1 >>The client seeing the psychiatric nurse in the mental health clinic tells the nurse, “If I tell you something very important, will you promise not to tell anyone?” Which statement is the nurse’s best response? ?
- (A) “I promise I will not tell anyone if you don’t want me to.”
- (B) “If it affects your care I will have to tell someone who can help.”
- (C) “If you don’t want me to tell anyone, then please don’t tell me.”
- (D) “Why do you not want me to tell anyone if it is so important?”
2 >>Which situation would warrant immediate intervention by the charge nurse on the psychiatric unit after receiving the a.m. shift report? ?
- (A) The client diagnosed with paranoid schizophrenia who is delusional.
- (B) The p.m. shift licensed practical nurse (LPN) called in to say he or she would not be able to work today.
- (C) The male mental health worker (MHW) reports losing his unit key and identification card.
- (D) The unit secretary has HCP’s orders that need to be co-signed.
3 >>The client enters a mental health clinic with a gun and is threatening to kill the nurse who told his wife to leave him. Which action should the nurse implement first? ?
- (A) Instruct a staff member to call the local police department.
- (B) Evacuate the clients and staff to a safe and secure place.
- (C) Encourage the client to talk about his feelings of anger.
- (D) Calmly and firmly ask the man to put the gun down on the floor.
4 >>The charge nurse of the psychiatric unit is making assignments. Which clients should be assigned to the medical-surgical nurse who is working in the psychiatric unit for the day? Select all that apply. ?
- (A) The client diagnosed with depression who has attempted suicide four times and now is refusing to go to therapy.
- (B) The client diagnosed with bipolar disease who has diabetes and requires blood glucose monitoring.
- (C) The female client diagnosed with dissociative identity disorder (DID) who is complaining that she is being falsely imprisoned.
- (D) The client diagnosed with schizophrenia who is blocking the screen of the television and refuses to move so other clients can watch the television.
5 >>The outpatient clinic psychiatric nurse is preparing to assist the healthcare provider to perform electroconvulsive therapy. Rank in order of performance the nursing interventions to be implemented. ?
- (A) Attach the electrodes to the client.
- (B) Check the client’s name and date of birth against the chart/orders.
- (C) Start an intravenous line and run at a keep open rate.
- (D) Determine that the client has not eaten or had any liquids since midnight.
6 >>The charge nurse responds to an emergency situation on the psychiatric unit in which the male client is angry, yelling, and attempting to hit other clients and the staff. Which interventions should the nurse implement? Select all that apply. ?
- (A) Notify the operator to initiate a call for emergency responders to assist.
- (B) Tell the client to sit down and be quiet or he will lose privileges.
- (C) Have the mental health worker escort the other clients to their rooms.
- (D) Make sure that the staff speaks loudly and directly to the client.
7 >>Mr. Allan is triaging and returning phone calls. Which client should Mr. Allan call first? ?
- (A) The client diagnosed with a narcissistic personality disorder who needs to see the psychiatrist today.
- (B) The client with schizophrenia who is hearing voices telling him to hurt his wife.
- (C) The client with major depression who is refusing to get out of bed and go to work.
- (D) The client with bipolar disorder who is manic and has sold the family car for cash.
8 >>Ms. Belinda is working in at the triage desk. Which client should Ms. Belinda intervene with first? ?
- (A) The client who had a baby 2 months ago and thinks she has postpartum depression.
- (B) The client who told the receptionist he wants to kill himself and has a gun in the car.
- (C) The woman who thinks her mother has Alzheimer’s disease because her mother is confused.
- (D) The client who has been washing his hands in the bathroom for almost 20 minutes.
9 >>Mr. Allan is reviewing laboratory data for clients seen in the clinic. Which of the following client data warrants notifying the psychiatric healthcare provider? ?
- (A) The client on lithium (Eskalith) whose serum lithium level is 2.0 mEq/L.
- (B) The client on clozapine (Clozaril) whose white blood cell count is 10,000.
- (C) The client on alprazolam (Xanax) whose potassium level is 3.7 mEq/L.
- (D) The client on divalproex sodium (Depakote) who has a depakote serum level of 60 �g/mL.
10 >>Mr. Allan is working in the mental health clinic and returns a telephone call to a male client who says that “voices are telling me to hurt myself, now.” Which intervention should Mr. Allan implement first? ?
- (A) Call 911 and tell the paramedics the client is a danger to himself and/or others.
- (B) Ask the client if he has taken his medication this morning.
- (C) Notify the healthcare provider of the client’s statement.
