Caring for Mental Health Clients: Best Practices and Challenges, Exams of Health psychology

Download Caring for Mental Health Clients: Best Practices and Challenges and more Exams Health psychology in PDF only on Docsity! Saunders Mental Health Questions with 100% Correct Answers 2024 Update. 1073. A client in a long-term care facility who had multiple sclerosis is embarrassed about the need to use a wheelchair and the muscle spasms that are readily visible in her legs. Which approach is therapeutic in assisting the client to cope? 1. Keep the client in her room as much as possible . 2. Assist the client with all activities of daily living (ADLs). 3. Tell the client that many of the people in the facility have these same sorts of problems. 4. Encourage and praise perseverance in performing ADLs, and assist the client to dress and groom daily. - Correct Answers 4. Encourage and praise perseverance in performing ADLs, and assist the client to dress and groom daily 1074. The nurse uses which approach when caring for a client with a diagnosis of acute undifferentiated schizophrenia? 1. Repeatedly points out inconsistencies in the client's communication . 2. Allows the client to set his or her own treatment goals for the plan of care. 3. Lets the client act out initially and uses the quiet room and restraints as needed. 4. Provides assistance with grooming and nutrition until the client's thinking is cleared. - Correct Answers 4. Provides assistance with grooming and nutrition until the client's thinking is cleared 1075. A client is admitted to the mental health unit after a suicide attempt by hanging. The nurse's most important aspect of care is to maintain client safety. The is best accomplished by which action? 1. Requesting that a peer remain with the client at all times. 2. Removing the client's clothing and placing the client in a hospital gown. 3. Assigning a staff member to the client who will remain with the client at all times. 4. Admitting the client to a seclusion room where all potentially dangerous articles are removed. - Correct Answers 3. Assigning a staff member to the client who will remain with the client at all times 1076. The nurse providing end-of-life care to a Muslim client understands that which practice is accurate regarding end-of-life care? 1. The client's head should be positioned below the body. 2. Discussions about death are usually welcomed and open. 3. A same-gendered Muslim should handle the body if possible. 4. Stopping medical treatment is allowed if permitted by the family. - Correct Answers 3. A same-gendered Muslim should handle the body if possible. 1077. On admission assessment, the nurse is obtaining subjective data about a client's sexual and reproductive status. The client states, "I don't want to discuss this; it's private and personal." Which response by the nurse is most therapeutic? 1. "I'd hate being asked these sorts of questions too, but it's a necessary part of providing you with the best care." 2. "This is difficult for you to speak about, but I need this information from you in order to perform a complete assessment." 3. "I am a professional registered nurse, and , as such, I'll have you know that all your information is certainly kept confidential." 4. " I know that some of these questions are difficult for you, but, as a professional nurse, I am obligated to respect your confidentiality." - Correct Answers 4. " I know that some of these questions are difficult for you, but, as a professional nurse, I am obligated to respect your confidentiality." 1078. The nurse should include which information in the nursing plan of care for a client with obsessive-compulsive disorder (OCD)? Select all that apply. 1. The medical diagnosis of the client. 2. Individualized goals and objectives. 3. Attendance at group therapy sessions. 4. Self-care measures to improve hygiene. 5. Interruption of all compulsive behaviors. - Correct Answers 2. Individualized goals and objectives. 3. Attendance at group therapy sessions. 4. Self-care measures to improve hygiene. 1086. The nurse is preparing to care for a client who witnessed her mother being shot by an unknown attacker. The nurse interprets that the client is demonstrating behavior that indicates denial if which finding is noted? 1. The client is calm, cooperative, and reserved. 2. The client is justifying unacceptable self behaviors. 3. The client is verbalizing generalizations about the incident. 4. The client is blaming her brother for the incident for not being with them to protect them. - Correct Answers 1. The client is calm, cooperative, and reserved. 1087. A client with an eating disorder is planning to attend group meetings with overeaters anonymous. The nurse describes this group to the client, knowing that which finding(s) are characteristic of this form of self-help group? Select all that apply. 