Mental Health - Exam 1 - Evolve
A client tells the mental health nurse "I am terribly frightened! I hear whispering in my head that someone is going to kill me." Which criteria of mental health can the nurse assess as lacking? A) Self-control B) Rational thinking C) Learning and productivity D) Positive self-concept
ANS: B. The ability to think rationally is lacking for this client. The client does not have an accurate picture of what is happening that is based on reliable cognitive thinking. The statement fails to meet the criteria for any of the other options
The nurse is conducting an admission interview with a client who was raped 2 weeks ago. When asked about the rape, the client becomes very anxious and upset and begins to sob. What should be the nurse's response to the client's reaction? A) Push gently for more information about the rape because the information needs to be documented. B) Acknowledge that the topic of the rape is upsetting and reassure the client that it can be discussed at another time when she feels more comfortable. C) Use silence as a therapeutic tool and wait until the client is done sobbing to continue discussing the rape. D) Reassure the client that anything she says to you will remain confidential.
ANS: B. The best atmosphere for conducting an assessment is one with minimal anxiety on the patient's part. If a topic causes distress, it is best to abandon the topic at that time. It is important not to pry or push for information that is difficult for the patient to discuss. The use of silence continues to expect the patient to discuss the topic now. Reassurance of confidentiality continues to expect the patient to discuss the topic now
A 43-year-old client being seen in the mental health clinic states, "I have always been a practicing Jew, but in the past few months I am questioning everything. I just don't know if I believe in it anymore." Which of the following nursing diagnoses best describes the client's comment? A) Ineffective coping. B) Spiritual distress. C) Risk for self-harm. D) Hopelessness.
ANS: B. The client is expressing distress regarding his religion and spiritual well-being. The client could be experiencing ineffective coping, but this does not directly relate to his comment. There is nothing in the client's comment that would lead to the conclusion that the patient is having thoughts of harming himself or experiencing hopelessness
What three structural components comprise a nursing diagnosis? A) Problem, outcome, intervention B) Problem, related factors, defining characteristics C) Unmet need, goal, outcome criterion D) Presenting symptom, treatment, goal
ANS: B. The components of the nursing diagnosis are problem, related factors, and defining.
The mental health status of a particular client can best be assessed by considering which factor? A) The degree of conformity of the individual to society's norms B) The degree to which an individual is logical and rational C) Status placement on a continuum from health to illness D) Rate of demonstrated intellectual and emotional growth
ANS: C. Many (but not all) of the most prevalent and disabling mental disorders have been found to have strong biological influences. Therefore, these disorders can be regarded as "diseases." Visualizing these disorders along the mental health continuum is helpful
What tem is used to describe the process implemented when members of a group are introduced to the culture's worldview, beliefs, values, and practices? A) Acculturation B) Ethnocentrism C) Enculturation D) Cultural encounters
ANS: C. Members of a group are introduced to the culture's worldview, beliefs, values, and practices in a process called enculturation. Ethnocentrism is the universal tendency of humans to think that their way of thinking and behaving is the only correct and natural way. Acculturation is learning the beliefs, values, and practices of a new cultural setting, which sometimes takes several generations. Cultural encounters occur when members of varying cultures meet and interact.
The nurse best assesses the client's spiritual life by asking which question? A) "Do you practice a specific religion?" B) "To whom do you turn in times of crisis?" C) "Do you attend church regularly?" D) "What role does religion play in your life?"
ANS: D. Asking the client to define the role of religion in their life allows for discussion related to the other topics
An individual is found to consistently wear only a bathrobe and neglect the cleanliness of his apartment. When neighbors ask him to stop his frequent outbursts of operatic arias, he acts outraged and tells them he must sing daily and will not promise to be quieter. This behavior supports what conclusion about this client? A) The client is demonstrating symptoms of bipolar disorder. B) The client is demonstrating socially deviant behavior. C) The client is engaging in egocentric behaviors. D) The client is not conforming with social norms.
ANS: D. Behavior that deviates from socially accepted norms does not indicate a mental illness unless there is significant disturbance in mental functioning
In order to be most effective, the community mental health nurse involved in assertive community treatment (ACT) needs to possess which characteristic? A) Knowledge of both national and local political activism B) The ability to cross service systems C) An awareness of own cultural and personal values D) Creative problem-solving and intervention skills
ANS: D. Creative problem-solving and intervention skills are the hallmark of care provided by the ACT team
Considering mental health, what term is used to define a deviation from expectations by members of the cultural group? A) Hostility B) Lack of self-will C) Variation from tradition D) Illness
ANS: D. Deviation from cultural expectations is considered by others in the culture to be a problem and is frequently defined by the cultural group as "illness." None of the other terms are used to describe this concept
Which situation demonstrates the nurse functioning in the role of advocate? A) Providing one-to-one supervision for a client on suicide precautions B) Co-leading a medication education group for clients and families C) Attending an in-service education program to obtain recertification in cardiopulmonary resuscitation D) Negotiating with the client's HMO for extension of a 3-day hospitalization to 5 days
ANS: D. In the inpatient setting, case managers on the hospital team communicate daily or weekly with the client's insurer and provide the treatment team guidance regarding the availability of resources. In the community, multiple levels of intervention are available within case management service, ranging from daily assistance with medications to ongoing resolution of housing and financial issues.
