Behavioral Health Final
Considering the many criteria for good mental health, the nursing student has been instructed to list four of these criteria. The student's list consists of the following: (1) an appropriate perception of reality, (2) the ability to accept oneself, (3) the ability to establish relationships, (4) a need for detachment, and the desire for privacy. How would the nurse evaluate the nursing student's list? A. Excellent. All the student's criteria are correct B. Good. Three of the four criteria are correct C. Mediocre. Two of the four are correct D. Poor. All four of the criteria are incorrect
A. Excellent. All the student's criteria are correct (Rationale: there are numerous descriptors depicting the concept of good mental health. The student's list is not comprehensive, but all four criteria listed are correct reflections of good mental health. A mentally healthy individual views reality with a realistic perception based on objective data. Accepting oneself, including strengths and weaknesses, is indicative of good mental health. The ability to establish relationships by use of communication skills is essential for good mental health. Mentally healthy individuals seek time to be alone and appreciate periods of privacy.)
According to Maslow's hierarchy of needs, which client action would be considered most basic? A. a client discusses the need for order in his life and freedom from fear B. a client feels lonely and is seeking to share life experiences C. a client begins to realize their full potential D. a client is role-playing a situation with a nurse to practice assertiveness skills
A. a client discusses the need for order in his life and freedom from fear (Rationale: discussing order in one's life and freedom from fear relates to Maslow's description of safety and security, which is the second most basic need after the client has met physiological needs.)
Which is an example of appropriate psychosexual development? A. an 18-month old relives anxiety by the use of a pacifier B. a 5-year-old boy focuses on relationships with other boys C. a 7-year-old girl identifies with her mother D. a 12 month-old begins learning about independence and control
A. an 18-month old relives anxiety by the use of a pacifier (Rationale: from birth to 18 months of age, a child is in the oral stage of Freud's psychosexual development. During this stage, an infant would attempt to decrease anxiety by finding relief using oral gratification)
A nurse is communicating with a client who was just admitted for treatment of a substance use disorder. Which of the following communication techniques should the nurse identify as a barrier to therapeutic communication? A. offering advice B. reflecting C. listening attentively D. giving information
A. offering advice (Rationale: offering advice to a client is a barrier to therapeutic communication that the nurse should avoid using. Advice tends to interfere with the client's ability to make personal decisions and choices.)
Which initial information gathered by the nurse is most important when assessing Erikson's stages of development? A. the chronological age of the individual B. the developmental age exhibited through behaviors C. the time frame needed to complete a successful outcome at a previous stage D. the implementation of interventions based on developmental age
A. the chronological age of the individual (Rationale: Erikson based his psychosocial theory on an individual's chronological age. Although individuals may have some unresolved issues from pervious stages, the individual is assessed in a stage based on chronological age.)
A nurse is caring for a client who is in mechanical restraints. Which of the following statements should the nurse include in documentation? (select all that apply) A. "client ate most of his breakfast" B. "client was offered 8oz of water every hour" C. "client shouted obscenities at assistive personnel" D. "client received chlorpromazine 15mg by mouth at 1000" E. "client acted out after lunch"
B, C, D (Rationale: how much water was offered and how often it was offered, the client's verbal communication, and the dosage and time of medication administration is objective data that the nurse should document when caring for a client in mechanical restraints)
A nurse is caring for a client who is experiencing moderate anxiety. Which of the following actions should the nurse take when trying to give necessary information to the client? (select all that apply) A. reassure the client that everything will be okay B. discuss prior use of coping mechanisms with the client C. ignore the client's anxiety so that she will not be embarrassed D. demonstrate a calm manner while using simple and clear directions E. gather information from the client using close-ended questions
B, D (Rationale: discussing the prior use of coping mechanisms assists the client in identifying ways of effectively coping with the current stressor. Providing a calm presence assists the client in feeling secure and promotes relaxation. Clients experiencing moderate levels of anxiety often benefit from the direction of others.)
