
A nurse is caring for a client who has just returned to the unit after receiving an
electroconvulsive therapy treatment. Which of the following assessments is the nurse’s
priority?
A. First voiding
B. Short-term memory
C. Presence of gag reflex
D. Return of bowel sounds
Answer: B. Short-term memory
A nurse is talking to a client following a group therapy session. The client tells the nurse that
one of the other clients in the group made an inappropriate comment. Which of the following
responses should the nurse make?
A. “I think you should ignore the comment”
B. “You sound upset about today’s session”

C. “Why do you think that he said that to you?”
D. “I agree that the comment was inappropriate”
Answer: B. “You sound upset about today’s session”
A nurse is assessing a client who is experiencing acute alcohol withdrawal. Which of the
following findings should the nurse expect?
A. Hypotension
B. Insomnia
C. Bradycardia
D. Diminished reflexes
Answer: B. Insomnia
A nurse is teaching a client who has bipolar disorder and a new prescription for lithium
carbonate. Which of the following statements by the client indicates an understanding of the
teaching?
A. “I should drink at least 6 liters of water per day”
B. “I should be on a low-sodium diet”
C. “I will call my doctor if I have diarrhea”
D. “I will see my doctor to check my lithium levels annually”
Answer: C. “I will call my doctor if I have diarrhea”
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 a prescription for medication to promote nighttime sleep while in the
facility
B. The client needs to find a place to live after discharge
C. The client needs to begin a group therapy program prior to discharge
D. The client needs to relearn how to perform skill that require fine motor coordination
Answer: C. The client needs to begin a group therapy program prior to discharge
A nurse is reviewing the laboratory report of a client who is taking carbamazepine for bipolar
disorder. Which of the following laboratory results should the nurse report to the provider?
A. Urine specific gravity 1.029

B. Platelets 90,000/mm3
C. Urine pH 5.6
D. RBC 4.7/mm3
Answer: B. Platelets 90,000/mm3
A nurse is teaching the caregiver of a client who has advanced Alzheimer’s disease about
home safety. Which of the following statements by the caregiver indicates an understanding
of the teaching?
A. I will ensure the bedroom is dark while he is sleeping at night
B. I will place a sliding bolt lock just above the doorknob
C. I will notify law enforcement within 2 hours if he cannot be found
D. I will give his most recent photo to the police
Answer: C. I will notify law enforcement within 2 hours if he cannot be found
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. Hypertensive crisis
B. Cardiac toxicity
C. Serotonin Syndrome
D. Urinary retention
Answer: A. Hypertensive crisis
A nurse in an outpatient clinic is assessing a client who has anorexia nervosa. Which of the
following findings indicates the need for hospitalization?
A. Potassium 3.8mEq/L
B. Heart Rate 56/min
C. Temperature 35.6C (96.1F)
D. Weight 10% below ideal weight
Answer: C. Temperature 35.6C (96.1F)
A nurse us obtaining a medical history from a client who is requesting a prescription for
bupropion for smoking cessation. Which of the following assessment finding in the client’s
history should the nurse report to the provider?
A. Hepatitis B Infection

B. Hypothyroidism
C. Knee arthroplasty 1 month ago
D. Recent head injury
Answer: D. Recent head injury
A nurse is providing crisis intervention for a client who was involved in a violent mass
causality situation in the community. Which of the following actions should the nurse take
during the initial session with the client?
A. help the client focus on a wide variety of topics regarding the crisis
B. identify the client’s usual coping style
C. tell the client that his life will soon return to normal
D. encourage the client to display anger toward the cause of the crisis
Answer: B. identify the client’s usual coping style
A nurse in the community health facility is interviewing a client who recently lost his job.
The client states “I was fired because my boss doesn’t like me” Which of the following
defense mechanisms is the client displaying?
A. Rationalization
B. Displacement
C. Dissociation
D. Repression
Answer: A. Rationalization
A nurse is providing teaching to a client who has depressive disorder and a new prescription
for doxepin. Which of the following instructions should the nurse include in the teaching?
A. sit on the side of the bed for a few minutes before standing
B. decrease the prescribed dose by half when mood improves
C. avoid over the counter magnesium when taking this medication
D. eat a snack before going to bed
Answer: C. avoid over the counter magnesium when taking this medication
A nurse is planning care for a client who has dementia. Which of the following interventions
should the nurse include in the plan?
A. give detailed instructions for completion of self-care activities

B. confront the client when he exhibits inappropriate behavior
C. provide finger foods to enhance caloric intake
D. remove clocks from the client’s room
Answer: C. provide finger foods to enhance caloric intake
A nurse is planning overall strategies to address problems for a client who has borderline
personality disorder. Which of the following strategies is the priority for the nurse to
incorporate in the plan of care?
A. discuss the appropriate use of assertive behavior with the client
B. encourage the client to attend weekly support group meetings
C. assist the client to maintain awareness of her thoughts and feelings
D. implement measures to prevent intentional self-inflicted injury
Answer: D. implement measures to prevent intentional self-inflicted injury
A nurse is caring for a school-aged child who has conduct disorder and is being physically
aggressive toward other children in the unit. Which of the following actions should the nurse
take first?
A. Place the child in seclusion
B. Use therapeutic hold technique
C. Apply wrist restraints
D. Administer risperidone
Answer: A. Place the child in seclusion
A nurse is caring for a client who has a new diagnosis of bulimia nervosa. Which of the
following diagnosis procedures should the nurse anticipate the provider should describe
during the medical evaluation?
A. Chest x-ray
B. ECG
C. Coagulation studies
D. Liver function test
Answer: B. ECG

A nurse is caring for a client who exhibits excessive compliance, passivity, and self-denial.
The nurse should recognize that these findings are associated with which of the following
personality disorders?
A. Dependent
B. Paranoid
C. Borderline
D. Histrionic
Answer: A. Dependent
A nurse is caring for a client who is involuntarily admitted for major depressive disorder and
refuses to take prescribed antianxiety medication.
Which of the following actions should the nurse take?
A. Inform the client that he does not have the right to refuse medication
B. Administer the medication to the client via IM injection
C. Offer the client the medication at the next scheduled dose time
D. Implement consequences until the client take the medication
Answer: C. Offer the client the medication at the next scheduled dose time
A nurse is caring for a client in the emergency department who states she was beaten and
sexually assault by her partner. After a rapid assessment, which of the following actions
should the nurse plan to take next?
A. Conduct a pregnancy test
B. Requests mental health consultation for the client
C. Provide a trained advocate to stay with the client
D. Offer prophylactic medication to prevent STI’s
Answer: D. Offer prophylactic medication to prevent STI’s
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. Request that the client’s partner sign the consent form
B. Cancel the scheduled ECT procedure
C. Proceed with the preparation for ECT based on implied consent
D. Inform the client about the risks of refusing the ECT

Answer: B. Cancel the scheduled ECT procedure
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. Rationalization
B. Denial
C. Compensation
D. Displacement
Answer: D. Displacement
A nursing is advising an assistive personnel (AP) on the care of a client who has major
depressive disorder. The AP states that he is irritated by the client’s depression. Which of the
following statements by the nurse is appropriate?
A. Please don’t take what the client said seriously when she is depressed
B. It’s important that the client feel safe verbalizing how she is feeling
C. Everybody feels that way about this client so don’t worry about it
D. I’ll change your assignment to someone who doesn’t have depressive disorder
Answer: B. It’s important that the client feel safe verbalizing how she is feeling
A nurse is assessing a child in the emergency department. Which of the following findings
places the child at the greatest risk for physical abuse?
A. The child is 10years old
B. The child is homeschooled
C. The has no siblings
D. The child has cystic fibrosis
Answer: D. The child has cystic fibrosis
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. Keep a journal of how often you check the locks each night
B. Snap a rubber band on your wrist when you think about checking the locks

C. Ask a family member to check the lock for you at night
D. Focus on abdominal breathing whenever you go to check the locks
Answer: B. Snap a rubber band on your wrist when you think about checking the locks
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. Stupor
C. Afebrile
D. Hypertension
Answer: A. Bradycardia
A nurse is creating a plan of care of a client who has anorexia nervosa.
Which of the following intervention should the nurse include in the plan?
A. Weigh the client twice per day
B. Prepare the client for electroconvulsive therapy
C. Set a weight gain goal of 2.2kg (5lbs) per week
D. Encourage the client to participate in family therapy
Answer: D. Encourage the client to participate in family therapy
A nurse is planning care for a 3-year-old child who has autism spectrum disorder. Which of
the following finding should the nurse expect?
A. Readily initiates conversation
B. Enjoys imaginative play
C. Strong relationship with sibling and peers
D. Attachment to objects that spin
Answer: D. Attachment to objects that spin
A nurse is planning care for a client who has bipolar disorder. The client reports not sleeping
for 3 days and is exhibiting a euphoric mood. The nurse should identify which of the
following as the priority intervention.
A. Secure the client’s valuable possessions
B. Limit loud noises in the client’s environment
C. Encourage the client to participate in structured solitary activities

