Mental Health Final Review
Which statement made by the nurse would be most appropriate to an 89-year-old client who is confused but has no history of dementia and is hospitalized for an acute urinary tract infection?
"I know things are upsetting and confusing right now, but your confusion should clear as you get better"
The nurse has entered a hospital client's room and asked the client if the client plans to attend the morning's scheduled group life-skills session. Which response should signal the presence of thought blocking to the nurse?
"I might. I'll give it some...
A nurse is working with an adolescent client with a diagnosis of conduct disorder. The nurse is helping the client reflect on a situation in which the client became aggressive and asks how the client could have handled it differently. The nurse is employing which intervention
improving coping skills and self-esteem
The nurse is conducting a health history of a 35-year-old male client with a history of intermittent explosive disorder, diagnosed in adolescence. The nurse should include an assessment of which health issue?
increased blood pressure
When analyzing the behaviors of a client who meets the criteria for antisocial personality disorder, the nurse recognizes that which nursing diagnoses would be pertinent to the client's care?
ineffective coping
Termination takes place during the resolution phase of a nurse-client relationship. During the termination process, a client brings up resolved problems and presents them as new issues to work toward. The nurse interprets the client's action as indicating what? The client:
is attempting to prolong the nurse-client relationship.
A psychiatric nursing class is discussing current trends in mental health care. A student voices the opinion that there should be equitable access to mental health care and resources for those who live in rural areas, for those without health insurance, and for those with very little income. The student nurse's opinion most closely reflects which ethical principle?
nonmaleficence, paternalism, veracity
A school health nurse is seeing an 11-year-old child who is refusing to attend school for the past 3 weeks. On assessment, the child describes a recent school experience where the child has been deliberately isolated from social groups. The child tells the nurse this began after an argument with their "best friend". The child is describing:
ostracism
A nurse is caring for a client with delirium who is experiencing illusions. What environmental conditions should the nurse arrange for this client?
provide a well-lit room without glare or shadows and limit noise
A school health nurse is meeting with the parents of a 6-year-old child who has been selectively mute. The nurse is offering the parents education regarding this problem. The nurse can tell the parents that what is true about selective mutism?
selective mutism is associated with social anxiety
The nurse indicates interest in and acceptance of the client by all of the following except:
sitting behind a desk
The nurse enters the client's room and finds the client anxiously pacing the floor. The client begins shouting at the nurse, "Get out of my room!" The best intervention by the nurse would be to:
stand at the doorway and say, "You seem upset."
A client has just been served divorce papers from a spouse. The client has no financial resources and little social support. The client states, "My spouse is not really leaving. My spouse will be back." The most appropriate response by the nurse would be what?
"How is this affecting you right now?"
A client has repeatedly been physically abused by the spouse. The client asks the nurse whether to leave the spouse like the mother has demanded. The nurse responds most therapeutically when answering:
"How would leaving your spouse make you feel?"
A client is being discharged from treatment for addiction to cocaine. Which statement made by the client would cause the most concern for the nurse?
"I can still hang out with my old friends. I am just not going to use."
The nurse on an addictive disorders unit receives a phone call inquiring about the status of a client. The caller is not on the client's allowed contact list. Which is the appropriate response by the nurse to the caller?
"I cannot confirm or deny the existence of any client here."
The nurse is caring for a client with schizophrenia. The client tells the nurse, "My dead mother is calling me, I will finally be with her tonight. Please do not tell anyone." What is the most appropriate nursing response?
"I cannot keep this a secret. I will ensure that the staff helps keep you safe."
A client checks and rechecks the lock on the door five times before leaving home. What statement by the client indicates that this behavior is a result of obsessive-compulsive disorder (OCD)?
"I check until my anxiety subsides."
A client with schizophrenia is seen sitting alone and talking out loud. Suddenly, the client stops and turns as if listening to someone. The nurse approaches and sits down beside the client. Which is the best response by the nurse?
"I don't hear or see anyone else; what are you hearing and seeing?"
A nurse's colleague expresses sympathy for a client who is traumatized following a terrorist attack 1 week earlier. The colleague states, "I'm certain that the client has posttraumatic stress disorder (PTSD)." What is the nurse's best response?
"Acute stress disorder is a possibility, which might develop into PTSD."
A nurse is working with a client who has frequent angry outbursts. Which statement is most helpful when working with this client?
"Anger is a normal feeling, and you can use it to solve problems."
The mental health nurse assesses for the most common mental health disorder found in children when asking which question?
"Do you ever get scolded at school for not sitting still?
A client will be taking disulfiram after discharge from an alcohol treatment program. Which statement would indicate that teaching has been effective?
"Drinking alcohol while taking disulfiram can cause dangerous symptoms.", "If I drink while taking disulfiram, it will make me vomit before the alcohol affects me."
A nurse is seeing an adolescent with a diagnosis of conduct disorder for the first time to establish goals for treatment. During the first meeting, the adolescent yells a profanity at the nurse and states, "This is pointless." What is the nurse's best response?
