1 >>The nurse is discussing the grieving process with the client. Which stages are included in K�bler-Ross’s stages of grief? Rank in the correct order. ?
- (A) Acceptance.
- (B) Bargaining.
- (C) Denial.
- (D) Anger.
2 >>The nurse is in the middle/working phase of the nurse/client relationship. Which statement is a task in the orientation phase? ?
- (A) Identify the client’s strengths and weaknesses.
- (B) Help the client identify problem-solving techniques.
- (C) Evaluate the client’s experience while in the group.
- (D) Establish the rules for how the meetings will be conducted.
3 >>Which situation requires priority intervention on an inpatient psychiatric unit? ?
- (A) A client is threatening to throw the television at another client.
- (B) A male client wants to use the phone to call his spouse.
- (C) A client sitting in a chair is delusional and hallucinating.
- (D) A client has refused to eat anything for the last 2 days.
4 >>The client with long-term alcoholism asks the nurse, “How does Alcoholics Anonymous help me quit drinking?” Which statements are the nurse’s best responses? Select all that apply. ?
- (A) “AA has sponsors whom you can contact if you want to take a drink.”
- (B) “AA discusses medications used to help prevent drinking alcohol.”
- (C) “AA is a support group of alcoholics who have successfully quit drinking.”
- (D) “AA helps you realize the power you have over your addiction to alcohol.”
5 >>The client diagnosed with bipolar disorder and who is prescribed lithium, an antimania medication, is admitted to the psychiatric unit in an acute manic state. Which intervention should the nurse implement first? ?
- (A) Have the laboratory draw a STAT serum lithium level.
- (B) Evaluate what behavior prompted the psychiatric admission.
- (C) Assess and treat the client’s physiological needs.
- (D) Administer a STAT dose of lithium to the client.
6 >>The psychiatric unit staff is upset about the new female charge nurse who just sits in her office all day. One of the staff members informs the clinical manager about the situation. Which statement by the clinical manager indicates a laissez-faire leadership style? ?
- (A) “I will schedule a meeting to discuss the concerns of the charge nurse.”
- (B) “I hired the new charge nurse and she is doing what I told her to do.”
- (C) “You and the staff really should take care of this situation on your own.”
- (D) “I will talk to the charge nurse about your concerns and get back to you.”
7 >>The client diagnosed with paranoid schizophrenia is imminently aggressive and is dangerous to himself, the other clients, and the psychiatric staff members. The client is placed in a seclusion room. Which interventions should the psychiatric nurse implement? Select all that apply. ?
- (A) Assess the client every 2 hours for side effects of medication.
- (B) Tell the client what behavior will prompt the release from seclusion.
- (C) Do not notify the client’s family of the initiation of seclusion.
- (D) Explain that the client will be in the seclusion room for 24 hours.
8 >>The psychiatric nurse overhears a mental health worker (MHW) arguing with a client diagnosed with paranoid schizophrenia. Which action should the nurse implement? ?
- (A) Ask the MHW to go to the nurse’s station.
- (B) Tell the MHW to quit arguing with the client.
- (C) Notify the clinical manager of the psychiatric unit.
- (D) Report this behavior to the client abuse committee.
9 >>Which client should the psychiatric nurse working in a mental health clinic refer to the psychiatric social worker? ?
- (A) The client who was raped and wants help to be able to get on with her life.
- (B) The client who is scheduled for the first electroconvulsive therapy treatment.
- (C) The client who reports having difficulty going to work every day.
- (D) The client who is unable to buy the prescribed antipsychotic medications.
10 >>The psychiatric nurse has taken 15 minutes extra for the lunch break two times in the last week. Which action should the female clinical manager implement? ?
- (A) Take no action and continue to watch the nurse’s behavior.
- (B) Document the behavior in writing and place in the nurse’s file.
- (C) Tell the nurse to check in and out with her when taking lunch.
- (D) Talk to the nurse informally about taking 45 minutes for lunch.
11 >>The client diagnosed with Alzheimer’s disease is on a special unit for clients with cognitive disorders. Which assessment data would warrant immediate intervention by the psychiatric nurse? ?
