Mental Health Nursing Review 2

7. Danny who is diagnosed with bipolar disorder and acute mania, states the nurse, "Where is my daughter? I love Louis. Rain, rain go away. Dogs eat dirt." The nurse interprets these statements as indicating which of the following? A. Echolalia B. Neologism C. Clang associations D. Flight of ideas

D. Flight of ideas is speech pattern of rapid transition from topic to topic, often without finishing one idea. It is common in mania.

14. A client is suffering from catatonic behaviors. Which of the following would the nurse use to determine that the medication administered PRN have been most effective? A. The client responds to verbal directions to eat B. The client initiates simple activities without direction C. The client walks with the nurse to her room D. The client is able to move all extremities occasionally

B. Although all the actions indicate improvement, the ability to initiate simple activities without directions indicates the most improvement in the catatonic behaviors.

36. When developing an initial nursing care plan for a male client with a Bipolar I disorder (manic episode) nurse Ron should plan to? A. Isolate his gym time B. Encourage his active participation in unit programs C. Provide foods, fluids and rest D. Encourage his participation in programs

C. The client in a manic episode of the illness often neglects basic needs, these needs are a priority to ensure adequate nutrition, fluid, and rest.

4. When teaching Mario with a typical depression about foods to avoid while taking phenelzine(Nardil), which of the following would the nurse in charge include? A. Roasted chicken B. Fresh fish C. Salami D. Hamburger

C. Foods high in tyramine, those that are fermented, pickled, aged, or smoked must be avoided because when they are ingested in combination with MAOIs a hypertensive crisis will occur.

31. Joy's stream of consciousness is occupied exclusively with thoughts of her father's death. Nurse Ronald should plan to help Joy through this stage of grieving, which is known as: A. Shock and disbelief B. Developing awareness C. Resolving the loss D. Restitution

C. Resolving a loss is a slow, painful, continuous process until a mental image of the dead person, almost devoid of negative or undesirable features emerges.

46. When being admitted to a mental health facility, a young female adult tells Nurse Mylene that the voices she hears frighten her. Nurse Mylene understands that the client tends to hallucinate more vividly: A. While watching TV B. During meal time C. During group activities D. After going to bed

D. Auditory hallucinations are most troublesome when environmental stimuli are diminished and there are few competing distractions.

24. A female client is brought by ambulance to the hospital emergency room after taking an overdose of barbiturates is comatose. Nurse Trish would be especially alert for which of the following? A. Epilepsy B. Myocardial Infarction C. Renal failure D. Respiratory failure

D. Barbiturates are CNS depressants; the nurse would be especially alert for the possibility of respiratory failure. Respiratory failure is the most likely cause of death from barbiturate over dose.

41. When asking the parents about the onset of problems in young client with the diagnosis of schizophrenia, Nurse Linda would expect that they would relate the client's difficulties began in: A. Early childhood B. Late childhood C. Adolescence D. Puberty

C. The usual age of onset of schizophrenia is adolescence or early childhood.

11. Which of the following activities would Nurse Trish recommend to the client who becomes very anxious when thoughts of suicide occur? A. Using exercise bicycle B. Meditating C. Watching TV D. Reading comics

A. Using exercise bicycle is appropriate for the client who becomes very anxious when thoughts of suicidal occur.

39. A nursing diagnosis for a male client with a diagnosed multiple personality disorder is chronic low self-esteem probably related to childhood abuse. The most appropriate short term client outcome would be: A. Verbalizing the need for anxiety medications B. Recognizing each existing personality C. Engaging in object-oriented activities D. Eliminating defense mechanisms and phobia

B. The client must recognize the existence of the sub personalities so that interpretation can occur.

8. Terry with mania is skipping up and down the hallway practically running into other clients. Which of the following activities would the nurse in charge expect to include in Terry's plan of care? A. Watching TV B. Cleaning dayroom tables C. Leading group activity D. Reading a book

B. The client with mania is very active & needs to have this energy channeled in a constructive task such as cleaning or tidying the room.