"I want to continue to work with you but I don't accept the language you have chosen."
A client asks the nurse, "How can I tell if what I am experiencing is just regular worrying and not an anxiety disorder?" What is the nurse's best response?
"If you are unable to function occupationally and socially because of the anxiety"
An elderly client who lives alone is beginning to have difficulty maintaining the household and performing daily tasks. The nurse asks the client to identify someone who can help. The client replies, "I don't need help. I've been managing for years." Which response helps the client shift from denial to consciously coping with the situation?
"If you were to need help with your house, who might you ask for help?"
A client asks the nurse, "What is Alcoholics Anonymous all about?" Which is the best response by the nurse?
"It is a self-help group for which the norm is sobriety."
The client asks the nurse, "What does somatization mean?" What should the nurse reply?
"It means that stress and/or emotions are causing your symptoms."
Which statement made by the nurse to the family of a client diagnosed with obsessive-compulsive disorder (OCD) demonstrates the best general understanding of the chronic nature of the disorder and its management?
"It's important to know that the symptoms will intensify during periods of stress."
A nurse is presenting to a church group a program about domestic violence. During the presentation, a member of the audience asks the nurse to explain what "intergenerational transmission of violence" means because the person has seen that phrase used in the media. Which response by the nurse would be most appropriate?
"People who grow up in violent home situations tend to be involved in domestic violence situations as an adult."
The adult child of a client with dementia asks the nurse if the client will ever be able to live independently again. Which would be the most appropriate response by the nurse?
"Symptoms of dementia gradually get worse. Unfortunately, the client will not be independent again."
After an angry outburst, the client is tearful and remorseful. Which statement by the nurse would be most supportive?
"What could you have done when you first started to feel angry?"
The nurse approaches a client who looks very sad and is sitting alone crying. Which is the best response by the nurse in this situation?
"You look very sad. What is happening?"
A nurse is caring for a 10-year-old child with conduct disorder. The child starts throwing stones at the staff. What statement made by the nurse to control the child's behavior is most appropriate?
"You may injure people around you. If you feel angry, you could always come and talk to me or another nurse."
A client says, "It's been so long since I've been with my family." Which statement by the nurse is an example of restating?
"You say you haven't seen your family in a while."
The client asks the nurse, "What will happen if I drink while taking disulfiram?" What should be the nurse's reply?
"You will experience a severe reaction, including a throbbing headache and vomiting."
The nurse working in the psychiatric unit observes that the African American clients experience more side effects from psychotropic drugs compared to the White clients. This is most likely for which reason?
African Americans metabolize psychotropic drugs more slowly
A client reports drinking one to two drinks when drinking behavior first began. Now the client reports drinking at least six drinks with every episode in order to "have a good time." Which term would best describe this?
Tolerance
While talking with a schizophrenic client, the nurse observes that the client is looking straight ahead, maintains no eye contact, and moves facial muscles very little, even though the client is telling the nurse about a very emotional episode the client just experienced with a roommate. When describing the client's affect, the nurse documents it as what?
Blunted
A 15-year-old female is admitted for treatment of anorexia nervosa. Which is characteristic of anorexia nervosa?
Body weight less than normal for age, height, and overall physical health
Which eating disorder is characterized by consuming an amount of food much larger than a person of near-normal weight would normally eat? Afterward, the client may purge the food or exercise excessively, and between binges, the client may eat low-calorie foods or fast
Bulimia nervosa
Which of the following groups could benefit most from prevention programs?
Children, prior to first use, Teenagers
Anxiety disorder is considered chronic and generalized when excessive anxiety and worry about two or more life circumstances exist for at least ...
6 months
A psychiatric-mental health nurse is working on developing cultural competence. Which would be most appropriate for the nurse to do?
Demonstrate an appreciation of, and a genuine interest in, the individual and his or her cultural beliefs
The nurse is conducting an admission assessment of a 41-year-old client. Each time that the nurse asks the client a question, the client defers to the client's spouse to answer the question. Such behavior is consistent with which personality disorder?
Dependent personality disorder
The nurse is caring for a client with somatic symptom disorder. When assessing this client, the nurse would be especially alert for symptoms of what?
Depression
The nurse is teaching the family of a client who has bulimia about nutritional needs. Which dietary pattern would be most helpful to assist the client in recovering from bulimia?
Encourage the entire family to engage in a balanced and regular dietary pattern
Which losses are likely to result in disenfranchised grief? Select all that apply.
A middle aged adult whose dog has just died, A nurse who has just witnessed the death of a client, A couple who has just experienced pregnancy loss, The gay lover of a client who just died from AIDS
Which client is most likely suffering from dementia
A 90-year-old who has experienced progressive mental decline that started with forgetfulness
Which client is most likely to be diagnosed with body dysmorphic disorder (BDD)?