D. Provide high calorie snacks to the client
Answer: B. Limit loud noises in the client’s environment
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. Blocks aldehyde dehydrogenase
B. Prevents the anxiety of abstinence
C. Reduces substance craving
D. Decreases the likelihood of seizures
Answer: C. Reduces substance craving
A nurse in an alcohol treatment facility is caring for a client who states “my job is so stressful
that the only way I can come it is to drink.” The nurse should recognize that the client is
displaying which of the following defense mechanisms?
A. Repression
B. Rationalization
C. Introjection
D. Intellectualization
Answer: B. Rationalization
A nurse is caring for a client who has depression following a recent job loss. Which of the
following questions should the nurse ask to assess the client’s personal coping skills?
A. How does this situation affect your life?
B. Do you see your current situation affecting your future?
C. Can you describe how you are currently feeling?
D. How have you dealt with similar situations in the past
Answer: C. Can you describe how you are currently feeling?
A school nurse is caring for an adolescent client whose teacher reports changes in school
performance and withdrawal from interaction with classmates. Which of the following
intervention is the nurse’s priority at this time?
A. Contact the adolescent’s parents
B. Suggest the adolescent join support groups

C. Ask the adolescent if he is considering hurting himself
D. Determine when the adolescent’s change in behavior began
Answer: D. Determine when the adolescent’s change in behavior began
A nurse is assessing a client who is withdrawing from heroin. Which of the following
manifestations should the nurse expect?
A. Slurred speech
B. Hypotension
C. Bradycardia
D. Hyperthermia
Answer: A. Slurred speech
A nurse is assessing a client who has histrionic personality disorder. Which of the following
finds should the nurse expect?
A. Lack of remorse
B. Attention seeking
C. Splitting of staff
D. Identity disturbance
Answer: B. Attention seeking
A nurse is providing teaching to the daughter of an older client who has obsessivecompulsive disorder. Which of the following statements by the daughter indicates an
understanding of the disorder?
A. I will limit my mother’s clothing choices when she is getting dressed
B. I will provide my mother with detailed instructions about how to perform self-care
C. I will wake my mother up a couple of times in the night to check on her
D. I will discourage my mother from talking about physical complaints
Answer: A. I will limit my mother’s clothing choices when she is getting dressed
A nurse in a mental health facility is caring for a client who has borderline personality
disorder. Which of the following should the nurse expect?
A. Self-mutation
B. Pacing back and forth
C. Preoccupation with details

D. Disorganized speech
Answer: A. Self-mutation
a nurse is reviewing the laboratory results on adolescent who has anorexia nervosa. Which of
the following findings should the nurse expect?
A. Blood glucose 100 mg/dL
B. T4 11 mcg/dL
C. Potassium 3.7 mEq/L
D. Hgb 10 g/dL
Answer: D. Hgb 10 g/dL
A nurse is teaching about benztropine to a client who has schizophrenia. Which of the
following statements should the nurse include in the teaching?
A. This medication is given to help with extrapyramidal side effects
B. This medication is given to help with your depression
C. Benztropine helps alleviate your hallucinations
D. Benztropine is used to counteract your tachycardia
Answer: A. This medication is given to help with extrapyramidal side effects
A nurse is planning care for a client with acute delirium. Which of the following instructions
should the nurse include in the plan?
A. Reinforce the clients orientation with the calendar
B. Refute the clients perception of visual hallucinations
C. Teach the client assertive techniques
D. Assigned the client to a different caregiver each shift
Answer: A. Reinforce the clients orientation with the calendar
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 in the plan?
A. Discouraged client from expressing feelings of anger
B. Identify and schedule alternative group activities for the client
C. Encourage physical activity for the client during the day
D. Keep a bright light on in the clients room at night
Answer: C. Encourage physical activity for the client during the day

A nurse is caring for a client who has posttraumatic stress disorder related to military service.
Which of the following actions should the nurse take?
A. Encourage the client to suppress feelings of trauma
B. Assign the same staff to care for the client each day
C. Address the client in an authoritative manner
D. Limit the amount of time spent with the client
Answer: B. Assign the same staff to care for the client each day
A nurse is providing teaching for school age child and his parents regarding a new
prescription for risperidone. Which of the following statements by the parent indicates an
understanding of the teaching?
A. I will provide a low sodium diet for my son
B. I will make sure my son takes the last dose of the day by 4 PM
C. I should expect my son to develop hand tremors
D. I should contact my doctor if my son urinates excessively
Answer: C. I should expect my son to develop hand tremors
A nurse is caring for a client who has a lithium level of 0.8 mEq/L. Which of the following
actions should the nurse take?
A. Withhold the next does of lithium
B. Repeat the lithium level test
C. Administer the next does of lithium
D. Recommended a low sodium diet
Answer: C. Administer the next does of lithium
A nurse in a community mental health clinic is caring for a group of clients. The nurse should
encourage participation in cognitive behavioral family therapy in response to which of the
following client statements.
A. I want to learn how to change the way I react to problems within my family
B. I want to understand why my past experiences are affecting my family relationships
C. I want to improve my family’s understanding of each other’s boundaries
D. I want each of my family members to be more aware of each other’s feelings
Answer: D. I want each of my family members to be more aware of each other’s feelings

A nurse is providing teaching to the caregiver of an older adult client who has Alzheimer’s
disease and is being cared for at home. The client wonders at night and has a history of
previous falls. Which of the fund instructions should nurse including? (select all) in the
teaching
A. position the mattress on the floor
B. Install sensor devices on outside doors
C. Encourage physical activity prior to bedtime
D. put locks at top of doors
E. place the client in a reclining chair
Answer: A. position the mattress on the floor
B. Install sensor devices on outside doors
D. put locks at top of doors
A nurse is reviewing laboratory values for a client who has bipolar disorder and a prescription
for lithium. The nurse should identify that which of the following laboratory results places
the client at risk for lithium toxicity?
A. Calcium 9.0 mg/dL
B. sodium 130 mEq/L
C. chloride 98 mEq/L
D. potassium 5.0 mEq/L
Answer: B. sodium 130 mEq/L
A nurse is assisting with obtaining informed consent from 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 clients family
C. Request that the clients Guardian signed the consent
D. Ask the charge nurse to obtain an informed consent
Answer: C. Request that the clients Guardian signed the consent
A nurse is giving a presentation about intimate partner abuse for community group. Which of
the following statements buy a group member indicates understanding of teaching?
A. Survivors of abuse often feel guilty

B. abusers often have high self-esteem
C. the honeymoon stage of violence usually gets longer over time
D. as abuse continues, victims become more determined to be independent
Answer: A. Survivors of abuse often feel guilty
A nurse is planning care for a client who has experienced intimate partner abuse. The nurse
should identify which of the following outcomes as the priority?
A. The client joins a support group
B. the client identifies techniques to reduce her stress
C. The client develops a safety plan
D. The client identify support systems
Answer: C. The client develops a safety plan
A nurse is developing a behavioral contract with the client who has antisocial personality
disorder. Which of the following client goals should the nurse include in the contract?
A. Use projection during group therapy
B. increase self-esteem
C. use bargaining skills for behavioral consequences
D. Decrease the number of verbal outbursts
Answer: D. Decrease the number of verbal outbursts
A nurse is caring for a client who has schizophrenia and takes clozapine. Which of the
following findings is a priority for the nurse to report to the provider?
A. Nausea
B. Random blood glucose 130 mg/dL
C. Heart rate 104 per minute
D. sore throat
Answer: D. sore throat
A nurse is counseling and adult client whose parent just died. The client states, “My son is 4,
and I don’t know how he’ll react when he finds out that grandpa died.” The nurse should
inform the client that the preschool age child commonly has which of the following concepts
of death?
A. Death is not permanent and the loved one may come back to life

B. Death is contagious and can cause other people he loves to die
C. Death creates an interest in the physical aspects of dying
D. Death is a part of life that eventually happens to everyone
Answer: A. Death is not permanent and the loved one may come back to life
A nurse is reviewing the medical records for clients. Which of the following findings should
the nurse identified as a risk factor for violent behavior?
A. Schizoid personality disorder
B. Alcohol intoxication
C. Dysthymic disorder
D. long-term isolation
Answer: B. Alcohol intoxication
A nurse in a provider’s office is assessing a school age child who has a spiral fracture. The
parent of the child provides different accounts for the cause of the injury. Which of the
following actions should the nurse take first?
A. Request that the parent leaves the room while you interview the child
B. Report suspected abuse to child protective services
C. Ask the child how the injury occurred
D. Determine the immediate safety needs of the child
Answer: D. Determine the immediate safety needs of the child
An older adult client is brought to the mental clinic by her daughter. The daughter reports that
her mother is not eating and seems 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. everyone gets depressed from time to time
C. you shouldn’t worry about this, because depressive disorder is easily treated
D. tell me the reasons you think your mother is depressed
Answer: D. tell me the reasons you think your mother is depressed
A nurse in a mental health facility is caring for a client. Which of the following actions the
nurse take during though working phase of the nurseclient relationship?