When assessing and planning treatment for a client who has recently arrived in the United States from China, the nurse should be alert to the possibility that the client's explanatory model for his illness reflects which cultural concept? A) Supernatural causes B) Negative forces C) Inheritance D) Yin-Yang
ANS: D. Many Eastern cultures explain illness as a function of imbalance such as Yin-Yang. None of the other options are widely reflected in the Chinese culture
What function is shared by advanced practice and general practice psychiatric nurses? A) Prescriptive authority B) Admitting privileges C) Offers consultation services D) Membership on a multidisciplinary team
ANS: D. Nurses at both levels are expected to collaborate with multidisciplinary teams; only the advanced practice nurse has prescriptive authority and admitting privileges and can provide consultation
Which criterion is essential when the nurse plans nursing interventions designed to meet a specific goal? (Select all that apply) A) Safe B) Evidence based C) Individualized D) Economical E) Realistic
ANS: A, B, C, E. Although expense should be considered, interventions are chosen based on being safe, compatible and appropriate, realistic and individualized, and evidence based and not on their economic value
According to the DSM-V, which statement made by an adult client supports the criteria for generalized anxiety disorder? (Select all that apply). A) I've been really anxious for at least 2 years now. B) My anxiety has to be genetic; my mom was a terrible worrier too. C) My marriage is in trouble because I'm always so irritable. D) I've had a good physical and my health care provider says I'm in good health. E) Its hard falling asleep and even harder staying asleep; I'm restless all night.
ANS: A, C, D, E. The DSM-V criteria for generalized anxiety disorder include excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months; sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep) and irritability; the anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning; the disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition
Which idea held by the nurse would best promote the provision of culturally competent care? A) Western biomedicine is one of several established healing systems. B) Some individuals will profit from use of both Western and folk healing practices. C) Use of cultural translators will provide valuable information into health-seeking behaviors. D) Need for spiritual healing is a concept that crosses cultural boundaries.
ANS: A. A nurse who holds this belief would be likely be open to a variety of established interventions. In truth, nurses cannot apply a standard model of assessment, diagnosis, and intervention to all clients with equal confidence. This leads to culturally irrelevant interventions
Which statement best explains the term "worldview"? A) Beliefs and values held by people of a given culture about what is good, right, and normal. B) Ideas derived from the major health care system of the culture about what causes illness. C) Cultural norms about how, when, and to whom illness symptoms may be displayed. D) Valuing one's beliefs and customs over those of another group.
ANS: A. A worldview is a system of thinking about how the world works and how people should behave in the world and toward each other. It is from this view that people develop beliefs, values, and the practices that guide their lives. None of the other statements accurately describe the term worldview
Which hospitalized patient should the nurse identify as being a candidate for the appropriate use of a release from hospitalization known as against medical advice (AMA)? A) A 37-year-old patient scheduled for discharge in 24 hours wishes to be discharged immediately B) A 75-year-old patient with dementia who demands to be allowed to go back to his own home C) A 21-year-old actively suicidal patient who wants to be discharged to home and do outpatient counseling D) A 32-year-old female patient who wishes to stay in the hospital but whose husband demands that she be discharged into his care
ANS: A. AMS discharges are sometimes used when the patient does not agree with the provider, as long as the patient is not a danger to himself or herself or to others. The patient with dementia and the patient who is actively suicidal would pose a safety risk and would be not allowed to be discharged AMA. A patient who wishes to stay in the hospital can make that decision; a family member's opinion doesn't impact an AMA discharge
The nurse assesses the wellness beliefs and values of a client from another culture best when asking which question? A) "What do you think is making you ill?" B) "When did you first feel ill?" C) "How can I help you get better?" D) "Did you do something to cause the illness?"
ANS: A. Asking the client to suggest reasons for the illness will best provide an opportunity to become familiar with general beliefs and values the client holds regarding his wellness. While appropriate assessment questions, none of the remaining options are as well suited to gather culturally influenced information.
The use of seclusion or restraint to control the behavior of a client who is at risk of harming self or others gives rise to conflict between which ethical principles? A) Autonomy and beneficence B) Advocacy and confidentiality C) Veracity and fidelity D) Justice and humanism
ANS: A. Autonomy refers to self-determination and beneficence refers to doing good. When a client is restrained or secluded, the need to do good and prevent harm outweighs the client's autonomy
Most clients who are diagnosed with chronic mental illness are not likely to have their psychiatric mental health experiences covered by which payment method? A) Private insurance B) Medicare C) Medicaid D) Private pay
ANS: A. Because most health insurance is employer based, few chronically ill clients have private insurance. The other options are examples of ways patients pay for their needed mental health services.
A therapeutic inpatient milieu will include which characteristic? A) It provides for the client's safety and comfort. B) Voluntarily admitted clients are generally allowed additional privileges. C) Rules and behavioral limits are flexibly enforced. D) Staff provide frequent and ongoing negative feedback to clients.
ANS: A. Because the acuity level on inpatient units is high, nurses are responsible for ensuring that the environment is safe and that elopement and self-harm opportunities are minimized. The other choices are undesirable characteristics of a therapeutic milieu
A 29-year-old patient has been admitted following a suicide attempt. Which nursing statement illustrates the concept of patient advocacy? A) "Dr. Raye, I notice you ordered fluoxetine for this patient. During the admission interview, the client stated they will refuse the medication because of adverse effects they experienced previously." B) "Dr. Raye, during the admissions interview the patient stated that there is a family history of three other suicide attempts in the past." C) "I'd like you tell me more about your depression and your suicide attempt?" D) "I will take you on a tour of the unit and orient you to the rules so you can get adjusted here."
