Chp 9
19. During a therapy session, a client reveals that he masturbates eight to ten times daily and feels powerless to stop doing so, despite the fact that his behavior causes him shame and self-loathing. This client is exhibiting which of the following problems? A) Compulsion B) Obsession C) Dyssomnia D) Paramnesia
Ans: A Feedback: Compulsions are insistent, repetitive, intrusive, and unwanted urges to perform an act contrary to one's ordinary wishes or standards. An obsession is characterized by intrusive thinking; dyssomnias are disorders in which a client has difficulty with the amount, quality, or timing of sleep; paramnesia is the falsification of memory.
16. A hospital patient is unwilling to enter the unit's shower room, stating, "That's the place where the special forces lie in wait." The nurse would recognize that this patient may have what kind of delusion? A) Persecution B) Nihilism C) Grandeur D) Somatic
Ans: A Feedback: Delusions of persecution involve a perception that a person is under threat or being singled out for harassment. A nihilistic delusion involves the denial of a body part or self, and a delusion of grandeur is a misperception of importance.
8. A male client has been diagnosed with schizophrenia. Of the following facts, which one would be the most important factor in determining whether or not the client would be diagnosed with a mental disorder? A) The client is unable to continue his school work and has been sitting on his bed for three days. B) The client has been receiving good grades in college and has a GPA of 3.8. C) The client used cocaine up until one week ago. D) The client's father died in a tragic automobile accident when he was 10 years old.
Ans: A Feedback: Disturbance in functional status, or activities of daily living, is the most important factor in determining whether or not a mental disorder is present. Other data in the answers listed could be present even in the absence of mental disorder.
6. Which of the following statements made by a client would indicate that she has delusions of grandeur? A) "I am a magician, and my magic powers are good when the moon is full." B) "I let my baby die. I don't deserve to live." C) "I hear messages from aliens that tell me to steal cars." D) "I can't eat this food. It's poisoned."
Ans: A Feedback: The correct answer is the only statement that reflects that the client believes she has powers, abilities, or characteristics that go beyond those of normal individuals (delusions of grandeur).
11. A 20-year-old patient who has a diagnosis of schizophrenia frequently experiences delusions of persecution. At the prompting of the client's mother, the nurse attempts to determine the character and severity of these delusions on a particular day. In doing so, the nurse is conducting what type of assessment? A) Comprehensive B) Focused C) Screening D) Secondary
Ans: B Feedback: A focused assessment includes the collection of specific data regarding a particular problem as determined by the client, a family member, or a crisis situation. A comprehensive assessment is broader in scope, while a screening assessment aims to identify the presence or absence of health problems.
15. The nurse has entered a hospital patient's room and asked him if he plans to attend the morning's scheduled group life-skills session. Which of the following responses should signal the presence of thought blocking to the nurse? A) "Warning, warning, watch your back." B) "I might. I'll give it some...." C) "Well, that's certainly the end of that." D) The client makes eye contact with the nurse but does not respond verbally.
Ans: B Feedback: Blocking refers to a sudden stoppage in the spontaneous flow or stream of thinking or speaking for no apparent external or environmental reason. Clanging involves perceived similarities in meaning between words of similar sound ("morning"; "warning"). Mutism is the absence of a verbal response.
18. A well-known client with a diagnosis of schizophrenia has been brought to the emergency department by police after causing a disturbance in a store. Which of the nurse's assessment questions would best identify whether the client has insight into his illness? A) "Why do you think the police brought you here?" B) "Do you think that you're sick?" C) "Has anything like this happened to you before?" D) "Do you ever hear voices or see things that other people do not see?"
Ans: B Feedback: Insight is defined as self-understanding about the origin, nature, and mechanisms of one's attitudes and behavior; it can often be ascertained by asking whether the client believes himself to be in need of treatment. Asking a client about hallucinations or previous encounters with the law or the medical system is less likely to reveal the client's presence or absence of insight.