A. Summarize goals and objectives
B. Address confidentiality
C. promote problem-solving skills
D. establish a participation contract
Answer: C. promote problem-solving skills
a nurse is caring for a client who suddenly directs profanities at her, then abruptly hangs his
head and says, “please forgive me, I’m not sure what came over me I don’t know why said
those things.” The nurse interprets this behavior as which of the following?
A. Emotional lability
B. Confabulation
C. flight of ideas
D. Neologism
Answer: A. Emotional lability
A nurse is providing teaching for the family of a client who has dementia. Which of the
following should the nurse include in the teaching as a contributing factor for this disorder?
A. Hypotension
B. alcohol use disorder
C. Dehydration
D. change in environment
Answer: B. alcohol use disorder
A nurse is caring for a client who has been taking valproic acid. Which of the following is
expected outcome of the medication?
A. The client reports improved short-term memory
B. the client has a decreased euphoric mood
C. the client reports absence of auditory hallucinations
D. the client has decreased anxiety
Answer: D. the client has decreased anxiety
A nurse is teaching a client who has major depressive disorder about electroconvulsive
therapy. Which of the phone information should the nurse include?
A. This therapy works as a cure for major depressive disorders

B. You will be awake and alert during the procedure
C. You might experience confusion for a few hours after treatment
D. This therapy will stimulate the vagus nerve to improve your mood
Answer: C. You might experience confusion for a few hours after treatment
A nurse emergency department is assessing a client who has major depressive disorder.
Which of the following actions should the nurse take? (Exhibit question)
A. ask the client if she has eaten foods containing thyramine
B. Give regular insulin subcutaneously to the client
C. Prepare the client for electroconvulsive therapy
D. administer dantrolene IV bolus to the client
Answer: C. Prepare the client for electroconvulsive therapy
A nurse is reviewing the laboratory report of a client who is taking carbamazepine for bipolar
disorder. Which of the following laboratory results should the nurse report to the provider?
A. Urine specific gravity 1.029
B. Platelets 90,000/mm3
C. urine pH 5.6
D. RBC 4.7/mm3
Answer: B. Platelets 90,000/mm3
A nurse is caring for a client who has schizophrenia and started taking clozapine two months
ago. Which of the following laboratory results should the nurse report to the provider?
A. WBC 3,000/mm3
B. Potassium 4.2 mEq/L
C. Hgb 16 g/dL
D. Platelets 300,000/mm3
Answer: A. WBC 3,000/mm3
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 right now.” The nurse should recognize that the
following family boundaries?
A. Rigid
B. Inconsistent

C. Enmeshed
D. Clear
Answer: D. Clear
A nurse is assessing a client who requires bupropion for smoking cessation. Which of the
following findings in the client’s history should the nurse recognized as a contraindication for
taking this medication?
A. Seizures
B. Anemia
C. Migraines
D. Asthma
Answer: A. Seizures
A nurse is caring for a client with Alzheimer’s disease. Which of the following actions should
the nurse take?
A. Seat the client at a dining table with six or more residents
B. provide the client with several choices for meal selection
C. give complete directions before starting client care
D. use symbols to assist the client in locating rooms
Answer: D. use symbols to assist the client in locating rooms
A nurse is assessing a newly admitted client who has schizophrenia and takes thioridazine.
Which of the following findings should the nurse document as an adverse effect of this
medication?
A. Anhedonia
B. Waxy flexibility
C. contractions of the jaw
D. incongruent affect
Answer: B. Waxy flexibility
A nurse in an inpatient mental health facility is assessing a client who has schizophrenia and
is taking haloperidol. Which of the following clinical findings is the nurse’s priority?
A. High fever
B. Insomnia

C. Urinary hesitancy
D. Headache
Answer: A. High fever
A nurse is speaking with a client. Which of the following responses by the nurse
demonstrates the communication technique of reflection?
A. “I would like to sit with you for a while”
B. “You feel upset when this happens?”
C. “Let’s work together to try to solve your problem”
D. “Can you tell me what is happening now?”
Answer: B. “You feel upset when this happens?”
A nurse is leading grief support group for bereaved clients. Which of the following client
statements should the nurse report to the provider as an indication of clinical depression?
A. “I don’t know how I could cope if I didn’t have my family’s support”
B. “It’ll be a long time before I’m happy again”
C. “I don’t feel anything but numbness anymore”
D. “I feel like I’m angry at the whole world right now”
Answer: C. “I don’t feel anything but numbness anymore”
A nurse is preparing to administer chlorpromazine hydrochloride 25 mg PO to an older adult
client. Available is chlorpromazine hydrochloride syrup 10 mg/5 mL. How many mL should
the nurse administer? (Round to nearest tenth)
A. 12.5
B. 10
C. 11.6
D. 8.8
Answer: A. 12.5
A nurse is teaching the parent of a school age child who has ADHD and a prescription for
atomoxetine 40 mg daily. Which of the following information should the nurse include in the
teaching?
A. Expect the child to gain weight while taking this medication
B. Crush the medication and mix it with 120 mL (4 oz) of juice

C. Therapeutic effects will occur within 24 hr of starting treatment
D. Administer the medication before the child goes to school in the morning
Answer: D. Administer the medication before the child goes to school in the morning
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. Place the client in a group therapy session
B. Rotate staff members who work with the client
C. Encourage the client to participate in physical activities
D. Distract the client with increased environmental stimuli
Answer: C. Encourage the client to participate in physical activities
A nurse in a mental facility is assessing a client for suicide risk factors using the SAD
PERSONS scale. Which of the following findings indicates a risk for suicide?
A. The client is married
B. The client is female
C. The client is 50 years of age
D. The client has diabetes mellitus
Answer: D. The client has diabetes mellitus
A nurse is performing a mental status examination for a client who has schizophrenia. The
nurse should recognize that which of the following actions requires the client to think
abstractly?
A. Explain what to do if he misses the bus
B. Determine the meaning of a proverb
C. Name the last three presidents of the United States of America
D. Count by adding sevens consecutively
Answer: B. Determine the meaning of a proverb
A nurse is developing a plan of care for a school age child who has ADHD.
Which of the following interventions should the nurse include in the plan?
A. Administer olanzapine
B. Institute consequences for deliberate behaviors
C. Provide a stimulating environment

D. Encourage thought stopping techniques
Answer: C. Provide a stimulating environment
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. Clinical nurse specialist
B. Recreational therapist
C. Social worker
D. Occupational therapist
Answer: C. Social worker
A nurse is providing crisis intervention for a client who was involved in a violent mass
casualty situation in the community. Which of the following actions should the nurse take
during the initial session with the client?
A. Encourage the client to display anger toward the cause of the crisis
B. Tell the client that his life will soon return to normal
C. Identify the client’s usual coping style
D. Help the client focus on a wide variety of topics regarding the crisis
Answer: C. Identify the client’s usual coping style
A nurse is planning to conduct a support group for adolescents who have cancer. Which of
the following actions should the nurse include during the orientation phase?
A. Manage conflict within the group
B. Establish rapport with group members
C. Encourage the use of problem-solving skills
D. Maintain the group’s focus on identified issues
Answer: B. Establish rapport with group members
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. Increased energy
B. Hypersomnia

C. Unkempt appearance
D. Psychomotor retardation
Answer: C. Unkempt appearance
A nurse in a rehabilitation unit is caring for a client who has a traumatic brain injury. To
which of the following members of the client’s interprofessional team should the nurse refer
the client in order to help him relearn how to use eating utensils?
A. Neuropsychiatrist
B. Occupational therapist
C. Physical therapist
D. Social worker
Answer: B. Occupational therapist
A nurse is caring for a group of clients on a mental health unit. For which of the following
clients is the nurse mandated to report to the appropriate agency?
A. A client who reports that she took $20 from the cash register where she works
B. A client who reports that her partner ties their child to a bed as punishment
C. A client who reports that he enjoys smoking marijuana on weekends
D. A client who reports lying to his provider about having suicidal ideation
Answer: B. A client who reports that her partner ties their child to a bed as punishment
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. Recent head injury
B. Hepatitis B infection
C. Hypothyroidism
D. Knee arthroplasty 1 month ago
Answer: A. Recent head injury
A charge nurse is orienting a newly licensed nurse and observes the newly licensed nurse
imitating her behaviors. The nurse should recognize this behavior as which of the following
defense mechanisms?
A. Suppression

B. Reaction formation
C. Identification
D. Compensation
Answer: C. Identification
A nurse is caring for a school-aged child who has conduct disorder and is being physically
aggressive toward other children in the unit. Which of the following actions should the nurse
take first?
A. Place the child in seclusion
B. Use therapeutic hold technique
C. Apply wrist restraints
D. Administer risperidone
Answer: A. Place the child in seclusion
A nurse is caring for a client who has a new diagnosis of bulimia nervosa. Which of the
following diagnosis procedures should the nurse anticipate the provider should describe
during the medical evaluation?
A. Chest x-ray
B. ECG
C. Coagulation studies
D. Liver function test
Answer: B. ECG
A nurse is caring for a client who exhibits excessive compliance, passivity, and self-denial.
The nurse should recognize that these findings are associated with which of the following
personality disorders?
A. Dependent
B. Paranoid
C. Borderline
D. Histrionic
Answer: A. Dependent
A nurse is caring for a client who is involuntarily admitted for major depressive disorder and
refuses to take prescribed antianxiety medication.