ANS: A. By letting the provider know that the patient does not want the treatment the provider is prescribing, you have advocated for the patient and her right to make decisions regarding her treatment. The other selections do not describe patient advocacy since they do not represent actions by the nurse that the patient is incapable of on their own.
When considering the civil rights of persons diagnosed with mental illness and hospitalized for treatment, which statement is true? A) They are assured the same as those for any other citizen. B) Their rights are altered to prevent use of poor judgment. C) Their rights are always ensured by appointment of a guardian. D) Their rights are limited to provision of humane treatment.
ANS: A. Civil rights are not lost because of hospitalization for mental illness. None of the other statements are accurate when describing the rights of a hospitalized mentally
According to the Western scientific view of health, what causes illness? A) Pathogens B) Energy blockage C) Spirit invasion D) Soul loss
ANS: A. Disease has a cause (e.g., pathogens, toxins) that creates the effect; disease can be observed and measured. None of the other concepts are considered as illness produced by the Western view of health.
Which of the following structural safety precautions is most important when attempting to prevent a common type of inpatient suicide? A) Break-away closet bars to prevent hanging B) Bedroom and dining areas with locked windows to prevent jumping C) Double-locked doors to prevent escaping from the unit D) Platform beds to prevent crush injuries
ANS: A. Hangings are the most common method of inpatient suicide. The other options are important safety measures but don't directly address the suicide method of hanging'
In the Chinese tradition, disease is believed to be caused by what factor? A) Fluctuations in opposing forces B) Outside influences C) Members' disobedience D) Adoption of Western beliefs
ANS: A. In the Eastern tradition, disease is believed to be caused by fluctuations in opposing forces. None of the other options are included in the Chinese view of diseas
The nurse planning care for a mentally ill client bases interventions on which concept? A) Every client has a certain degree of resilience. B) It is a client right to be treated respectfully. C) Every client comes with experiences that contribute to their problem. D) There are universal fears that are shared by all mentally healthy individuals.
ANS: A. Nurses are expected to evaluate clients with mental health issues for their strengths and their areas of high functioning. You will find many attributes of mental health in some of your clients with mental health issues. These strengths should be built upon and encouraged. Resilience is the ability and capacity for people to secure the resources they need to support their well-being. None of the remaining options describe concepts that are the foundation for the actual creation of individualized care plans
In addition to physicians, what other members of the mental health disciplines have been identified as having the knowledge, skills, ability, and legal authority to intervene in the full range of mental health care? A) Nurses B) Social workers C) Clinical psychologists D) Chemical dependency counselors
ANS: A. Nurses are the only caregivers listed who can provide both physical and psychological care for mental health clients.
What principle forms the basis of nursing outcome planning? A) Individuals have the right to outcomes that is reflective of their abilities. B) Nursing interventions are designed to solve individuals' problems for them. C) The goal of nursing action is to create a dependency between the client and the caregiver. D) Nurses have the best understanding of client problems and so they direct outcome selection.
ANS: A. Outcome criteria are the hoped-for outcomes that reflect the maximal level of patient health that the patient can realistically achieve through nursing interventions. None of the other options accurately describes the guiding principle of outcome planning
The client's priority nursing diagnosis has been established as risk for self-directed violence: suicide related to multiple losses. What is the priority outcome for this client? A) Refrain from attempting suicide. B) Be placed on suicide precautions. C) Attend self-help group daily. D) State absence of feelings of powerlessness.
ANS: A. Refraining from suicidal attempts is the only outcome that addresses the risk for self-directed violence. The absence of a feeling of powerlessness is not appropriate for the stated nursing diagnosis. The remaining options are interventions
Which statement best describes the Diagnostic and Statistical Manual, fifth edition (DSM-5) DSM-5? A) It is a medical psychiatric assessment system. B) It is a compendium of treatment modalities. C) It offers a complete list of nursing diagnoses. D) It suggests common interventions for mental disorders.
ANS: A. The DSM-5 is a classification of mental disorders that includes descriptions and criteria of diagnoses. None of the other options are accurate descriptions
According to current information what factor is associated with the most disabling mental disorders? A) Biological influences B) Psychological trauma C) Learned ways of behaving D) Faulty patterns of early nurturance
ANS: A. The biologically influenced illnesses include schizophrenia, bipolar disorder, major depression, obsessive-compulsive and panic disorders, posttraumatic stress disorder, and autism. Therefore many (but not all) of the most prevalent and disabling mental disorders have been found to have strong biological influences. Psychological trauma, learned behaviors, and faulty patterns of nurturance may contribute to some forms of mental illness, but they are not major factors in most disabling mental disorders.
The primary source for data collection during a psychiatric nursing assessment is the A) client's own words and actions. B) client's family and friends. C) client's nonverbal responses. D) client's medical treatment records.
ANS: A. The client should always be considered the primary data source. At times, however, the client will be unable to fulfill this role
When considering the duty to warn and protect third parties, which client statement should the nurse report to the treatment team members? A) "That judge is going to really regret putting me in here." B) "All politicians need to be shot." C) "When I'm elected president, I'll make them all pay for doubting me." D) "The man out there who is laughing at me is going to die."
ANS: A. The duty to protect is an ethical and legal obligation of health care workers to protect patients from physically harming themselves or others. This duty arises when the patient presents a serious danger to another. While all that statements infer the client's intention to harm, only the correct option is credible since it actually identifies the possible victim.
