1 )A female client on a psychiatric unit is sweating profusely while she vigorously does push-ups and then runs the length of the corridor several times before crashing into furniture in the sitting room

1 )A female client on a psychiatric unit is sweating profusely while she vigorously does push-ups and then runs the length of the corridor several times before crashing into furniture in the sitting room. Picking herself up, she begins to toss chairs aside, looking for a red one to sit in. When another client objects to the disturbance, the client shouts, “I am the boss here. I do what I want.” Which nursing problem best supports these observations?

1. Deficient diversional activity related to excess energy level.
2. Risk for other related violence related to disruptive behavior.
3. Risk for activity intolerance related to hyperactivity.
4. Disturbed personal identity related to grandiosity.

2 . A RN is preparing the physical environment to interview a new client for admission to the mental health unit. Which environmental setting facilitates the best outcome of the interview?

1. Dim the lights in the room to help the patient feel calm.
2. Sit within two feet of the client to enhance level of safety and security.
3. Reduce the noise level in the room by turning off the television and radio.
4. Position table between the client and the RN for extra personal space.

3 . The RN is providing education about strategies for a safety plan for a female client who is a victim of intimate partner violence. Which strategies should be included in the safety plan? (SOA)

1. Purchase a gun to use for protection.
2. Establish a code with family and friends to signify violence.
3. Take a self-defense course that retaliates the abuser with injury.
4. Have a bag ready that has extra clothes for self and children.
5. Plan an escape route to use if the abuser blocks the main exit.

4 . The RN is admitting a male client who takes lithium carbonate (Eskalith) twice a day. Which information should the RN report to the HCP immediately?

 A. Short term memory loss.

B. Five pound weight gain

3. Decreased affect.
4. Nausea and vomiting.

5 . A homeless client who reports feeling sad and depressed tells the mental health nurse that in the past 2 days she has only had 4 hours of sleep. Which action is most important for the RN to implement within the first 24 hours after treatment is initiated?

 A. Allow the client to rest and sleep.

2. Ensure client attend groups addressing coping skills for dealing with depression.
3. Begin planning for the clients discharge.
4. Encourage verbalization of feelings.

6 . A RN is teaching a client about initiation of a prescribed abstinence therapy using Disulfiram (Antabuse). What information should the client acknowledge understanding?

 A. Admit to others that he is a substance abuser.

2. Remain alcohol free for 12 hours prior to first dose.
3. Attend monthly meetings of alcoholics anonymous.
4. Completely sustain from heroin or cocaine use.

7 . Which client statement suggests the RN that the client is using a defense mechanism of projection to deal with anxiety related to admission to a psychiatric unit?

A. At least I hit the wall instead of hitting the psychiatric aide.

2. I am here because the police thought I was doing something wrong.
3. I want to be here because I know it is the best psychiatric facility.
4. Don’t believe everything my family tells you, I am not crazy.

8 . The RN documents the mental status of a female client who has been hospitalized for several days by court order. The client states”I don’t need to be here,” and tells the RN that she believes that the t.v talks to her. The RN should document these assessment statements in which section of the mental status exam?

A. Insight and judgement.

2. Mood and affect.
3. Remote memory.
4. Level of concentration.

9 . An older ale client with schizophrenia is found smearing feces n the bathroom walls of the chronic mental health unit where he resides. What action should the RN implement?

1. Explain that the feces belong in the toilet.
2. Show the client how to clean the walls.
3. Escort the client out of the bathroom.
4. Assist the client to clean the walls

10 . A male client tells the RN that he does not want to take the atypical antipsychotic drug, olanzapine (Zypexa), because of the side effects he experienced when he took the drug for a year. Which experience is most likely related to taking olanzapine?

A. Weight gain of 75 lbs.

2. Thoughts of wanting to hurt himself.
3. Frequent days with diarrhea.
4. Alerted liver function test.