Mental Health - Exam 2

Question 1

A student nurse caring for a depressed client reads in the client’s medical record: “This client clearly shows the vegetative signs of depression.” What can the student expect to observe?

a. suicidal ideation
b. feelings of hopelessness, helplessness, and worthlessness
c. constipation, anorexia, sleep disturbance
d. anxiety and psychomotor agitation

Answer 1

c. constipation, anorexia, sleep disturbance

Question 2

Information given to a depressed client when the client is begun on tricyclic antidepressant therapy such as Norpramin should include

a. the need to have weekly blood draws to closely monitor risk for toxicity
b. the fact that mood improvement may take 7 to 28 days
c. instructions to restrict sodium intake to 1 g daily
d. the need to maintain a tyramine-free diet

Answer 2

b. the fact that mood improvement may take 7 to 28 days

Question 3

A depressed client who is scheduled to receive ECT this morning asks the nurse, “How is this treatment supposed to help me?” The best reply would be, “ECT

a. probably increases the availability of brain neurotransmitters.”
b. makes you confused and you forget why you’re feeling depressed.”
c. serves as a punishment, so your own conscience can stop punishing you.”
d. works by opening your mind to learning new coping skills

Answer 3

a. probably increases the availability of brain neurotransmitters.”

Question 4

What initial nursing intervention is appropriate to take in the immediate post-ECT treatment period?

a. Monitor vital signs closely
b. Repeatedly stimulate the client to respond.
c. Assist the client to sit up, then ambulate.
d. Begin forcing fluids

Answer 4

a. Monitor vital signs closely

Question 5

Which observations, if documented in the medical record, would indicate that the treatment plan of a severely depressed client has been effective?

a. “Slept 6 hours uninterrupted, sang with group in activities, anticipates seeing grandchild.”
b. “Slept 10 hours, attended craft group, stated his project was a mess, just like me.”
c. “Slept 5 hours, personal hygiene adequate with assistance, weight loss of 1 pound.”
d. “Slept 7 hours, states he feels tired most of the time, preoccupied with perceived inadequacies.”

Answer 5

a. “Slept 6 hours uninterrupted, sang with group in activities, anticipates seeing grandchild.”

Question 6

Which is true of the SSRI’s?

a. they have a favorable side effect profile and efficacy.
b. they are usually a last choice option
c. they usually take 4-6 weeks to see full effect
d. all of the above

Answer 6

a. they have a favorable side effect profile and efficacy.

Question 7

Serotonin syndrome results in:

a. stiffness in the patient’s gait
b. hypothyroidism and cardiotoxicity
c. confusion and myoclonus
d. catatonic muteness

Answer 7

c. confusion and myoclonus

Question 8

A serious side effect from the tricyclic antidepressants that warrants medication attention is:

a. stomach upset
b. restlessness
c. severe constipation
d. dry mouth

Answer 8

c. severe constipation

Question 9

Which of the following are examples of food to avoid when taking the antidepressant Parnate?

a. oranges, grapefruits, and lemons
b. avocados, figs, smoked meats
c. chicken, salmon and veal
d. any food with salt

Answer 9

b. avocados, figs, smoked meats

When taking any MAOI, must not eat foods high in tyramine - can increase BP

• Aged cheeses
• Cured meats
• Fermented cabbage, such as sauerkraut and kimchee.
• Soy sauce, fish sauce and shrimp sauce.
• Yeast-extract spreads, such as Marmite.
• Broad bean pods, such as fava beans.
• Avocado or overripe, dried fruit.

Question 10

Hypertensive Crisis is a serious side effect of which medication?

a. Lithium
b. Parnate (MAOI)
c. Prozac (SSRI)
d. Ativan (Benzodiazepine)

Answer 10

b. Parnate (MAOI)

Question 11

G is a client with fluctuating levels of consciousness, disturbed orientation, and perceptual alterations. An important facet of nursing care for G will be

a. application of wrist and ankle restraints
b. avoidance of physical contact
c. careful observation and supervision
d. providing a high level of sensory stimulation

Answer 11

c. careful observation and supervision

Question 12

What environmental conditions should the nurse ensure for G while she is experiencing sensory perceptual alterations?
a a quiet, well-lit room without glare while client experiences sensory perceptual alterations
b. allowing client to sit by nurse’s desk while out of bed; providing frequent rest periods in room with television or radio on
c. a brightly lit room around the clock; awakenings hourly to check mental status
d. a softly lit room around the clock; television on during day and evening