A client who firmly believes that everyone who sees the client fixates on the size of the client's ears
Which client is most likely to benefit from the administration of selective serotonin reuptake inhibitors (SSRIs)
A client whose obsessive-compulsive disorder (OCD) has not responded to cognitive- behavioral therapy, A client whose unusual pattern of hair loss has been attributed to a mental health disorder, A client who has diffuse skin lesions as a result of excoriation disorder, A client whose family is deeply concerned that the client may have hoarding disorder
The client has begun to wash the hands every hour due to the fear of germs becoming embedded in the client's skin leading the client to develop cancer. The nurse interprets this behavior as indicating which condition?
A compulsion
An adult client is put in restraints after all other attempts to reduce aggression have failed. Which is required now that restraints have been instituted?
A face-to-face evaluation by a licensed independent practitioner within 1 hour of restraint
What does the nurse teach the client with obsessive-compulsive disorder about relaxation techniques?
A friend should assist with relaxation therapy., They help to eliminate ritualistic behavior completely., Relaxation techniques should be practiced whenever possible., Relaxation techniques should be attempted when anxiety subsides.
Which client should the nurse assess most closely for signs and symptoms of posttraumatic stress disorder (PTSD)?
A service member in the military who has recently returned from two tours of duty
Which assessment finding can help the nurse differentiate a child experiencing child neglect rather than child abuse?
A young child is admitted to the hospital with hypothermia because the child is inadequately dressed
A client was admitted to an inpatient unit with a diagnosis of dementia. A nursing assessment and interview of the client would include what?
Intellectual ability, health history, and self-care ability
Which phase of the aggression cycle is defined as occurring when an event or circumstance in the environment initiates the client's response?
Triggering
The nurse teaches an antisocial client to take a time-out in his room when challenged by another person instigating an argument. What is the main reason for the time-out?
It allows an opportunity for the client to regain control of emotions.
Which personality disorder is characterized by a pervasive pattern of grandiosity, need for admiration, and a lack of empathy?
Narcissistic
Which characteristic of the abuser should the nurse look for when completing the family assessment of a victim of intimate partner violence?
Needy and possessive of the partner
The nurse is assessing the new grieving widow. Which are critical components to assess in a grieving person? Select all that apply.
Perception of the loss, Support system, Coping behaviors, Religion
If the client provides a literal explanation of a proverb and cannot interpret its meaning, which thought process is lacking?
Abstract thinking
In which ways can anticipatory grief be helpful for the client and family?
Acceptance of impending death
A client diagnosed with hypochondriasis reports to the nurse that others doubt the seriousness of the client's illness. The client is angry, frustrated, and anxious. Which nursing intervention takes priority?
Acknowledge the client's frustrations without fostering continued focus on physical illness
A client with depression who is undergoing a colonoscopy tomorrow is receiving preoperative education regarding the procedure. Which nursing task best describes the explanation of the procedure and the associated risks and benefits?
Acquiring informed consent, Acting in a beneficent manner
When assessing a client with dementia, the nurse notes that the client is having difficulty identifying common items, such as a ball or book. The nurse interprets this finding as what?
Agnosia
A mental health client has been prescribed clozapine for the treatment of schizophrenia. The nurse should be alert to which potentially life-threatening adverse effects of this medication?
Agranulocytosis
A psychiatric-mental health nurse works to avoid using non therapeutic communication techniques when engaging with clients. Which techniques would the nurse most likely avoid using? Select all that apply.
Agreeing, Challenging, Disapproving
A client is admitted for major depression. The client has stated that nothing seems to bring him pleasure anymore. What should the nurse expect to find during assessment?
Anhedonia, feelings of worthlessness, and difficulty focusing
Fluoxetine has been approved for the treatment of anorexia nervosa. Fluoxetine is from which drug classification?
Antidepressant
A 13-year-old child is constantly involved in breaking tables and chairs at school. On further assessment, the nurse finds that the child has conduct disorder. Which condition is the child most likely to develop in the future if not treated effectively for this condition?
Antisocial personality disorder
A client has just been diagnosed as having major depression. At which time would the nurse expect the client to be at highest risk for self-harm?
Approximately 2 weeks after starting antidepressant medication
Seclusion and restraint are nursing interventions to be used for an individual in which situation?
As a last resort
A 22-year-old client who has just ended a 2-year relationship with a woman he planned to marry states that he is confused about his life and feels hopeless about his future. Which of the following nursing responses would be most therapeutic?
Ask him what is important to him
After teaching a group of nursing students about pharmacotherapy and attention deficit hyperactivity disorder (ADHD), the instructor determines that the education was successful when they identify which agent as the second line choice?
Atomoxetine
A nurse is working in a psychiatric-mental health facility. The nurse observes a client pacing and punching the wall. Which measure can the nurse take for personal safety?
Avoid being alone with the client
Safe alcohol withdrawal usually is accomplished with the administration of which medication classification?
Benzodiazepines
A group of nursing students is reviewing information about grief and bereavement. The students demonstrate understanding of the information when they state:
Bereavement is the process of mourning and grief is the emotional reaction.
