Question

A nurse on a mental health unit is assisting with developing an in-service for staff members about legal issues. Which of the following examples should the nurse include as an example of libel?

Answer 1

Correct Answers:

Documenting false information about a client's substance use history

Rationale :

🔷 Libel is the act of making a false written statement that damages a person’s reputation.

🔷 In nursing practice, charting incorrect or untrue information in the medical record is a classic example of written defamation.

🔷 Falsely documenting a client’s substance use history could harm the client’s treatment, reputation, and legal rights.

🔷 Accurate documentation is both an ethical and legal responsibility of the nurse.

🔷 For this reason, documenting false information about a client's substance use history is an example of libel.

Leaving a client in a wheelchair with the wheels unlocked

🔷 Leaving a client in a wheelchair with the wheels unlocked is a safety issue and can constitute negligence.

🔷 It is not an example of libel because it does not involve a false written statement.

Administering a medication without the client's consent

🔷 Administering medication without consent can be considered battery.

🔷 It involves unauthorized physical contact, not written defamation.

Threatening to apply restraints on a client who is refusing medication

🔷 Threatening restraints can be considered assault because it creates fear of harmful contact.

🔷 It is not libel because no false written statement is involved.

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Answer 2

Correct Answers:

Encourage the client to walk around the courtyard

Rationale :

💠 A client who has moderate anxiety often has difficulty focusing, but they can still benefit from physical activity and a calm, structured environment.

💠 Walking helps reduce excess energy, lowers tension, and can improve the client’s ability to regain control.

💠 Simple, nonthreatening activities are more appropriate than placing the client in highly stimulating situations.

💠 The nurse should use short, clear directions and promote a setting with minimal external stressors.

💠 For this reason, the nurse should encourage the client to walk around the courtyard.

Escort the client to the dayroom to interact with others

💠 The dayroom may be too stimulating for a client with moderate anxiety who is already distracted and unable to focus.

💠 Increased environmental stimulation can worsen anxiety.

Administer a dose of escitalopram to the client

💠 Escitalopram is an SSRI used for long-term treatment of anxiety and depression, but it does not provide immediate relief of moderate anxiety.

💠 It is not the best nursing action for the client’s current presentation.

Request an antipsychotic medication from the provider

💠 An antipsychotic medication is not indicated for uncomplicated moderate anxiety.

💠 This response is too aggressive for the client’s current symptoms.

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Answer 3

Correct Answers:

Use a calm, clear tone when speaking to the client

Rationale :

🟢 Clients who have schizophrenia and display hostile verbal outbursts benefit from communication that is calm, clear, and nonthreatening.

🟢 A neutral tone helps reduce environmental stress and prevents escalation of agitation.

🟢 Short, simple communication is especially helpful when the client may have impaired thought processing or suspiciousness.

🟢 Consistent, respectful interaction can promote trust and decrease the likelihood of further hostility.

🟢 For this reason, the nurse should use a calm, clear tone when speaking to the client.

Touch the client on the shoulder to console them

🟢 Touching a client unexpectedly can be perceived as threatening and may increase agitation or aggression.

🟢 Physical contact should be used cautiously, especially with a hostile client.

Encourage the client to participate in a board game

🟢 A board game may be too stimulating or socially demanding when the client is already showing hostile outbursts.

🟢 The immediate priority is de-escalation, not group activity.

Bring a security guard whenever approaching the client

🟢 Bringing security with every approach may increase the client’s suspiciousness and sense of threat.

🟢 Security is used only if there is an actual danger, not as a routine first intervention.

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Answer 4

Correct Answers:

Implement 24-hr one-to-one nursing observation

Rationale :

🟣 An adolescent newly admitted after an overdose of prescription pain medication is at very high risk for self-harm or another suicide attempt.

🟣 Continuous one-to-one observation is the safest precaution because it allows immediate intervention if the client attempts self-injury again.

🟣 This level of observation is appropriate during the acute period when the client’s safety cannot be reliably maintained otherwise.

🟣 A history of overdose, especially in a mental health setting, requires the highest level of safety monitoring.

🟣 For this reason, the nurse should implement 24-hour one-to-one nursing observation.