- (D) Keep the client on the telephone to discuss the voices he is hearing.
11 >>The client diagnosed with a panic attack disorder in the clinic waiting room becomes anxious, starts to hyperventilate and tremble, and is diaphoretic. After removing the client from the day room which intervention should Ms. Marguerite implement next? ?
- (A) Administer the benzodiazepine alprazolam (Xanax).
- (B) Allow the client to verbalize feelings of anxiety.
- (C) Encourage to the client to take slow, deep breaths.
- (D) Instruct MHW to obtain the client’s pulse oximetry reading.
12 >>Which client would be most appropriate for Mr. Allan to assign to Mr. Benjamin, the LPN, in the psychiatric clinic? ?
- (A) The client diagnosed with dementia who is confused and disoriented.
- (B) The client with schizophrenia who is experiencing extrapyramidal side effects.
- (C) The client diagnosed with bipolar disorder who is pacing up and down the hallway.
- (D) The client with anorexia nervosa who is hypotensive and complaining of dizziness.
13 >>Which task is inappropriate for Mr. Allan to delegate to the MHW? ?
- (A) Instruct the MHW to observe the client who is exhibiting compulsive behavior.
- (B) Ask the MHW to stay in the waiting room and watch the clients.
- (C) Tell the MHW to sit with the client who reports being suicidal.
- (D) Request the MHW to draw blood for a serum lithium level.
14 >>The client diagnosed with paranoid schizophrenia is yelling, talking to himself, and blocking the view of the television. The other clients in the waiting room are becoming angry. Which action should Mr. Allan implement first? ?
- (A) Place the client in a quiet room.
- (B) Escort the other clients from the day room.
- (C) Request the receptionist to call 911.
- (D) Approach the client calmly along with Mr. Benjamin.
15 >>Mr. Allan observes Ms. Brenda, the MHW, arguing with a client in the waiting room. Mr. Allan requests Ms. Brenda to go to his office immediately. Which action should Mr. Allan implement first? ?
- (A) Ask the client what caused the argument.
- (B) Discuss the behavior with Ms. Brenda.
- (C) Document Ms. Brenda’s behavior in writing.
- (D) Terminate Ms. Brenda immediately.
16 >>Ms. Belinda has been late to work three times in the last week. Mr. Allan talks to Ms. Belinda and finds out Ms. Belinda has to take the bus to work until her car is fixed, which should be completed in 1 week. Which action should Mr. Allan implement? ?
- (A) Ask Ms. Marguerite to give Ms. Brenda a ride to work until the car is fixed.
- (B) Document the behavior in writing and place in Ms. Brenda’s file.
- (C) Tell Ms. Belinda if she is late again she will be placed on administrative leave.
- (D) Do not take any action at this time since Ms. Belinda has an excellent attendance record.
17 >>The new graduate working on a medical unit night shift is concerned that the charge nurse is drinking alcohol on duty. On more than one occasion, the new graduate has smelled alcohol when the charge nurse returns from a break. Which action should the new graduate nurse implement first? ?
- (A) Confront the charge nurse with the suspicions.
- (B) Talk with the night supervisor about the concerns.
- (C) Ignore the situation unless the nurse cannot do her job.
- (D) Ask to speak to the nurse educator about the problem.
18 >>The nurse on the psychiatric unit observes one client shove another client. Which intervention should the nurse implement first? ?
- (A) Discuss the aggressive behavior with the client.
- (B) Document the occurrence in the client’s chart.
- (C) Approach the client with another staff member.
- (D) Instruct the client to go to the unit’s quiet room.
19 >>The graduate nurse is working with an unlicensed assistive personnel (UAP) who has been an employee of the hospital for 12 years. However, tasks delegated to the UAP by the graduate nurse are frequently not completed. Which action should the graduate nurse take first? ?
- (A) Tell the charge nurse the UAP will not do tasks as delegated by the nurse.
- (B) Write up a counseling record with objective data and give it to the manager.
- (C) Complete the delegated tasks and do nothing about the insubordination.
- (D) Address the UAP to discuss why the tasks are not being done as requested.
20 >>The primary nurse informs the shift manager one of the unlicensed assistive personnel (UAPs) is falsifying vital signs. Which action should the shift manager implement first? ?
- (A) Notify the unit manager of the potential situation of falsifying vital signs.
- (B) Take the assigned client’s vital signs and compare with the UAP’s results.
- (C) Talk to the UAP about the primary nurse’s allegation.
- (D) Complete a counseling record and place in the UAP’s file.