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Nurse Isabelle enters the room of a client with a cognitive impairment disorder and asks what day of the week it is; what the date, month, and year are; and where the client is. The nurse is attempting to assess: A. Confabulation B. Perseveration C.

The nurse is attempting to assess: **D. Orientation**. Orienting questions like asking for the day of the week, date, month, year, and location are used to determine a client's awareness and understanding of their current situation in time and place, which is referred to as orientation.

. A hospitalized client, diagnosed with a borderline personality disorder, consistently breaks the unit’s rules. This behavior should be confronted because it will help the client: A. Control anger B. Become more self-aware C. Set realistic goals D. R

The behavior of consistently breaking unit rules by a client with borderline personality disorder should be confronted to help the client: **B. Become more self-aware**. Confrontation in this context serves to bring attention to the client's behaviors and the consequences they have, promoting self-awareness and insight. This can be particularly important in borderline personality disorder, where individuals may struggle with understanding the

. Which of the following behavioral crises is most likely to lead to suicide? A. PTSD B. Excited delirium C. Depression D. Psychosis

C. Depression While all of these conditions can potentially lead to suicidal thoughts or behaviors, depression is the most strongly associated with suicide risk. Individuals suffering from depression often experience persistent feelings of sadness, hopelessness, and worthlessness, which can increase the likelihood of suicidal ideation and actions.

. What is the purpose when a nurse gathers client information? A. It enables the nurse to make sound clinical judgments and plan appropriate client care. B. It enables the nurse to prescribe the appropriate medications. C. It enables the nurse to assi

A. It enables the nurse to make sound clinical judgments and plan appropriate client care. Gathering client information is fundamental for nurses to assess the situation accurately, establish a diagnosis, and develop a tailored care plan to meet the specific needs of the client.

A patient is admitted to the psychiatric unit after a suicide attempt. The nurse plans to write a suicide prevention contract. To promote compliance and build a trusting relationship with the patient, the contract should A. be written by the social wo

The correct answer is B. **be written jointly by the nurse and the patient.** A suicide prevention contract should be a collaborative effort between the patient and the healthcare provider (in this case, the nurse) to promote a strong therapeutic alliance, encourage the patient's engagement in their care, and ensure that the patient feels heard and respected in the process. This approach fosters trust and encourages the patient to take ownership

. A 3-year-old and her parents checked into the emergency room. The parents are complaining that the babysitter is abusing their child. What action should the nurse take first A. Notify the social worker. B. Assess the child. C. Call the physician. D.

In a situation where there is a suspicion of child abuse, the first action the nurse should take is to **B. Assess the child**. Assessing the child is crucial to determine any signs of abuse or injury and to ensure the child's safety and health. It's important to gather information directly from the child while ensuring they feel safe and supported. Following the assessment, the nurse can then take appropriate actions, such as reporting the

9. A 50-year-old woman brings her mother to the hospital for a mental health assessment. The woman states that her mother is verbally abusive toward her, has thrown items at her when she visits, and has called the woman's employer to complain about

The most appropriate response from the nurse in this situation is: **D. Explore options for limiting time with the mother while she can still maintain a relationship.** This response acknowledges the daughter's difficult situation and provides an opportunity to explore healthy boundaries in the relationship with her mother, which may help to reduce the emotional and verbal abuse she is experiencing. It also shows empathy and support for the

he nurse is conducting a group therapy session, and a client with a manic disorder is monopolizing the group. The appropriate nursing action is which of the following? A. Refer the client to another group. B. Thank the client for the contribution and

The appropriate nursing action in this scenario is **B. Thank the client for the contribution and tell him or her to allow others a chance to contribute.** This approach acknowledges the client’s enthusiasm and participation while gently redirecting the focus to the group as a whole. It promotes an inclusive environment and encourages other group members to engage. Options A and C may not address the immediate issue effectively, and option D

. The nurse employed in a mental health clinic is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, “How is Carol doing? She is my best friend and is seen at your clinic every week.” The appropriate nursing response is

The appropriate nursing response in this situation is: **A. I cannot discuss any client situation with you.** This response maintains client confidentiality and adheres to ethical standards in nursing practice. It is crucial for healthcare providers to protect the privacy of their clients and not disclose any information without the client's explicit consent. The other options either imply sharing confidential information or compromise

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6. A 23-year-old patient with borderline personality disorder reports a frequent desire to cut him- or herself and insists that only a specific psychiatric and mental health nurse can help the patient. The nursing care plan for the patient includes: A

In this scenario, the patient is expressing self-harm urges and has a strong attachment to a specific nurse. The priorities for care should include ensuring the safety of the patient, which is critical given the suicidal ideation. Given the choices: A. Decreasing the patient's stimuli - While this may help some patients, it does not address the immediate risk of self-harm. B. Providing one-to-one suicide precautions - This is important for

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