29. The nursing assistant tells nurse Ronald that the client is not in the dining room for lunch. Nurse Ronald would direct the nursing assistant to do which of the following? A. Tell the client he'll need to wait until supper to eat if he misses lunch B. Invite the client to lunch and accompany him to the dining room C. Inform the client that he has 10 minutes to get to the dining room for lunch D. Take the client a lunch tray and let the client eat in his room

B. The nurse instructs the nursing assistant to invite the client to lunch & accompany him to the dinning room to decrease manipulation, secondary gain, dependency and reinforcement of negative behavior while maintaining the client's worth.

2. Malou is diagnosed with major depression spends majority of the day lying in bed with the sheet pulled over his head. Which of the following approaches by the nurse would be the most therapeutic? A. Question the client until he responds B. Initiate contact with the client frequently C. Sit outside the clients room D. Wait for the client to begin the conversation

B. The nurse should initiate brief, frequent contacts throughout the day to let the client know that he is important to the nurse. This will positively affect the client's self-esteem.

45. Nurse Bea notices a female client sitting alone in the corner smiling and talking to herself. Realizing that the client is hallucinating. Nurse Bea should: A. Invite the client to help decorate the dayroom B. Leave the client alone until he stops talking C. Ask the client why he is smiling and talking D. Tell the client it is not good for him to talk to himself

B. This provides a stimulus that competes with and reduces hallucination.

1. Nurse Tony should first discuss terminating the nurse-client relationship with a client during the: A. Termination phase when discharge plans are being made. B. Working phase when the client shows some progress. C. Orientation phase when a contract is established. D. Working phase when the client brings it up.

C. When the nurse and client agree to work together, a contract should be established, the length of the relationship should be discussed in terms of its ultimate termination.

40. A 25 year old male is admitted to a mental health facility because of inappropriate behavior. The client has been hearing voices, responding to imaginary companions and withdrawing to his room for several days at a time. Nurse Monette understands that the withdrawal is a defense against the client's fear of: A. Phobia B. Powerlessness C. Punishment D. Rejection

D. An aloof, detached, withdrawn posture is a means of protecting the self by withdrawing and maintaining a safe, emotional distance.

44. One morning, nurse Diane finds a disturbed client curled up in the fetal position in the corner of the dayroom. The most accurate initial evaluation of the behavior would be that the client is: A. Physically ill and experiencing abdominal discomfort B. Tired and probably did not sleep well last night C. Attempting to hide from the nurse D. Feeling more anxious today

D. The fetal position represents regressed behavior. Regression is a way of responding to overwhelming anxiety.

18. Nurse John is talking with a client who has been diagnosed with antisocial personality about how to socialize during activities without being seductive. Nurse John would focus the discussion on which of the following areas? A. Discussing his relationship with his mother B. Asking him to explain reasons for his seductive behavior C. Suggesting to apologize to others for his behavior D. Explaining the negative reactions of others toward his behavior

D. The nurse would explain the negative reactions of others towards the client's behaviors to make the clients aware of the impact of his seductive behaviors on others.

26. Jose is diagnosed with amphetamine psychosis and was admitted in the emergency room. Nurse Ronald would most likely prepare to administer which of the following medication? A. Librium B. Valium C. Ativan D. Haldol

D. The nurse would prepare to administer an antipsychotic medication such as Haldol to a client experiencing amphetamine psychosis to decrease agitation & psychotic symptoms, including delusions, hallucinations & cognitive impairment.

10. Jun has been hospitalized for major depression and suicidal ideation. Which of the following statements indicates to the nurse that the client is improving? A. "I'm of no use to anyone anymore." B. "I know my kids don't need me anymore since they're grown." C. "I couldn't kill myself because I don't want to go to hell." D. "I don't think about killing myself as much as I used to."

D. The statement "I don't think about killing myself as much as I used to." Indicates a lessening of suicidal ideation and improvement in the client's condition.