Which of the following actions should the nurse take?
A. Inform the client that he does not have the right to refuse medication
B. Administer the medication to the client via IM injection
C. Offer the client the medication at the next scheduled dose time
D. Implement consequences until the client take the medication
Answer: C. Offer the client the medication at the next scheduled dose time
A nurse is caring for a client in the emergency department who states she was beaten and
sexually assault by her partner. After a rapid assessment, which of the following actions
should the nurse plan to take next?
A. Conduct a pregnancy test
B. Requests mental health consultation for the client
C. Provide a trained advocate to stay with the client
D. Offer prophylactic medication to prevent STI’s
Answer: D. Offer prophylactic medication to prevent STI’s
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. Request that the client’s partner sign the consent form
B. Cancel the scheduled ECT procedure
C. Proceed with the preparation for ECT based on implied consent
D. Inform the client about the risks of refusing the ECT
Answer: B. Cancel the scheduled ECT procedure
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. Rationalization
B. Denial
C. Compensation
D. Displacement
Answer: D. Displacement

A nursing is advising an assistive personnel (AP) on the care of a client who has major
depressive disorder. The AP states that he is irritated by the client’s depression. Which of the
following statements by the nurse is appropriate?
A. Please don’t take what the client said seriously when she is depressed
B. It’s important that the client feel safe verbalizing how she is feeling
C. Everybody feels that way about this client so don’t worry about it
D. I’ll change your assignment to someone who doesn’t have depressive disorder
Answer: B. It’s important that the client feel safe verbalizing how she is feeling
A nurse is assessing a child in the emergency department. Which of the following findings
places the child at the greatest risk for physical abuse?
A. The child is 10years old
B. The child is homeschooled
C. The has no siblings
D. The child has cystic fibrosis
Answer: D. The child has cystic fibrosis
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. Keep a journal of how often you check the locks each night
B. Snap a rubber band on your wrist when you think about checking the locks
C. Ask a family member to check the lock for you at night
D. Focus on abdominal breathing whenever you go to check the locks
Answer: B. Snap a rubber band on your wrist when you think about checking the locks
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. Stupor
C. Afebrile
D. Hypertension
Answer: A. Bradycardia

A nurse is creating a plan of care of a client who has anorexia nervosa.
Which of the following intervention should the nurse include in the plan?
A. Weigh the client twice per day
B. Prepare the client for electroconvulsive therapy
C. Set a weight gain goal of 2.2kg (5lbs) per week
D. Encourage the client to participate in family therapy
Answer: D. Encourage the client to participate in family therapy
A nurse is planning care for a 3-year-old child who has autism spectrum disorder. Which of
the following finding should the nurse expect?
A. Readily initiates conversation
B. Enjoys imaginative play
C. Strong relationship with sibling and peers
D. Attachment to objects that spin
Answer: D. Attachment to objects that spin
A nurse is planning care for a client who has bipolar disorder. The client reports not sleeping
for 3 days and is exhibiting a euphoric mood. The nurse should identify which of the
following as the priority intervention.
A. Secure the client’s valuable possessions
B. Limit loud noises in the client’s environment
C. Encourage the client to participate in structured solitary activities
D. Provide high calorie snacks to the client
Answer: B. Limit loud noises in the client’s environment
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. Blocks aldehyde dehydrogenase
B. Prevents the anxiety of abstinence
C. Reduces substance craving
D. Decreases the likelihood of seizures
Answer: C. Reduces substance craving

A nurse in an alcohol treatment facility is caring for a client who states “my job is so stressful
that the only way I can come it is to drink.” The nurse should recognize that the client is
displaying which of the following defense mechanisms?
A. Repression
B. Rationalization
C. Introjection
D. Intellectualization
Answer: B. Rationalization
A nurse is caring for a client who has depression following a recent job loss. Which of the
following questions should the nurse ask to assess the client’s personal coping skills?
A. How does this situation affect your life?
B. Do you see your current situation affecting your future?
C. Can you describe how you are currently feeling?
D. How have you dealt with similar situations in the past
Answer: C. Can you describe how you are currently feeling?
A school nurse is caring for an adolescent client whose teacher reports changes in school
performance and withdrawal from interaction with classmates. Which of the following
intervention is the nurse’s priority at this time?
A. Contact the adolescent’s parents
B. Suggest the adolescent join support groups
C. Ask the adolescent if he is considering hurting himself
D. Determine when the adolescent’s change in behavior began
Answer: D. Determine when the adolescent’s change in behavior began
A nurse is assessing a client who is withdrawing from heroin. Which of the following
manifestations should the nurse expect?
A. Slurred speech
B. Hypotension
C. Bradycardia
D. Hyperthermia
Answer: A. Slurred speech

A nurse is assessing a client who has histrionic personality disorder. Which of the following
finds should the nurse expect?
A. Lack of remorse
B. Attention seeking
C. Splitting of staff
D. Identity disturbance
Answer: B. Attention seeking
A nurse is providing teaching to the daughter of an older client who has obsessivecompulsive disorder. Which of the following statements by the daughter indicates an
understanding of the disorder?
A. I will limit my mother’s clothing choices when she is getting dressed
B. I will provide my mother with detailed instructions about how to perform self-care
C. I will wake my mother up a couple of times in the night to check on her
D. I will discourage my mother from talking about physical complaints
Answer: A. I will limit my mother’s clothing choices when she is getting dressed
A nurse in a mental health facility is caring for a client who has borderline personality
disorder. Which of the following should the nurse expect?
A. Self-mutation
B. Pacing back and forth
C. Preoccupation with details
D. Disorganized speech
Answer: A. Self-mutation
a nurse is reviewing the laboratory results on adolescent who has anorexia nervosa. Which of
the following findings should the nurse expect?
A. Blood glucose 100 mg/dL
B. T4 11 mcg/dL
C. Potassium 3.7 mEq/L
D. Hgb 10 g/dL
Answer: D. Hgb 10 g/dL

A nurse is teaching about benztropine to a client who has schizophrenia. Which of the
following statements should the nurse include in the teaching?
A. This medication is given to help with extrapyramidal side effects
B. This medication is given to help with your depression
C. Benztropine helps alleviate your hallucinations
D. Benztropine is used to counteract your tachycardia
Answer: A. This medication is given to help with extrapyramidal side effects
A nurse is planning care for a client with acute delirium. Which of the following instructions
should the nurse include in the plan?
A. Reinforce the clients orientation with the calendar
B. Refute the clients perception of visual hallucinations
C. Teach the client assertive techniques
D. Assigned the client to a different caregiver each shift
Answer: A. Reinforce the clients orientation with the calendar
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 in the plan?
A. Discouraged client from expressing feelings of anger
B. Identify and schedule alternative group activities for the client
C. Encourage physical activity for the client during the day
D. Keep a bright light on in the clients room at night
Answer: C. Encourage physical activity for the client during the day
A nurse is caring for a client who has posttraumatic stress disorder related to military service.
Which of the following actions should the nurse take?
A. Encourage the client to suppress feelings of trauma
B. Assign the same staff to care for the client each day
C. Address the client in an authoritative manner
D. Limit the amount of time spent with the client
Answer: B. Assign the same staff to care for the client each day

