Mental Health Final
1. An adolescent hospitalized after a violent physical outburst tells the nurse, "I'm going to kill my father but you cant tell anyone." Select the nurses best response.
"I am obligated to that share information with the treatment team
A voluntarily hospitalized patient tells the nurse, "Get me the forms for discharge. I want to leave now" Select the nurse's best response.
"I will get them for you, but lets talk about your decision to leave treatment."
How should the nurse respond if a patient says, "Please don't share information about me with the other people?
"I won't share information with your family or friends without your permission, but I will share information with other staff."
Which patient statement would lead the nurse to suspect unsuccessful completion of the developmental task of infancy?
"I'm afraid to allow anyone to really get to know me"
A patient tells the nurse, "I don't think I'll ever get out of here." Select the nurse's most therapeutic response:
"It sounds like you don't feel like you're making progress."
Which individual is at higher risk for committing suicide?
71 year old male, alcohol user, independent minded
Which nursing intervention demonstrates false imprisonment?
A confused and combative patient says, "I'm getting out of here and no one can stop me." The nurse restrains this patient without a health care provider's order and the promptly obtains an order.
Three years after the death of her father in an ICU, the infection prevention nurse was visiting an ICU in a different hospital to complete a chart review. At one point, the nurse looked at a bed where the patient who had the same diagnosis as her father had and saw her father's facial features on the patient and had a sense of panic. In a few moments, the nurse realized that the patient in the bed was not her father. Which of these manifestations of PTSD was this nurse experiencing?
A flashback
The patients below present in the emergency department. The psychiatric unit has one bed available. Which patient should be admitted? The patient:
A patient who is a parent and hears voices saying "smother your baby"
An interdisciplinary health care team met 12 hours after an adolescent was hospitalized following a suicide attempt. What result can be expected from this meeting?
A treatment plan will be determined
A client with a history of heavy alcohol use, whose last drink was 24 hours ago, is seen in the emergency department. The client is oriented but is tremulous, weak, and sweaty and has some gastrointestinal (GI) symptoms. Which of the following is typical of these symptoms?
Alcohol withdrawal syndrome
30. Which of the following treatment modalities is most effective for OCD?
Behavioral techniques and medication
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
When teaching a client with generalized anxiety disorder, which is the highest priority for the nurse to teach the client to avoid?
Caffeine
When working with the family of a client with anorexia nervosa, which of the following issues must be addressed?
Control issues
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 clients environmental stimuli
Which of the following increases the risk for neuroleptic malignant syndrome?
Dehydration
The nurse correctly identifies that which of OCDs self-soothing behaviors may involve self-destruction of the body of a person who has OCD? Select all that apply.
Dermatillomania Trichotillomania Onychophagia
The nurse is assessing a client with an eating disorder. Which personality characteristic would the nurse expect to detect when interacting with the client?
Eager to please
The following nursing interventions should take priority for a child with ADHD?
Ensuring the child safety and that of others
The nurse is mindful of maintaining relationships with patients that are therapeutic certain characteristics of the relationships the nurse will Foster include: select all that apply
Establishing boundaries for both the nurse and patient, maintaining a patient focus at all times, avoiding concern with whether the patient likes the nurse
A nurse is meeting with a crisis support group. In efforts to help patients identify with one another, the nurse explains which of the following about the crisis experience?
Even happy events can cause a crisis if the stress is overwhelming
Which techniques would be most effective for a client who has situational phobias? Select all that apply.
Flooding, Systematic desensitization
Before eating a meal, a client with obsessive compulsive disorder must wash her hands for 14 minutes, comb her 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 treatment objective for this client?
Gradually decrease the amount of time spent for performing rituals.
The nurse plans to teach a client about dietary modifications to manage diabetes. Teaching would be most effective if the client displayed which one of the following characteristics?
Heightened focus
Select the example of primary prevention.
Helping school-aged children describe normal emotions people experience.