1. A common goal is shared by all members. 2. Members are required to remain anonymous. 3. The leader is a professional mental health care provider. 4. Attendance must be prescribed by the health care provider. 5. The program is designed to provide support to bring about personal change. 6. The group is composed of individuals who are experiencing similar problems. - Correct Answers 1. A common goal is shared by all members. 5. The program is designed to provide support to bring about personal change. 6. The group is composed of individuals who are experiencing similar problems. 1088. A client who has been diagnosed with depression is preparing for discharge. The nurse determines that the client has an understanding of the disorder if the client makes which statement? 1. "I don't need anyone; I have myself to rely on!" 2. "I'll never let my boss, my job, or my family get to me like this ever again!" 3. "I've always been able to make decisions for myself. I'll do anything not to ever feel this horrible way ever again!" 4. "It's important for me to eat well, exercise, and to take my medication. If I begin to feel bad again, I'll see my doctor." - Correct Answers 4. "It's important for me to eat well, exercise, and to take my medication. If I begin to feel bad again, I'll see my doctor." 1089. The nurse is working with an anxious client who has sought counseling after an unsuccessful attempt to rescue a neighbor who was trapped in a house fire. Which goal should be addressed during the working phase of the nurse-client relationship? 1. Confirming the client's ability to function normally. 2. Exploring the client's potential for self-harm behaviors. 3. Inquiring about the client's perception or appraisal of the neighbor's death. 3. Inquiring about the client's perception or appraisal of the neighbor's death. 4. Identifying any feelings about the client's actions that may affect his normal adaptive coping. - Correct Answers 4. Identifying any feelings about the client's actions that may affect his normal adaptive coping. 1090. A client approaches the nurse' station, becomes very loud and offensive, and demands to be seen by the health care provider immediately. Which nursing intervention is appropriate for this situation? 1. Inform the client that the behavior is unacceptable. 2. Offer to assist the client to an examination room until the health care provider is notified. 3. Tell the client to go to her room and stay there because being demanding is not tolerated. 4. Tell the client that the health care provider will be called as soon as the other client's needs are met. - Correct Answers 2. Offer to assist the client to an examination room until the health care provider is notified. 1091. A client with schizophrenia is experiencing distressful thoughts secondary to paranoia. Which intervention(s) should the nurse include in the plan of care? Select all that apply. 1. Avoid laughing when near the client. 2. Whisper when communicating near the client. 3. Increase socialization of the client among his peers. 4. Have the client sign a written release of information form. 5. Provide food items that are in containers that need to be opened. 6. Begin to educate the client about social supports in the community. - Correct Answers 1. Avoid laughing when near the client. 5. Provide food items that are in containers that need to be opened. 1092. An emergency department nurse is caring for an adult client who is a victim of family violence. Which priority instruction should be included in the discharge instructions? 1. Information about shelters. 2. Instructions about fighting back. 3. Instructions about calling the police. 4. Instructions about self-defense classes. - Correct Answers 1. Information about shelters. 1093. A client is preparing to attend a Gamblers Anonymous meeting for the first time. The prototype used by this group is the 12-step program developed by Alcoholics Anonymous. Number is order of priority how the steps would be addressed. (Number 1 is the first step, and number 5 is the last step) -Admitting to oneself and to another human being the exact nature of one's wrongs. -Acknowledging that one is entirely ready to have his or her defects of character removed. -Admitting that oneself is powerless over gambling and that one's life had become unmanageable. -Making an effort to practice the 12-step principles in all affairs, and to carry this message to other compulsive gamblers. -Making direct amends wherever possible to all people that have been hurt, except when to do so would further harm them or others. - Correct Answers -Acknowledging that one is entirely ready to have his or her defects of character removed. -Admitting that oneself is powerless over gambling and that one's life had become unmanageable. -Admitting to oneself and to another human being the exact nature of one's wrongs. -Making direct amends wherever possible to all people that have been hurt, except when to do so would further harm them or others. -Making an effort to practice the 12-step principles in all affairs, and to carry this message to other compulsive gamblers. 