A nurse is providing teaching for school age child and his parents regarding a new
prescription for risperidone. Which of the following statements by the parent indicates an
understanding of the teaching?
A. I will provide a low sodium diet for my son
B. I will make sure my son takes the last dose of the day by 4 PM
C. I should expect my son to develop hand tremors
D. I should contact my doctor if my son urinates excessively
Answer: C. I should expect my son to develop hand tremors
A nurse is caring for a client who has a lithium level of 0.8 mEq/L. Which of the following
actions should the nurse take?
A. Withhold the next does of lithium
B. Repeat the lithium level test
C. Administer the next does of lithium
D. Recommended a low sodium diet
Answer: C. Administer the next does of lithium
A nurse in a community mental health clinic is caring for a group of clients. The nurse should
encourage participation in cognitive behavioral family therapy in response to which of the
following client statements.
A. I want to learn how to change the way I react to problems within my family
B. I want to understand why my past experiences are affecting my family relationships
C. I want to improve my family’s understanding of each other’s boundaries
D. I want each of my family members to be more aware of each other’s feelings
Answer: D. I want each of my family members to be more aware of each other’s feelings
A nurse is providing teaching to the caregiver of an older adult client who has Alzheimer’s
disease and is being cared for at home. The client wonders at night and has a history of
previous falls. Which of the fund instructions should nurse including? (select all) in the
teaching
A. position the mattress on the floor
B. Install sensor devices on outside doors
C. Encourage physical activity prior to bedtime
D. put locks at top of doors

E. place the client in a reclining chair
Answer: A. position the mattress on the floor
B. Install sensor devices on outside doors
D. put locks at top of doors
A nurse is reviewing laboratory values for a client who has bipolar disorder and a prescription
for lithium. The nurse should identify that which of the following laboratory results places
the client at risk for lithium toxicity?
A. Calcium 9.0 mg/dL
B. sodium 130 mEq/L
C. chloride 98 mEq/L
D. potassium 5.0 mEq/L
Answer: B. sodium 130 mEq/L
A nurse is assisting with obtaining informed consent from 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 clients family
C. Request that the clients Guardian signed the consent
D. Ask the charge nurse to obtain an informed consent
Answer: C. Request that the clients Guardian signed the consent
A nurse is giving a presentation about intimate partner abuse for community group. Which of
the following statements buy a group member indicates understanding of teaching?
A. Survivors of abuse often feel guilty
B. abusers often have high self-esteem
C. the honeymoon stage of violence usually gets longer over time
D. as abuse continues, victims become more determined to be independent
Answer: A. Survivors of abuse often feel guilty
A nurse is planning care for a client who has experienced intimate partner abuse. The nurse
should identify which of the following outcomes as the priority?
A. The client joins a support group
B. the client identifies techniques to reduce her stress

C. The client develops a safety plan
D. The client identify support systems
Answer: C. The client develops a safety plan
A nurse is developing a behavioral contract with the client who has antisocial personality
disorder. Which of the following client goals should the nurse include in the contract?
A. Use projection during group therapy
B. increase self-esteem
C. use bargaining skills for behavioral consequences
D. Decrease the number of verbal outbursts
Answer: D. Decrease the number of verbal outbursts
A nurse is caring for a client who has schizophrenia and takes clozapine. Which of the
following findings is a priority for the nurse to report to the provider?
A. Nausea
B. Random blood glucose 130 mg/dL
C. Heart rate 104 per minute
D. sore throat
Answer: D. sore throat
A nurse is counseling and adult client whose parent just died. The client states, “My son is 4,
and I don’t know how he’ll react when he finds out that grandpa died.” The nurse should
inform the client that the preschool age child commonly has which of the following concepts
of death?
A. Death is not permanent and the loved one may come back to life
B. Death is contagious and can cause other people he loves to die
C. Death creates an interest in the physical aspects of dying
D. Death is a part of life that eventually happens to everyone
Answer: A. Death is not permanent and the loved one may come back to life
A nurse is reviewing the medical records for clients. Which of the following findings should
the nurse identified as a risk factor for violent behavior?
A. Schizoid personality disorder
B. Alcohol intoxication

C. Dysthymic disorder
D. long-term isolation
Answer: B. Alcohol intoxication
A nurse in a provider’s office is assessing a school age child who has a spiral fracture. The
parent of the child provides different accounts for the cause of the injury. Which of the
following actions should the nurse take first?
A. Request that the parent leaves the room while you interview the child
B. Report suspected abuse to child protective services
C. Ask the child how the injury occurred
D. Determine the immediate safety needs of the child
Answer: D. Determine the immediate safety needs of the child
An older adult client is brought to the mental clinic by her daughter. The daughter reports that
her mother is not eating and seems 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. everyone gets depressed from time to time
C. you shouldn’t worry about this, because depressive disorder is easily treated
D. tell me the reasons you think your mother is depressed
Answer: D. tell me the reasons you think your mother is depressed
A nurse in a mental health facility is caring for a client. Which of the following actions the
nurse take during though working phase of the nurseclient relationship?
A. Summarize goals and objectives
B. Address confidentiality
C. promote problem-solving skills
D. establish a participation contract
Answer: C. promote problem-solving skills
a nurse is caring for a client who suddenly directs profanities at her, then abruptly hangs his
head and says, “please forgive me, I’m not sure what came over me I don’t know why said
those things.” The nurse interprets this behavior as which of the following?

A. Emotional lability
B. Confabulation
C. flight of ideas
D. Neologism
Answer: A. Emotional lability
A nurse is providing teaching for the family of a client who has dementia. Which of the
following should the nurse include in the teaching as a contributing factor for this disorder?
A. Hypotension
B. alcohol use disorder
C. Dehydration
D. change in environment
Answer: B. alcohol use disorder
A nurse is caring for a client who has been taking valproic acid. Which of the following is
expected outcome of the medication?
A. The client reports improved short-term memory
B. the client has a decreased euphoric mood
C. the client reports absence of auditory hallucinations
D. the client has decreased anxiety
Answer: D. the client has decreased anxiety
A nurse is teaching a client who has major depressive disorder about electroconvulsive
therapy. Which of the phone information should the nurse include?
A. This therapy works as a cure for major depressive disorders
B. You will be awake and alert during the procedure
C. You might experience confusion for a few hours after treatment
D. This therapy will stimulate the vagus nerve to improve your mood
Answer: C. You might experience confusion for a few hours after treatment
A nurse emergency department is assessing a client who has major depressive disorder.
Which of the following actions should the nurse take?
(Exhibit question)
A. ask the client if she has eaten foods containing thyramine

B. Give regular insulin subcutaneously to the client
C. Prepare the client for electroconvulsive therapy
D. administer dantrolene IV bolus to the client
Answer: C. Prepare the client for electroconvulsive therapy
A nurse is reviewing the laboratory report of a client who is taking carbamazepine for bipolar
disorder. Which of the following laboratory results should the nurse report to the provider?
A. Urine specific gravity 1.029
B. Platelets 90,000/mm3
C. urine pH 5.6
D. RBC 4.7/mm3
Answer: B. Platelets 90,000/mm3
A nurse is caring for a client who has schizophrenia and started taking clozapine two months
ago. Which of the following laboratory results should the nurse report to the provider?
A. WBC 3,000/mm3
B. Potassium 4.2 mEq/L
C. Hgb 16 g/dL
D. Platelets 300,000/mm3
Answer: A. WBC 3,000/mm3
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 right now.” The nurse should recognize that the
following family boundaries?
A. Rigid
B. Inconsistent
C. Enmeshed
D. Clear
Answer: D. Clear
A nurse is assessing a client who requires bupropion for smoking cessation. Which of the
following findings in the client’s history should the nurse recognized as a contraindication for
taking this medication?
A. Seizures

B. Anemia
C. Migraines
D. Asthma
Answer: A. Seizures
A nurse is caring for a client with Alzheimer’s disease. Which of the following actions should
the nurse take?
A. Seat the client at a dining table with six or more residents
B. provide the client with several choices for meal selection
C. give complete directions before starting client care
D. use symbols to assist the client in locating rooms
Answer: D. use symbols to assist the client in locating rooms
A nurse is assessing a newly admitted client who has schizophrenia and takes thioridazine.
Which of the following findings should the nurse document as an adverse effect of this
medication?
A. Anhedonia
B. Waxy flexibility
C. contractions of the jaw
D. incongruent affect
Answer: B. Waxy flexibility
A nurse in an inpatient mental health facility is assessing a client who has schizophrenia and
is taking haloperidol. Which of the following clinical findings is the nurse’s priority?
A. High fever
B. Insomnia
C. Urinary hesitancy
D. Headache
Answer: A. High fever
A nurse is speaking with a client. Which of the following responses by the nurse
demonstrates the communication technique of reflection?
A. “I would like to sit with you for a while”
B. “You feel upset when this happens?”