Answer 12

a a quiet, well-lit room without glare while client experiences sensory perceptual alterations

Question 13

Which of the following would the nurse assess as an example of cognitive impairment?

a. crying when the occasion calls for laughter
b. inability to name a familiar object
c. incontinence
d. agitation

Answer 13

b. inability to name a familiar object

Question 14

What is considered expected behavior for a client in Stage 2 of Alzheimer’s Disease?

a. Short term memory impairment
b. Decline in AdL’s
c. Increasingly labile mood and anger
d. All of the above

Answer 14

d. All of the above

Question 15

A nursing intervention designed to help the client with progressive memory deficit function in his or her environment is to

a. assist client to perform simple tasks by giving step-by-step directions
b. avoid frustrating client by performing routines associated with activities of daily living for the client
c. stimulate the client’s intellectual functioning by bringing new topics, objects, etc. to the client’s attention
d. promote use of client’s sense of humor by telling jokes or riddles and discussing cartoons

Answer 15

a. assist client to perform simple tasks by giving step-by-step directions

Question 16

V has Alzheimer’s disease. During morning care, the nursing assistant asks her, “How was your night?” V replies, “It was lovely. My husband and I went out to dinner and to a movie.” The nurse who overhears this should make the assessment that V is

a. demonstrating a sense of humor
b. using confabulation
c. perseverating
d. delirious

Answer 16

b. using confabulation

Question 17

The best predictor of future violence is

a. Escalating anger
b. Past violence
c. The patient stopping their medication regimen
d. All of the above

Answer 17

b. Past violence

Question 18

The initial task of the nurse who is manning the suicide telephone line is to

a. assess lethality of the suicide plan
b. establish rapport with the caller
c. encourage alternative expression of anger
d. determine whether the caller is making a crank call

Answer 18

b. establish rapport with the caller

Question 19

F’s business has gone bankrupt. His wife has filed for divorce. F has been despondent for 2 weeks. Which statement could be assessed as a covert clue to suicide?

a. “Life isn’t worth living.”
b. “I wish I were dead.”
c. “My family will be better off without me.”
d. “I have a plan that will fix everything.”

Answer 19

d. “I have a plan that will fix everything.”

Question 20

People who are serious about suicide usually don’t give clues

a. true
b. false

Answer 20

b. false

Question 21

Which is included in the lethality assessment of suicide?

a. specificity of the plan
b. lethality of the plan
c. availability of means
d. all of the above

Answer 21

d. all of the above

Question 22

Which of the following is an intervention to minimize suicidal opportunity on the inpatient locked adult unit?

a. A telephone crisis line
b. A support group
c. Suicidal precautions every 15 minutes
d. Private time alone in room

Answer 22

c. Suicidal precautions every 15 minutes

Question 23

The best predictor of future violence is

a. Escalating anger
b. Past violence
c. The patient stopping their medication regimen
d. All of the above

Answer 23

b. Past violence

Question 24

A perpetrator giving their partners a dozen of roses after an assault is part of the ____ phase of the Cycle of Abuse

a. Tension building
b. Acute battering
c. Honeymoon
d. Guilt

Answer 24

c. Honeymoon

Question 25

Which of the following are considerations of priority when caring for the psychologically and medically ill?

a. following developmental theory
b. a holistic approach
c. following Maslow’s theory
d. all of above

Answer 25

d. all of above

Question 26

Human rights abuses while caring for the psychological needs of a med surg patient can include:

a. neglect
b. labeling
c. avoidance
d. all of the above

Answer 26

d. all of the above

Question 27

A new psychiatric technician mentions to the nurse, “Depression seems to be a disease of old people. All the depressed clients on the unit are older than 60 years.” The reply by the nurse that clarifies prevalence is

a. “That is a good observation. Depression does mostly strike people older than 50 years.”
b. “Depression is seen in people of all ages, from childhood to old age.”
c. “Depression is most often seen among the middle adult age group.”
d. “The age of onset for most depressive episodes is given as 18 years.”

Answer 27

b. “Depression is seen in people of all ages, from childhood to old age.”