When discussing various types of anxiolytic medications with a client, the nurse recognizes that which medication has the lowest potential for abuse?
Buspirone
An angry client has just thrown a chair across the room and is racing to pick up another chair to throw. The most appropriate action by the nurse would be what?
Call for an emergency response from trained personnel
The client has been diagnosed with schizophrenia and is showing the following symptoms: immobility, rigidity, and stupor. These symptoms can be further classified as which characteristic symptoms of schizophrenia?
Catatonic
A psychiatric-mental health nurse is working with several clients and decides to use silence during the interaction. In which situation would it be therapeutically appropriate to use silence? Select all that apply.
Client who is experiencing depression, Client who is lost in own thoughts, Client who is constructing a response, Client who is pondering the question
What is the primary difference between anorexia nervosa and bulimia nervosa?
Clients who are anorexic are proud of their control over eating, and clients with bulimia are ashamed of their behavior.
A client spends hours stacking and unstacking towels. The client is repeatedly checking to make sure that the towels are in order of color. What term is used to identify this behavior?
Compulsion
The mental health nurse explains that the difference between an obsession and a compulsion can correctly be identified as what?
Compulsion involves repeating a purposeful action
Asking the client to complete serial sevens assesses what?
Concentration
A client has lost emotional and physical control. The client is shouting, screaming, hitting others, and throwing objects. Which phase of the aggression cycle is this client expressing?
Crisis
Which statement about culture is true?
Cultural identity reflects what determines behavior
A client with bipolar disorder is admitted to the psychiatric unit. The client is talking loudly, walking back and forth rapidly, and exhibiting a short attention span. Which nursing intervention should occur first?
Decrease the client's environmental stimuli.
The client has been diagnosed with depression. He asks the nurse what imbalances influence depression. Which of the following best explains the neurochemical processes responsible for depression?
Decreased serotonin and norepinephrine activity
A patient who had been in a substance abuse treatment program asks the nurse for a date after the patient is discharged. The nurse talks to the patient about the importance of a therapeutic relationship and its characteristics. The nurse is using which technique?
Defining boundaries
A client with schizophrenia states that the client is God's messenger and the client's mission is to become president. The nurse documents these comments as evidence of what?
Delusional thinking
The nurse is questioning the family of a client brought in with cognitive impairment as the nurse assesses and evaluates the client's condition. Which distinguishes delirium from dementia?
Dementia has a gradual onset and is progressive in course
The nurse working with pediatric clients knows the importance of checking for developmental delays, which not only slow the child's progress but also are often associated with what?
Development of poor self-esteem
A client diagnosed with body dysmorphic disorder (BDD) will primarily focus on what?
Discussing real or imagined defects in appearance, such as having a "long" nose
A client in a psychiatric clinic has a history of two distinct personality states. The client is also unable to remember important personal information. What is the client likely to be suffering from?
Dissociative amnesia, Dissociative identity disorder, Derealization disorder, Acute stress disorder
A nurse is preparing a plan of care for a client diagnosed with body dysmorphic disorder. Which nursing diagnosis would the nurse likely identify as the priority?
Disturbed body image
Positive symptoms of schizophrenia, specifically hallucinations and delusions, are thought to be caused by hyperactivity of which neurotransmitter?
Dopamine
In what phase of the therapeutic relationship does the assessment process begin?
During the initiating or orienting phase
Which is likely to be most effective for adolescents with conduct disorder?
Early intervention
In teaching a client who has been prescribed a benzodiazepine for panic disorder, the nurse must be certain to do what?
Educate the client that this medication has a high risk for withdrawal symptoms, and the client should not discontinue without a doctor's supervision.
Which of the following would be most supportive for family and friends of a client with an eating disorder?
Emotional support, love, and attention
Which is the most important skill the nurse must bring to the therapeutic nurse-client relationship?
Empathy
When comparing social relationships with therapeutic relationships, the nurse understands that therapeutic relationships do what?
Encourage personal goal setting
In the psychiatric setting, what is the most effective intervention in preventing the hostile client's behavior from escalating to physical aggression?
Engaging the hostile person in dialogue
A 33-year-old client has been treated for a periorbital hematoma and a broken nose that the client suffered when the client's spouse struck the client. The client does not know where the client currently is, and the client is scheduled for discharge. What action should the care team prioritize in this client's care?
Ensuring that the client goes to a safe place
Which is a dental complication associated with purging?
Erosion of dental enamel
Which goal of therapeutic communication would the nurse strive to attain first?
Establish a therapeutic nurse-client relationship
For a client diagnosed with anorexia nervosa, which goal takes priority?
Establishing adequate daily nutritional intake
Which of the following is a psychosocial explanation for the development of personality disorders?
Failure to complete a developmental task jeopardizes future personality development.
The inappropriate use of restraints or seclusion is considered which form of intentional tort?
False imprisonment
The nurse has completed the psychosocial assessment. Which is the best approach toward analysis of the data to identify nursing diagnoses and develop an appropriate plan of care?