C. “Let’s work together to try to solve your problem”
D. “Can you tell me what is happening now?”
Answer: B. “You feel upset when this happens?”
A nurse is leading grief support group for bereaved clients. Which of the following client
statements should the nurse report to the provider as an indication of clinical depression?
A. “I don’t know how I could cope if I didn’t have my family’s support”
B. “It’ll be a long time before I’m happy again”
C. “I don’t feel anything but numbness anymore”
D. “I feel like I’m angry at the whole world right now”
Answer: C. “I don’t feel anything but numbness anymore”
A nurse is preparing to administer chlorpromazine hydrochloride 25 mg PO to an older adult
client. Available is chlorpromazine hydrochloride syrup 10 mg/5 mL. How many mL should
the nurse administer? (Round to nearest tenth)
A. 12.5
B. 8.5
C. 11.8
D. 2.9
Answer: A. 12.5
A nurse is teaching the parent of a school age child who has ADHD and a prescription for
atomoxetine 40 mg daily. Which of the following information should the nurse include in the
teaching?
A. Expect the child to gain weight while taking this medication
B. Crush the medication and mix it with 120 mL (4 oz) of juice
C. Therapeutic effects will occur within 24 hr of starting treatment
D. Administer the medication before the child goes to school in the morning
Answer: D. Administer the medication before the child goes to school in the morning
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. Place the client in a group therapy session
B. Rotate staff members who work with the client

C. Encourage the client to participate in physical activities
D. Distract the client with increased environmental stimuli
Answer: C. Encourage the client to participate in physical activities
A nurse in a mental facility is assessing a client for suicide risk factors using the SAD
PERSONS scale. Which of the following findings indicates a risk for suicide?
A. The client is married
B. The client is female
C. The client is 50 years of age
D. The client has diabetes mellitus
Answer: D. The client has diabetes mellitus
A nurse is performing a mental status examination for a client who has schizophrenia. The
nurse should recognize that which of the following actions requires the client to think
abstractly?
A. Explain what to do if he misses the bus
B. Determine the meaning of a proverb
C. Name the last three presidents of the United States of America
D. Count by adding sevens consecutively
Answer: B. Determine the meaning of a proverb
A nurse is developing a plan of care for a school age child who has ADHD. Which of the
following interventions should the nurse include in the plan?
A. Administer olanzapine
B. Institute consequences for deliberate behaviors
C. Provide a stimulating environment
D. Encourage thought stopping techniques
Answer: C. Provide a stimulating environment
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. Clinical nurse specialist
B. Recreational therapist

C. Social worker
D. Occupational therapist
Answer: C. Social worker
A nurse is providing crisis intervention for a client who was involved in a violent mass
casualty situation in the community. Which of the following actions should the nurse take
during the initial session with the client?
A. Encourage the client to display anger toward the cause of the crisis
B. Tell the client that his life will soon return to normal
C. Identify the client’s usual coping style
D. Help the client focus on a wide variety of topics regarding the crisis
Answer: C. Identify the client’s usual coping style
A nurse is planning to conduct a support group for adolescents who have cancer. Which of
the following actions should the nurse include during the orientation phase?
A. Manage conflict within the group
B. Establish rapport with group members
C. Encourage the use of problem-solving skills
D. Maintain the group’s focus on identified issues
Answer: B. Establish rapport with group members
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. Increased energy
B. Hypersomnia
C. Unkempt appearance
D. Psychomotor retardation
Answer: C. Unkempt appearance
A nurse in a rehabilitation unit is caring for a client who has a traumatic brain injury. To
which of the following members of the client’s interprofessional team should the nurse refer
the client in order to help him relearn how to use eating utensils?
A. Neuropsychiatrist

B. Occupational therapist
C. Physical therapist
D. Social worker
Answer: B. Occupational therapist
A nurse is caring for a group of clients on a mental health unit. For which of the following
clients is the nurse mandated to report to the appropriate agency?
A. A client who reports that she took $20 from the cash register where she works
B. A client who reports that her partner ties their child to a bed as punishment
C. A client who reports that he enjoys smoking marijuana on weekends
D. A client who reports lying to his provider about having suicidal ideation
Answer: B. A client who reports that her partner ties their child to a bed as punishment
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. Recent head injury
B. Hepatitis B infection
C. Hypothyroidism
D. Knee arthroplasty 1 month ago
Answer: A. Recent head injury
A charge nurse is orienting a newly licensed nurse and observes the newly licensed nurse
imitating her behaviors. The nurse should recognize this behavior as which of the following
defense mechanisms?
A. Suppression
B. Reaction formation
C. Identification
D. Compensation
Answer: C. Identification
A nurse is reviewing the medication administration record of a client who has major
depressive disorder and a new prescription for selegiline. The nurse should recognize that
which of the following client medications is contraindicated when taken with selegiline?

A. Wafarin
B. Fluoxetine
C. Calcium carbonate
D. Acetaminophen
Answer: B. Fluoxetine
A nurse in a long-term care facility is assessing a client who has dementia. Which of the
following findings should the nurse identify as a risk for this client?
A. Outside doors have locks
B. The bed is in the low position
C. Hallways are long distances
D. The room has an area rug
Answer: D. The room has an area rug
A nurse is providing behavioral therapy for a client who has obsessivecompulsive 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. “Keep a journal of how often you check the locks each night”
C. “Snap a rubber band on your wrist when you think about checking the locks”
D. “Focus on abdominal breathing whenever you go to check the locks”
Answer: C. “Snap a rubber band on your wrist when you think about checking the locks”
A nurse in an inpatient mental health facility is assessing a client who has schizophrenia and
is taking haloperidol. Which of the following clinical findings is the nurse’s priority?
A. Insomnia
B. Urinary hesitancy
C. Headache
D. High fever
Answer: D. High fever
A nurse is caring for a client who has Alzheimer’s disease. Which of the following findings
should the nurse expect?
A. Failure to recognize familiar objects

B. Altered level of consciousness
C. Excessive motor activity
D. Rapid mood swings
Answer: A. Failure to recognize familiar objects
A nurse in a mental health facility is interviewing a new client. Which of the following
outcomes must occur if the nurse is to establish a therapeutic nurse-client relationship?
A. The nurse is seen as an authority figure
B. A written contract is established to clarify the steps of the treatment plan
C. The nurse maintains confidentiality unless the client’s safety is compromised
D. The nurse is seen as a friend
Answer: C. The nurse maintains confidentiality unless the client’s safety is compromised
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. “If I cut myself, I can clean the wound with isopropyl alcohol”
B. “I can wear my cologne on special occasions”
C. “When I bake my favorite cookies, I can use pure vanilla extract for flavoring”
D. “I can continue to eat aged cheese and chocolate”
Answer: D. “I can continue to eat aged cheese and chocolate”
A nurse is planning care for a client who has narcissistic personality disorder. Which of the
following actions is appropriate for the nurse to include in the plan of care?
A. Ask the client to sign a no-suicide contract
B. Remain neutral when communicating with the client
C. Request an antipsychotic medication from the provider
D. Provide the client with high-calorie finger foods
Answer: B. Remain neutral when communicating with the client
A nurse is reviewing the laboratory report of a client who is taking carbamazepine for bipolar
disorder. Which of the following laboratory results should the nurse report to the provider?
A. Urine specific gravity 1.029
B. Platelets 90,000/mm3
C. Urine pH 5.6

D. RBC 4.7/mm3
Answer: B. Platelets 90,000/mm3
A nurse is providing teaching about relapse prevention to a client who has schizophrenia.
Which of the following statements by the client indicates an understanding of the teaching?
A. “I should avoid being around others if I think I’m having a relapse”
B. “I should let my counselor know if I am having trouble sleeping”
C. “I shouldn’t worry about the voices because they are a part of my illness”
D. “I should increase my carbohydrate intake to maintain my energy level”
Answer: B. “I should let my counselor know if I am having trouble sleeping”
A nurse is assessing a client for negative manifestations of schizophrenia.
Which of the following findings should the nurse expect?
A. Echopraxia
B. Delusions
C. Anergia
D. Tangentiality
Answer: C. Anergia
A nurse is preparing for an interprofessional team meeting regarding a newly admitted client
who has major depressive disorder. Which of the following findings obtained during the
initial assessment is the priority to report to other disciplines?
A. Poor problem-solving skills
B. Markedly neglected hygiene
C. Significant weight loss
D. Psychomotor retardation
Answer: D. Psychomotor retardation
A nurse is preparing to administer methylphenidate 25 mg PO to a school age child who has
ADHD. Available is methylphenidate 10mg/5mL liquid.
How many mL should the nurse administer? (Round to nearest tenth)
A. 12.5
B. 11.2
C. 13.5