Depression can occur at any age. Children, adolescents, adults, and the elderly may all experience depression.
Text page: 246

Question 28

What statement about the comorbidity of depression is accurate?

a. Depression most often exists in an individual as a single entity.
b. Depression is commonly seen among individuals with medical disorders.
c. Substance abuse and depression are seldom seen as comorbid disorders.
d. Depression may coexist with other disorders but is rarely seen with schizophrenia.

Answer 28

b. Depression is commonly seen among individuals with medical disorders.

Depression commonly accompanies medical disorders. The other options are false statements.
Text page: 250

Question 29

Beck suggests that the etiology of depression is related to

a. sleep abnormalities.
b. serotonin circuit dysfunction.
c. negative processing of information.
d. a belief that one has no control over outcomes.

Answer 29

c. negative processing of information.

Beck is a cognitive theorist who developed the theory of the cognitive triad of three automatic thoughts responsible for people becoming depressed: (1) a negative, self-deprecating view of self, (2) a pessimistic view of the world, and (3) the belief that negative reinforcement will continue.
Text page: 252

Question 30

When the clinician mentions that a client has anhedonia, the nurse can expect that the client

a. has poor retention of recent events.
b. has weight loss of 10 lb or more from anorexia.
c. obtains no pleasure from previously enjoyed activities.
d. has difficulty with tasks requiring fine motor skills.

Answer 30

c. obtains no pleasure from previously enjoyed activities.

Anhedonia is the term for the lack of ability to experience pleasure.
Text page: 262

Question 31

Assessment of thought processes of a client with depression is most likely to reveal

a. good memory and concentration.
b. delusions of persecution.
c. self-deprecatory ideation.
d. sexual preoccupation.

Answer 31

c. self-deprecatory ideation.

Depressed clients never feel good about themselves. They have a negative, self-deprecating view of the world.
Text page: 254

Question 32

A client who has been assessed by the nurse as moderately depressed is given a prescription for daily doses of a selective serotonin reuptake inhibitor. The client mentions she will take the medication along with the St. John’s wort she uses daily. The nurse should

a. agree that taking the drugs at the same time will help her remember them daily.
b. caution the client to drink several glasses of water daily.
c. suggest that the client also use a sun lamp daily.
d. explain the high possibility of an adverse reaction.

Answer 32

d. explain the high possibility of an adverse reaction.

Serotonin malignant syndrome is a possibility if St. John’s wort is taken with other antidepressants.
Text page: 272

Question 33

The nursing diagnosis Imbalanced nutrition: less than body requirements has been identified for a client with severe depression. The most reliable evaluation of outcomes will be based on

a. energy level.
b. weekly weights.
c. observed eating patterns.
d. client statement of appetite.

Answer 33

b. weekly weights.

Client body weight is the most reliable and objective evaluation of success in treating this nursing diagnosis.
Text page: 261

Question 34

It is likely that a client with seasonal affective disorder will begin to feel better in the

a. fall.
b. winter.
c. spring.
d. summer.

Answer 34

c. spring.

Seasonal affective disorder occurs during the months, when sunlight diminishes. Clients may begin to feel effects in the late fall and will be affected throughout the winter. They improve during the spring and feel well during the summer.
Text page: 248

Question 35

A depressed client is noted to pace most of the time, pull at her clothes, and wring her hands. These behaviors are consistent with

a. senile dementia.
b. hypertensive crisis.
c. psychomotor agitation.
d. central serotonin syndrome.

Answer 35

c. psychomotor agitation.

These behaviors describe the psychomotor agitation sometimes seen in clients with the agitated type of depression.
Text page: 255

Question 36

Dysthymia cannot be diagnosed unless it has existed for

a. at least 3 months.
b. at least 6 months.
c. at least 1 year.
d. at least 2 years.

Answer 36

d. at least 2 years.

Dysthymia is a chronic condition that by definition has to have existed for more than 2 years.
Text page: 249

Question 37

Which nursing diagnosis would be least useful for a depressed client who shows psychomotor retardation?

a. Constipation
b. Death anxiety
c. Activity intolerance
d. Self-care deficit: bathing/hygiene

Answer 37

b. Death anxiety

A client with psychomotor retardation has vegetative signs of depression and is often constipated, too tired to engage in activities, and lacks the energy to attend to personal hygiene. Depressed clients usually do not have death anxiety. They are more likely to welcome the idea of dying.
Text page: 254

Question 38

When the nurse remarks to a depressed client “I see you are trying not to cry. Tell me what is happening.” The nurse should be prepared to

a. wait quietly for the client to reply.
b. prompt the client if the reply is slow.
c. repeat the question if the client does not answer promptly.
d. seek information from the client’s significant others.