During a regular Home Health visit to an elderly client, the nurse observes that the client has feeling of hopelessness and despair. The client says I'm old and my life has no purpose anymore. But promise me you won't tell anyone. How should the nurse respond?
I am sorry but I cannot keep that kind of secret
A nurse is working with a client to develop assertive communication skills. The nurse documents achievement of treatment outcomes when the client makes a statement such as,
I feel upset when you interrupt me.
All of the following nursing diagnoses are appropriate for the care of a client with anorexia. Which nursing diagnosis has the highest priority?
Imbalanced nutrition: less than body requirements
Which is the most commonly used treatment for Oppositional Defiant Disorder?
Individual therapy
A client asks the nurse, Why do I have to go to counseling? Why can't I just take medications? The best response by the nurse would be,
Medications combined with therapy help you change how well you function.
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.
A client has a lithium level of 1.2 meq / L which of the following interventions by the nurse is indicated?
No intervention is necessary at this time
Several medications are prescribed for a client who has anorexia. Which medication may be prescribed to help treat the client's distorted body image?
Olanzapine (Zyprexa)
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?
One parent who is an alcoholic
When documenting the mental status exam findings in the chart of a client with anorexia, the nurse notes poor judgment and insight. Which client statement would support this impression?
Others are just trying to keep me from looking good.
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
The nurse is teaching a client with an anxiety disorder ways to manage anxiety. The nurse suggests which of the following schedules for practicing stress management techniques?
Practice the techniques when relatively calm.
Which of the following would be key points for the nurse to remember when working with persons who are suffering from anxiety disorders?
Remember to practice techniques to manage stress and anxiety in your own life.
Which of the following neurochemical influences is a probable cause of substance abuse?
Stimulation of dopamine pathways in the brain
A nurse at the mental health center prepares to administer a scheduled injection of haloperidol decanoate (Haldol depot) to a patient with schizophrenia. As the nurse swabs the site, the patient shouts, "Stop, stop. I don't want to take that medicine anymore because I hate the side effects." Select the nurses first action:
Stop the medication administration procedure and say to the patient "tell me more about the side effects you've been having."
The nurse is caring for her first client with obsessive compulsive disorder. During the treatment team meeting, the nurse shares her frustration as to the client's inability to stop washing his hands. The nurse manager offers which one of the following explanations?
The client feels terrible but cannot stop washing his hands to try to get rid of his anxiety.
After several therapeutic encounters with a patient wo recently attempted suicide, which behavior should cause the nurse to consider the possibility of countertransference:
The nurse feels very happy when the patient's mood begins to lift.
A client has been admitted to the inpatient unit after using inhalants recently. Which is an antidote to treat inhalant toxicity?
There is no antidote
An anxiolytic agent, lorazepam (Ativan), has been prescribed for the client. Which of the following statements by the client would indicate to the nurse that client education about this medication has been effective?
This medication will relax me, so I can focus on problem solving.
Which of the following is an important part of therapeutic communication for clients who have OCD?
To encourage the client to discuss his or her obsession with the nurse.
The nurse consults the DSM for which of the following purposes?
To serve as a guide for client assessment
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 phenomenon?
Tolerance
A teenage patient defies the nurses repeated requests to turn off the video game and go to sleep. The teen says angrily, "you sound just like my mother at home!" and continues to play the video game. The nurse understands that this statement likely indicate:
Viewing the nurse as her mother
Which client is at higher risk for carrying out a suicide plan?
a client who has a private gun collection
Which of the following disorders are extrapyramidal symptoms that may be caused by antipsychotic drugs? Select all that apply
akathisia, pseudoparkinsonism, dystonia
A basic Assumption of Freud's psychoanalytic theory is that
all human behavior can be caused and can be explained
An African American patient originally from Haiti, was admitted for depression. A staff nurse tells a peer, "This patient frequently looks down and does not express feelings. When I observe interactions with other African American patients, however, the patient appears spontaneous." What remark by the peer would be most helpful?
ask the patient to describe feelings in a group setting, it will be less intimidating than a one on one interaction.