D. 6.8
Answer: A. 12.5
A nurse is caring for a school age child who has a fractured arm. The child has other injuries
that cause the nurse to suspect abuse. Which of the following actions is appropriate for the
nurse to take when assessing the child’s situation?
A. Ask the parents directly if the child’s fracture is due to physical abuse
B. Direct the parents to the waiting room before interviewing the child
C. Interview the child with the provider and social worker present
D. Ask clarifying questions as the child explains how the injuries occurred
Answer: D. Ask clarifying questions as the child explains how the injuries occurred
A nurse is assisting with obtaining consent for a client who has been declared legally
incompetent. Which of the following actions should the nurse take?
A. Ask the charge nurse to obtain informed consent
B. Contact the facility social worker to obtain consent
C. Request that the client’s guardian sign the consent
D. Explain implied consent to the clients family
Answer: C. Request that the client’s guardian sign the consent
A nurse in a mental health facility is reviewing a client’s medical record. Which of the
following actions should the nurse take first? (Click on the exhibit button for additional
information about the client. There are 3 tabs that contain separate categories of data)
A. Teach the client about nutritional needs
B. Initiate 0.9% sodium chloride with 40 mEq potassium chloride
C. Administer acetaminophen 500 mg PO
D. Encourage the client to attend group therapy sessions
Answer: B. Initiate 0.9% sodium chloride with 40 mEq potassium chloride
A nurse is assessing a client who has delirium. Which of the following findings requires
immediate intervention by the nurse?
A. Rapid mood swings
B. Command hallucinations
C. Impaired memory

D. Inappropriate speech patterns
Answer: A. Rapid mood swings
A nurse is developing a teach plan for the family of an older adult client who is to receive
transcranial magnetic stimulation. Which of the following information should the nurse
include n the teaching plan?
A. The client is at risk for aspiration during treatment
B. The client will experience a seizure during treatment
C. The client will require intubation after treatment
D. The client might have a headache after treatment
Answer: D. The client might have a headache after treatment
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. Recent head injury
B. Hypothyroidism
C. Knee arthroplasty 1 month ago
D. Hepatitis B infection
Answer: A. Recent head injury
A nurse is developing a plan of care for a client who has paranoid personality disorder. Which
of the following actions should the nurse include in the plan?
A. Provide written information about the client’s treatment plan
B. Monitor the client for splitting behaviors
C. Encourage countertransference when developing the nurse-client relationship
D. Isolate the client from social or group interactions
Answer: D. Isolate the client from social or group interactions
A nurse is caring for a client who receives lamotrigine daily for bipolar disorder and reports a
rash on his arm. Which of the following actions should the nurse take?
A. Ask the client about a recent change in laundry detergent
B. Explain that the medication causes a temporary rash
C. Apply hydrocortisone cream on the client’s rash

D. Withhold the next dose of the medication
Answer: D. Withhold the next dose of the medication
A nurse is caring for a client who begins yelling and pacing around the room. Which of the
following actions should the nurse take? (select all that apply)
A. Stand directly in front of the client
B. Identify the client’s stressors
C. Request that security guards restrain the client
D. Talk to the client using short, simple sentences
E. Speak to the client in a loud voice
Answer: A. Stand directly in front of the client
D. Talk to the client using short, simple sentences
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. Allow flexibility in the child’s daily schedule
B. Assign the child to a room with another child of the same age
C. Discourage the child from making eye contact with caregivers
D. Use a reward system for appropriate behavior
Answer: D. Use a reward system for appropriate behavior
A nurse is caring for a client who has post-traumatic stress disorder. Which of the following
clinical findings is associated with this disorder?
A. Depersonalization
B. Pressured speech
C. Hypervigilance
D. Compulsive behavior
Answer: A. Depersonalization
A nurse is teaching a client about the use of cognitive reframing for stress management.
Which of the following statements by the client indicates an understanding of the teaching?
A. “I will focus on a mental image while concentration on my breathing.”
B. “I will practice replacing negative thoughts with positive self statements.”
C. “I will progressively relax each of my muscle groups when feeling stressed.”

D. “I will learn how to voluntarily control my blood pressure and heart rate.”
Answer: B. “I will practice replacing negative thoughts with positive self statements.”
A nurse is caring for a client who has schizophrenia and has been taking chlorpromazine for 5
years. Which of the following assessment tools should the nurse use to determine if the client
is experiencing adverse effects of the medication?
A. Addiction Severity Index (ASI)
B. Mood Disorder Questionnaire (MDQ)
C. Abnormal Involuntary Movement Scale (AIMS)
D. Hamilton Depression Scale
Answer: C. Abnormal Involuntary Movement Scale (AIMS)
A nurse in a mental health facility is assessing a client for suicide risk factors using the SAD
PERSONS scale. Which of the following finding indicates a risk suicide?
A. The client is married
B. The client has diabetes mellitus
C. The client is 50 years of age
D. The client is female
Answer: B. The client has diabetes mellitus
A nurse is providing crisis intervention for a client who was involved in a violent mass
casualty situation in the community. Which of the following actions should the nurse take
during the initial session with the client?
A. Identify the client’s usual coping style
B. Help the client focus on a wide variety of topics regarding the crisis
C. Tell the client that his life will soon return to normal
D. Encourage the client to display anger toward the cause of the crisis
Answer: A. Identify the client’s usual coping style
A nurse is caring for a client who has schizophrenia and is experiencing auditory
hallucinations. Which of the following actions should the nurse take first?
A. Encourage the client to listen to music
B. Monitor the client for indications of anxiety
C. Ask the client what she is missing

D. Focus the client on reality-based topics
Answer: D. Focus the client on reality-based topics
A nurse is planning to lead a support group for clients who have alcohol use disorder. One of
the group members is a client who speaks a different language than the nurse. The nurse
should ask which of the following individuals to assist with communication?
A. A family member of the client
B. Another client who speaks the same language as the client
C. A translator of the same gender as the client
D. A unit secretary who speaks the same language as the client
Answer: C. A translator of the same gender as the client
A nurse in an emergency department is assessing a client who reports recently using cocaine.
Which of the following clinical manifestations should the nurse expect?
A. Lethargy
B. Hypothermia
C. Hypertension
D. Bradycardia
Answer: C. Hypertension
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
Answer: A. Muscle distress
A nurse in an outpatient clinic is assessing a client who has anorexia nervosa. Which of the
following findings indicates the need for hospitalization?
A. Temperature 35.6 C (96.1 F)
B. Heart rate 56/min
C. Weight 10% below ideal weight

D. Potassium 3.8 mEq/L
Answer: A. Temperature 35.6 C (96.1 F)
A nurse is caring for a client who is under observation for suicidal ideations and has
verbalized a suicide plan. The client demands privacy and to be left alone. Which of the
following statements should the nurse make?
A. “Since you are trying to follow the treatment plan, we can submit your request to the
provider.”
B. “We are concerned about you and need to keep you safe.”
C. “Until your medication has reached therapeutic levels, you will need constant
observation.”
D. “If you complete a contract that states you will not harm yourself, you can be alone.”
Answer: B. “We are concerned about you and need to keep you safe.”
A nurse on a mental health unit is leading a therapy session for a group of clients. One client
challenges the nurse and shows no empathy for others in the group. Which of the following
actions should the nurse take?
A. Request that the client leave the therapy session immediately
B. Place the client in seclusion
C. Reassign the client to another group
D. Ask the client privately what is causing the anger
Answer: D. Ask the client privately what is causing the anger
A nurse in a mental health clinic is assessing a client who has borderline personality disorder.
Which of the following findings should the nurse expect?
A. Inability to maintain employment
B. Intense efforts to avoid abandonment
C. Avoidance of interpersonal relationships
D. Reluctance to discard worthless objects
Answer: B. Intense efforts to avoid abandonment
A nurse in a long-term care facility is assessing an older adult client for depression. Which of
the following findings should the nurse expect?
A. Rapid mood swings

B. Sun downing
C. Insomnia
D. Rambling speech
Answer: C. Insomnia
A nurse is assessing a client who has been taking thioridazine for 2 weeks. The client reports
an inability to be still. Which of the following adverse effects should the nurse suspect?
A. Tardive dyskinesia
B. Pseudo parkinsonism
C. Akathisia
D. Acute dystonia
Answer: C. Akathisia
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. Clinical nurse specialist
B. Social worker
C. Occupational therapist
D. Recreational therapist
Answer: B. Social worker
A nurse is interviewing a client who was recently sexually assaulted. The client cannot recall
the attack. The nurse should identify that the client is using which of the following defense
mechanisms?
A. Sublimation
B. Reaction formation
C. Suppression
D. Repression
Answer: D. Repression
A nurse is assessing a client who has antisocial personality disorder. Which of the following
client behaviors should the nurse expect?
A. Attention-seeking