A nurse is caring for a client who smokes and has lung cancer. The client reports, "I'm coughing because I have that cold that everyone has been getting." The nurse should identify the client is using which of the following defense mechanisms. A. reaction formation B. denial C. displacement D. sublimation
B. denial (Rationale: this is an example of denial, which is pretending the truth is not reality to manage the anxiety of acknowledging what is real.)
A nurse decides to put a client who has psychosis in seclusion overnight because the unit is very short‑staffed, and the client frequently fights with other clients. This is an example of... A. invasion of privacy B. false imprisonment C. assault D. battery
B. false imprisonment (Rationale: a civil wrong that violates a client's civil rights is a tort. In this case, it is false imprisonment, which is the confining of a client to a specific area, such as a seclusion room, if the reason for such confinement is for the convenience of staff)
A nurse providing preoperative teaching for a client who was just informed that she requires emergency surgery. The client has a RR 30/min, and says, "This is difficult to comprehend. I feel shaky and nervous." The nurse should identify that the client is experiencing which of the following levels of anxiety? A. mild B. moderate C. severe D. panic
B. moderate (Rationale: moderate anxiety decreases problem-solving and may hamper the client's ability to understand information. Vital signs may increase somewhat, and the client is visibly anxious)
A nurse hears a newly licensed nurse discussing a client's hallucinations in the hallway with another nurse. Which of the following actions should the nurse take first? A. notify the nurse managed B. tell the nurse to stop discussing the behavior C. provide an in-service program about confidentiality D. complete an incident report
B. tell the nurse to stop discussing the behavior (Rationale: the greatest risk to this client is an invasion of privacy through sharing confidential information in a public place. The first action the nurse should take is to tell the nurse to stop discussing the client's hallucinations in a public location)
A 4-year old is unable to consider another child's ideas about playing house. This situation is an example of which concept of Piaget's theory of cognitive development? A. object permanence B. Reversibility and spatiality C. Egocentrism D. Formal operations
C. Egocentrism (Rationale: according to Piaget, egocentrism occurs during the stage of preoperational thought (2-6 years of age). Personal experiences are thought to be universal, and the child is unable to accept the differing viewpoints of others)
A client tells a nurse, "don't tell anyone, but I hid a sharp knife under my mattress to protect myself from my roommate, who is always yelling at me and threatening me." Which of the following actions should the nurse take? A. keep the client's communication confidential, but talk to the client daily, using therapeutic communication to convince him to admit to hiding the knife B. keep the client's communication confidential, but watch the client and his roommate closely C. Tell the client that this must be reported to the health care team because it concerns the health and safety of the client and others D. Report the incident to the healthcare team, but not inform the client of the intention to do so
C. Tell the client that this must be reported to the health care team because it concerns the health and safety of the client and others (Rationale: the information presented by the client is a serious safety issue that the nurse must report to the health care team. Using the ethical principle of veracity, the student tells the client truthfully what must be done regarding the issue.)
Which client situation is an example of normal ego development? A. a client calls out in pain to get his or her needs met B. a client complains of poor self-esteem because of punishments from his or her past C. a client exhibits the ability to assert him/herself without anger or aggression D. a client feels guilty without wanting to have sexual relations outside of marriage
C. a client exhibits the ability to assert him/herself without anger or aggression (Rationale: the ego is considered the "reality principle" and is developed between 4-6 months of age. The ego experiences the outside world and then adapts and responds to it. The ego's main goal is to maintain harmony between the id and the superego. The ability to assert oneself without anger or aggression is an example of healthy ego development.)
According to Maslow's hierarchy of needs, which situation on an inpatient unit would require priority intervention? A. a client is disturbed that family can be seen only during visiting hours B. a client exhibits hostile and angry behaviors toward another client C. a client states, "I have no one who cares about me" D. a client states, "I have never met my career goals."
