The client reports becoming involved with legislation that promotes gun safety after the death of the child by accidental shooting. Which defense mechanism is the client exhibiting?

The client is admitted to the psychiatric unit with a diagnosis of paranoid schizophrenia. Two days after admission, the client’s mother tells the nurse, “He’s still talking about how the government is controlling his thoughts.” What is the most accurate nursing assessment of the mother’s statement?

The nurse is reviewing the discharge plan with the father of the adolescent recently diagnosed with paranoid schizophrenia. Which statement made by the father indicates understanding of the client’s diagnosis?

The nurse is providing care for the client diagnosed with paranoid hallucination. The nurse determines that the client is experiencing a stage IV reaction to hallucinations. Which client behavior supports this assessment?

The mental health assistant is assigned to work with the client who has delusions. Which action requires the most immediate attention by the nurse?

The nurse is discussing discharge plans with a homeless client diagnosed with paranoid schizophrenia. What is the primary factor that will affect developing the discharge plan for this client?

The client diagnosed with schizophrenia is refusing to take a prescribed psychotropic medication. The nurse attempts to persuade the client to comply with the HCP’s orders. Under which circumstance could the client be forced to take medication?

The nurse is assessing the client who reports symptoms descriptive of hypoactive sexual desire disorder. Which biological factor identified in the client’s history may predispose the cheat to hypoactive sexual desire disorder?

The nurse is assessing the client who claims to have sexual fantasies that recur on a daily basis. The nurse should consider paraphilia when the client describes which sexual fantasy?

The client diagnosed with paraphilia has been advised to participate in psychoanalytical therapy and asks the nurse about the therapy. Which statement by the nurse is correct?

The nurse observes the client, who has a history of aggressive behavior toward others, swearing and kicking the furniture in the dayroom. Based on the client’s behavior, what should be the nurse’s priority?

During the orientation of new staff to the mental health unit, the nurse states, “I’m not sure how I’ll react when faced with a violent client.” Which response by the nurse manager would enhance the nurse’s self-awareness?

The nurse is caring for multiple clients with unpredictable and often dangerous behaviors on a mental health unit. Which is the nurse’s best method for managing the safety of multiple clients?

The nurse is caring for four clients in the ED. Which cheat has the greatest potential for demonstrating violent behavior toward the staff?

The client diagnosed with dissociative amnesia is increasingly frustrated and begins to threaten to commit suicide. Which technique should the nurse use to establish a rapid working relationship with the client?

The nurse is assessing the client diagnosed with pseudocyesis. Which statement from the client is consistent with pseudocyesis?

The nurse includes milieu therapy in the treatment plan for the client with antisocial personality disorder. What is the nurse’s best rationale for including milieu therapy?

The client with a BPD is prescribed phenelzine for decreasing impulsivity and self destructive acts. The nurse teaches the client to avoid foods high in tyramine when taking phenelzine to prevent What effect?

The HCP writes in the client’s progress notes, “Will switch medications from the older medications to a newer GABA-ergic anticonvulsant to treat client’s instability of mood, transient mood crashes, and inappropriate and intense outbursts of anger.” Which medication should the nurse consider when reviewing the HCP’s new prescriptions?

The nurse is caring for the client prescribed the traditional antipsychotic drug haloperidol for the treatment of schizophrenia. Which medication should the nurse expect to administer if extra pyramidal side effects develop?

The nurse includes the nursing problem of Disturbed thought processes secondaly to paranoia in the care plan for the newly admitted client with schizophrenia Which nursing intervention is most appropriate for this client?

The nurse is discussing the importance of taking medication as prescribed with the client diagnosed with paranoid schizophrenia. Which response demonstrates that the nurse understands the importance of relapse prevention?

The nurse is evaluating the client with paranoid schizophrenia who reports hearing a voice say, “Do not remove your hat because they will be able to read your mind.” Which response by the nurse is therapeutic?

The client states to the nurse, “I can’t sleep. I’m getting just a few hours of sleep at night. I started a new job, and I can’t do my best without getting enough sleep.” The client’s history includes a recent breakup with a long-term companion. Which should be the nurse’s initial statement?

The mother of the teenager diagnosed with anorexia nervosa confides in the nurse that she has always been very protective and is concerned her over protectiveness is the reason her child developed the eating disorder. Which statement is the most therapeutic response by the nurse?

The father of the teenager diagnosed with an eating disorder states to the nurse, “My wife was always too protective; that’s the reason our child has this problem now.” The nurse should realize that the father’s statement is indicative of what?