B. Anxious
C. Projects blame
D. Manipulative
Answer: D. Manipulative
A nurse is caring for a client who has physical restraints applied. The nurse determines that
the restraints should be removed when which of the following occurs?
A. The client states that he will harm himself unless the restraints are removed
B. The client refuses to take his medication unless he is released
C. The client demonstrates that he is oriented to person, place, and time
D. The client is able to follow commands
Answer: D. The client is able to follow commands
A nurse is caring for a client who states, “Things will never work out.” Which of the
following responses should the nurse make?
A. “Why do you feel like things will never work?”
B. “Have you been thinking about harming yourself?”
C. “You should try to focus on yourself for a change.”
D. “Maybe an antidepressant will make you feel better.”
Answer: B. “Have you been thinking about harming yourself?”
A nurse in an emergency department is caring for a client who reports a recent sexual assault
by her partner. Which of the following statements is the priority for the nurse make?
A. “I want you to know that you are in a safe place here.”
B. “I can contact a support person for you.”
C. “A trained sexual-assault nurse will be assigned to your care.”
D. “I can provide information about an advocacy group in your area”
Answer: A. “I want you to know that you are in a safe place here.”
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. Help the client identify social support
B. Involve the client in planning interventions
C. Assist the client to lower his anxiety level

D. Teach the client specific coping skills to handle stressful situations
Answer: C. Assist the client to lower his anxiety level
A nurse is assessing a client who has bulimia nervosa. Which of the following findings
should the nurse expect?
A. Acrocyanosis
B. Amenorrhea
C. Lanugo
D. Hyponatremia
Answer: A. Acrocyanosis
A nurse is caring for client who reports smoking marijuana several times per day. The client
tells the nurse, “ I don’t know what the big deal is marijuana is a harmless herb” The nurse
should identify that the client is displaying which of the following mechanisms?
A. Rationalization
B. reaction formation
C. compensation
D. suppression
Answer: A. Rationalization
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 in the plan?
A. identify and schedule alternative group activities for the client
B. encourage physical activity for the client during the day
C. discourage the client from expressing feelings of anger
D. keep a bright light on in the client’s room at night.
Answer: B. encourage physical activity for the client during the day
A nurse is teaching the family of a client who has Alzheimer’s disease about the safety
interventions for nighttime wandering, which of the following interventions should the nurse
include?
A. place rubber backed throw rugs on tile floors
B. encourage the client to take naps during the day
C. install locks at the bottom of exit doors

D. place the clients mattress on the floor.
Answer: C. install locks at the bottom of exit doors
A nurse in a mental health facility is reviewing the lab results of a client who is taking lithium
carbonate. Which of the following findings places the client at risk for lithium toxicity.
A. calcium 10.0
B. WBC 6,0000
C. sodium 132 mEq/L
D. aspartate aminotransferase 40 units/L
Answer: C. sodium 132 mEq/L
A nurse in an acute care facility is planning care for a client who has a history of alcohol use
disorder and is admitted while intoxicated. Which of the following interventions should the
nurse plan for the client
A. monitor for orthostatic hypotension
B. administer methadone hydrochloride
C. implement seizure precautions
D. acidify the client’s urine
Answer: C. implement seizure precautions
A nurse is developing a safety plan for a client who has experienced intimate partner abuse.
Which of the following items should the nurse include in the plan that will provide immediate
safety for the client and her children?
A. the phone numbers for law enforcement agencies
B. a code phrase to use when it is time to leave the house
C. the phone number of the local shelter
D. a referral to a support group
Answer: C. the phone number of the local shelter
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. Denial

B. Rationalization
C. displacement
D. compensation
Answer: C. displacement
A nurse is observing a newly licensed nurse administer an IM medication to a client who is
manic and refuses the medication. Which of the following actions should the nurse take first?
A. stop the newly licensed nurse from administering the medication
B. call the provider for an alternate medication route
C. report the occurrence to the nurse manager
D. talk to the newly licensed nurse about the incident
Answer: A. stop the newly licensed nurse from administering the medication
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. explain that it can take a year or more to learn to live with loss
B. discourage the client from reliving the events surrounding her loss
C. suggest that the client avoid social interactions that remind her of her partner
D. direct the client to maintain an unstructured daily routine
Answer: A. explain that it can take a year or more to learn to live with loss
A nurse is caring for a client who has bipolar disorder. The client is walking in and out of
rooms, speaking inappropriately, and giggling. Which of the following actions should the
nurse take?
A. tell the client there will be negative consequences for her behavior
B. take the client to the day room to watch a movie with the other clients
C. have the client return to her room to read a book
D. lead the client outside for a walk
Answer: D. lead the client outside for a walk
A nurse is admitting a client who has a new diagnosis of schizophrenia and a history of
aggression. Which of the following actions should the nurse include in the clients initial plan
of care?
A. agree with the client when he is upset until he can calm down

B. provide physical exercise activity for the client
C. avoid eye contact with the client for the first few days
D. ignore the clients hallucinations
Answer: B. provide physical exercise activity for the client
a nurse is caring for a client who has bipolar disorder and is exhibiting mania. Which of the
following findings should the nurse expect?
A. disorganized speech
B. heightened concentration
C. hypersomnia
D. agoraphobia
Answer: A. disorganized speech
a nurse is caring for a client who has schizophrenia. The client’s employer calls to discuss the
client’s condition. Which of the following is the appropriate nursing action?
A. consult the client
B. consult the client’s family
C. contact the provider
D. contact the facility legal department
Answer: A. consult the client
A nurse is providing teaching to a client who is prescribed methylphenidate for ADHD.
Which of the following statements by the client indicates accurate understanding of this
medications effects?
A. I know that I will be able to think more clearly now
B. this medicine will help me relax and feel less anxious
C. ill take my medicine at bedtime because it will make my drowsy
D. I need to tell my doctor if I start gaining weight
Answer: A. I know that I will be able to think more clearly now
An older adult client is brought to the mental health clinic by her daughter. The daughter
reports that her mother is not eating and seems very uninterested in routine activities. The
daughter states “ im so worried that my mother is depressed” Which of the following
responses should the nurse take?

A. “you shouldn’t worry about this, because depressive disorder is easily treated”
B. older adults are usually diagnosed with depressive disorder as they age
C. tell me the reasons you think your mother is depressed
D. everyone gets depressed from time to time.
Answer: C. tell me the reasons you think your mother is depressed
A nurse is providing teaching to a client who has a new prescription for tranylcypromine.
Which of the following over the counter medications should the nurse instruct the client to
avoid taking due to adverse interactions?
A. Ranitidine
B. Pseudoephedrine
C. Ibuprofen
D. magnesium hydroxide
Answer: B. Pseudoephedrine
A nurse in the ED is admitting a client who has a history of alcohol use disorder. The client
has a blood alcohol level of 0.26 g/dl. The nurse should anticipate a prescription for which of
the following medications?
A. Disulfiram
B. Cholridiazepoxide
C. Naltrexone
D. Acamprosate
Answer: B. Cholridiazepoxide
A nurse is building a therapeutic relationship with a client who has an eating disorder. Which
of the following activities should the nurse initiate during the relationships orientation phase?
A. Mutually deciding and agreeing on the goals of the relationship
B. using memories to validate the relationship experience
C. discussing the incorporation of new strategies into daily life
D. teaching and encouraging the use of problem solving skills
Answer: A. Mutually deciding and agreeing on the goals of the relationship

A nurse is assessing a client who has schizophrenia. The client tells the nurse, “My heart
exploded and my blood is draining out” The nurse should interpret this statement as which of
the following manifestations?
A. concrete thinking
B. a visual hallucination
C. a somatic delusion
D. paranoia
Answer: C. a somatic delusion
A nurse is interviewing a client who has schizophrenia. The client states, “aliens are going to
abduct me at midnight tonight” Which of the following responses should the nurse make?
A. why are the aliens going to abduct you?
B. you are safe from aliens here
C. believing that aliens will abduct you must be scary
D. have you ever been abducted by aliens before?
Answer: C. believing that aliens will abduct you must be scary
A nurse is caring for a client who has generalized anxiety disorder and a history of substance
abuse use disorder. Which of the following medications would the nurse expect the provider
to prescribe?
A. Chlordiazepoxide
B. Clonazepam
C. Busprione
D. Alprazolam
Answer: C. Busprione
A nurse in an ED is creating a plan of care for a client who reports experiencing intimate
partner violence. Which of the following interventions should the nurse include as the
priority?
A. teach the client stress reduction techniques
B. help the client devise a safety plan
C. refer the client to a support group
D. follow the facilities protocol for reporting the abuse
Answer: D. follow the facilities protocol for reporting the abuse

A nurse in a mental health facility is caring for a client who is being aggressive toward other
clients. Which of the following actions is the priority for the nurse to take?
A. Assist the client to explore techniques to reduce stress
B. Ask the client if he intends to harm others,
C. role model healthy ways to express anger
D. suggest the client make a list of things that make him angry.
Answer: B. Ask the client if he intends to harm others,
A nurse in the ED is caring for a client who has serotonin syndrome. The nurse should assess
the client for which of the following manifestations?
A. Hyperpyrexia
B. Priapism
C. Parathesisa
D. bradycardia
Answer: A. Hyperpyrexia