Which statement regarding clients' rights after being voluntarily admitted to a behavioral health unit is true? A) All rights remain intact. B) Only rights that do not involve decision making remain intact. C) The right to refuse treatment is no longer guaranteed. D) All rights are temporarily suspended.
ANS: A. The hospitalized client is not a convicted criminal thus all civil rights remain
When considering mental illness, recovery is best described to a client by which statement? A) Working, living, and participating in the community B) Never having to visit a mental health provider again C) Being able to understand the nature of the diagnosed illness D) A period of time when signs and symptoms are being managed
ANS: A. ecovery is described as the ability of the individual to work, live, and participate in the community. Never having to visit a mental health provider is unrealistic. While important to recovery understanding of the disorder is not a demonstration of recovery. Remission is a period of time when signs and symptoms are being managed.'
Which severe mental illness is recognized across cultures? (Select all that apply). A) Antisocial disorder B) Schizophrenia C) Anorexia nervosa D) Social phobia E) Bipolar disorder F) Borderline personality disorder
ANS: B, E. Worldwide studies indicate that both schizophrenia and bipolar disorder are recognized cross-culturally
When considering client rights, which client can be legally medicated against his or her wishes? A) The client has accepted the medication in the past. B) The client may cause imminent harm to himself or others. C) The client's primary provider orders the medication. D) The client's mental illness may relate to cognitive impairment.
ANS: B. A patient may be medicated against his or her will without a court hearing in an emergency if the patient poses a danger to himself or herself or to others. The other options are not legally valid reasons to give medication against a patient's will.
The nurse who provides therapeutic milieu management supports the clients best by concentrating on which client need? A) Opportunity to act out fears and frustrations B) Providing a safe place to practice coping skills C) Meeting their physical as well as emotional needs D) Encouraging group communication about existing problems
ANS: B. A therapeutic milieu can serve as a real-life training ground for learning about the self and practicing communication and coping skills in preparation for a return to the community. The other options are considered components of a therapeutic milieu
Which assessment question would produce data that would help a nurse understand healing options acceptable to a client of a different culture? A) "Is there someone in your community who usually cures your illness?" B) "What usually helps people who have the same type of illness you have?" C) "What questions would you like to ask about your condition?" D) "What sorts of stress are you presently experiencing?"
ANS: B. Asking about typical treatment seeks information about the "usual" cultural treatment of the disorder experienced by the client. No other option focuses on this information
Which ethical principle refers to the individual's right to make his or her own decisions? A) Beneficence B) Autonomy C) Veracity D) Fidelity
ANS: B. Autonomy refers to self-determination, or the right to make one's own decisions. None of the other options are directly related to the client's right to makes decisions
What nursing action supports a client's right to autonomy? A) Spending time with an extremely anxious client B) Witnessing the informed consent for electroconvulsive therapy from a client C) Spending equal amount of one-on-one time with each client on the unit D) Attending an inservice on a newly approved medication
ANS: B. Autonomy refers to self-determination. One way to exercise self-determination is to make decisions about one's care. Witnessing the client's informed consent demonstrates attention to the client's right to autonomy. None of the other options are associated with autonomy
A client who presents no danger to himself or to others is forced to take medication against his will. This situation represents A) Assault B) Battery C) Defamation D) Invasion of privacy
ANS: B. Battery is the harmful, nonconsensual touching of another person. Forceful administration of medication constitutes battery.
What is the primary advantage of using a case manager when considering the planning and implementation of client care? A) Increases collaborative practice. B) Enhances resource management. C) Increases client satisfaction with care. D) Promotes evidence-based psychiatric nursing.
ANS: B. Case management coordinates and monitors the effectiveness of services appropriate for the client. While the other options are true statements, none describes the primary advantage of the case manager model of health care delivery
A 52-year-old Chinese American client comes to the emergency room reporting anxiety and states, "I am a failure." During the assessment interview, the client shares that they have recently been reprimanded at work for an error they were responsible for. The nurse should explore which possible trigger for the client's anxiety and feelings of failure? A) The inability to achieve her personal goals in the workplace B) Shaming the family by being responsible for the error C) Feeling personally inadequate regarding dependability D) Traditional belief that failure may result in a changed fate
ANS: B. Eastern tradition, such as in China, sees the family as the basis for one's identity, and family interdependence as the norm. The views expressed in options A and C demonstrate Western tradition where self-reliance, individuality, and autonomy are highly valued. In the Eastern view one is born into an unchangeable fate.
A client was admitted to the behavioral health unit for evaluation and diagnosis after being found wandering the streets. His personal hygiene is poor, and his responses to questions are bizarre and inappropriate. The client's constitutional rights are violated when the nurse makes which statement? A) "We will help you make decisions that will keep you safe." B) "I am going to help you shower, so you will not smell so bad." C) "Your pocket knife and nail clippers will be kept in the nurses' station." D) "You will be having a number of tests to help us learn about your condition."
ANS: B. Every client has the right to be treated with dignity. This statement is demeaning. All of the other statements support the client's rights.
The nurse is caring for an admitted client with a history of becoming aggressive when angry and has caused physical injury to another client and two staff members. When this client begins to demonstrate signs of anger while in the day room what intervention should the nurse implement to address the safety of the milieu? A) Alert security to come to the unit for a show of strength B) Request that the client accompany the nurse to the client's room C) Inform the client that restraints will be used if the behavior continues D) Prepare to administer a prn chemical restraint to the client
ANS: B. Least restrictive alternative doctrine requires using the least drastic means of achieving a specific goal. By first attempting to remove the client to a safer location, the nurse is respecting the client's right to treatment that is less restrictive than the other options.