1094. The nurse is caring for a Jewish client who was in a serious car accident and is currently on life support. With regard to the client's religious beliefs, the nurse understands which information? 1. The client most likely will not undergo any further life-saving measures. 4. Inform the client to stop monopolizing the group or be prepared to leave the group. 5. Refer the client to another group that already has an established informal group leader. - Correct Answers 1. Inform the client that this is not appropriate behavior. 2. Suggest that the client stop talking and try listening to the others in the group. 1101. The nurse educator is conducting a teaching session regarding bullying. The nurse educator informs the students that power arises for the bully from which source(s)? Select all that apply. 1. Physical strength and maturity. 2. Exposing one's own weaknesses. 3. Higher status within a peer group. 4. Knowing another child's weakness. 5. Recruiting other children as support. - Correct Answers 1. Physical strength and maturity. 3. Higher status within a peer group. 4. Knowing another child's weakness. 5. Recruiting other children as support. 1102. A client is admitted to the mental health unit with a diagnosis of depression, and the nurse is developing a plan of care for the client. Which activity is the most appropriate and safest activity to be included in the plan of care? 1. Nothing until the client asks to participate in the milieu. 2. A menu of daily activities, with the nurse insisting that the client participate in all of them. 3. A structured daily program of activities, with the nurse encouraging the client to participate. 4. An activity that is quiet and solitary, to avoid, increased fatigue, such as working on a puzzle or reading a book. - Correct Answers 3. A structured daily program of activities, with the nurse encouraging the client to participate. 1103. A client with a phobia will be treated for the condition using a behavior modification technique known as systematic desensitization. The nurse described the components of this form of therapy to the client and instructs the client that which is descriptive of the program? 1. The client will take medication daily to control the condition. 2. The client will talk to self to control actions more effectively. 3. The client will meet with others with the same problem in a support group. 4. The client will be introduced to short periods of exposure to the phobic object. - Correct Answers 4. The client will be introduced to short periods of exposure to the phobic object. 1104. A client with anxiety is preoccupied with his health. The nurse determines that the client is experiencing which condition(s)? Select all that apply. 1. Agoraphobia. 2. Social phobia. 3. Apprehension. 4. Claustrophobia. 5. Hypochondriasis. - Correct Answers 3. Apprehension. 5. Hypochondriasis. 1105. The nurse care plan indicated that a client is at risk for self-harm. A priority outcome of care is that the client performs which action? 1. Displays less anxiety and agitation. 2. Establishes a relationship with staff and peer. 3. Develops adequate coping and problem-solving skills. 4. Denies suicidal ideation and identifies options to deal with stressors. - Correct Answers 4. Denies suicidal ideation and identifies options to deal with stressors. 1106. A mother is reprimanding her child for writing on the playroom wall with a crayon. Later that afternoon, the child blames her younger sister for making a mess in their playroom. This is an example of which type of behavior? 1. Denial 2. Repression 3. Suppression 4. Displacement - Correct Answers 4. Displacement 1107. The nurse is preparing a plan of care for the client who will be seen in the mental health clinic for the first time. In preparing for the orientation phase of the therapeutic relationship, the nurse plans to address which issue? 1. Facilitating behavioral change. 2. Promoting self-esteem in the client. 3. Discussing termination of the relationship. 4. Promoting problem-solving skills in the client. - Correct Answers 3. Discussing termination of the relationship. 1108. The nurse understands that which area(s) need to be explored in order to conduct a culturally sensitive assessment related to end-of-life care? Select all that apply. 1. Communication about death. 2. The decision-making process. 3. Financial support for client care. 4. The significance of pain and suffering. 5. The nurse's beliefs on death and dying. 