Extract:

Question 1 of 5

The nurse manager overhears two staff members talking in the snack room. One of the staff members states, 'Her superficial cuts are just a means of getting our attention. She never should have been admitted. I hope she's out of here soon.' Which of the following responses by the nurse manager is most appropriate?

Correct Answer: D

Rationale: All suicidal behaviors, even superficial ones, require serious assessment due to potential escalation.

Question 2 of 5

A client reports having blurred vision after 4 days of taking haloperidol (Haldol) 1 mg BID, and benztropine (Cogentin) 2 mg BID. The nurse contacts the physician to explain the situation, background, and the patient's disease, which information reported to the physician is the assessment of the situation?

A. Mr. Roberts is taking 1 mg of Haldol BID and Cogentin 2 mg BID.' B. I think Mr. Roberts might need a lower dose of Cogentin.' C. Mr. Roberts reports having blurred vision since this morning.' D. The higher dose of Cogentin could be causing Mr. Roberts' blurred vision.'

Correct Answer: C

Rationale: Reporting the client's symptom (blurred vision since this morning) provides the physician with the specific assessment data needed to evaluate the situation.

Question 3 of 5

A client who has had three episodes of recurrent endogenous depression within the past 2 years states to the nurse, 'I want to know why I'm so depressed.' Which of the following statements by the nurse is most helpful?

A. I know you'll get better with the right medication.' B. Let's discuss possible reasons underlying your depression.' C. Your depression is most likely caused by a brain chemical imbalance.' D. Members of your family seem very supportive of you.'

Correct Answer: B

Rationale: Discussing possible reasons encourages exploration of triggers and fosters therapeutic engagement.

Question 4 of 5

A nurse is assessing a client experiencing hypomania who wants to stop her mood stabilizing medication because she is 'feeling good,' has a high energy level and thinks she is productive at work. Which response by the nurse is most appropriate?

A. Maybe you really don't need your medication anymore.' B. If you stop your medication, your behavior will quickly spiral out of control.' C. I believe you were hospitalized the last time you stopped your medication.' D. Why don't you cut your medication dosage in half for a while and see how you respond?'

Correct Answer: C

Rationale: Reminding the client of past consequences reinforces the importance of medication adherence.

Question 5 of 5

A married female client has been referred to the mental health center because she is depressed. The nurse notices bruises on her upper arms and asks about them. After denying any problems, the client starts to cry and says, 'He didn't really mean to hurt me, but I hate for the kids to see this. I'm so worried about them.' Which of the following is the most crucial information for the nurse to determine?

A. The type and extent of abuse occurring in the family. B. The potential of immediate danger to the client and her children. C. The resources available to the client. D. A child in the client wants to be separated from her husband.

Correct Answer: B

Rationale: The most crucial information is the potential for immediate danger to the client and her children, as this directly impacts their safety and requires urgent intervention to prevent harm.