20. Which of the following clients or patients is exhibiting the signs of primary insomnia? A) Jason, who has delusions of persecution and drinks copious quantities of energy drinks to remain vigilant B) Mr. Kwan, whose debts and business problems have caused him great stress in recent months. C) Mrs. Fleming, who has frequent awakenings since becoming depressed D) Amber, a methamphetamine user who sometimes goes several nights without sleep.
Ans: B Feedback: Primary insomnia is caused by emotional discomfort such as chronic stress. It is not caused by the direct physiologic effects of a substance or a general medical condition. Secondary insomnia is the inability to initiate or maintain sleep or nonrestorative sleep due to a psychiatric disorder such as depression, schizophrenia, or substance abuse.
4. When differentiating a tactile hallucination from a gustatory one, the nurse understands that a gustatory hallucination is evidenced by what? A) An unusual sensation not felt by others B) A complaint of tasting something unusual C) Hearing voices not based in reality D) Seeing things that are not there
Ans: B Feedback: Tactile hallucinations involve the sense of touch, while gustatory hallucinations involve the sense of taste. Gustatory hallucination is related to sensory perceptions of taste that occur in the absence of an actual external stimulus.
9. A mental health nurse is caring for a schizophrenic client. The nurse observes the client laughing about the recent death of her father. The nurse would correctly document this mood as which of the following? A) Blunted B) Inappropriate C) Flat D) Labile
Ans: B Feedback: The correct answer is inappropriate affect or lack of harmony between one's voice and movements with one's speech or verbalized thoughts. Blunted affect is a severe reduction or limitation in the intensity of one's affective responses to a situation. Flat affect describes absence or near absence of any signs of affective responses. Labile affect is the abnormal fluctuation of one's expressions.
5. The nurse observes a female client rubbing the chest of her asthmatic daughter with a coin. Which of the following reflects a culturally sensitive, or transcultural, response to this client? A) "Stop! You're hurting your child!" B) "What is it that you are doing right now?" C) "I'll have to inform the doctor that you are not following instructions." D) "You are making your daughter cry."
Ans: B Feedback: The correct answer reflects that the nurse is attempting to ask a question that will help her to understand the client's behaviors, which would be a culturally sensitive approach. The other answers demonstrate nonacceptance or a negative attitude from the nurse.
13. As part of a focused assessment, the nurse asked the client to describe her mood this morning. In response, the client stated, "It is what it is." Which of the following examples of nursing documentation is most appropriate? A) "Client is nonspecific about her mood." B) "Client states about her mood, 'It is what it is.'" C) "Client is currently feeling ambivalent." D) "Client feels resigned to her symptoms of depression."
Ans: B Feedback: When documenting assessment findings, it is important to use the client's own words whenever possible. Subjectively describing a client's mood or speculating about underlying meanings is inappropriate and potentially inaccurate.
2. A client has obsessive-compulsive disease, which has seriously interfered with his ability to work. To help the client, the nurse must understand that a compulsion is what? A) A feeling of unreality or strangeness concerning oneself, the environment, or both B) An insistent thought recognized as arising from the self but not controllable by the person C) A repetitive intrusive and unwanted urge to perform or performance of an act contrary to one's usual standards D) A fixed false belief not true to fact and not ordinarily accepted by other members of the person's culture
Ans: C Feedback: A compulsion is an urge to perform a behavior or the actual performance of the behavior (such as washing the hands), while an obsession is an intrusive thought that recurs, even when unwanted. Depersonalization is a feeling of unreality or strangeness, concerning self, environment, or both. Obsessions are insistent thoughts, recognized as arising from the self, which cannot be controlled. Delusions encompass fixed false beliefs not true and not ordinarily accepted by other members of the person's culture.