When a nurse says, "I work with a mobile mental health unit," what assumption can a client accurately make about the care being provided? A) The patients who are convicted criminals sentenced to home confinement. B) Care is provided to clients in unconventional settings. C) Care is provided by a preferred provider for a large HMO. D) The patients are provided for by a clinical specialist with the visiting nurse service.
ANS: B. Mobile mental health units travel throughout the community, seeing clients on their own "turf," such as in shelters, on street corners, in homes, and at factories
A nurse, active in local consumer mental health groups and in local and state mental health associations, keeps aware of state and national legislation affecting mental illness treatment. How can this nurse positively affect the climate for effective, mental health treatment? A) "By becoming active in politics leading to a potential political career." B) "By educating the public on the effects that stigmatizing has on mental health clients." C) "Advocating for laws that would make the involuntary long-term commitment process easier and faster for caregivers of mentally ill persons." D) "Advocating for reduced mental health insurance benefits to discourage abuse of the system by inappropriate psychiatric admissions."
ANS: B. Nurses who are aware of legislative concerns and who are active in organizations that promote mental health awareness and appropriate and equal treatment for mental illness help achieve the goal of parity, or equality of treatment for mentally ill individuals. Becoming active in politics may be a personal goal but does not directly or necessarily reduce stigma or encourage treatment equality. The other options are undesirable outcomes.
When considering the ongoing, crucial responsibilities of nurses working on an inpatient psychiatric unit, which activity has highest priority? A) Fostering research B) Maintaining a therapeutic milieu C) Providing sympathetic listening D) Providing constructive negative feedback
ANS: B. Nursing is the discipline primarily responsible for maintenance of a therapeutic milieu, an environment that serves as a real-life training ground for learning about self and practicing communication and coping skills in preparation for a return to the community outside the hospital. While the remaining options are nursing responsibilities, none has the priority of maintaining a therapeutic milieu
How can a nurse best differentiate whether an Asian client is demonstrating a mental illness after having attempted suicide? A) Ask the client whether he views himself as being depressed. B) Identify the client's culture's view regarding suicide. C) Explain that suicide is often regarded as a desperate act. D) Assess the client for other examples of depressive behaviors.
ANS: B. One approach to differentiating mental health from mental illness is to consider what a particular culture regards as acceptable or unacceptable. In this view, the mentally ill are those who violate social norms and thus threaten (or make anxious) those observing them. For example, traditional Japanese may consider suicide to be an act of honor Contrast that viewpoint with Western culture, where people who attempt or complete suicides are nearly always considered mentally ill. While the remaining options are appropriate interventions, they fail to address the possible cultural component of the client's behavior
Which of the following patients would be appropriate to refer to a partial hospitalization program (PHP)? A) A depressed patient with a suicidal plan B) A patient being discharged from an inpatient alcohol rehabilitation unit C) A client who has stopped taking his or her antipsychotic medication and is neglecting his or her basic needs D) Jeff, who has mild depression symptoms and is starting outpatient therapy
ANS: B. PHP is for patients who may need a "step-down" environment from inpatient status or for those who are being diverted from hospitalization with intensive, short-term care from which they return home each day. This patient would be a good candidate after completing alcohol rehab; PHP could possibly help prevent relapse in the early stages after rehab. This patient can be managed with regular outpatient therapy and does not need intensive short-term therapy such as PHP. Someone who is suicidal would require inpatient hospitalization for safety as would someone who is decompensated and not caring for herself. A patient exhibiting mild depression would be managed with outpatient therapy and would not need intensive short-term therapy such as PHP.
Resilience is characteristic of mental health that allows people to adapt to tragedies, trauma, and loss. Which client behavior demonstrates this characteristic? A) "My mother made decisions about my husband's funeral when I just couldn't do that." B) "Losing my job was hard but my skills will help me get another one." C) "In spite of all the treatment, I know I'll never be really healthy." D) "My kids, happiness is worth any sacrifice I have to make."
ANS: B. Resilience is a characteristic that helps individuals cope with loss and trauma that may occur in life. Dependence is described as relying on others for decision making and care. Pessimism is a life philosophy that things are more likely to go wrong than right. Altruism is described as putting others before yourself
A recent Hispanic immigrant comes to the mental health clinic after being referred to by her primary care provider. Josefina came to live in the United States from Brazil 5 years ago. During the initial intake assessment, the client reports headaches and backaches "almost every day" and "can't sleep at night." The client looks away when asked about anxiety or depression and states, "I don't know why I was referred to the mental health clinic." Which assessment information should the nurse further explore to assess for possible somatization? A) Impaired sleep patterns B) Denial of anxiety or depression C) Unexplained physical pain D) )Recent immigration to the United States
ANS: B. Somatization is described as experiencing and expressing emotional or psychological distress as physical symptoms. The client's behavior associated with the denial of any mental illness or understanding of the possible connection between the symptom/signs and a mental illness presents a need to explore the possibility of somatization. None of the other options support this possibility as directly.
What assumption can be made about the client who has been admitted on an involuntary basis? (Select all that apply). A) The client can be discharged from the unit on demand of next of kin. B) For the first 48 hours, the client can be given medication over objection. C) The client has failed to agree to fully participate in treatment and care planning. D) The client is a danger to self or others or unable to meet basic needs. E) The commitment was court ordered.
