Question

A home care nurse is visiting an older adult client who tells the nurse that she is feeling tired, is unable to shop for groceries, and would like the nurse to shop for her. Shopping and performing personal errands for the client is prohibited in the nurse's job description. Which of the following is an appropriate nursing response?

Answer 1

Correct Answers:

"Let's look at some other resources to solve this problem."

Rationale :

🔷 This response demonstrates professional boundaries while still showing concern for the client’s needs.

🔷 The nurse appropriately collaborates with the client to explore community resources (e.g., meal delivery services, family assistance, or social services).

🔷 It maintains a therapeutic relationship without violating the nurse’s job description.

🔷 Offering to help find alternative solutions respects both ethical standards and agency policies.

🔷 Other responses either cross professional boundaries or fail to address the client’s expressed need.

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Answer 2

Correct Answers:

"Her behavior changed so quickly, I wasn't sure what was happening."

Rationale :

🔷 Delirium is characterized by an acute and sudden onset of confusion, behavioral changes, and fluctuating mental status.

🔷 The rapid change described by the partner suggests delirium rather than dementia or depression, which are more gradual in onset.

🔷 Delirium is often reversible and may be triggered by infection, electrolyte imbalance, or medication effects in older adults.

🔷 Immediate assessment is crucial to identify and treat the underlying cause to prevent complications.

🔷 Unlike delirium, dementia has a slow progressive decline, and depression presents with persistent sadness and withdrawal.

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Answer 3

Correct Answers:

Limit the client's choices for daily activities.

Rationale :

🔷 Clients with dementia often experience confusion and difficulty processing multiple options, which can increase anxiety and agitation.

🔷 Limiting choices to simple, clear options (e.g., choosing between two outfits instead of several) helps reduce decision-making stress.

🔷 A calm, structured environment promotes safety and emotional comfort.

🔷 Cognitive overstimulation or confrontation can worsen behavioral symptoms and lead to distress.

🔷 Consistency in routine and caregivers also enhances orientation and security for dementia patients.

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Answer 4

Correct Answers:

Ask the partner to talk about his difficulties in caring for the client.

Rationale :

🔷 The first priority is to use therapeutic communication to allow the partner to express feelings, frustrations, and concerns.

🔷 Active listening helps the nurse assess caregiver burden, determine the extent of exhaustion, and identify immediate needs.

🔷 Once the partner’s concerns are clarified, the nurse can then provide appropriate resources, such as respite care, family support, or counseling.

🔷 Jumping directly to recommending long-term care or counseling without assessment may increase anxiety or feelings of guilt in the caregiver.

🔷 Early intervention and emotional support help prevent caregiver burnout and improve the quality of care for the patient.

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Answer 5

Correct Answers:

Obsessive-compulsive disorder (OCD)

Rationale :

🔷 OCD is less common in children compared to other mental health conditions like ADHD, anxiety, and ASD, which are among the most frequently diagnosed disorders in pediatric populations.

🔷 ADHD is one of the most common childhood mental health disorders, often identified in school-aged children due to symptoms of inattention and hyperactivity.

🔷 Anxiety disorders are highly prevalent in children, often presenting as separation anxiety, social anxiety, or generalized anxiety.

🔷 ASD is also a common developmental disorder diagnosed in early childhood, characterized by communication and social interaction difficulties.

🔷 OCD typically has a later onset, often in late childhood or adolescence, making it less common in younger children.

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Answer 6

Correct Answers:

Set aside short, frequent times each day to spend with the client.

Rationale :

🔷 Consistent and predictable interactions help build trust with a suspicious client, which is essential in establishing a therapeutic relationship.

🔷 Spending short, scheduled periods with the client communicates dependability and helps reduce feelings of paranoia or mistrust.

🔷 Therapeutic relationships require the nurse to demonstrate reliability and professionalism rather than sharing personal information or forcing interactions.

🔷 Regular contact allows the client to become gradually comfortable with the nurse, increasing opportunities for meaningful interaction.

🔷 Maintaining a structured interaction pattern is an essential therapeutic communication technique for clients exhibiting suspicious or paranoid behaviors.

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Answer 7

Correct Answers:

To provide a safe and supportive environment for clients to engage in therapeutic activities and interactions.

Rationale :

🔷 A therapeutic milieu focuses on creating an environment that supports emotional healing and promotes psychological well-being.

🔷 It provides a structured, safe space where clients can interact with peers and staff in a manner that encourages personal growth and social skill development.

🔷 Therapeutic activities within the milieu are designed to reinforce healthy coping mechanisms and reduce maladaptive behaviors.

🔷 The environment promotes a sense of belonging and stability, which is crucial for clients with mental health disorders.