Focus individually on each piece of information obtained from the client., Look for patterns reflected in the overall assessment., Consider only the abnormal findings in the assessment., Present all data obtained in the treatment team meeting
Before eating a meal, a client with obsessive-compulsive disorder must wash the hands for 14 minutes, comb the hair for 114 strokes, and switch the light off and on 44 times. When evaluating the progress of the client, what is the most important objective for this client?
Gradually decrease the amount of time spent for performing rituals
Which would the nurse expect to assess in a client with narcissistic personality disorder?
Grandiose and superior self-concept
A client with delusional disorder tells the nurse that the client has discovered how to jump to the moon. The nurse would document this belief as what?
Grandiose delusion
A child is taking methylphenidate for treatment of attention deficit hyperactivity disorder (ADHD). Which side effect much be monitored in this child?
Growth delays
The client is an 84-year-old suffering from delirium. The client has been in a nursing home for the past 2 years but recently is becoming combative and has become a threat to staff. Which medication would the client most likely receive for these symptoms?
Haloperidol
Which would be an appropriate intervention for a child diagnosed with conduct disorder?
Have the child accept responsibility for individual behavior
Which would most likely be a type of behavior that would be manifested by a client who has histrionic personality disorder?
Having a tantrum if not getting enough attention
A client has posttraumatic stress disorder (PTSD) following a disaster that resulted in mass casualties. What question should the nurse prioritize when exploring the physical dimensions of this client's PTSD?
How would you describe the quality and quantity of your sleep since the incident?
Which area of the brain has been associated with the symptoms of eating disorders?
Hypothalamus
A nurse is providing education about trauma and its effects to a community group in a community that has just been hit by a devastating tornado. One of the participants asks about what kind of support a survivor of the tornado will need. Which would be the best response of the nurse?
If a person is reluctant to share his or her feelings, he or she may be denying his or her importance and may be at increased risk for future problems such as posttraumatic stress disorder (PTSD)
A client is seen in the primary care clinic reporting headaches. The client appears extremely distressed and insists that the client must have a brain tumor. Which mental health diagnosis is most probable for this client?
Illness anxiety disorder
All of the following nursing diagnoses are appropriate for the care of a client with anorexia nervosa. Which nursing diagnosis has the highest priority?
Imbalanced nutrition: less than body requirements
A mental health nurse is caring for a client with schizophrenia. The nurse observes the client laughing about the recent death of the client's father. The nurse would correctly document this mood as what?
Incongruent
The nurse is assessing a client and finds two enlarged supraclavicular lymph nodes. The nurse asks the client how long these enlarged nodes have been there. The client states, "I can't remember. A long time I think. Do I have cancer?" The nurse is aware that that body responds to stress. Which is an immediate physiologic response to stress the nurse would expect to see in this client?
Increased blood pressure
A nurse is providing education to a group of parents who have children with attention deficit hyperactivity disorder (ADHD). Which statement would be accurate and should be included in the education? Select all that apply.
It is important for parents of children with ADHD to learn how to rebuild their child's self-esteem., Because raising a child with ADHD can be frustrating and exhausting, it often helps parents to attend support groups that can provide information and encouragement from other parents with the same problems., ADHD is not the fault of the parents or the child and techniques and school programs are available to help
A nurse is working with a client who has a history of repeated abusive intimate relationships. The nurse has difficulty understanding why a person would repeatedly enter into relationships with abusive partners. When working with this client, the nurse can best maintain a therapeutic relationship through which approach?
Keeping focused on the client's feelings about the client's life situation
After educating a group of students on attention deficit hyperactivity disorder (ADHD), the instructor determines that additional education is required when the group identifies which as a typical characteristic?
Language difficulty
Which would be the most appropriate intervention for an adolescent who is frequently manipulative and exhibits aggressive behaviors?
Limit setting
The client suffers from bipolar disorder. The client is experiencing a downward spiral. For which one of the following drugs should the nurse expect the client to require serum level monitoring?
Lithium
A client with psychosis who was recently admitted to a psychiatric unit says to the nurse, "The car is red. Are you ready for lunch? My head is hurting. Dogs bark loud." The client is exhibiting which type of speech?
Loose associations
A nurse is gathering information regarding discharging a client and documenting the client's support system. Which are factors in family support?
Loving and caring
Which is the drug of choice for a tic disorder?
Risperidone
The nurse is caring for a client who was in a motorcycle accident 2 months ago. The client says the client still has terrible neck pain, but the client will be better once he gets "a big insurance settlement." What condition might the nurse suspect?
Malingering
Which is the most effective intervention for clients with delirium?
Managing environmental stimuli
Which medication is the most effective treatment for attention deficit hyperactivity disorder (ADHD)?
Methylphenidate
Antisocial personality disorders are assessed with which tool?
Milton Clinical Multiaxial Inventory (MCMI)
A client is admitted for a drug overdose with a barbiturate. Which is the priority nursing action when planning care for this client?
