1 >>The nurse in the outpatient psychiatric unit is returning phone calls. Which client should the psychiatric nurse call first? ?
- (A) The female client diagnosed with histrionic personality disorder who needs to talk to the nurse about something very important.
- (B) The male client diagnosed with schizophrenia who is hearing voices telling him to hurt his mother.
- (C) The male client diagnosed with major depression whose wife called and said he was talking about killing himself.
- (D) The client diagnosed with bipolar disorder who is manic and has not slept for the last 2 days.
2 >>The nurse is caring for children in a psychiatric unit. Which client requires immediate intervention by the psychiatric nurse? ?
- (A) The 10-year-old child diagnosed with oppositional defiant disorder who refuses to follow the directions of the mental health worker (MHW).
- (B) The 5-year-old child diagnosed with pervasive developmental disorder who refuses to talk to the nurse and will not make eye contact.
- (C) The 7-year-old child diagnosed with conduct disorder who is throwing furniture against the wall in the day room.
- (D) The 8-year-old mentally retarded child who is sitting on the playground and eating dirt and sand.
3 >>The male client diagnosed with major depression is returning to the psychiatric unit from a weekend pass with his family. Which intervention should the nurse implement first? ?
- (A) Ask the wife for her opinion of how the visit went.
- (B) Determine whether the client took his medication.
- (C) Ask the client for his opinion of how the visit went.
- (D) Check the client for sharps or dangerous objects.
4 >>The client on the psychiatric unit is yelling at other clients, throwing furniture, and threatening the staff members. The charge nurse determines the client is at imminent risk for harming the staff/clients and instructs the staff to place the client in seclusion. Which intervention should the charge nurse implement first? ?
- (A) Document the client’s behavior in the nurse’s notes.
- (B) Instruct the MHWs to clean up the day room area.
- (C) Obtain a restraint/seclusion order from the HCP.
- (D) Ensure that none of the other clients were injured.
5 >>A woman comes to the emergency department (ED) and tells the triage nurse she was raped by two men. The woman is crying and disheveled, and has bruises on her face. Which action should the triage nurse implement first? ?
- (A) Ask the client whether she wants the police department notified.
- (B) Notify a Sexual Assault Nurse Examiner (SANE) to see the client.
- (C) Request an ED nurse to take the client to a room and assess for injuries.
- (D) Assist the client to complete the emergency department admission form.
6 >>The nurse is working in an outpatient mental health clinic and returning phone calls. Which client should the psychiatric nurse call first? ?
- (A) The client diagnosed with agoraphobia who is calling to cancel the clinic appointment.
- (B) The client diagnosed with a somatoform disorder who has numbness in both legs.
- (C) The client diagnosed with hypochondriasis who is afraid she may have breast cancer.
- (D) The client diagnosed with post-traumatic stress disorder (PTSD) who is threatening his wife.
7 >>The psychiatric nurse is working in an outpatient mental health clinic. Which client should the nurse intervene with first? ?
- (A) The client who had a baby 2 months ago and who is sitting alone and looks dejected.
- (B) The client whose wife just died and who wants to go to heaven to be with her.
- (C) The client whose mother brought her to the clinic because the mother thinks the client is anorexic.
- (D) The client who is rocking compulsively back and forth in a chair by the window.
8 >>The emergency department nurse is assessing a female client who has a laceration on the forehead and a black eye. The nurse asks the man who is with the client to please leave the room. The man refuses to leave the room. Which action should the nurse take first? ?
- (A) Tell the man the client needs to go to the x-ray department.
- (B) Notify hospital security and have the man removed from the room.
- (C) Explain that the man must leave the room while the nurse checks the client.
- (D) Give the client a brochure with information about a woman’s shelter.
9 >>The charge nurse received laboratory data for clients in the psychiatric unit. Which client data warrants notifying the psychiatric healthcare provider? ?
- (A) The client on lithium (Eskalith) whose serum lithium level is 1.0 mEq/L.
- (B) The client on clozapine (Clozaril) whose white blood cell count is 13,000.
- (C) The client on alprazolam (Xanax) whose potassium level is 3.7 mEq/L.
- (D) The client on quetiapine (Seroquel) whose glucose level is 128 mg/dL.
10 >>The client diagnosed with a somatization disorder is complaining of vomiting, having diarrhea, and having a fever. Which intervention should the nurse implement first? ?
- (A) Assess the client’s anxiety level on a scale of 1 to 10.