ANS: C, D, E. Involuntary admission which is court ordered implies that the client did not consent to the admission. The usual reasons for admitting a client over his or her objection is if the client presents a clear danger to self or others or is unable to meet even basic needs independently. Neither of the remaining options is accurate assumption regarding an involuntary admission.
A nurse is about to interview an older client whose glasses and hearing aid were placed in the bedside drawer for safe keeping. Before beginning the interview, which nursing intervention that will best facilitate data collection? A) Ask the client if she needs her glasses and hearing aid. B) Give the client her glasses and hearing aid. C) Assist the client in putting on glasses and hearing aid. D) Explain the importance of wearing her hearing aid and glasses.
ANS: C. A client whose hearing or sight is impaired may have difficulty providing information if these items have been removed from his or her possession. Assisting the client in wearing these assistive devices is the best initial intervention. None of the other options will be as effective in facilitating the interview
The primary goal and benefit of assertive community treatment (ACT) is demonstrated by which situation? A) A client and family members attend counseling sessions together at a neighborhood clinic B) Implementation of a more flexible work schedule for staff C) Improved reimbursement for services provided in the community D) A client diagnosed with schizophrenia has avoided being rehospitalization for 16 months.
ANS: C. A primary goal of ACT is working intensely with the patient in the community to prevent rehospitalization. The other options are not goals of ACT
A nurse's identification badge includes the term, "Psychiatric Mental Health Nurse." A client with a history of paranoia asks, "What does that title mean?" Keeping in mind the diagnosis of the patient, how should the nurse respond to this question? A) "Don't be afraid; it means I'm here to help, not hurt, you." B) "Psychiatric mental health nurses care for people with mental illnesses." C) "We have the specialized skills needed to care for those with mental illnesses." D) "The nurses who work in mental health facilities have that title."
ANS: C. A psychiatric mental health nurse has specialized nursing skills and implements the nursing process to manage and deliver nursing care to the mentally ill. The remaining options either do not effectively answer the client's question or assume that the question is the result of the client's paranoia.
A 17-year-old patient confides to the nurse that they have been thinking of ways to kill a peer. What response should the nurse give when the patient states, "you have to keep it a secret because its confidential information"? A) "I will keep it a secret, but you and I need to discuss ways to deal with this situation appropriately without committing a crime." B) "Yes, I will keep it confidential. We have laws to protect patients' confidentiality." C) "Issues of this kind have to be shared with the treatment team and your parents." D) "I will have to share this with the treatment team, but we will not share it with your parents."
ANS: C. Although adolescent patients request confidentiality, issues of sexual abuse, threats of suicide or homicide, or issues that put the patient at risk for harm must be shared with the treatment team and the parents. A threat of this nature must be discussed with the treatment team and the parents. Confidentiality laws do not protect information that would lead to harm to the patient or others
A new nurse has accepted a position as staff nurse on a psychiatric unit. Which statement made by the new nurse requires additional instructions regarding the therapies provided on the unit? A) "You will participate in unit activities and groups daily." B) "You will be given a schedule daily of the groups we would like you to attend." C) "You will attend a psychotherapy group that I lead that will help you care for yourself." D) "You will see your provider daily in a one-to-one session."
ANS: C. Basic level RNs cannot perform psychotherapy. The other options are all appropriate expectations of a patient's schedule on a psychiatric unit.
Which right of the client has been violated if he is medicated without being asked for his permission? A) Right to dignity and respect B) Right to treatment C) Right to informed consent D) Right to refuse treatment
ANS: C. Before being given medication, the client should be fully informed about the reason for, the expected outcomes of, and any side effects of the medication. The client has the right to refuse medication. If, in a nonemergency situation, he is given medication after refusing it, his right to informed consent has been violated.
Which branch of epidemiology is the nurse involved in when seeking outcomes for patients whose depression was treated with electroconvulsive therapy (ECT)? A) Experimental. B) Descriptive. C) Clinical. D) Analytic
ANS: C. Clinical epidemiology represents a broad field that addresses what happens to people with illnesses who are seen by providers of clinical care. Studies use traditional epidemiological methods and are conducted in groups that are usually defined by illness or symptoms or by diagnostic procedures or treatments given for the illness or symptoms. None of the other options accurately identify the field that is associated with clinical practice
After the death of a client, what rule of confidentiality should be followed by nurses who provided care for the individual? A) Confidentiality is now reserved to the immediate family. B) Only HIV status continues to be protected and privileged. C) Nothing may be disclosed that would have been kept confidential before death. D) The nurse must confer with the next of kin before divulging confidential, sensitive information.
ANS: C. Confidentiality extends to death and beyond. Nurses should never disclose information after the death of a client that they would have kept confidential while the client was alive. None of the other statements are accurate.
Which nursing behavior best demonstrates the concept of cultural competence? A) Acquiring knowledge about different cultures B) Educating patients about the cultural norms of the United States C) Adjusting personal practice to meet the patients' cultural preferences, beliefs, and practices D) Engaging in continuing education classes on culture in the process of becoming culturally competent
ANS: C. Cultural competence means that nurses adjust and conform to their patients' cultural needs, beliefs, practices, and preferences rather than their own. This option does not describe cultural competence. Although nurses are continually learning regarding culture, it is a career-long process. The goal is not to educate patients about our own culture but rather to adjust to their cultural preferences. Although nurses may take continuing education regarding culture, this does not describe the term cultural competence. The other options do not describe cultural competence.