During a home visit to the client with Alzheimer’s disease, the nurse attempts to determine whether the client’s daughter understands her father’s prognosis. Which question by the daughter best indicates an understanding of the prognosis of Alzheimer’s disease?

The cognitively impaired nursing home resident is beginning to show physical signs of agitation Which activity would be most therapeutic to de-escalate the client’s agitation?

The nurse has been discussing the medication therapy prescribed for the client newly diagnosed with Alzhcimer’s disease. Which statement by the client’s wife best demonstrates an understanding of the treatment goals of anticholincstcrasc medications?

The nurse is caring for the client who states, “Lately I’m getting forgetful about things. I’m so afraid I’m getting Alzheimer’s disease.” Which response by the nurse is most therapeutic?

The nurse is assessing the client recently admitted into a psychiatric unit for observation. Which client behavior is indicative of impaired cognition?

The client with delirium is restrained to prevent the removal of a urinary catheter and an IV line. Which response should the nurse expect after the client is restrained?

The nurse is planning a counseling session with the client who has antisocial personality disorder. The nurse should anticipate that the client would use which primary ego defense mechanism?

During a home visit to the client with Alzheimer’s disease, the nurse assesses the stress level of the client’s spouse, the primary caregiver. Which question is most appropriate for assessing the spouse’s stress level?

The nurse in an inpatient mental health unit is aware of the importance of managing sexual behavior among clients. Which statement is accurate regarding the standard protocol of managing sexual behavior on adult psychiatric inpatient units?

The client has a history of hallucinations and is at risk to harm self or others. In preparing the client for discharge, the nurse provides instructions regarding interventions directed toward managing hallucinations and anxiety. Which statement indicates that the client has an appropriate understanding of the instructions?

The client experiencing paranoid delusions tells the nurse that “the foreigner who lives next to me wants to kill me.” Which nursing response is most therapeutic to assist the client experiencing paranoid delusions?

The nurse is caring for the client experiencing paranoid delusions. While the nurse is attempting to explain the need for obtaining laboratory blood work, the client shouts, “You all just want to drain my blood. Get away from me!” Which nursing response is most therapeutic?

The nurse is evaluating the client who threatens suicide. Which nursing intervention is most effective in establishing a safe environment for the client?

The client with paranoid schizophrenia is being discharged. The family member asks, “What should I do if the voices come back again?” Which nurse response is most appropriate?

The nurse observes that the client with a history of violent command hallucinations mumbles erratically while making threatening gestures directed toward a particular staff member. Which nursing intervention is most appropriate?

The client experiencing paranoid delusions asks the nurse to turn off the television, stating, “It controls my thoughts.” Which nursing intervention is most appropriate?

The nurse is evaluating the client experiencing paranoid delusions. The client states, “Two men wearing gray shirts keep coming into the dayroom and watching me.” Which response by the nurse is most therapeutic?

The nurse engages the older adult client by describing the weather as “raining cats and dogs.” The client looks bewildered and shows concern for the “animals." Which response by the nurse is most therapeutic?

The client on a psychiatric unit is very demanding and belittling of one of the nurses. The client is talking with others and telling them how mean the nurse is to clients. Which nursing problem should the nurse include in the client’s written plan of care?

The client with a dissociative identity disorder (DID) has amnesia. Which intervention should the nurse initially implement?

The nurse is working with the individual with OCPD. Which approach should the nurse use?

The client is being discharged after hospitalization for a suicide attempt. Which question asked by the nurse assesses the learned prevention and future coping strategies of the client?

The nurse is caring for the client with a major depressive disorder. Which nursing problem should be priority?

The nurse is interviewing the client at a mental health clinic who recently attempted suicide and continues to report active suicidal ideation. Which care setting is most appropriate for this client?

The nurse is reviewing diet restrictions with the client taking an MAOI. The nurse should inform the client of which symptom that can occur when the client is non adherent to diet restrictions?

The client who was recently divorced and has a court appearance the following week for DUI is seeing the nurse for possible depression. Which statement by the nurse is most therapeutic?

The client diagnosed with mania tells the nurse, “I think you’re nice looking. Maybe we could go to my room.” Which response by the nurse is most therapeutic?

The nurse is planning care for the recently admitted client who is exhibiting agitation associated with acute mania. Which intervention should the nurse plan to implement?

The client recently admitted to a psychiatric unit is experiencing acute mania. Which intervention should the nurse include when developing the client’s plan of care?

The client tells the nurse about an intense fear of dogs that causes the client to avoid visiting others unless it is continued that there are no dogs on the premises. The client further explains that these fears seem unreasonable, but the fear continues in spite of this acknowledgment. Which conclusion by the nurse is accurate?