48. When planning care for a male client using paranoid ideation, nurse Jasmin should realize the importance of: A. Giving the client difficult tasks to provide stimulation B. Providing the client with activities in which success can be achieved C. Removing stress so that the client can relax D. Not placing any demands on the client

B. This will help the client develop self-esteem and reduce the use of paranoid ideation.

30. The initial nursing intervention for the significant-others during shock phase of a grief reaction should be focused on: A. Presenting full reality of the loss of the individuals B. Directing the individual's activities at this time C. Staying with the individuals involved D. Mobilizing the individual's support system

C. This provides support until the individuals coping mechanisms and personal support systems can be immobilized.

38. One morning a female client on the inpatient psychiatric service complains to nurse Hazel that she has been waiting for over an hour for someone to accompany her to activities. Nurse Hazel replies to the client "We're doing the best we can. There are a lot of other people on the unit who needs attention too." This statement shows that the nurse's use of: A. Defensive behavior B. Reality reinforcement C. Limit-setting behavior D. Impulse control

A. The nurse's response is not therapeutic because it does not recognize the client's needs but tries to make the client feel guilty for being demanding.

17. Which statement about an individual with a personality disorder is true? A. Psychotic behavior is common during acute episodes B. Prognosis for recovery is good with therapeutic intervention C. The individual typically remains in the mainstream of society, although he has problems in social and occupational roles D. The individual usually seeks treatment willingly for symptoms that are personally distressful.

C. An individual with personality disorder usually is not hospitalized unless a coexisting Axis I psychiatric disorder is present. Generally, these individuals make marginal adjustments and remain in society, although they typically experience relationship and occupational problems related to their inflexible behaviors. Personality disorders are chronic lifelong patterns of behavior; acute episodes do not occur. Psychotic behavior is usually not common, although it can occur in either schizotypal personality disorder or borderline personality disorder. Because these disorders are enduring and evasive and the individual is inflexible, prognosis for recovery is unfavorable. Generally, the individual does not seek treatment because he does not perceive problems with his own behavior. Distress can occur based on other people's reaction to the individual's behavior.

32. When taking a health history from a female client who has a moderate level of cognitive impairment due to dementia, the nurse would expect to note the presence of: A. Accentuated premorbid traits B. Enhance intelligence C. Increased inhibitions D. Hyper vigilance

A. A moderate level of cognitive impairment due to dementia is characterized by increasing dependence on environment & social structure and by increasing psychologic rigidity with accentuated previous traits & behaviors.

12. When developing the plan of care for a client receiving haloperidol, which of the following medications would nurse Monet anticipate administering if the client developed extra pyramidal side effects? A. Olanzapine (Zyprexa) B. Paroxetine (Paxil) C. Benztropine mesylate (Cogentin) D. Lorazepam (Ativan)

C. The drug of choice for a client experiencing extra pyramidal side effects from haloperidol (Haldol) is benztropine mesylate (cogentin) because of its anti cholinergic properties.

22. After administering naloxone (Narcan), an opioid antagonist, Nurse Ronald should monitor the female client carefully for which of the following? A. Respiratory depression B. Epilepsy C. Kidney failure D. Cerebral edema

A. After administering naloxone (Narcan) the nurse should monitor the client's respiratory status carefully, because the drug is short acting & respiratory depression may recur after its effects wear off.

5. When assessing a female client who is receiving tricyclic antidepressant therapy, which of the following would alert the nurse to the possibility that the client is experiencing anticholinergic effects? A. Urine retention and blurred vision B. Respiratory depression and convulsion C. Delirium and Sedation D. Tremors and cardiac arrhythmias

A. Anticholinergic effects, which result from blockage of the parasympathetic (craniosacral) nervous system including urine retention, blurred vision, dry mouth & constipation.