During the initial interview with a client in crisis, the initial priority is to
assess the adequacy of the support system
A college freshman is admitted to the hospital with a diagnosis of schizophrenia. Friends reported that she had been in her room for two days in a trance-like state, not eating nor speaking to anyone. Which of the following is the highest priority for this patient?
assessing fluid intake and output
A client underwent a procedure before the nurse verify the client's signature on the consent form. The client actually did not sign the form before the procedure. If the client is dissatisfied with the outcome of the procedure and files a suit against the healthcare team, which kind of case can the client file?
battery
For which reasons is it more difficult to diagnose psychiatric disorders in children than adults? Select all that apply
children usually lack the abstract cognitive ability than verbal skills to describe what is happening, because they are constantly changing and developing children are unable to discriminate unusual or unwanted symptoms from normal feelings and Sensations, behaviors that are appropriate for a child of one developmental level may be inappropriate for a child of a different developmental level
Which approach to therapy in most effective when planning for a client with negative thinking?
cognitive therapy
A client who had been in a substance abuse treatment program asks the nurse for a date after the client is discharged. The nurse talks to the client about the importance of a therapeutic relationship and its characteristics. The nurse is using which of the following techniques?
defining boundaries
A nurse encounters an unfamiliar psychiatric disorder on a new patient's admission form. To determine criteria used to establish this diagnosis, the nurse should consult which resource?
diagnostic and statistical manual of mental disorders
The client with Mania attempt to hit the nurse. Which is the best response by the nurse?
do not swing at me again. If you cannot control yourself, we will help you
The nurse initiating a therapeutic relationship with a client should explain the purpose which is to:
facilitate a positive change
Which one of the following goals of therapeutic communication would the nurse strive to attain first?
facilitate the clients expression of emotions
Which of the following occurrences is considered a breach of professional boundaries?
having a lengthy social conversation with a patient
A client was brought to the emergency department by police after neighbors complained that he was loud and disruptive. The client is paranoid and upset and States no one can be trusted. Which of the criteria for involuntary admission does the client meet?
he does not meet any of the necessary criteria
During the orientation phase of the nurse-patient relationship, the nurse directs the patient to do which of the following?
identify problems to examine
Which of the following are true regarding mental health and mental illness?
in most cases, mental health is a state of emotional, psychological, and social Wellness evidence by satisfying interpersonal relationships, effective behavior and coping, positive self-concept, and emotional stability.
A nurse inspects an inpatient psychiatric unit and finds that exits are free from obstruction, no one else is smoking, the janitor's closet is locked, and sharp objects are used under staff supervision. These observations relate to:
management of milieu safety
A nurse is meeting with the city council to advocate for mentally ill person and the establishment of a group home in a neighborhood where the plans have been strongly opposed by the neighbors. The nurse can effectively educate the public on the realities of group home by citing research that indicates:
most people with mental illness do not represent a significant danger to others
A client with bipolar disorder has been taking lithium, and today his serum blood level is 2.0 meq/ L. What effect would the nurse expect to see
nausea, diarrhea, and confusion
One week after beginning therapy with thiothixene (Navane) the client demonstrates muscle rigidity, the temperature of 103 degrees Fahrenheit, an elevated serum creatinine phospokinase level, stupor and incontinent. The nurse should notify the physician because these symptoms are indicative of?
neurologic malignant syndrome
which of the following statements about verbal and nonverbal communication skills is accurate?
nonverbal communication is as important, if not more than, verbal communication
The nurse is attending an in-service training unsafe takedown techniques for aggressive clients. Preparation for Safe physical handling prepares the nurse to practice which ethical principle?
normaleficence
1.A patient is suspicious and frequently manipulates others. To which psychosexual stage do these traits relate?
oral
A patient with psychosis became aggressive, struck another patient, and required seclusion. Select the best documentation:
patient pacing, shouting, haloperidol 5mg given PO at 1300 . No effect by 1315 at 1415 patient yelled "I'll punch anyone who gets near me." And struck another patient with fist. Physically placed in seclusion at 1420 . Seclusion order obtained from MD at 1430.
