A client on the mental health unit is becoming more agitated, shouting at the staff, and pacing in the
hallway. When the PRN medication is offered, the client refuses the medication and defiantly sits on
the floor in the middle of the unit hallway. What nursing intervention should the RN implement first?
A. Transport of the client to the seclusion room.
B. Quietly approach the client with additional staff members.
C. Take other clients in the area to the client lounge.
D. Administer medication to chemically restrain the patient.
A client is admitted to the mental health unit and reports taking extra antianxiety medication because,
“I’m so stressed out. I just want to go to sleep.” The RN should plan one-on-one observation of the
client based on which statement?
A. “What should I do? Nothing seems to help.”
B. “I have been so tired lately and needed to sleep.”
C. “I really think that I don’t need to be here.”
D. “I don’t want to walk. Nothing matters anymore.”
A male hospital employee is pushed out the way by a female employee because of an oncoming
gurney. The pushed employee becomes very angry and swings at the female employee. Both
employees are referred for counseling with the staff psychiatric RN. Which factor in the pushed
employee’s history is most related to the reaction that occurred?
A. Is worried about losing his job to a woman.
B. Tortured animals as a child.
C. Was physically abused by his mother.
D. Hates to be touched by anyone.
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 the
television talks to her. The RN should document these assessment findings in which section of the
mental status exam/
A. Level of concentration.
B. Insight and judgement.
C. Remote memory.
D. Mood and affect.
A client is admitted to the mental health unit reports shortness of breath and dizziness. The client tells
the RN, “I feel like I’m going to die”. Which nursing problem should the RN include in this client’s plan
of care?
A. Mood disturbance.
B. Moderate anxiety.
C. Altered thoughts.
D. Social isolation.
A female client who is wearing dirty clothes and has foul body odor, comes to the clinic reporting
feeling scared because she is being stalked. What action is most important for the RN to take?
A. Offer the client a safe place to relax before interviewing her.
B. Ask the client to describe why she is being stalked.
C. Recommend that the client talk with a social worker.
D. Assure the client that the HCP will see her today