- (A) The client does not know his or her name, date, or place.
- (B) The client is unable to dress himself or herself without assistance.
- (C) The client is difficult to arouse from sleep.
- (D) The client needs assistance when eating a meal.
12 >>The mother of a client recently diagnosed with schizophrenia says to the nurse, “I was afraid of my son. Will he be all right?” Which response by the psychiatric nurse supports the ethical principal of veracity? ?
- (A) “I can see your fear; you are concerned your son will not be all right.”
- (B) “If your son takes medication, the symptoms can be controlled.”
- (C) “Why were you afraid of your son? Did you think he would hurt you?”
- (D) “Schizophrenia is a mental illness and your son will not be all right.”
13 >>The nurse is caring for clients in an outpatient psychiatric clinic. Which client would the nurse discuss with the healthcare provider? ?
- (A) The client diagnosed with bipolar disorder who is receiving carbamazepine (Tegretol), an anticonvulsant.
- (B) The client diagnosed with schizophrenia who reports taking the antacid Maalox daily for heartburn.
- (C) The client diagnosed with major depression who is receiving isoniazid (INH), an antituberculosis medication.
- (D) The client diagnosed with anorexia nervosa who is receiving amitriptyline (Elavil), a tricyclic antidepressant.
14 >>The client in the psychiatric unit tells the nurse, “Someone just put a bomb under the couch in the lobby.” Which action should the nurse implement first? ?
- (A) Look under the couch for a bomb.
- (B) Implement the bomb scare protocol.
- (C) Have the staff evacuate the unit.
- (D) Tell the client there is no bomb.
15 >>The new nurse on the psychiatric unit tells the charge nurse, “I don’t like how the shift report is given.” Which statement is the charge nurse’s best response? ?
- (A) “Since you’re new I think you should try it our way before making any comments.”
- (B) “We have been doing the shift report this way since I started working here more than 5 years ago.”
- (C) “Have you discussed your concerns about the shift report with the other nurses?”
- (D) “I would be happy to listen to any ideas you have on how to give the shift report.”
16 >>The client on the psychiatric unit tells the nurse, “I am so bored. I hate just sitting on the unit doing nothing.” Which intervention should the nurse implement? ?
- (A) Explain that with time the client will be able to go to the activity area.
- (B) Allow the client to vent feelings of being bored on the unit.
- (C) Notify the psychiatric recreational therapist about the client’s concerns.
- (D) Tell the client that there is nothing that can be done about being bored.
17 >>The head nurse in a psychiatric unit in the county emergency department is assigning clients to the staff nurses. Which client should be assigned to the most experienced nurse? ?
- (A) The client who is crying and upset because she was raped.
- (B) The client diagnosed with bipolar disorder who is agitated.
- (C) The client who was found wandering the streets in a daze.
- (D) The client diagnosed with schizophrenia who is hallucinating.
18 >>The client diagnosed with anorexia is refusing to eat and is less than 20% of ideal body weight (IBW) for her height and structure. The client has not eaten anything since admission 2 days ago. Which action should the nurse implement? ?
- (A) Notify the psychiatrist to request a court order to feed the client.
- (B) Take no action because the client has the right to refuse treatment.
- (C) Discharge the client because she is not complying with the treatment.
- (D) Physically restrain the client and insert a nasogastric tube for feeding.
19 >>The client on a psychiatric involuntary admission is threatening to run away from the unit. Which intervention should the nurse implement first? ?
- (A) Notify the police department of the client’s threats.
- (B) Place the unit on high alert for unauthorized departure.
- (C) Talk to the client about the threat of running away.
- (D) Have the client sign out against medical advice (AMA).
20 >>The nurse answers the client’s phone in the lobby area and the person asks, “May I speak to Mr. Jones?” Which action should the nurse implement? ?
- (A) Ask the caller who is asking for Mr. Jones.
- (B) Tell the caller Mr. Jones cannot have phone calls.
- (C) Request the caller to give the access code for information.
- (D) Find Mr. Jones and tell him he has a phone call.