34. Jerome who has eating disorder often exhibits similar symptoms. Nurse Lhey would expect an adolescent client with anorexia to exhibit: A. Affective instability B. Dishered, unkempt physical appearance C. Depersonalization and derealization D. Repetitive motor mechanisms

A. Individuals with anorexia often display irritability, hospitality, and a depressed mood.

47. Nurse John recognizes that paranoid delusions usually are related to the defense mechanism of: A. Projection B. Identification C. Repression D. Regression

A. Projection is a mechanism in which inner thoughts and feelings are projected onto the environment, seeming to come from outside the self rather than from within.

20. Joy has entered the chemical dependency unit for treatment of alcohol dependency. Which of the following client's possession will the nurse most likely place in a locked area? A. Toothpaste B. Shampoo C. Antiseptic wash D. Moisturizer

C. Antiseptic mouthwash often contains alcohol & should be kept in locked area, unless labeling clearly indicates that the product does not contain alcohol.

49. Nurse Gerry is aware that the defense mechanism commonly used by clients who are alcoholics is: A. Displacement B. Denial C. Projection D. Compensation

B. Denial is a method of resolving conflict or escaping unpleasant realities by ignoring their existence.

6. For a male client with dysthymic disorder, which of the following approaches would the nurse expect to implement? A. ECT B. Psychotherapeutic approach C. Psychoanalysis D. Antidepressant therapy

B. Dysthymia is a less severe, chronic depression diagnosed when a client has had a depressed mood for more days than not over a period of at least 2 years. Client with dysthymic disorder benefit from psychotherapeutic approaches that assist the client in reversing the negative self image, negative feelings about the future.

23. Which of the following would nurse Ronald use as the best measure to determine a client's progress in rehabilitation? A. The way he gets along with his parents B. The number of drug-free days he has C. The kinds of friends he makes D. The amount of responsibility his job entails

B. The best measure to determine a client's progress in rehabilitation is the number of drug- free days he has. The longer the client is free of drugs, the better the prognosis is.

25. Joey who has a chronic user of cocaine reports that he feels like he has cockroaches crawling under his skin. His arms are red because of scratching. The nurse in charge interprets these findings as possibly indicating which of the following? A. Delusion B. Formication C. Flash back D. Confusion

B. The feeling of bugs crawling under the skin is termed as formication, and is associated with cocaine use.

19. Tina with a histrionic personality disorder is melodramatic and responds to others and situations in an exaggerated manner. Nurse Trish would recommend which of the following activities for Tina? A. Baking class B. Role playing C. Scrap book making D. Music group

B. The nurse would use role-playing to teach the client appropriate responses to others and in various situations. This client dramatizes events, drawn attention to self, and is unaware of and does not deal with feelings. The nurse works to help the client clarify true feelings & learn to express them appropriately.

37. Grace is exhibiting withdrawn patterns of behavior. Nurse Johnny is aware that this type of behavior eventually produces feeling of: A. Repression B. Loneliness C. Anger D. Paranoia

B. The withdrawn pattern of behavior presents the individual from reaching out to others for sharing the isolation produces feeling of loneliness.

9. When assessing a male client for suicidal risk, which of the following methods of suicide would the nurse identify as most lethal? A. Wrist cutting B. Head banging C. Use of gun D. Aspirin overdose

C. A crucial factor is determining the lethality of a method is the amount of time that occurs between initiating the method & the delivery of the lethal impact of the method.

43. In recognizing common behaviors exhibited by male client who has a diagnosis of schizophrenia, nurse Josie can anticipate: A. Slumped posture, pessimistic out look and flight of ideas B. Grandiosity, arrogance and distractibility C. Withdrawal, regressed behavior and lack of social skills D. Disorientation, forgetfulness and anxiety

C. These are the classic behaviors exhibited by clients with a diagnosis of schizophrenia.

33. What is the priority care for a client with a dementia resulting from AIDS? A. Planning for remotivational therapy B. Arranging for long term custodial care C. Providing basic intellectual stimulation D. Assessing pain frequently

C. This action maintains for as long as possible, the clients intellectual functions by providing an opportunity to use them.