6. Amount and type of accepted intervention. - Correct Answers 1. Communication about death. 2. The decision-making process. 4. The significance of pan and suffering. 5. The nurse's beliefs on death and dying. 6. Amount and type of accepted intervention. 1109. The nurse is caring for a chemically dependent client who had the potential to experience violent episodes. The nurse should implement which intervention(s)? Select all that apply. 1. Speaking slowly to the client. 2. Moving slowly when approaching the client. 3. Bargaining with the client to prevent the violent episodes. 4. Projecting an attitude of calmness when caring for the client. 5. Encouraging the client to talk out feelings rather than act on them. - Correct Answers 1. Speaking slowly to the client. 2. Moving slowly when approaching the client. 4. Projecting an attitude of calmness when caring for the client. 5. Encouraging the client to talk out feelings rather than act on them. 1110. A client with a diagnosis of depression has experienced poor nutritional intake for the last 3 weeks. Which nursing intervention(s) are most appropriate to address the client's poor nutritional intake? Select all that apply. 1. Arranging to site with the client during meals. 2. Offering the client several small meals and snacks per day. 3. Weighing the client three times per week before breakfast. 1. The admission was mandated by official court order. 2. The admission was made without the client's consent. 3. The client had the right to demand and obtain release from the hospital. 4. The client has been committed by a group of mental health professionals. - Correct Answers 3. The client had the right to demand and obtain release from the hospital. 1119. Which behavior presented by the client with mania requires the nurse's immediate intervention? 1. Being "too busy to eat" 2. Outlandish, inappropriate dress. 3. Grandiose delusions of being "a royal" 4. Incessant talking that includes sexual innuendo. - Correct Answers 1. Being "too busy to eat" 1120. The nurse interprets that which comment by the woman whose husband uses physical violence against her is consistent with the presence of self-deprecation commonly found with battered wife syndrome? 1. "Things would be fine if I could just do better." 2. "I stay because I can stay home and I don't have to work." 3. "I told him that this is his last chance; if he hits me again, I'm leaving for good." 4. "I feeling fortunate to be married to a man who really loves me the way that he does" - Correct Answers 1. "Things would be fine if I could just do better." 1121. A client who is diagnosed with chronic depression is being considered for electroconvulsive therapy (ECT). The client appears calm, but the family is anxious and states, "My son's brain will be destroyed. How can you be doing this to people?" 1. "It sounds as though you need to speak to your son's psychiatrist." 2. "You should be supportive of your son's decision to have this treatment." 3. "Would it help if I arranged for you to see the ECT room and speak to the staff?" 4. "It appears that you have fears about the procedure. Let's sit down and discuss them." - Correct Answers 4. "It appears that you have fears about the procedure. Let's sit down and discuss them." 1122. The nurse is preparing a discharge plan for a client who attempted suicide. What should be the focus of this client's plan of care? 1. Follow-up appointments. 2. Providing the hospital telephone number. 3. Encouraging the family to always be with the client. 4. Contracts and immediately available crisis resources. - Correct Answers 4. Contracts and immediately available crisis resources. 1123. The nurse completes an assessment of a client who is being admitted to the mental health unit. Which finding requires immediate intervention? 1. The spouse states that she disapproves of the treatment plan. 2. The client states that he wishes he could find a way to harm himself. 3. The presence of new bruises on the client's body and old scars on both wrists. 4. The client states that he can't eat much and hasn't been able to sleep for the past week. - Correct Answers 2. The client states that he wishes he could find a way to harm himself. 1124. The nurse understands that which cultural group(s) emphasize the family as the decision maker as opposed to the individual? Select all that apply. 1. Asian Americans. 2. Native Americans. 3. African Americans. 4. Mexican Americans. 5. European Americans. - Correct Answers 1. Asian Americans. 2. Native Americans. 3. African Americans. 4. Mexican Americans. 1125. The nurse providing end-of-life care to a client who is of Islamic background should contact which family member in order to determine whether the family should be given any information about the client's health condition? 1. The client's sister. 