Answer 38

a. wait quietly for the client to reply.

Depressed clients think slowly and take long periods to formulate answers and respond. The nurse must be prepared to wait for a reply.
Text page: 259

Question 39

A nurse caring for a nearly mute depressed client wishes to show acceptance of the client. An intervention that would meet this objective would be to say

a. “I will be spending time with you each day to try to improve your mood.”
b. “I would like to sit with you for 15 minutes now and again this afternoon.”
c. “Each day we will spend time together to talk about things that are bothering you.”
d. “It is important for you to share your thoughts with someone who can help you evaluate whether your thinking is realistic.”

Answer 39

b. “I would like to sit with you for 15 minutes now and again this afternoon.”

Spending time with the client without making demands is a good way to show acceptance.
Text page: 259

Question 40

Select the nursing diagnosis least likely to be chosen after analysis of data pertinent to a client with postpartum depression.

a. Impaired parenting
b. Ineffective role performance
c. Health-seeking behaviors
d. Risk for impaired parent/infant/child attachment

Answer 40

c. Health-seeking behaviors

A client with severe depression of any etiology will not have the mental or physical energy to engage in health-seeking behaviors. Further, her negative view of self and the world would preclude such thinking.
Text page: 252

Question 41

A depressed client tells the nurse “There is no sense in trying. I am never able do anything right!” The nurse can identify this cognitive distortion as an example of

a. self-blame.
b. catatonia.
c. learned helplessness.
d. discounting positive attributes.

Answer 41

c. learned helplessness.

Learned helplessness results in depression when the client feels no control over the outcome of a situation.
Text page: 252

Question 42

A depressed client tells the nurse “There is no sense in trying. I am never able to do anything right!” The nurse can best begin to attack this cognitive distortion by

a. suggesting “Let’s look at what you just said, that you can ‘never do anything right.’”
b. querying “Tell me what things you think you are not able to do correctly.”
c. asking “Is this part of the reason you think no one likes you?”
d. saying “That is the most unrealistic thing I have ever heard.”

Answer 42

a. suggesting “Let’s look at what you just said, that you can ‘never do anything right.’”

Cognitive distortions can be refuted by examining them, but to examine them the nurse must gain the client’s willingness to participate.
Text page: 252

Question 43

A depressed client tells the nurse he is in the ‘acute phase’ of his treatment for depression. The nurse recognizes that the client has been in treatment:

a. for more than 4 months
b. that is directed toward relapse prevention
c. that focuses on prevention of future depression
d. to reduce depressive symptoms

Answer 43

d. to reduce depressive symptoms

The acute phase of depression therapy (6 ? 12 weeks) is directed towards the reduction of symptoms and restoration of psychosocial and work function and may require some hospitalization.
Text page: 259

Question 44

A client with severe depression has been regulated on a monamine oxidase inhibitor because trials of other antidepressants proved unsuccessful. She has a pass to go out to lunch with her husband. Given a choice of the following entrees, which can she safely eat?

a. avocado salad plate.
b. fruit and cottage cheese plate.
c. kielbasa and sauerkraut.
d. liver and bacon plate.

Answer 44

b. fruit and cottage cheese plate.

Fruit and cottage cheese do not contain tyramine. Avocados, fermented food such as sauerkraut, processed meat, and organ meat contain tyramine. Monoamine oxidase inhibitors inhibit the breakdown of tyramine, which can lead to high blood pressure, hypertensive crisis, and eventually a cerebrovascular accident.
Text page: 267

Question 45

A client has a severe sleep pattern disturbance and psychomotor retardation. The nurse has developed a plan for him to spend 20 minutes in the gym at 1 PM. The hour immediately after the exercise period should be scheduled for

a. rest.
b. group therapy.
c. individual therapy.
d. occupational therapy.

Answer 45

a. rest.

A depressed client usually has little energy. After even a short exercise period, the client may feel exhausted and need rest.
Text page: 261

Question 46

Which statement about antidepressant medications, in general, can serve as a basis for client and family teaching?

a. Onset of action is from 1 to 6 weeks.
b. They tend to be more effective for men.
c. They may cause recent memory impairment.
d. They often cause the client to have diurnal variation.