Monitor respiratory function
Schizoaffective disorder has symptoms typical of both schizophrenia and which type of disorder?
Mood disorders
When a client is experiencing panic, which is the priority intervention?
Move the client to a quiet environment
A client is admitted to the mental health unit because the client was found trying to inject diluted feces into the client's hospitalized child's intravenous line. The client has a history of similar attempts of harming the child. The nurse would most likely suspect what?
Munchausen's syndrome by proxy
Which drug reverses opioid toxicity?
Naloxone
Which ethical principle focuses on the duty to do no harm?
Nonmaleficence
It is the nurse's responsibility to define the boundaries of the relationship during which phase of the nurse-client relationship?
Orientation
While assessing the family dynamics of a client with an eating disorder, which of the following does the nurse most likely discover?
Over controlling parents
A nurse's response to aggressive behavior on the unit is influenced by the which ability of the nurse?
Own awareness and reaction to aggression
A nurse is caring for a client in the mental health unit. The client states, "They are poisoning my food by telepathy." This is an example of which type of delusion?
Paranoid
Which disorder is characterized by pervasive mistrust and suspiciousness of others?
Paranoid personality disorder
A client with schizophrenia believes that the cook at the psychiatric hospital is trying to poison the client. The nurse would record this type of delusion as what?
Persecutory
When assessing a client who has been referred to the outpatient mental health clinic with symptoms of depression, the psychiatric nurse should closely observe the client's affect and which assessment component?
Physical appearance
A client with dementia becomes extremely agitated shortly after being admitted to the psychiatric unit. The nurse is reluctant to use physical restraints to control the client. What is a likely reason the nurse has this reluctance?
Physical restraints may increase the client's agitation
A visitor comes to see a client who is suicidal. Upon entering the unit, the nurse notices that the visitor has brought the client a can of his favorite soda. Which action should the nurse take at his time?
Pour the soda into a plastic cup
The nurse in an psychiatric inpatient facility encourages clients to attend daily prayer sessions. What is the most likely reason for the nurse's action? Choose the best answer.
Prayer helps in coping with stress.
What kind of behavior does the nurse anticipate observing when treating a client obsessed with blasphemous thoughts?
Praying repeatedly
A family member of an adolescent who has expressed a desire to commit suicide asks the nurse, "What might predict the possibility of future suicide attempts?" Which would the nurse include in the response?
Previous suicide attempt
The community health nurse meets with the family members of an elderly client. The nurse includes which in the plan of care as a preventive measure to guard against elder abuse?
Provide the primary caregiver with additional resources to meet the elder's needs
The psychiatric nurse correctly identifies the client's form of communication as circumstantiality when the client does what?
Provides long, irrelevant explanations when asked why the client abuses alcohol
Which zone is an acceptable distance between a speaker and an audience?
Public
During which phase of the aggression cycle does the client regain physical and emotional control?
Recovery
The nurse is caring for clients in the outpatient unit. Which would be key points for the nurse to remember when working with clients who are suffering from anxiety disorders?
Remember to practice techniques to manage stress and anxiety in the nurse's own life.
Which is the primary objective of nursing interventions in the care of a client with anorexia nervosa?
Restoring nutritional status to normal
The nurse is educating the client's family about compulsive behavior. The nurse is correct when making which statement?
The behavior neutralizes anxiety caused by obsessive thoughts
A client with somatic symptom illness tells the nurse that the client is sick so often that the client's spouse and children take over most of the household duties, such as cooking, cleaning, doing laundry, and so forth. Which is this evidence of?
Secondary gain
Which characteristic would be most prevalent in an individual demonstrating low self-efficacy?
Self-doubt
Which thought process would cause a client with antisocial personality disorder to want to do everything for himself?
Sense of mistrust of others
Which medication classification has been shown to be effective in some cases of somatoform disorders?
Serotonin reuptake inhibitors (SSRIs)
Which behavior would first alert the school nurse or teacher to suspect sexual abuse in a 7-year-old child?
The child tells sexually explicit stories to peers
The client is 42 years old, married, and has two children, ages 16 and 18. The client is also caring for the client's parent, who is in the late stages of Alzheimer's disease. The nurse would want to assess the client for what?
Signs of stress
Which form of nonverbal communication would be least effective for the nurse to engage in to demonstrate interest in and acceptance of the client?
Sitting behind a desk
A 30-year-old client who has been unemployed secondary to anxiety disorder states that the client would like to have a job where the client is alone and no one needs to evaluate the client's work. The nurse interprets these comments as an indicator of what?
Social phobia
Which condition involves a persistent, irrational fear attached to an object or situation that objectively does not pose a significant danger?
Specific phobia
Which would be an appropriate intervention of a client experiencing a panic attack?
Staying with the client and speaking in short sentences
Which of the following neurochemical influences is a probable cause of substance abuse?