13. Jon a suspicious client states that "I know you nurses are spraying my food with poison as you take it out of the cart." Which of the following would be the best response of the nurse? A. Giving the client canned supplements until the delusion subsides B. Asking what kind of poison the client suspects is being used C. Serving foods that come in sealed packages D. Allowing the client to be the first to open the cart and get a tray

D. Allowing the client to be the first to open the cart & take a tray presents the client with the reality that the nurses are not touching the food & tray, thereby dispelling the delusion.

35. The primary nursing diagnosis for a female client with a medical diagnosis of major depression would be: A. Situational low self-esteem related to altered role B. Powerlessness related to the loss of idealized self C. Spiritual distress related to depression D. Impaired verbal communication related to depression

D. Depressed clients demonstrate decreased communication because of lack of psychic or physical energy.

21. Which of the following assessment would provide the best information about the client's physiologic response and the effectiveness of the medication prescribed specifically for alcohol withdrawal? A. Sleeping pattern B. Mental alertness C. Nutritional status D. Vital signs

D. Monitoring of vital signs provides the best information about the client's overall physiologic status during alcohol withdrawal & the physiologic response to the medication used.

3. Joe who is very depressed exhibits psychomotor retardation, a flat affect and apathy. The nurse in charge observes Joe to be in need of grooming and hygiene. Which of the following nursing actions would be most appropriate? A. Waiting until the client's family can participate in the client's care B. Asking the client if he is ready to take shower C. Explaining the importance of hygiene to the client D. Stating to the client that it's time for him to take a shower

D. The client with depression is preoccupied, has decreased energy, and is unable to make decisions. The nurse presents the situation, "It's time for a shower", and assists the client with personal hygiene to preserve his dignity and self-esteem.

50. Within a few hours of alcohol withdrawal, nurse John should assess the male client for the presence of: A. Disorientation, paranoia, tachycardia B. Tremors, fever, profuse diaphoresis C. Irritability, heightened alertness, jerky movements D. Yawning, anxiety, convulsions

C. Alcohol is a central nervous system depressant. These symptoms are the body's neurologic adaptation to the withdrawal of alcohol.

27. Which of the following liquids would nurse Leng administer to a female client who is intoxicated with phencyclidine (PCP) to hasten excretion of the chemical? A. Shake B. Tea C. Cranberry Juice D. Grape juice

C. An acid environment aids in the excretion of PCP. The nurse will definitely give the client with PCP intoxication cranberry juice to acidify the urine to a ph of 5.5 & accelerate excretion.

16. When planning care for Dory with schizotypal personality disorder, which of the following would help the client become involved with others? A. Attending an activity with the nurse B. Leading a sing a long in the afternoon C. Participating solely in group activities D. Being involved with primarily one to one activities

C. Attending activity with the nurse assists the client to become involved with others slowly. The client with schizotypal personality disorder needs support, kindness & gentle suggestion to improve social skills & interpersonal relationship.

15. Nurse Hazel invites new client's parents to attend the psycho educational program for families of the chronically mentally ill. The program would be most likely to help the family with which of the following issues? A. Developing a support network with other families B. Feeling more guilty about the client's illness C. Recognizing the client's weakness D. Managing their financial concern and problems

A. Psychoeducational groups for families develop a support network. They provide education about the biochemical etiology of psychiatric disease to reduce, not increase family guilt.

42. Jose who has been hospitalized with schizophrenia tells Nurse Ron, "My heart has stopped and my veins have turned to glass!" Nurse Ron is aware that this is an example of: A. Somatic delusions B. Depersonalization C. Hypochondriasis D. Echolalia

A. Somatic delusion is a fixed false belief about one's body.

28. When developing a plan of care for a female client with acute stress disorder who lost her sister in a car accident. Which of the following would the nurse expect to initiate? A. Facilitating progressive review of the accident and its consequences B. Postponing discussion of the accident until the client brings it up C. Telling the client to avoid details of the accident D. Helping the client to evaluate her sister's behavior

A. The nurse would facilitate progressive review of the accident and its consequence to help the client integrate feelings & memories and to begin the grieving process.