The nurse manager on a psychiatric unit is planning an in-service that focuses on staff management of potential suicidal ideation among clients. Which activity has the greatest likelihood for improving staff effectiveness?

The client with an anxiety disorder tells the nurse that being in crowds creates thoughts of losing control and the need to hurriedly leave. What should the nurse recommend as an effective , nonpharmacological therapy for managing the client’s symptoms of anxiety?

The client has been seeking treatment for insomnia secondary to situational depression. Which statement made by the client requires follow-up by the nurse?

The recently discharged veteran who served in active combat reports symptoms of recurring intrusive thoughts, insomnia, and hyper vigilance. Which question would be most helpful in establishing a diagnosis?

The nurse is caring for a victim of sexual assault brought to the ED by a roommate. How should the nurse respond when the client begins to angrily insist upon reporting the details of the assault?

The NA comments to the nurse about the recently admitted client with bipolar disorder. “I think the new admit is faking being ill. Yesterday the client didn’t say a word, and today it’s nonstop talking.” Which response by the nurse is most helpful?

The nurse is caring for the client with paranoid personality disorder. Which approach should the nurse use when working with the client?

The client presents to the ED reporting that he was sexually assaulted by several men he met at a local bar. Which action should the nurse plan to include when preparing to assess the client?

The nurse is working with the client with paranoid personality disorder. The nurse understands that the client likely experienced what in the past?

The nurse is assessing the client with paranoid personality disorder. Which behavior should the nurse expect?

The client with no psychiatric history is admitted to an ED after physically assaulting his wife. The client is frightened by his loss of control, which he states was precipitated by his wife’s complaining and lack of support. The client tells the nurse he is self-employed, recently expanded his company nationally, and has many well-known friends. The client’s wife states, “The business is losing money, yet he continues his lavish lifestyle; what’s important to him is who he knows and how it looks!” The nurse determines that the client’s behavior is typical of which disorder?

The nurse is developing the plan of care for the client with schizoid personality disorder. Which primary outcome should the nurse include?

The client with BPD states to the nurse, “Hey, you know what! You are my favorite nurse.That night nurse sure doesn’t understand me the way you do.” Which response by the nurse is most therapeutic?

The client is being treated after surviving a major hurricane that took the lives of many neighbors. Which statement by the client provides the nurse with the [best evidence that therapy has been successful?

The client’s home was destroyed by a major flood. The client is attending a support group and says, “I will rebuild my home as good as new and be back in it in a few months.” What should be the nurse’s initial response?

The child who was physically abused has begun pulling out hair. The behavior appears to be a result of the child’s repressed anger. In order to facilitate the child’s recovery, the nurse encourages the parent to initially implement which response?

The nurse in the ED is assessing the client who was injured in a car accident. The nurse considers that the client may have psychogenic amnesia when the client is unable to recall any personal information. Which statement that reflects the nurse’s critical thinking about psychogenic amnesia is correct?

The nurse reads in the medical record that the client with BPD has “splitting.” What is the nurse’s interpretation of “splitting”?

The nurse is evaluating the attainment of outcomes for the adolescent client diagnosed with bulimia nervosa. Which behavior indicates that the client is meeting an expected outcome for the disorder?

The nurse is completing a health history for the client with narcolepsy. Which finding should the nurse anticipate when completing the assessment?

During the client education class, the nurse is asked, “What is an effective treatment for seasonal affective disorder?” Which intervention should the nurse recommend as an evidenced-based practice for the first-line treatment of seasonal affective disorder?

The client is displaying behaviors consistent with stage 2 Alzheimer’s disease. The client can no longer recognize family members and requires assistance with personal hygiene and dressing. The client is frequently incontinent of both urine and feces and displays violent outbursts during these times. Which nursing problem should be the nurse’s priority?

The experienced nurse is orienting a new nurse on a mental health unit. Which intervention should the nurse suggest when attempting to establish a therapeutic relationship with the newly admitted client diagnosed with major depressive disorder?

The client recently diagnosed with depression tells the nurse that she is 2 months pregnant and is reluctant to take an antidepressant. Which type of therapy should the nurse discuss when the client asks about an alternate treatment for depression?

The nurse is assessing the client with dysthymia who reports symptoms of depressed mood. Which assessment finding should the nurse most associate with the essential feature of dysthymia?

The nurse is assessing the client with a history of paranoid schizophrenia and chronic alcohol abuse. The client has been taking olanzapinc for 2 weeks and has not consumed alcohol in the last 5 days. The client reports shaky hands and nightmares causing trouble sleeping, and has a concern that olanzapinc is the cause of the problems. Which is the nurse’s most therapeutic response?