2. The client's mother. 3. The client's male cousin. 4. The client's female cousin. - Correct Answers 3. The client's male cousin. 1126. The nurse is conducting a group therapy session when a client threatens to act out physically and states that he will punch another member of the group. The nurse should take which initial action? 1. Tell the client that he must leave immediately. 2. Call security to come to the session immediately. 3. Tell the client that if he hits another client he will be restrained and placed in seclusion. 4. Tell the client that he can talk about his anger but cannot act on it during the group session. - Correct Answers 4. Tell the client that he can talk about his anger but cannot act on it during the group session. 1127. The nurse understand that which statement describes a person who is mentally healthy? 1. Self-concept is distorted. 2. Life direction is disturbed. 3. Thoughts are not reality-based. 4. Perceptions of strengths are realistic. - Correct Answers 4. Perceptions of strengths are realistic. 1128. Which information should the nurse include in the plan of care for a client with obsessive-compulsive disorder? Select all that apply. 1. Ensure that basic needs are met. 2. Interrupt the client's use of compulsive behaviors. 3. Identify situations that precipitate compulsive behavior. 4. Set limits on behaviors that may interfere with the client's physical well- being. 5. Implement a schedule for the client that distracts from the compulsive behaviors. - Correct Answers 1. Ensure that basic needs are met. 3. Identify situations that precipitate compulsive behavior. 4. Set limits on behaviors that may interfere with the client's physical well- being. 5. Implement a schedule for the client that distracts from the compulsive behaviors. 1129. The nurse if forming a psychotherapy group, and several clients are interested in attending the session. The nurse plans the group, knowing that the maximum number of group members to include is which number? 1. 3 2. 10 3. 12 1138. A client who witnessed a terrorist attack exhibits the inability to talk. The nurse interprets this characteristic as indicative of which condition? 1. Depression 2. Somatization disorder 3. Posttraumatic stress disorder (PTSD) 4. Obsessive-compulsive disorder (OCD) - Correct Answers 2. Somatization disorder 1139. Which culture emphasizes the "right to know" perspective with regard to diagnosis and prognosis so the client can make informed health care decisions? 1. Asian 2. Middle Eastern 3. Native American 4. American/ European - Correct Answers 4. American/ European 1140. The nurse must choose a roommate for a client who is in a state of starvation due to anorexia nervosa. Which client(s) are appropriate choice(s) for this client's roommate? Select all that apply. 1. A client with pneumonia. 2. A client who had back surgery. 3. A client with a fractured pelvis. 4. A client who had a myocardial infarction. 5. A client who is receiving antibiotics and experiencing severe diarrhea. - Correct Answers 2. A client who had back surgery. 3. A client with a fractured pelvis. 4. A client who had a myocardial infarction. 1141. The nurse understands that which statement describes a person who is mentally ill? 1. Life productivity is undisturbed. 2. Meeting one's own needs is not problematic. 3. Ability to find meaning in life is unimpaired. 4. Preoccupation with thoughts and self is present. - Correct Answers 4. Preoccupation with thoughts and self is present. 1142. A client tells the nurse, "After I have my breast removed, I know that my husband will not find me as pretty as I was before we got married." Which response to the client is appropriate? 1. "You never know, you husband will still love you, so just forget it." 2. "I understand that you are sad, but after your surgery, you will look normal." 3. "You should focus on taking care of yourself. Your husband still needs you." 4. "You're concerned about how your husband will think of you after surgery." - Correct Answers 4. "You're concerned about how your husband will think of you after surgery." 1143. The nurse is monitoring a group therapy session whose members are expressing intimate personal opinions and feelings around personal tasks. The nurse recognizes that these activities are characteristic of which stage of group development? 1. Forming 2. Storming 3. Norming 4. Performing - Correct Answers 3. Norming 1144. A client who sustained severe injuries in a motorcycle crash was diagnosed with intensive care unit (ICU) psychosis. The nurse would conclude that the client's status is improving if which client observation is made? 1. Increase the number of hours slept at one time and is increasingly alert. 2. Appears to be delirious but has stopped trying to pull out the nasogastric tube. 3. Tells his wife, "I feel better, but the doctors want to give me a lethal injection!" 