Restrict interactions with other clients

🟣 Restricting all interactions does not directly address the primary safety risk of self-harm.

🟣 Observation and suicide precautions are more important.

Administer prescribed medication via the IM route

🟣 Giving medication by the IM route is not the standard precaution simply because of overdose admission.

🟣 Medication route should be based on the prescription and clinical need, not used as a safety substitute.

Document the client's behavior every 2hr

🟣 Documentation is important, but recording behavior every 2 hours is not enough to protect a high-risk suicidal client.

🟣 Continuous observation is the safer priority intervention.

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Answer 5

Correct Answers:

Place the client in a room close to the nurses' station

Rationale :

🌸 A client who has dementia and an increased number of falls needs close observation and quick staff access.

🌸 Placing the client near the nurses’ station allows more frequent monitoring and earlier intervention if wandering or unsafe movement occurs.

🌸 This intervention promotes safety without unnecessarily restricting the client’s movement.

🌸 Environmental measures are preferred before restraints whenever possible.

🌸 For this reason, the nurse should place the client in a room close to the nurses’ station.

Obtain a PRN prescription for a vest restraint

🌸 Restraints increase the risk of injury, agitation, and decreased mobility in clients with dementia.

🌸 They should be avoided unless absolutely necessary and after less restrictive measures fail.

Request a consult with recreational therapy

🌸 Recreational therapy may be beneficial for engagement and activity planning, but it is not the priority response to an immediate fall risk.

🌸 Safety monitoring comes first.

Lower the window shade in the client's room

🌸 Lowering the window shade does not directly reduce fall risk and may even increase disorientation by decreasing natural cues.

🌸 Environmental visibility and supervision are more important.

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Answer 6

Correct Answers:

St. John's wort

Rationale :

⭐ Amitriptyline is a tricyclic antidepressant, and combining it with St. John’s wort can increase the risk of serotonin syndrome and other adverse interactions.

⭐ St. John’s wort also affects neurotransmitters and may intensify side effects or alter medication effectiveness.

⭐ Clients should be taught to avoid combining prescribed antidepressants with herbal mood products unless specifically approved by the provider.

⭐ Careful review of herbal supplements is essential because many clients do not realize these products can interact with medications.

⭐ For this reason, the nurse should instruct the client to avoid St. John’s wort.

Glucosamine

⭐ Glucosamine is commonly used for joint support and is not the herbal supplement most strongly associated with interaction with amitriptyline.

⭐ It is not the best answer in this question.

Echinacea

⭐ Echinacea is typically used for immune support and is not the classic supplement associated with major interaction with tricyclic antidepressants.

⭐ The more important concern is St. John’s wort.

Saw palmetto

⭐ Saw palmetto is commonly used for prostate-related symptoms and is not the classic contraindicated herbal supplement with amitriptyline.

⭐ It is not the primary interaction concern here.

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Answer 7

Correct Answers:

Disorganized thinking

Rationale :

💎 Delirium is characterized by an acute change in cognition, especially disorganized thinking, confusion, and fluctuating attention.

💎 In an older adult with a respiratory infection, delirium can develop quickly as a response to infection, hypoxia, or other physiologic stress.

💎 Disorganized thinking is a key mental status change that distinguishes delirium from stable chronic cognitive decline.

💎 Early recognition is important because delirium may signal worsening illness and requires prompt treatment of the underlying cause.

💎 For this reason, disorganized thinking indicates that the client is developing delirium.

Pinpoint pupils

💎 Pinpoint pupils are more commonly associated with opioid intoxication or certain neurologic conditions.

💎 They are not a typical defining sign of delirium.

Pale, dry skin

💎 Pale, dry skin may suggest dehydration or other physical problems, but it does not specifically indicate delirium.

💎 Mental status changes are more directly related to this condition.

Decreased blood pressure

💎 Decreased blood pressure can occur with various illnesses, but it is not the hallmark sign of delirium.

💎 Delirium is primarily recognized by acute changes in cognition and attention.

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Answer 8

Correct Answers:

Assist the client in developing a safety plan

Rationale :

🔶 When a client reports that their partner hit them, the priority is to address immediate safety.