Stimulation of dopamine pathways in the brain
The parents of a child with attention deficit hyperactivity disorder (ADHD) bring the child for a follow-up visit. During the visit, they tell the nurse that the child receives the first dose of methylphenidate at about 7:30 a.m. every morning before leaving for school. The teacher and school nurse have noticed a return in the child's overactivity and distractibility just before lunch. The child's second dose is scheduled for about 12 p.m. Which might the nurse suggest as a possible solution to control the child's symptoms a bit more effectively?
Switch to a longer-acting preparation
A client comes to the clinic for an evaluation. During the interview, the client states that the client feels insects crawling all over the skin on the client's arms and legs. The nurse interprets this as which type of sensorium or processing deficit?
Tactile hallucination
A client who has been discharged home on citalopram calls the nurse complaining that the medication causes her to feel too drowsy. The nurse should make which of the following suggestions?
Take the medication at night.
A concerned family member tells the nurse, "I am concerned about my brother. He has been acting very different lately." Knowing the family has a history of bipolar disorder, the nurse inquires further about this. Which behavior during the past week might indicate that the brother has bipolar disorder?
Taking unnecessary risks
A client suffered a gunshot injury in a robbery and subsequently developed posttraumatic stress disorder (PTSD). What aspect of the client's current condition was confirm that the client is experiencing hyperarousal?
The client is easily startled by sudden noises
What assessment finding would suggest to the nurse that the client with posttraumatic stress disorder (PTSD) is experiencing dissociation?
The client is often "staring into space" and has no idea how much time has passed
The nurse is assessing a client who has been unable to speak after witnessing a murder. The assessment and subsequent testing reveal no physical abnormality that may cause speech impairment. What is the most likely cause of this speech impairment in the client?
The client may be attempting to block the witnessed event to reduce anxiety
A client reports a headache. On further assessment, the nurse finds that the client has been spending long hours on a difficult project at work. What should the nurse conclude from the assessment?
The client may be stressed from work
The nurse is working in the emergency department with a client who was raped 1 hour ago. Which is most important for the nurse to remember when planning care?
The client may feel threatened by some of the procedures
The nurse is establishing outcomes for a grieving client. Which is an appropriate outcome?
The client will develop a plan for coping with the loss
Which outcome would be appropriate to determine an early favorable response to antidepressant medication?
The client will establish a balance of rest, sleep, and activity
The nurse is planning care for a client with major depression. Which is an appropriate expected outcome?
The client will independently carry out activities of daily living.
The nurse is providing care for a client who has obsessive-compulsive disorder (OCD). What aspect of this client's history was the most likely contributor to its etiology?
The client's mother had OCD
The nurse is assessing a client's risk factors for developing a substance abuse disorder. Which family characteristics would the nurse identify as a significant risk factor?
The correct answer is: One parent who is an alcoholic
The nurse finds that the client is constantly rubbing the hands. Under which component of psychosocial assessment should the nurse document this finding?
The general assessment and motor behavior component
A school nurse is educating a group of adolescent girls about rape and sexual assault. The nurse evaluates the students' understanding when they report which as a high-risk factor regarding the incidence of rape?
The highest incidence of rape occurs in adolescents and young adult women
A client is admitted to the hospital with posttraumatic stress disorder (PTSD). When approaching the client for the first time, the nurse speaks softly and gently, in a nonthreatening manner. What is the most appropriate reason for this behavior of the nurse?
To prevent the risk of triggering fears in the client
Professional regulations and laws that govern nursing practice are in place for what reason?
To protect the safety of the public
Which behavior of the nurse indicates that the nurse has a therapeutic relationship with the client?
The nurse expresses empathy to a client who has recently lost the client's son in an accident
Which observation should lead the nurse manager to recognize that countertransference is affecting the therapeutic effectiveness of an individual nurse on the unit?
The nurse frequently refers to an elderly, cognitively impaired client as "my granny"
The nurse is speaking with a client. The nurse sits with legs crossed and arms folded across the chest while listening to the client. How might the client interpret this posture of the nurse?
The nurse may be showing nonacceptance toward the client
Which would not increase the likelihood that an older adult will incur physical abuse?
The older adult is independent with activities of daily living
Which is a possible explanation for the increased risk of suicide in persons who have had a relative who committed suicide?
The relative's suicide offers a sense of "permission" or acceptance of suicide as a method of escaping a difficult situation.
Which statement regarding posttraumatic stress disorder (PTSD) and children is accurate?
The risk of developing PTSD following leukemia treatment is about the same as all children of the same age., Best practices demonstrate that adolescents who have PTSD are at increased risk of drug abuse., In a family unit where one child is diagnosed with cancer, all the children in the household are at increased risk for developing PTSD., Children who were abused during childhood are more likely to be diagnosed with obsessive-compulsive disorder rather than PTSD.
A nurse is caring for a Jewish client with a terminal illness who is on a ventilator. The spouse of the client intends to stay near the client when the ventilator is removed. What is the reason for such a request, according to the Jewish culture? Choose the best answer.
The soul of the deceased should not be alone while leaving the body
The bereaved client has worked through many processes of grief with the nurse. Which are eventual outcomes of the emotional dimension of grieving? Select all that apply.