C. a client states, "I have no one who cares about me" (Rationale: maintaining a safe environment is a priority intervention because, according o Maslow, safety and security needs must be met before any other needs with the exception of physiological ones. When a client exhibits hostile and angry behaviors toward another client, interventions must be focused on safety)
A nurse in an emergency health facility is caring for a group of clients. The nurse should identify that which of the following clients requires a temporary emergency admission? A. a client who has schizophrenia with delusions of grandeur B. a client who has manifestations of depression and attempted suicide a year ago C. a client who has borderline personality and assaulted a homeless man with a metal rod D. a client who has bipolar disorder and paces quickly around the room while talking to himself
C. a client who has borderline personality and assaulted a homeless man with a metal rod (Rationale: a client who is a current danger to self or others is a candidate for a temporary emergency admission)
A 25 year old client diagnosed with major depressive disorder remains in his room and avoids others. According to Erikson, which describes this client's developmental task assessment? A. stagnation B. despair C. isolation D. role confusion
C. isolation (Rationale: isolation is the negative outcome of Erikson's "young adulthood" stage of development, intimacy versus isolation. This stage ranges from 20-30 years of age. The major developmental task for young adulthood is to form an intense, lasting relationship or a commitment to another person, cause, institution, or creative effort. The 25 year old client falls within the age range for young adulthood and is exhibiting behaviors association with isolation.)
A nurse is caring for a client who has anorexia nervosa. Which of the following examples demonstrates the nurse's use of interpersonal communication? A. the nurse discusses the client's weight loss during a health care team meeting B. the nurse examines her own personal feelings about clients who have anorexia nervosa C. the nurse asks the client about her body image perception D. the nurse presents an educational session about anorexia nervosa to a large group of adolescents
C. the nurse asks the client about her body image perception (Rationale: the nurse's one-on-one communication with the client is an example of interpersonal communication)
A nurse is caring for the parents of a child who has demonstrated recent changes in behavior and mood. When the mother of the child asks the nurse for reassurance about her son's condition, which of the following responses should the nurse make? A. "I think your son is getting better. What have you noticed?" B. "I'm sure everything will be okay. It just takes time." C. "I'm not sure what's wrong. Have you asked the doctor about your concerns?" D. "I understand you're concerned. Let's discuss what concerns you specifically."
D. "I understand you're concerned. Let's discuss what concerns you specifically." (Rationale: this therapeutic response reflects upon, and accepts, the parents' feelings, and it allows them to clarify what they are feeling.)
Which is an example of an interpersonal intervention for a client on an inpatient psychiatric unit? A. assist the client to note common defense mechanisms and coping skills that are being used B. discuss "acting out" behaviors, and assist the client in understanding why they occur C. ask the client to use a journal to record thoughts he or she is having behavior acting out behaviors occur D. ask the client to acknowledge one positive person in his or her life to assist the client after discharge
D. ask the client to acknowledge one positive person in his or her life to assist the client after discharge (Rationale: interpersonal theory states that individual behavior and personality development are the direct result of interpersonal relationships. The identification of a positive relationship is an intervention that reflects interpersonal theory.)
A charge nurse is conducting a class on therapeutic communication to a group of newly licensed nurses. Which of the following aspects of communication should the nurse identify as a component of verbal communication. A. personal space B. posture C. eye contact D. intonation
D. intonation (Rationale: the nurse should identify itonation as a component of verbal communication. It is the tone of one's voice and can communicate a variety of feelings)
A nurse in an acute mental health facility is communicating with a client. The client states, "I can't sleep. I stay up all night." The nurse responds, "you are having difficulty sleeping?" Which of the following therapeutic communication techniques is the nurse demonstrating? A. offering general leads B. summarizing C. focusing D. restating
D. restating (Rationale: restating allows the nurse to repeat the main idea expressed)
Which assessment is most important when evaluating signs and symptoms of mental illness? A. the decreased amount of creativity a client exhibits B. the inability to face problems within one's life C. the intensity of an emotional reaction D. the client's social and cultural norms
D. the client's social and cultural norms (Rationale: the context of cultural norms determines if behaviors are considered acceptable or aberrant. Belief in reincarnation can be acceptable in one culture and considered "delusional" in another.)