The nurse is overheard responding to the client who reports sleeping only 3 hours at night. Which statement by the nurse is inappropriate?

The client of Latino/Hispanic ethnicity reports poor appetite, lack of energy, and feeling hopeless nearly every day for the past 3 weeks. The admitting nurse notices that the client does not make eye contact upon questioning. What is the most likely explanation for the client’s behavior?

The client on the mental health unit is diagnosed with major depressive disorder and was started on an antidepressant two days ago. The nurse observes that two days ago the client appeared sad and remained in bed. Now the client is awake at 4 am. and planning a unit party. Which conclusion should the nurse make regarding the client’s change in behavior?

The young adult after being robbed is attending counseling sessions to address anxiety issues. What is the nurse’s best response when the client asks, “When will things get better for me?”

The nurse is assessing the client. Which statement made by the client best indicates the possibility of a sleep disorder?

The client reports becoming physically ill with frequent crying episodes, intense feelings of worthlessness, and loss of appetite on the anniversary of the death of the client’s spouse. The client reports that this has occurred for the last 5 years- What should be the nurse’s focus when counseling the client?

The client admitted to a behavioral medicine unit with a diagnosis of catatonic schizophrenia is constantly rearranging furniture and appears to be responding to internal stimuli. In addition to being flee of physical injury during phases of hyperactivity, which short-term goal is appropriate for this client?

The nurse completes teaching with the client diagnosed with schizophreniform disorder. Which statement made by the client demonstrates an understanding of the disorder?

The 10—year-old who was sexually abused by a family member experiences flashbacks of a disagreement with that adult and the resulting sexual assault. Which suggestion should the nurse make to the parents in order to help minimize this reaction?

The nurse reads in the 12-year-old client’s medical record, “Fractured left leg from a fall during an episode of somnambulism.” Which nursing intervention is most important to add to the client’s plan of care?

The client is being treated for insomnia. The nurse thinks that the client is also experiencing a common comorbid condition. Which client behavior prompted the nurse’s conclusion?

The nurse is planning care for the client diagnosed with acute mania. What situation must occur prior to initiating treatment with lithium carbonate?

The NA is assigned to provide care for a severely disoriented older adult client who has been restrained for client safety after least-restrictive methods have been tried. Which statement made by the NA indicates the most immediate need for education regarding safe client care?

The nurse assesses that the client with acute mania has coarse hand tremors, and the serum lithium level is 1.8 m Eq/L. What should the nurse do?

The nurse assesses that the client with an eating disorder is taking 20 laxative products daily, diuretics twice daily, and is self-inducing vomiting. What should the nurse do next?

The nurse is assessing the client with a history of aggressive behavior toward others. Which client behavior requires immediate nursing intervention?

The client with BPD often attempts to manipulate staff to promote self needs. Which behavior indicates that the client is able to overcome this manipulative behavior?

The client is newly prescribed tramadol hydrochloride for chronic pain. The client is also taking fluoxetine 40 mg daily for depression. Which nursing action is most important?

The nurse assesses the client who reports feeling full of energy in spite of having been awake for the past 48 hours. Which diagnosis is the nurse likely to find documented in the client’s medical record?

The client diagnosed with schizoaffective disorder was recently treated for a major depressive episode. Following a 72-hour involuntary commitment, the client is stable, no longer displaying suicidal ideation, and asking to leave the hospital. Which client right should the nurse consider while deciding if the client can be discharged?

The nurse is educating the client about prescription antidepressant medications and the appropriate expectations when taking these medications. Which statement by the nurse is accurate?

During an initial home visit with the client, the nurse discovers cluttered possessions taking up 75% of the living space and obstructing access into the home and all rooms except the bathroom. What should be the nurse’s interpretation of the client’s behavior?

The nurse is assessing the client’s alcohol intake as part of a routine screening examination. The client reports drinking three to four beers five times per week. The client is being treated for depression with sertraline 100 mg daily. Which conclusion by the nurse is accurate?

The client recently prescribed haloperidol is experiencing severe muscle pain. Assessment findings include a heart rate of 104 bpm, BP of 172/92 mm Hg, and an oral temperature of 101.2°F (384°C). What should the nurse do next?

The client who is taking amitriptyline 150 mg daily is scheduled for elective surgery. Which statement reflects accurate understanding of safety concerns in this situation?

The nurse is assessing the older adult postoperative client who is displaying signs of delirium. The nurse observes that the client is convinced that it is 1954 and is complaining about “the bugs in this hotel.” Which should be the nurse’s priority intervention?