🔶 A safety plan helps the client identify where to go, who to call, how to leave quickly, and what to do if violence happens again.

🔶 This intervention directly reduces the risk of further harm and is more urgent than counseling or support-group referrals.

🔶 Nursing care in intimate partner violence focuses first on protection and safety, then on long-term support.

🔶 For this reason, the nurse’s priority is to assist the client in developing a safety plan.

Suggest the client call a friend

🔶 Calling a friend may provide support, but it does not fully address the client’s immediate safety needs.

🔶 A structured safety plan is more protective and comprehensive.

Encourage the client to seek counseling

🔶 Counseling may be very helpful later, but it is not the first priority when abuse has just been disclosed.

🔶 Immediate safety takes precedence.

Provide information regarding a support group

🔶 Support groups can offer ongoing help, but they do not address the client’s immediate danger.

🔶 Safety planning comes before referral to support groups.

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Answer 9

Correct Answers:

"I will use written signs to direct my dad to areas of the house."

Rationale :

✅ Clients who have dementia benefit from clear environmental cues that support orientation and independence.

✅ Written signs can help direct the client to important areas such as the bathroom or bedroom and reduce confusion.

✅ Using simple labels is a practical home-safety strategy that supports memory deficits without overwhelming the client.

✅ This approach is consistent with dementia care principles that emphasize structure, routine, and cueing.

✅ For this reason, the statement about using written signs indicates correct understanding.

"I will offer my dad at least three choices at mealtime."

✅ Clients with dementia usually do better with limited choices, often one or two options rather than several.

✅ Too many choices can increase confusion and frustration.

"I will allow my dad to take a nap in the afternoon."

✅ Frequent or long daytime naps can interfere with nighttime sleep and worsen sleep-wake disruption.

✅ Rest may be needed, but this is not the strongest teaching point demonstrating understanding.

"I will dim the lights during the day to provide a quiet environment."

✅ Dimming lights during the day can worsen disorientation and increase fall risk.

✅ Adequate daytime lighting helps promote normal orientation and circadian rhythm.

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Answer 10

Correct Answers:

"Have you been thinking about death lately?"

Rationale :

🟡 When a client says, “Everyone would be better off if I were not around,” the nurse should respond with a direct suicide assessment question.

🟡 Asking clearly about thoughts of death or suicide is therapeutic and helps determine the level of risk.

🟡 Direct questioning does not plant the idea in the client’s mind; instead, it opens communication and supports safety.

🟡 This response allows the nurse to gather essential information for immediate intervention and suicide precautions if needed.

🟡 For this reason, the nurse should ask, “Have you been thinking about death lately?”

"What would your loved ones do without you?"

🟡 This response may create guilt and is not a therapeutic way to assess suicide risk.

🟡 The nurse should focus on direct, nonjudgmental assessment instead.

"You won't feel like that with further treatment."

🟡 This response offers false reassurance and does not assess the seriousness of the suicidal statement.

🟡 Immediate risk must be explored directly.

"You shouldn't be having thoughts like that."

🟡 This statement is judgmental and may shut down communication.

🟡 The client needs an open, supportive assessment rather than criticism.

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PN Mental Health 2023 March

No.

1 :
A nurse on a mental health unit is assisting with developing an in-service for staff members about legal issues. Which of the following examples should the nurse include as an example of libel?

2 :
A nurse is caring for a client who is experiencing moderate anxiety and appears distracted and unable to focus. Which of the following actions should the nurse take?

3 :
A nurse is contributing to the plan of care for a client who has schizophrenia. The client often directs brief, hostile verbal outbursts toward the staff. Which of the following interventions should the nurse recommend?

4 :
A nurse in a mental health facility is caring for an adolescent who is newly admitted for an overdose of prescription pain medication. The client has prescriptions for an anxiolytic and an SSRI antidepressant. Which of the following precautions should the nurse take?

5 :
A nurse is caring for a client who has dementia and is experiencing an increased number of falls. Which of the following actions should the nurse take?