4. Keeps his eyes fixed on the nurses while in the room but has stable vital signs. - Correct Answers 1. Increase the number of hours slept at one time and is increasingly alert. 1145. A client who was found on the ground of his back yard by a neighbor is dead on arrival (DOV) to the emergency department. The nurse asks the accompanying family about religious background, understanding that which religion(s) may prohibit autopsy? Select all that apply. 1. Muslim 2. Mormon 3. Buddhist 4. Orthodox Jew 5. Eastern Orthodox - Correct Answers 1. Muslim 4. Orthodox Jew 5. Eastern Orthodox 1146. The nurse understands that which resource creates more opportunity for bullying to occur unnoticed in children? 1. The internet 2. Small classes 3. Low teacher-to-student ratio 4. Parent involvement in school activities - Correct Answers 1. The internet 1147. The nurse is conducting an assessment on a client with dissociative amnesia. Which description characterizes localized amnesia? 1. The client has a loss of all memories about past life. 2. The client blocks out all memories about a specifies period. 3. The client is able to recall some memories in a recent period. 4. The client recalls some but not all memories about a recent period. - Correct Answers 2. The client blocks out all memories about a specifies period. 1148. A client had been admitted to the psychiatric unit for displaying violent behavior and is at risk for potentially harming others. The nurse should take which action(s) when care for this client? Select all that apply. 1. Admit the client to a room near the nurses' station. 2. Face the client while speaking and providing nursing care. 3. Arrange for a security officer to be available in the general area. 4. Close the door to the client's room when giving care to the client. 5. Place the client in seclusion as an initial intervention when aggression escalates. - Correct Answers 1. Admit the client to a room near the nurses' station. 2. Face the client while speaking and providing nursing care. 3. Arrange for a security officer to be available in the general area. 1149. A client demonstrates acute anxiety when hospitalized after experiencing a seizure. The appropriate intervention to decrease the client's anxiety is which action? 1. Ignore the signs and symptoms of anxiety so that they will soon disappear. 2. Make sure the client knows all the correct medical terms to understand what is happening. 4. Decreased self-esteem 1156. The nurse is providing end-of-life care to a Hindu client. The nurse understands that which behavior is included in this religious group's end-of- life practice? 1. Tying a thread around the neck. 2. Receiving sacraments upon request. 3. Expressing grief through hitting the body. 4. Prohibiting adornment of caskets at the funeral. - Correct Answers 1. Tying a thread around the neck. 1157. The nursing student is providing end-of-life care to a client who is a Jehovah's Witness. Which nursing action indicates the need for further research with regard to religious influences on health care? 1. The student contacts the chaplain to provide sacrament to the client. 2. The student provides a calendar to the client that does not mark holidays. 3. The student suggests to other members of the health care team that palliative surgery may be an option for this client. 4. The student makes a note in the client's medical record to indicate that blood transfusions are not allowed for this client. - Correct Answers 1. The student contacts the chaplain to provide sacrament to the client. 1158. A client who is delusional states, "The guards in that prison across the street are coming over here to handcuff me." Which response by the nurse is therapeutic? 1. "You believe the guards are going to handcuff you?" 2. "The guards will only handcuff those who misbehave." 3. "Do you feel afraid that someone is trying to hurt you?" 4. "The guards can't cross the street. So, don't worry about them." - Correct Answers 3. "Do you feel afraid that someone is trying to hurt you?" 1159. The nurse is developing a plan of care for a client who is scheduled to have electroconvulsive therapy (ECT). Which factor is a priority for this client? 1. The client's fear. 2. The family's anxiety. 3. The risk for aspiration. 4. The possibility of incontinence during the procedure. - Correct Answers 3. The risk for aspiration. 1160. A client who attempted suicide by overdosing with antidepressant pills has been admitted to the psychiatric unit. The nurse, being most concerned with the client's safety, would initially take which action? 1. Stay with the client at all times. 2. Request that a friend remain with the client at all times. 