The survivor begins to reestablish a sense of personal identity, direction, and purpose for living., The survivor begins to gain independence and confidence., The survivor develops new ways of managing life and new relationships.
A parent expresses concern to the nurse that the child's regularly scheduled vaccines may not be safe. The parent states hearing reports that they cause autism. Which is the most appropriate response by the nurse?
There has been no research to establish a relationship between vaccines and autism."
Which is the most important reason for the nurse who cares for children with conduct disorders to discuss feelings, fears, or frustrations with colleagues?
To keep negative emotions from interfering with the ability to provide care to clients with problems with aggression
The nurse is sitting with a client who is crying. After a few minutes, the nurse places one hand on the client's shoulder. Which best describes the purpose of the nurse's touch with this client?
To offer comfort and support for the client
The psychiatric nurse recognizes that excessive social communication with a client is to be avoided primarily due to which reason?
To prevent the client from viewing the nurse as a friend rather than health care provider
A nurse is considering using restraint and seclusion for a client who is acting out. Which is the primary guideline for the use of restraint and seclusion?
Use should be limited to emergencies in which the risk of a client physically harming self, staff, or others is imminent
Which is a nonneurologic side effect of antipsychotic medications?
Weight gain
The nurse is interviewing the parents of a child with conduct disorder. Which question is appropriate for the nurse to ask?
What type of discipline do you use at home?"
The nurse is assessing the orientation of a client who belongs to the religious group Jehovah's Witnesses. Which questions should the nurse ask this client? Select all that apply.
Where is your residence located?, What is your mother's name?, Where is your workplace located?
Which question should be avoided because it may be perceived as criticism by the client?
Why?
A client who has been grieving the loss of the client's spouse 2 weeks ago says to the nurse, "The best part of my day is when I am back at work. Is that wrong?" The nurse states to the client that work and other daily activities serve which purpose?
Working is letting you take an emotional break from grieving. There's nothing wrong with that."
After losing the client's father in a car accident, a client has started practicing effective coping strategies. According to Horowitz's stages of loss and adaptation, which stage is this indicative of?
Working through
Which client on the mental health unit should be assessed as being at highest risk for directing violent behavior toward others?
a client who has paranoid delusions and believes is being followed by members of the mafia
A nurse documents that "the client describes the recent breakup of a dating relationship with an emotionless tone and a flat facial expression." In which section of the mental status exam would the nurse have documented this statement?
affect
A student nurse is assigned to administer oral medications to a client. Which of these actions should a student nurse take if a client refuses to take prescribed oral medications?
ask the client's reason for refusing and report it to the primary care nurse
A 22-year-old client with schizophrenia is refusing antipsychotic medication. The client states, "I don't like the dopey way it makes me feel. I feel like I'm walking underwater when I take it." The nurse explains to the client, "Your schizophrenia is caused by a chemical imbalance in your brain, and this medication helps fix that chemical imbalance. You need to take it so your symptoms will get better." This conversation reflects a conflict between which two types of ethical principles?
autonomy and beneficence
A female client who has recently been diagnosed with end-stage lymphoma tells the nurse, "I need to be able to go to my son's wedding. God, will you please just give me a little more time so I can see my first grandchild?" The nurse identifies that the client is experiencing which stage of Kubler-Ross' stages of grieving?
bargaining
A student is reviewing a patient's chart before giving care. She notes the following diagnoses in the contents of the chart: "schizophrenia" and "Alzheimer's disease." Which of these diagnoses is a medical diagnosis?
both schizophrenia and Alzheimer's disease
A community health nurse visits a home and finds a child who stayed home from school to care for a younger sibling. The nurse observes that the house is cluttered and dirty. When asked about the parents, the child states he does not think his father likes him because he calls him "stupid." The nurse suspects which type of abuse?
emotional abuse
During an individual therapy session, a nurse is listening to a client describe the client's drug addiction. The client says, "I know I am doing the wrong thing for my kids, but I just can't stop using drugs." The nurse maintains eye contact and nods occasionally. The nurse responds by saying, "You're going through a difficult time." The nurse's actions and words are an example of:
empathy
A client has been referred to a mental health center by a juvenile court after being arrested for vandalism. At the mental health center, the client refuses to participate in scheduled activities. The client was seen pushing another client, causing the person to fall. Which approach by nursing staff would be most therapeutic?
establishing firm limits
What activity should be included in the first step of self-awareness?
identifying one's own values, attitudes, strengths and weakness
When a young client is disruptive, the nurse responds, "You must take a time-out." What is the expectation of a client during a time-out?
to sit in a designated place until able to regain self-control and review the episode
The client tells the nurse, "I don't think you can help me. Every time I talk to you, I am reminded of my mother, and I hated her." The nurse should recognize this as:
transference
The nurse is assessing a client who has recently received a diagnosis of posttraumatic stress disorder. When conducting this assessment, the nurse should
try to identify any strengths or skills that can be applied during recovery.