1. While talking with a schizophrenic client, the nurse observes that he is looking straight ahead, maintains no eye contact, and moves his facial muscles very little, even though he is telling her about a very emotional episode he just experienced with his roommate. When describing the client's affect, the nurse documents it as what? A) Labile B) Constricted C) Flat D) Blunted
Ans: C Feedback: The client's affect, or facial expression, would be described as "flat." Labile affect is the abnormal fluctuation or variability of one's expressions, such as repeated, rapid, or abrupt shifts. Constricted affect relates to a reduction in one's expressive range and intensity of affective responses. Blunted affect is a severe reduction or limitation in the intensity of one's affective responses to a situation.
3. Which of the following statements made by a client diagnosed with depression would indicate that she may have a thought disorder? A) "I'm so angry. Wait until my daughter hears about this!" B) "I'm a little confused. What time is it?" C) "I can't find my mesmer foot holders. Have you seen them?" D) "I'm fine. It's my husband who has the problem."
Ans: C Feedback: The incorrect answers reflect cognitive awareness and clear thought, while the correct answer reveals that the client has made up a new word (neologism) for her shoes, which indicates the presence of a thought disorder.
14. A former soldier has returned from a tour of duty with posttraumatic stress disorder. During a therapy session, he has been asked to describe some of the scenes he witnessed. Which of the following responses would prompt the nurse to document the client's affect as flat? A) The client describes the death of a fellow soldier in darkly comic terms. B) The client fights back tears when describing a fellow soldier's suffering from injuries. C) The client adamantly refuses to describe what he witnessed overseas. D) The client provides a factual but monotone and nonexpressive description of wartime events.
Ans: D Feedback: A flat affect is characterized by an absence or near absence of any signs of affective responses, such as an immobile face and monotonous tone of voice.
12. A nurse who provides care at a community mental health center (CMHC) is conducting an assessment of a new client who has long-standing diagnosis of major depression. How can the nurse best assess the client's perspective of her mental health problem? A) "Have you had any thoughts of suicide in the past 24 hours?" B) "Do you have a family history of depression?" C) "Have you been taking your medications consistently?" D) "What do you think has contributed to your depression in the past?"
Ans: D Feedback: Asking for a client's explanation of the etiology and contributing factors to his or her disease can provide insight into the client's overall perspective of the illness. Questions about medications, family history, and medication use are appropriate assessment questions, but they do not ascertain the client's perspective of her illness.
7. During a conversation, the client states, "It's raining outside and raining in my heart. Did you know that St. Valentine used to visit jails? I've never been to jail." The nurse assesses that the client is experiencing a speech pattern commonly seen in manic episodes called what? A) Perseveration B) Circumstantiality C) Neologisms D) Flight of ideas
Ans: D Feedback: Flight of ideas is the expression of multiple, unrelated ideas in a string of statements. Neologisms are new words, circumstantiality is when the client speaks about topics that are loosely related with each other, and perseveration is the repetition of words or ideas over and over.
10. A manic client recently admitted to a locked ward in the psychiatric unit is talking with the nurse. He states, "The car is red. Are you ready for lunch? My head is hurting. Dogs bark loud." The client is exhibiting which type of speech? A) Echolalia B) Clang association C) Neologism D) Looseness of association
Ans: D Feedback: Looseness of association is a disturbance of thinking shown by speech in which ideas shift from one unrelated, or minimally unrelated, subject to another. Echolalia is the parrot-like repetition of overheard words or phrases. Clang association is a type of thinking in which the sound of a word (rhyming) substitutes for logic during communication. Neologism describes the use of a new word or combination of several words coined or self-invented by a person and not readily understood by others.
17. During the scheduled assessment of a patient who is experiencing acute alcohol withdrawal, the nurse has identified that the patient does not know where he is and that he feels like there are bugs crawling on his forearms. The nurse would document the presence of what? A) Olfactory hallucinations and delusions B) Perseveration and lack of orientation C) Looseness of association and lack of insight D) Disorientation and tactile hallucinations
Ans: D Feedback: The fact that an individual does not know his or her present location constitutes a lack of orientation; feeling a sense of touch from an object that is not present is an example of a tactile hallucination.