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 this time?
pour the soda into a plastic cup
Client is supposed to be ambulating ad-lib. Instead, he refuses to get out of bed, asks for a bed bath, and makes many demands of the nurses. He also yells that they are lazy and incompetent. The client's behavior is an example of which of the following defense mechanisms?
projection
A college student decides to go to a party the night before a major exam instead of studying. After receiving a low score on the exam, the student tells a fellow student, "I have to work too much and don't have time to study. It wouldn't matter anyways because the teacher is so unreasonable." The defense mechanisms the student is using are
rationalization and projection
Placing a client in restraints before using other methods of intervention violates which of the client's rights?
receive treatment in the least restrictive environment
After leaving work, a nurse realizes documentation of administration of a PRN medication was omitted. This off-duty nurse phones the unit and tells the nurse, "Please document administration of the medication for me; I forgot to do it. My password is alpha1." The nurse receiving the call should:
refer the matter to the charge nurse to resolve.
Individuals who grow up in an environment but are able to become productive successful citizens are believed to possess which of the following characteristics?
resilience
Which of the following is the highest priority for admission to inpatient care??
safety of self or others
What thought process would cause a client with antisocial personality disorder to want to do everything for himself?
sense of mistrust of others
Which of the following antidepressant drugs is a preferred drug for clients at risk of suicide?
sertraline (Zoloft)
A client States I am dead I have come back from the dead and appropriate response by the nurse is?
show me what you did in art therapy this morning?
All of the following are nursing diagnosis has identified for a client with schizophrenia. The student nurse correctly anticipates which diagnosis will resolve when the client negative symptoms improve?
social isolation
Spirituality is especially important in helping people cope primarily for which of the following reasons?
spirituality guides beliefs about the meaning of life events
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.
The priority of inpatient care for people with severe mental illness is
symptoms management
The nurse is teaching a client with schizoid personality to function more comfortably with others in the community. Which nursing intervention would be effective to improve the client's social skills?
teach the client to make necessary request in writing or over the phone
Which of the following considerations should have the most influence in the nurses choice of treatment for the client?
the client's feelings and perceptions about his or her situation
The nurse is talking to a client with schizoid personality disorder about finding a job. Which suggestion by the nurse would be most helpful?
there is a job posting at the hospital for a file clerk in medical records
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
Patient reports a pattern of being suspicious and mistrusting of others, causing difficulty in sustaining lasting relationships. Which stage of according to Erikson's psychosocial development was not successfully completed?
trust vs mistrust
One of the primary differences between social and therapeutic relationships is the
type of responsibility involved
Which would be a reason for a student nurse to use the DSM?
understand the reason for the admission in the nature of psychiatric illnesses
Which of the following would be circumstances when a client could be subjected to involuntary hospitalization? Select all that apply
when a client states that he or she intends to commit suicide and is making plans to do so, when a client states that he or she intends to harm others by a deliberate act, when a client is unable to control his or her rage and is assaulting everyone around him or her.
A new antidepressant is prescribed for an elderly patient with major depression, but the dose is more then the usual dose. The nurse should:
withhold the medication and confer with the health provider.
A patient states, I feel fine. It's a good day. The nurse notes the patient looking away, and a decreasing pitch in his voice while speaking. Which of the following is the most therapeutic response by the nurse?
you say you feel fine, but you don't really sound fine
when the client asks the nurse how long it will take before the SSRI antidepressant medication will be effective, which of the following replies is the most accurate and therapeutic
you will have gradual Improvement in symptoms over the next few weeks, but the changes may be so subtle that you may not notice them for a while. It is important for you to keep taking your medication