Answer 46

a. Onset of action is from 1 to 6 weeks.

People are accustomed to fast results from medication. Thirty minutes for aspirin, 24 hours for antibiotics. Information is necessary to prevent discouragement and maintain compliance.
Text page: 262

Question 47

Characteristics of major depressive disorder

Answer 47

History of one or more major depressive episodes

No history of manic or hypomanic episodes

Symptoms interfere with social or occupational functioning

May include psychotic features

Question 48

Characteristics of dysthymic disorder

Answer 48

Chronic depressive syndrome

Present for most of the day

More days than not

At least 2 years

Question 49

Risk factors for depression

Answer 49

Female gender
Being unmarried
Low socioeconomic status
Early childhood trauma
The presence of a negative life event, especially loss and humiliation
Family history of depression, especially in first-degree relatives
High levels of neuroticism (predisposition to respond to stress poorly)
Postpartum period
Medical illness
Absence of social support
Alcohol or substance abuse

Question 50

3 phases in treatment and recovery from major depression

Answer 50

1. Acute phase - 6 to 12 weeks - directed at reduction of depressive symptoms and restoration of psychosicial and work function. Hospitalization may be required.
2. Continuation phase - 4 to 9 months - directed at prevention of relapse
3. Maintenance phase - 1 year or more - prevention of further episodes

Question 51

SSRIs

Answer 51

• Recommended as first-line therapy for most types of depression.
• Blocks the reuptake of serotonin
• Side effects: agitation, insomnia, headache, N&V, sexual dysfunction, hyponatremia
• Relatively low side effect profile compared to older antidepressants, low cardiotoxicity (*Serotonin syndrome rare and life-threatening risk)
• Contraindicated in people taking MAOIs
• Citalopram (Celexa), Escitalopram (Lexapro), Fluxetine (Prozac), Fluvoxamine (Luvox), Paroxetine (Paxil), Sertraline (Zoloft)

Question 52

Serotonin syndrome

Answer 52

Rare and life-threatening risk of SSRIs - related to overactivation of central serotonin receptors.

Abdominal pain, diarrhea, sweating, fever, tachycardia, elevated BP, delirium, muscle spasms (myoclonus), increased motor activity, irritability, hostility, mood change.

Severe manifestations - hyperpyrexia (excessively high fever), CV shock, death

• Risk greatest when administered with a second serotonin-enhancing agent, such as MAOI
• Pt. should d/c all SSRIs 2-5 weeks before starting MAOI

Question 53

Which of the following represents the greatest protective factor against the risk of suicide?

a. Previous suicide attempt(s)
b. Sense of responsibility to family (e.g., spouse, children)
c. Fear of dying
d. Cultural belief that suicide is a shameful resolution for a dilemma

Answer 53

b. Sense of responsibility to family (e.g., spouse, children)

Having family responsibility makes a client less likely to commit suicide. Hopelessness, however, is the greatest risk factor.
Text page: 551

Question 54

An assessment tool that is useful to nurses in rating suicide risk is the

a. AIMS scale.
b. Sad Persons scale.
c. CAGE questionnaire.
d. Mini-Mental Status Examination.

Answer 54

b. Sad Persons scale.

The evaluation of a suicide plan is extremely important in determining the degree of suicidal risk. The Sad Persons scale is short and easy to use. It thoroughly covers major risk factors and gives guidelines for action to meet patient needs.
Text page: 553

Question 55

Which statement represents a fact about suicide?

a. More women than men commit suicide.
b. Suicide is the fourth leading cause of death in the United States.
c. Native Americans and Alaskan Natives have low suicide rates.
d. A schizophrenic client is at a great risk for attempting suicide.

Answer 55

d. A schizophrenic client is at a great risk for attempting suicide.

Schizophrenics are 50 times more likely to attempt suicide than the general public. Suicide is the eleventh leading cause of death in the United States, Native Americans and Alaskan Natives had high suicide rates, and more women attempt suicide but more men are successful.
Text page: 548

Question 56

A suicidal individual calls a suicide hot line. This represents the level of intervention classified as

a. primary.
b. secondary.
c. tertiary.
d. quaternary.

