Question

A nurse on an inpatient mental health unit is assessing a client.

Answer 1

Correct Answers:

Delusions
Hallucinations

Rationale :

🔷Delusions are false fixed beliefs that are not based in reality, such as the client believing the FBI is calling or that they are a "highly ranked military officer."

🔷This represents a distortion of thought content, which is classified as a positive symptom because it is an addition to normal functioning.

🔷Delusions interfere with the client’s ability to accurately interpret reality, making them a hallmark positive symptom of schizophrenia.

🔷 Hallucinations are false sensory perceptions, such as hearing, seeing, or feeling something that is not actually present.

🔷In the scenario, the client reports that the FBI is calling to warn them, which may suggest auditory hallucinations.

🔷Hallucinations are also classified as positive symptoms, as they represent an excess or distortion of normal sensory perception.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 2

Correct Answers

Blank 1 Correct Option: hypertensive crisis
Blank 2 Correct Option: ingestion of tyramine

Rationale :

🎀Selegiline is a monoamine oxidase inhibitor (MAOI), and MAOIs block the enzyme that breaks down tyramine.

🎀When foods high in tyramine (such as smoked meats, aged cheeses, wine, or pickled products) are ingested, tyramine builds up in the bloodstream.

🎀Excess tyramine causes sudden vasoconstriction and release of norepinephrine, leading to a hypertensive crisis.

🎀Hypertensive crisis is a medical emergency, presenting with severe headache, hypertension, palpitations, diaphoresis, and risk for stroke.

🎀Discharge education must emphasize dietary restrictions to prevent this life-threatening interaction.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 3

Correct Answers:

Inform the client that seductive behavior is an indication of distress.

Rationale :

🔷Clients with histrionic personality disorder often display dramatic, attention-seeking, and seductive behaviors as a maladaptive way of coping with emotional distress.

🔷The nurse should help the client recognize these behaviors as signals of underlying stress rather than reinforcing them.

🔷By labeling seductive actions as signs of distress, the nurse promotes insight and encourages the client to express feelings more appropriately.

🔷Teaching should focus on developing healthier coping strategies and improving interpersonal effectiveness.

🔷This approach fosters self-awareness and reduces reliance on maladaptive attention-seeking behaviors.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 4

Correct Answers:

A client who is experiencing command hallucinations

Rationale :

💙Command hallucinations involve hearing voices that direct the client to harm self or others, making this a priority safety concern.

💙This symptom indicates an immediate risk for violence or suicide, requiring urgent nursing intervention.

💙The nurse’s role is to assess the content of the hallucinations, ensure close monitoring, and implement safety precautions.

💙Clients with catatonia, echolalia, or akathisia may need timely intervention, but they do not present the same immediate danger as command hallucinations.

💙Following the safety-first principle (Maslow & ABCs), protecting the client and others from harm is the top priority.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 5

Correct Answers:

Ask the client if they have a plan for ending their life.

Rationale :

💎The most urgent priority in suicide assessment is determining if the client has a specific plan, because this indicates the level of risk and immediacy of danger.

💎If a plan exists, the nurse can then assess lethality, means, and intent, which directly guide safety interventions.

💎Other assessments, such as past history or social supports, are important but are secondary to establishing current suicide risk.

💎This aligns with the safety-first principle, as suicide is a life-threatening emergency.

💎Asking directly about suicide does not increase risk—instead, it provides an opportunity for intervention and demonstrates therapeutic concern.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 6

Correct Answers:

Identify the client's stressors.
Talk to the client using short. simple sentences.

Rationale :

🟣Agitation and pacing often result from underlying triggers such as fear, frustration, or unmet needs.

🟣Identifying stressors allows the nurse to address the root cause of the agitation, which can help de-escalate the situation.

🟣This demonstrates therapeutic communication and supports client-centered care.

🟣 Talk to the client using short, simple sentences During agitation, the client may have impaired concentration and decreased ability to process complex information.

🟣Using clear, concise statements reduces misinterpretation and helps prevent further escalation.

🟣Simple communication also conveys a calm and controlled presence, which is essential for de-escalation.

🟣The nurse should use nonthreatening, therapeutic interventions first to de-escalate behavior.

🟣Standing directly in front, yelling, or restraining the client can escalate aggression and should not be the initial approach.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 7

Correct Answers:

“I will concentrate on what I am seeing, feeling, and hearing in the moment."

Rationale :

🎀Mindfulness is a therapeutic strategy that emphasizes being fully present in the current moment without judgment.

🎀By focusing on what is seen, felt, and heard, the client practices grounding techniques that reduce anxiety and prevent being overwhelmed by intrusive memories.

🎀This approach enhances self-awareness and helps the client regulate emotional responses.

🎀Unlike distraction or avoidance, mindfulness encourages acceptance of the present and promotes calm.

🎀It is especially effective in clients with PTSD, who often struggle with flashbacks and hyperarousal.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 8

Correct Answers:

Constant activity

Rationale :

🧠Constant activity places the client at greatest risk for physical exhaustion and injury, making it the priority concern.

🧠Clients with mania often have little to no rest or nutrition, which can quickly lead to dehydration, weight loss, and cardiac strain.

🧠Safety and physiologic stability are prioritized using Maslow’s hierarchy, making uncontrolled activity more urgent than cognitive or behavioral changes.

🧠While increased self-confidence, pressured speech, and impaired problem-solving are characteristic of mania, they do not pose the same immediate physical danger.