- (B) Check the client’s vital signs.
- (C) Discuss problem-solving techniques.
- (D) Notify the client’s healthcare provider.
11 >>Which nursing intervention is priority for the client diagnosed with anorexia who is admitted to an inpatient psychiatric unit? ?
- (A) Obtain the client’s weight.
- (B) Assess the client’s laboratory values.
- (C) Discuss family issues and health concerns.
- (D) Teach the client about selective serotonin reuptake inhibitors.
12 >>Which client should the psychiatric clinic nurse assess first? ?
- (A) The client with long-term alcoholism who wants to stop drinking.
- (B) The client who is a cocaine abuser who is having chest discomfort.
- (C) The client with obsessive-compulsive disorder who won’t quit washing his hands.
- (D) The client who thinks she was given “the date rape drug” and was raped last night.
13 >>The client diagnosed with schizophrenia is being seen by the psychiatric clinic nurse for the initial visit. Which intervention should the nurse implement first? ?
- (A) Develop a trusting nurse/client relationship.
- (B) Determine the client’s knowledge of medication.
- (C) Assess the client’s support systems.
- (D) Allow the client to vent their feelings.
14 >>The client diagnosed with hypochondriasis is angry and yells at the psychiatric clinic nurse, “No one believes I am sick! Not my family, not my doctor, and not you.” Which statement is the nurse’s best response? ?
- (A) “Have you discussed your feelings with your family?”
- (B) “I am sure your doctor believes you are sick.”
- (C) “I can see you are upset. Sit down and let’s talk.”
- (D) “We cannot find any physiological reason for your illness.”
15 >>The clinical manager assigned the psychiatric nurse a client diagnosed with major depression who attempted suicide and is being discharged tomorrow. Which discharge instruction by the psychiatric nurse would warrant intervention by the clinical manager? ?
- (A) The nurse provides the client with phone numbers to call if needing assistance.
- (B) The nurse makes the client a follow-up appointment in the psychiatric clinic.
- (C) The nurse gives the client a prescription for a 1-month supply of antidepressants.
- (D) The nurse tells the client not to take any over-the-counter medications.
16 >>The charge nurse is caring for clients in an acute care psychiatric unit. Which client would be most appropriate for the charge nurse to assign to the licensed practical nurse (LPN)? ?
- (A) The client diagnosed with dementia who is confused and disoriented.
- (B) The client diagnosed with schizophrenia who is experiencing tardive dyskinesia.
- (C) The client diagnosed with bipolar disorder who has a lithium level of 2.0 mEq/L.
- (D) The client diagnosed with chronic alcoholism who is experiencing delirium tremens.
17 >>Which task would be inappropriate for the psychiatric charge nurse to delegate to the mental health worker (MHW)? ?
- (A) Instruct the MHW to escort the client to the multidisciplinary team meeting.
- (B) Ask the MHW to stay in the day room and watch the clients.
- (C) Tell the MHW to take care of the client on a 1-to-1 suicide watch.
- (D) Request the MHW to draw blood for a serum carbamazepine (Tegretol) level.
18 >>The male client in the psychiatric unit asks the MHW to mail a letter to his family for him. Which action would warrant intervention by the psychiatric nurse? ?
- (A) The MHW tells the client to place the letter in the mailbox.
- (B) The MHW informs the client he cannot send mail to his family.
- (C) The MHW takes the letter and places it in the unit mailbox.
- (D) The MHW reports the client mailed a letter at the team meeting.
19 >>The male client admitted to the medical unit after a motor vehicle accident (MVA) admits using heroin. The unlicensed assistive personnel (UAP) tells the nurse the client is really agitated and anxious, and has slurred speech. Which intervention should the nurse implement first? ?
- (A) Assess the client for heroin withdrawal.
- (B) Ask the UAP to take the client’s vital signs.
- (C) Notify the client’s healthcare provider.
- (D) Administer chlordiazepoxide (Librium), an antianxiety medication.
20 >>Which task would be most appropriate for the psychiatric nurse to delegate to the mental health worker (MHW)? ?
- (A) Request the MHW to take the client with lithium toxicity to the emergency room.
- (B) Have the MHW sit with a client diagnosed with bulimia for 1 hour after the meal.
- (C) Encourage the MHW to teach the client how to express his or her anger in a positive way.
- (D) Ask the MHW to sit with the client while the client talks to his mother on the telephone.