Which question asked by a nurse demonstrates the effective implementation of cultural desire when caring for a client from a different culture? A) "Where can I find information on the concept of Yin-Yang?" B) "How do I go about arranging for a Chinese translator?" C) "What can I do to provide ethnic foods that are still low in fat?" D) "How can I explain why we can't provide for his request for acupuncture?"
ANS: C. Cultural desire is a genuine interest in the patient's unique perspective; it enables nurses to provide considerate, flexible, and respectful care to patients of all cultures. Attempting to incorporate ethnic foods into the client's prescribed diet demonstrates all these characteristics. None of the other options are focused on providing such care
Which scenarios describe a HIPAA violation associated with a nurse's behavior? A) An ED (Emergency Department) nurse gives the intensive care unit nurse a client report from a telephone at the nurse's station. B) A nurse on the medical-surgical floor calls a patient's primary care provider to obtain a list of current medications. C) A nurse on the cardiac unit gives report to the nurse on the step-down unit while transporting a client in the staff elevator. D) A nurse on the psychiatric unit gives discharge information to the counseling office regarding a client's outpatient treatment.
ANS: C. Discussing a patient's information in public places where it may be overheard is a violation of a patient's confidentiality. The other options describe appropriate interactions for patient continuity of care and support of the treatment plan by the health care team.
What term is used to identify the quantitative study of the distribution of mental disorders in human populations? A) Mortality. B) Prevalence. C) Epidemiology. D) Clinical epidemiology.
ANS: C. Epidemiology is the quantitative study of the distribution of mental disorders in human populations. Mortality refers to deaths. Prevalence refers to the proportion of a population with a mental disorder at a given time. Clinical epidemiology deals with what happens to people with illnesses who are seen by providers of care.
Which statement made by the nurse would acknowledge that they understand the difference between the ethnicity and culture? A) "So, ethnicity refers to having the same life goals whereas culture refers to race." B) "So, ethnicity refers to norms within a culture, and culture refers to shared likes and dislikes." C) "So, ethnicity refers to shared history and heritage, whereas culture refers to sharing the same beliefs and values." D) "So, ethnicity refers to race, and culture refers to having the same worldview."
ANS: C. Ethnicity is sharing a common history and heritage. Culture comprises the shared beliefs, values, and practices that guide a group's members in patterned ways of thinking and acting. The other options are all incorrect definitions of either ethnicity and/or culture.
If a client is placed in seclusion and held there for 24 hours without a written order or examination by a physician, the client has experienced which illegal act? A) Battery B) Defamation of character C) False imprisonment D) Assault
ANS: C. False imprisonment is the arbitrary holding of a client against his or her will. When seclusion is ordered, it is not invoked arbitrarily, but after other less restrictive measures have failed. If the client is secluded without the medical order, the measure cannot be proven as instituted for medically sound reasons. None of the other options relate directly to such seclusion
If a nurse is charged with leaving a suicidal client unattended, it is being suggested that the nurse's behavior has violated which ethical principle? A) Autonomy B) Veracity C) Fidelity D) Justice
ANS: C. Fidelity refers to being "true" or faithful to one's obligations to the client. Client abandonment would be a violation of fidelity. None of the other options addressed abandonment
"Which of the following patients meets the criteria for an involuntary admission to a psychiatric mental health unit? A) A 23-year-old college student who has developed symptoms of anxiety and is missing classes and work B) A 30-year-old accountant who has developed symptoms of depression C) A 26-year-old kindergarten teacher who is not in touch with reality and was found wandering in and out of traffic on a busy road A73 D) A 76-year-old retired librarian who is experiencing memory loss and some confusion at times
ANS: C. Inpatient involuntary admission is reserved for patients who are at risk for self-harm or who cannot adequately protect themselves from harm because of their illness (e.g., a psychotic patient). The other options can all be managed at this point in the community setting and don't meet criteria (risk of harm to self and/or others) for admission
A nursing diagnosis for a client with a psychiatric disorder serves what purpose with considering the plan of care? A) Justifying the use of certain psychotropic medication. B) Providing data essential for insurance reimbursement. C) Establishing a framework for selecting appropriate interventions. D) Completing the medical diagnostic statement.
ANS: C. Nursing diagnoses provide the framework for identifying appropriate nursing interventions for dealing with the phenomena a client with a mental health disorder is experiencing. While the nursing diagnosis may contribute to the other options, none describe the purpose of the nursing diagnosis
What client assessment data demonstrates parity related to mental health care? A) The client is admitted for a 72-hour mental hygiene evaluation. B) Advance practice nurse can be certified as psychiatric nurse specialist. C) A client's mental health coverage is equal to his/her medical/surgical coverage. D) A client who has attempted suicide is hospitalized for a mental health evaluation.
ANS: C. Parity refers to equivalence that requires insurers who provide mental health coverage to offer annual and lifetime benefits at the same level provided for medical/surgical coverage. None of the other options are associated with mental health insurance coverage
Which criterion must be met to refer a client to a partial hospitalization program? A) The client is hospitalized at night in an inpatient setting. B) The client must be able to provide his or her own transportation daily. C) The client is able to return home each day. D) The clients are all recovering from an addiction.
ANS: C. Returning home each day is a criterion because doing so allows the person to test out new skills and gradually re-enter the family and society. None of the remaining options are true statements regarding partial hospitalization programs.