🧠Reporting this finding allows the provider to consider interventions such as mood stabilizers, antipsychotics, or hospitalization to prevent exhaustion and medical complications.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 9

Correct Answers:

Fever

Rationale :

✅Serotonin syndrome is a potentially life-threatening condition caused by excessive serotonergic activity, often due to SSRIs like citalopram.

✅Fever (hyperthermia) is a classic sign, resulting from increased neuromuscular activity and autonomic dysregulation.

✅Other associated findings include diaphoresis, agitation, tremors, hyperreflexia, and clonus.

✅Constipation, lethargy, and muscle flaccidity are not typical early signs of serotonin syndrome.

✅Prompt recognition is critical because untreated serotonin syndrome can progress to seizures, rhabdomyolysis, or death.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 10

Correct Answers:

Congestive heart failure

Rationale :

👍Electroconvulsive therapy (ECT) induces a controlled seizure, which causes a temporary surge in blood pressure and heart rate.

👍Clients with congestive heart failure (CHF) are at high risk for cardiac complications, such as arrhythmias, myocardial ischemia, or worsening heart failure.

👍The nurse must report this condition so the provider can evaluate cardiac stability and determine whether ECT is safe or if additional precautions are needed.

👍While conditions like rheumatoid arthritis, diabetes, or kidney failure require monitoring, they do not pose the same immediate cardiovascular danger during ECT.

👍A thorough cardiac assessment and clearance are essential before proceeding with treatment.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

RN Mental Health 2023 B

No.

1 :
A nurse on an inpatient mental health unit is assessing a client.

Answer Options

2 :
A nurse is caring for a client on an acute care mental health unit

Correct Answers

3 :
A nurse is providing teaching to a client who has been diagnosed with histrionic personality disorder. Which of the following actions should the nurse take?

4 :
A nurse is planning care for multiple clients who each have a diagnosis of schizophrenia. Which of the following clients should the nurse plan to see first?

5 :
A nurse in an emergency department is assessing a client who verbalized to a family member that they do not want to live anymore after the death Of their child. Which Of the following assessments should the nurse plan to perform first?

6 :
A nurse is caring for a client who begins yelling and pacing around the room. Which of the following actions should the nurse take? (Select all that apply.)

7 :
A nurse is teaching a client who has posttraumatic stress disorder about using mindfulness to manage stress. Which of the following statements by the client indicates an understanding of the teaching?

8 :
A nurse is assessing a client who has mania. Which of the following manifestations is the priority for the nurse to report to the provider?

9 :
A nurse is assessing a client who takes citalopram to treat depression. Which of the following findings should the nurse identify as an indication of serotonin syndrome?

10 :
A nurse is assessing a client who is scheduled to begin electroconvulsive therapy. Which of the following client health conditions should the nurse report to the provider?

Connect With Us

RN Mental Health 2023 B

No.

1 : A nurse on an inpatient mental health unit is assessing a client.

Answer Options

2 : A nurse is caring for a client on an acute care mental health unit

Correct Answers

3 : A nurse is providing teaching to a client who has been diagnosed with histrionic personality disorder. Which of the following actions should the nurse take?

4 : A nurse is planning care for multiple clients who each have a diagnosis of schizophrenia. Which of the following clients should the nurse plan to see first?

5 : A nurse in an emergency department is assessing a client who verbalized to a family member that they do not want to live anymore after the death Of their child. Which Of the following assessments should the nurse plan to perform first?

6 : A nurse is caring for a client who begins yelling and pacing around the room. Which of the following actions should the nurse take? (Select all that apply.)

7 : A nurse is teaching a client who has posttraumatic stress disorder about using mindfulness to manage stress. Which of the following statements by the client indicates an understanding of the teaching?

8 : A nurse is assessing a client who has mania. Which of the following manifestations is the priority for the nurse to report to the provider?

9 : A nurse is assessing a client who takes citalopram to treat depression. Which of the following findings should the nurse identify as an indication of serotonin syndrome?

10 : A nurse is assessing a client who is scheduled to begin electroconvulsive therapy. Which of the following client health conditions should the nurse report to the provider?

1 :
A nurse on an inpatient mental health unit is assessing a client.

2 :
A nurse is caring for a client on an acute care mental health unit

3 :
A nurse is providing teaching to a client who has been diagnosed with histrionic personality disorder. Which of the following actions should the nurse take?

4 :
A nurse is planning care for multiple clients who each have a diagnosis of schizophrenia. Which of the following clients should the nurse plan to see first?

5 :
A nurse in an emergency department is assessing a client who verbalized to a family member that they do not want to live anymore after the death Of their child. Which Of the following assessments should the nurse plan to perform first?

6 :
A nurse is caring for a client who begins yelling and pacing around the room. Which of the following actions should the nurse take? (Select all that apply.)

7 :
A nurse is teaching a client who has posttraumatic stress disorder about using mindfulness to manage stress. Which of the following statements by the client indicates an understanding of the teaching?

8 :
A nurse is assessing a client who has mania. Which of the following manifestations is the priority for the nurse to report to the provider?

9 :
A nurse is assessing a client who takes citalopram to treat depression. Which of the following findings should the nurse identify as an indication of serotonin syndrome?

10 :
A nurse is assessing a client who is scheduled to begin electroconvulsive therapy. Which of the following client health conditions should the nurse report to the provider?