🔷 Interpersonal interactions in the milieu allow clients to practice new skills in a supportive, supervised setting, fostering behavioral change.

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Answer 8

Correct Answers:

Compromise

Rationale :

🔷 Compromise is a key social task of adulthood, essential for maintaining healthy relationships in personal, family, and workplace settings.

🔷 Adults are expected to balance personal needs with the needs of others, requiring mutual adjustment and negotiation.

🔷 Developing the ability to compromise demonstrates emotional maturity and social responsibility.

🔷 This skill is vital for conflict resolution, as adults often face competing priorities in social and professional relationships.

🔷 Healthy interpersonal relationships rely heavily on compromise to foster cooperation and mutual respect.

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Answer 9

Correct Answers:

Monitoring client progress

Rationale :

🔷 A mental health treatment plan is a structured guide used to track a client’s progress throughout therapy and other interventions.

🔷 It includes specific goals and measurable outcomes, making it easier to evaluate whether interventions are effective.

🔷 Ongoing assessment based on the treatment plan allows for timely modifications to ensure optimal client outcomes.

🔷 It also serves as a communication tool among healthcare professionals, ensuring continuity of care.

🔷 Regular progress monitoring promotes accountability for both the healthcare team and the client, encouraging adherence to treatment.

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Answer 10

Correct Answers:

Set limits for the relationship.

Rationale :

🔷 Establishing clear boundaries is essential for maintaining a professional and therapeutic nurse-client relationship.

🔷 Setting limits helps prevent dependency, transference, or inappropriate interactions, which can hinder therapeutic progress.

🔷 Structured boundaries provide a sense of security for clients, particularly those with difficulty maintaining healthy relationships.

🔷 It allows the nurse to remain an objective and consistent therapeutic agent, rather than a friend or authority figure.

🔷 Maintaining limits encourages respectful interactions and ensures that communication remains focused on the client’s therapeutic needs.

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Custom -Mental Health Exam 2 B Eve April 2025 DMC-Lincoln Tech Moorestown NJ PN

No.

2 :
A nurse is assisting with the admission of an older adult who is confused. Which of the following statements by the client's partner indicates that the client may be experiencing delirium?

3 :
A nurse is contributing to the plan of care for a client who has dementia. Which of the following interventions is appropriate to include in the plan of care?

5 :
Which of the following is NOT a common mental health problem in children?

6 :
A nurse is caring for a newly admitted client who is suspicious of the nursing staff and other clients. Which of the following actions should the nurse take to establish a relationship with this client?

7 :
Which of the following best describes the purpose of a therapeutic milieu in mental health care?

8 :
Which of the following is a social task of adulthood?

9 :
The mental health treatment plan serves several purposes. Which of the following is one of those purposes?

10 :
A nurse in a mental health clinic is attempting to develop a therapeutic relationship with a client. Which of the following actions should the nurse take?

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Custom -Mental Health Exam 2 B Eve April 2025 DMC-Lincoln Tech Moorestown NJ PN

No.

2 : A nurse is assisting with the admission of an older adult who is confused. Which of the following statements by the client's partner indicates that the client may be experiencing delirium?

3 : A nurse is contributing to the plan of care for a client who has dementia. Which of the following interventions is appropriate to include in the plan of care?

5 : Which of the following is NOT a common mental health problem in children?

6 : A nurse is caring for a newly admitted client who is suspicious of the nursing staff and other clients. Which of the following actions should the nurse take to establish a relationship with this client?

7 : Which of the following best describes the purpose of a therapeutic milieu in mental health care?

8 : Which of the following is a social task of adulthood?

9 : The mental health treatment plan serves several purposes. Which of the following is one of those purposes?

10 : A nurse in a mental health clinic is attempting to develop a therapeutic relationship with a client. Which of the following actions should the nurse take?

2 :
A nurse is assisting with the admission of an older adult who is confused. Which of the following statements by the client's partner indicates that the client may be experiencing delirium?

3 :
A nurse is contributing to the plan of care for a client who has dementia. Which of the following interventions is appropriate to include in the plan of care?

5 :
Which of the following is NOT a common mental health problem in children?

6 :
A nurse is caring for a newly admitted client who is suspicious of the nursing staff and other clients. Which of the following actions should the nurse take to establish a relationship with this client?

7 :
Which of the following best describes the purpose of a therapeutic milieu in mental health care?

8 :
Which of the following is a social task of adulthood?

9 :
The mental health treatment plan serves several purposes. Which of the following is one of those purposes?

10 :
A nurse in a mental health clinic is attempting to develop a therapeutic relationship with a client. Which of the following actions should the nurse take?