The psychiatric community health nurse engages in secondary prevention when implementing which intervention? A) Visiting a homeless shelter to provide mental health screenings for its clients B) Discussing the need for proper nutrition with a depressed new mother C) Providing stress reduction seminars at the local senior center D) Visiting the home of a client currently displaying manic behavior
ANS: C. Secondary prevention is aimed at reducing the prevalence of psychiatric disorders. Early identification of problems, screening, and prompt and effective treatment are hallmarks of this level. While it does not stop the actual disorder from beginning, it is intended to delay or avert progression. None of the other options are focused on early identification of problems
A 26-year-old patient is brought to the emergency room by a friend. The patient is unable to give any coherent history. Which response should the nurse provide when the patient's friend offers to provide information regarding the patient? A) "I'm sorry, but I cannot take any information from you as it would violate confidentiality laws." B) "There is no need for that as I will call his primary care provider to obtain the information we need." C) "Yes, I will be happy to get any information and history that you can provide." D) "Yes, however, we will have to get a release signed from the patient for you to be able to talk with me."
ANS: C. The friend is a secondary source of information that will be helpful since the patient is not able to give any history or information at this time. Confidentiality laws do not prohibit obtaining information from a secondary source. The friend can provide information and/or history immediately and may be able to relate events that happened just before coming to the hospital. A release would not be necessary to take information about the patient from a secondary source, and a psychotic patient would not be competent to sign a release.
The mental status examination aids in the collection of what type of data? A) Covert B) Physical C) Objective D) Subjective
ANS: C. The mental status exam mostly aids in the collection of objective data.
The nurse reads the medical record and learns that a client has asked for treatment, agreed to receive treatment, and to abide by hospital rules. The nurse may correctly assume that the client has met the criteria for which type of admission? A) Outpatient B) Emergency C) Voluntarily D) Involuntarily
ANS: C. Voluntary admission occurs when the client seeks treatment and is willing to be admitted and agrees to comply with hospital and unit rules. None of the other options meet all these criteria.
A nurse states, "I am so frustrated trying to communicate with clients when they insist on speaking in their language instead of English. I think if people want to live here, they ought to have to speak our language and act like we do!" Which response by a peer best promotes culturally competent care? (Select all that apply). A) "You are right, but all patients do have a right to an interpreter, so you need to comply." B) "I agree that it is frustrating. We should work with their family members to help convince them to speak English." C) "They will have to learn to speak English eventually to live and work successfully in this country. Just try to be patient and encourage them to try speaking English." D) "What you are saying is actually considered cultural imposition, which is imposing our own culture onto someone from a different culture." E) "When their ability to speak and understand English is very limited, we need to have an interpreter present to make sure they can make their needs and feelings known."
ANS: D, E. Cultural imposition is imposing our own cultural norms onto those from another cultural group. By obtaining an interpreter for Mr. Tran, the nurse is promoting culturally competent care, ensuring the patient can communicate his feelings and needs thoroughly to the staff. Patients do have a right to an interpreter, but stating that Mike is right is not promoting culturally competent care and is instead confirming his opinion. Asking family members to convince the patient to speak English is not promoting culturally competent care and also undermines the trust between nurse and patient. Instead of encouraging the patient to speak English, an interpreter should be obtained for the patient.
It is not always guaranteed that all clients who are voluntarily admitted to a behavioral health unit will have the right to which privilege? A) Refusal of treatment. B) To send and receive mail. C) To seek legal counsel. D) To access all personal possessions.
ANS: D. A client has the right to keep personal belongings unless they are dangerous. Items such as sharp objects, glass containers, and medication are usually removed from the client's possession and kept in a locked area to be used by the client under supervision or returned at discharge. The remaining options are civil rights afforded to all clients
Which response should the nurse provide a client who asks, "Why you need to conduct an assessment interview"? A) "I need to find out more about you and the way you think in order to best help you." B) "The assessment interview lets you have an opportunity to express your feelings." C) "You are able to tell me in detail about your past so that we can determine why you are experiencing mental health alterations." D) "We will be able to form a relationship together where we can discuss the current problems and come up with goals and a plan for treatment."
ANS: D. Some of the purposes of the assessment interview are to establish rapport, learn more about the presenting issues, and form mutual goals and a plan for treatment. The other options do not appropriately explain the assessment purpose.
Which tool can the novice nurse might refer to when writing nursing outcomes? A) North American Nursing Diagnosis Association (NANDA) B) Joint Commission (formally JCAHO) C) Nursing Interventions Classification (NIC) D) Nursing Outcomes Classification (NOC)
ANS: D. The Nursing Outcomes Classification is a publication used as a resource across the United States. It is a standardized list of nursing outcomes that gives nurses a way to evaluate the effect of nursing interventions. That is not the function of any of the other options
A client reports to the nurse that once he is released he will make sure his wife will never again be able to have him committed to a psychiatric hospital. What action should the nurse take? A) None, because no explicit threat has been made. B) Ask the client if he is threatening his wife. C) Call the client's wife and report the threat. D) Report the incident to the client's therapist.
ANS: D. The Tarasoff ruling makes it necessary for nurses to report client statements that imply the client may harm another person or persons. The nurse reports to the treatment team, and the mandated reporter (usually the professional leader of the team) is responsible for notifying the person against whom the threat was made.
Which nursing diagnosis for a psychiatric client is correctly structured and worded? A) Hopelessness related to severe chronic depressio B) Spiritual distress as evidenced by client stating "God has abandoned me because I'm a bad person" C) Defensive coping related to lack of insight associated with illicit drug use D) Imbalanced nutrition: less than body requirements related to poor self-concept as evidenced by reporting "I'm not worthy of eating"
ANS: D. This diagnosis contains all the required components: problem statement, related factors, and defining characteristics