Answer 56

b. secondary.

Secondary prevention is essentially treatment.
Text page: 556

Question 57

Which neurotransmitter has been implicated as playing a part in the decision to commit suicide?

a. γ-Aminobutyric acid
b. Dopamine
c. Serotonin
d. Acetylcholine

Answer 57

c. Serotonin

Low serotonin levels have been noted among individuals who have committed suicide.
Text page: 551

Question 58

When working with a client that the nurse thinks may have made a covert reference to suicide, the nurse should

a. be careful not to mention the idea of suicide.
b. listen carefully to see if the client mentions it a second time.
c. ask about the possibility of suicidal thoughts in a covert way.
d. ask the client directly if he or she is thinking of attempting suicide.

Answer 58

d. ask the client directly if he or she is thinking of attempting suicide.

Covert references should be made overt. The nurse should directly address any suicidal hints given by the client. Self-destructive ideas are a personal decision. Talking openly about suicide leads to a decrease in isolation and can increase problem-solving alternatives for living. People who attempt suicide, even those who regret the failure of their attempt, are often extremely receptive to talking about their suicide crisis.
Text page: 553

Question 59

Nurses should assess the lethality of the client’s plan for suicide. What factor would be irrelevant to that assessment?

a. How long the client has been suicidal?
b. Does the plan have specific details?
c. Is the method one that causes death quickly?
d. Does the client have the means to implement the plan?

Answer 59

a. How long the client has been suicidal?

Lethality refers to how deadly a plan is. Length of time has nothing to do with lethality of the plan.
Text page: 553

Question 60

The suicide intervention that has the most impact on client safety is:

a. informing visitors regarding potential dangerous gifts.
b. restricting client from potential dangerous areas of the unit.
c. one-on-one observation by staff.
d. removal of personal items that might prove harmful.

Answer 60

c. one-on-one observation by staff.

One-on-one observation allows for constant supervision thus minimizing the client’s opportunity to self harm.
Text pages: 556, 557

Question 61

Some of the most important characteristics that staff, working with suicidal clients, need to have are

a. the ability to be consistently organized.
b. the ability to teach problem-solving skills.
c. warmth and consistency when interacting.
d. interview and counseling skills.

Answer 61

c. warmth and consistency when interacting.

Helpful staff characteristics for individuals who work with suicidal clients include warmth, sensitivity, interest, and consistency.
Text page: 557

Question 62

The nurse proposes that a suicidal client enter into a no-suicide contract. Such a contract would contain a provision that the client promises

a. never to attempt suicide.
b. to alert someone if he or she has made an attempt.
c. to not consider suicide for 72 hours.
d. not to attempt suicide in the next 24 hours.

Answer 62

d. not to attempt suicide in the next 24 hours.

A no-suicide contract is quite straightforward in seeking a promise not to attempt to harm oneself within a specified period. When that time expires, a new contract is negotiated.
Text page: 558

Question 63

A client tells the nurse that he has no hope for the future. He believes his situation is intolerable. The nurse assesses that he is isolated from his former social network. A nursing diagnosis that should be considered is

a. hopelessness.
b. deficient knowledge.
c. chronic low self-esteem.
d. compromised family coping.

Answer 63

a. hopelessness.

The defining characteristics are present for the nursing diagnosis of hopelessness.
Text page: 555

Question 64

The nursing diagnosis Risk for self-directed violence has been listed in the record of a suicidal client. An appropriate short-term goal for the client would be that the client will

a. reclaim any prized possessions that were given away.
b. name three personal strengths.
c. seek help when feeling self-destructive.
d. participate in a self help group.

Answer 64

c. seek help when feeling self-destructive.

Having the client cope with self-destructive impulses in a healthy way and is the only appropriate short-term goal here.
Text page: 561

Question 65

A woman of who recently lost one of her identical twin sons as a result of suicide, shares with the nurse, “Thank heavens suicide does not run in families. I won’t have to worry about my other son.” The nurse who hears this can make the assessment that the mother’s optimism

a. is not based on accurate knowledge because twin studies suggest the presence of genetic factors in suicide.
b. is justified because twin studies suggest no genetic factor is involved in suicide.
c. unjustified because she has failed to consider the importance of the “copycat” factor.
d. is likely evident of her denying the possibility of a maternal role in the causation of the suicide.