3. Have the client remove all clothing and then put on a hospital gown. 4. Place the client in a seclusion room where there are no dangerous articles. - Correct Answers 1. Stay with the client at all times. 1161. Which action is the best approach for the nurse to use in crisis counseling? 1. Reassuring. 2. Passive listening. 3. Exploring early life experiences. 4. Active focusing on the current situation. - Correct Answers 4. Active focusing on the current situation. 1162. The nurse planning care for a client who is at risk for suicide includes which intervention in the plan? 1. Place the client in a private room. 2. Establish a therapeutic relationship. 3. Assign a leadership task to the client. 4. Maintain a distance of 10 inches at all times. - Correct Answers 2. Establish a therapeutic relationship. 1163. The postsurgical client with a heavy history of alcohol intake is at risk for delirium tremens (DTs). The nurse would monitor this client carefully for development of which sign(s)/ symptom(s) of DTs? Select all that apply. 1. Fever 2. Insomnia 3. Bradycardia 4. Disorientation 5. Fine hand tremors 6. High blood pressure - Correct Answers 1. Fever 2. Insomnia 4. Disorientation 5. Fine hand tremors 6. High blood pressure 1164. The nurse understands that the client with which religious background will be prohibited from becoming an organ donor? 1. Hindu 2. Jewish 3. Muslim 4. Buddhist - Correct Answers 3. Muslim 1165. The nurse determines that which client is most characteristic of a victim of elder abuse? 1. A 75-year-old man with type 2 diabetes mellitus. 2. An 80-year-old man with newly diagnosed glaucoma. 3. A 70-year-old woman with early diagnosed skin melanoma. 4. An 85-year-old woman who lives alone and has an amputated leg. - Correct Answers 4. An 85-year-old woman who lives alone and has an amputated leg. 1166. A nurse is conversing with a client who was admitted to the hospital with a diagnosis of acute anxiety disorder The client says to the nurse, " I have a secret that I want to tell you. You won't tell anyone about it, will you?" What is the appropriate nursing response? 1. "No, I won't tell anyone." 2. "I cannot promise to keep a secret." 3. "I'll only tell if it's really important." 4. "Don't tell me anything that's a secret." - Correct Answers 2. "I cannot promise to keep a secret." 1167. A client arrives in the emergency department after complaining of unrelieved chest pain for 2 days. When the nurse approaches the client with a 0.4-mg nitroglycerin sublingual tablet, the client states, " I don't need that. The problem that I have is heartburn." The nurse interprets that the client is exhibiting which type of reaction? 1. Anger 2. Denial 3. Resistance 4. Obsessive-compulsive behavior - Correct Answers 2. Denial 1168. Which characteristic(s) accurately describes anorexia nervosa? Select all that apply. 5. Rape commitment - Correct Answers 3. Voyeurism 4. Exhibitionism 5. Rape commitment 1176. A client with a diagnosis of catatonic stupor is lying on the bed, hidden under the sheets, with her body pulled into a fetal position. The nurse should take which appropriate action(s)? Select all that apply. 1. Ask the client direct questions to encourage communication. 2. Leave the client alone, but check on her every 20 to 30 minutes. 3. Sit beside the client in silence, and ask occasional open-ended questions. 4. Provide brief, frequent contact with the client, but avoid touching the client. 5. Require that the client go into the dayroom with other clients for added supervision. - Correct Answers 3. Sit beside the client in silence, and ask occasional open-ended questions. 4. Provide brief, frequent contact with the client, but avoid touching the client. 1177. A client becomes agitated and makes inappropriate comments to other clients in the dayroom. The nurse should make which statement to the client? 1. "What is causing you to become agitated?" 2. "Please stop so I don't have to put you in seclusion." 3. "Why are you intent on upsetting all the other clients?" 4. "You are going to be restrained if you do not alter your behavior." - Correct Answers 1. "What is causing you to become agitated?" 1178. The nurse is caring for an older adult client who had been physically abused by a family member at home. The nurse understands that this constitutes which type of mistreatment? 1. Domestic 2. Self-neglect 3. Institutional 4. Abandonment - Correct Answers 1. Domestic 1179. A client in the mental health unit states, "I haven't been able to eat for the last few days." Which response by the nurse is most therapeutic? 1. "The last few days?" 2. "Please go on talking" 3. "Eating, tell me more" 4. "You haven't been able to eat?" - Correct Answers 1180. Which mental health professional is responsible for the milieu in an inpatient psychiatric setting? 1. Nurse 2. Psychiatrist 3. Psychologist 4. Social worker - Correct Answers 1. Nurse