6 :
A nurse is reinforcing teaching with a client who has a new prescription for amitriptyline. The client reports taking herbal supplements. The nurse should instruct the client that they should avoid taking which of the following supplements?

7 :
A nurse in a long-term care facility is collecting data from an older adult client who has a respiratory infection. Which of the following findings indicates that the client is developing delirium?

8 :
A nurse at an urgent care facility is collecting data from a client and notes numerous bruises on the client's abdomen and extremities. The client reports their partner hit them. After observing the client for further injuries, which of the following actions is the nurse's priority?

9 :
A nurse is reinforcing discharge teaching with the adult child of a client who has dementia. Which of the following statements by the client's child indicates an understanding of the teaching?

10 :
A nurse is caring for a client who has a depressive disorder. The client states, "Everyone would be better off if I were not around." Which of the following responses should the nurse make?

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PN Mental Health 2023 March

No.

1 : A nurse on a mental health unit is assisting with developing an in-service for staff members about legal issues. Which of the following examples should the nurse include as an example of libel?

2 : A nurse is caring for a client who is experiencing moderate anxiety and appears distracted and unable to focus. Which of the following actions should the nurse take?

3 : A nurse is contributing to the plan of care for a client who has schizophrenia. The client often directs brief, hostile verbal outbursts toward the staff. Which of the following interventions should the nurse recommend?

4 : A nurse in a mental health facility is caring for an adolescent who is newly admitted for an overdose of prescription pain medication. The client has prescriptions for an anxiolytic and an SSRI antidepressant. Which of the following precautions should the nurse take?

5 : A nurse is caring for a client who has dementia and is experiencing an increased number of falls. Which of the following actions should the nurse take?

6 : A nurse is reinforcing teaching with a client who has a new prescription for amitriptyline. The client reports taking herbal supplements. The nurse should instruct the client that they should avoid taking which of the following supplements?

7 : A nurse in a long-term care facility is collecting data from an older adult client who has a respiratory infection. Which of the following findings indicates that the client is developing delirium?

8 : A nurse at an urgent care facility is collecting data from a client and notes numerous bruises on the client's abdomen and extremities. The client reports their partner hit them. After observing the client for further injuries, which of the following actions is the nurse's priority?

9 : A nurse is reinforcing discharge teaching with the adult child of a client who has dementia. Which of the following statements by the client's child indicates an understanding of the teaching?

10 : A nurse is caring for a client who has a depressive disorder. The client states, "Everyone would be better off if I were not around." Which of the following responses should the nurse make?

1 :
A nurse on a mental health unit is assisting with developing an in-service for staff members about legal issues. Which of the following examples should the nurse include as an example of libel?

2 :
A nurse is caring for a client who is experiencing moderate anxiety and appears distracted and unable to focus. Which of the following actions should the nurse take?

3 :
A nurse is contributing to the plan of care for a client who has schizophrenia. The client often directs brief, hostile verbal outbursts toward the staff. Which of the following interventions should the nurse recommend?

4 :
A nurse in a mental health facility is caring for an adolescent who is newly admitted for an overdose of prescription pain medication. The client has prescriptions for an anxiolytic and an SSRI antidepressant. Which of the following precautions should the nurse take?

5 :
A nurse is caring for a client who has dementia and is experiencing an increased number of falls. Which of the following actions should the nurse take?

6 :
A nurse is reinforcing teaching with a client who has a new prescription for amitriptyline. The client reports taking herbal supplements. The nurse should instruct the client that they should avoid taking which of the following supplements?

7 :
A nurse in a long-term care facility is collecting data from an older adult client who has a respiratory infection. Which of the following findings indicates that the client is developing delirium?

8 :
A nurse at an urgent care facility is collecting data from a client and notes numerous bruises on the client's abdomen and extremities. The client reports their partner hit them. After observing the client for further injuries, which of the following actions is the nurse's priority?

9 :
A nurse is reinforcing discharge teaching with the adult child of a client who has dementia. Which of the following statements by the client's child indicates an understanding of the teaching?

10 :
A nurse is caring for a client who has a depressive disorder. The client states, "Everyone would be better off if I were not around." Which of the following responses should the nurse make?