Answer 65

a. is not based on accurate knowledge because twin studies suggest the presence of genetic factors in suicide.

Twin studies, in fact, show that a genetic component of suicide may be present.
Text page: 551

Question 66

A client with a history of repeated suicidal attempts refuses to participate in a no-suicide contract but says she will try to hang on a little longer to see if hospital treatment can help her. What intensity of nursing observation should be instituted?

a. Constant 24-hour, one-to-one observation at arm’s length
b. One-to-one observation while client is awake
c. Every 15-minute observation around the clock
d. Seclusion with 15-minute observation

Answer 66

a. Constant 24-hour, one-to-one observation at arm’s length

A client who will not enter into a no-suicide contract should be placed on the highest level of suicide watch.
Text page: 557

Question 67

The nurse observes the meal tray the psychiatric aide is about to serve a suicidal client. Which item should be removed from the tray?

a. Plastic plate
b. Cloth napkin
c. Styrofoam cup
d. Metal utensils

Answer 67

d. Metal utensils

In most health care agencies, suicidal clients receive plastic dinnerware on their meal trays.
Text page: 557

Question 68

A client on one-to-one supervision at arm’s length indicates a need to go to the bathroom. She tells the nurse “I cannot ‘go’ with you standing there.” The nurse should

a. say “I understand” and allow the client to close the door.
b. keep the door open, but step to the side out of the client’s view.
c. leave the client’s room and wait outside in the hall.
d. say “For your safety I can be no more than an arm’s length away.”

Answer 68

d. say “For your safety I can be no more than an arm’s length away.”

This level of suicide watch does not make adjustments based on client preference. The explanation quoting the protocol and the reason (your safety) is appropriate.
Text page: 557

Question 69

Unit practice requires inspection of all items being brought onto the unit by visitors. This can be most effectively done by

a. having a staff member sit at the door and check packages as visitors enter.
b. having a staff member make frequent rounds during visiting hours to inspect gifts.
c. asking all visitors to report to the nurse’s station before visiting a client.
d. asking clients to give staff any unsafe item that might have been left by a visitor.

Answer 69

a. having a staff member sit at the door and check packages as visitors enter.

A number of ways to inspect items are possible. Taking all potentially harmful gifts from visitors before allowing them to see clients, going through client’s belongings (with client present) and removing all potentially harmful objects, ensuring that visitors do not leave potentially harmful objects in the client’s room, and searching clients for harmful objects on return from pass are all effective methods to ensure a high rate of client safety.
Text page: 557

Question 70

The morning after he was admitted, a suicidal client wishes to use the cordless electric razor the staff took from his suitcase the night before. The nurse should

a. allow him to use the razor under staff supervision.
b. tell him he must use a safety razor provided by the unit.
c. suggest that this would be a good time to grow a beard.
d. give him the razor and ask him to return it when he is finished.

Answer 70

a. allow him to use the razor under staff supervision

Because the razor is cordless, independent use is relatively safe.
Text page: 557

Question 71

If a suicidal client is to be treated outside the hospital, which intervention would be of high priority?

a. Have the client identify three people to call if he is overwhelmed by hopelessness.
b. Make sure the client has food enough to last for 2 to 3 days.
c. Arrange for a police visit every 24 hours.
d. Provide a 1-week supply of antidepressant medication.

Answer 71

a. Have the client identify three people to call if he is overwhelmed by hopelessness.

For suicidal clients treated in the community, establishing a network of individuals to whom the client may turn if the suicidal urge becomes great is important.
Text page: 558

Question 72

When a colleague committed suicide, the nurse stated “I do not understand why she would take her own life.” This is an expression of

a. anger.
b. denial.
c. confusion.
d. sympathy.

Answer 72

b. denial.

Denial and the minimization of suicidal ideation or gestures is a defense against experiencing the feelings aroused by a suicidal person. Denial can be seen in such statements as “I cannot understand why anyone would want to take his own life.”
Text page: 554

Question 73

Which phase of grief is the acute stage of mourning, when a person begins to feel intense feelings of anguish and despair and may exhibit anger, guilt, and tearfulness?

a. Shock and disbelief
b. accepting the reality
c. Restitution
d. Bereavement

Answer 73

b. accepting the reality

As awareness develops, the denial prominent in the stage of shock and disbelief fades and painful feelings surface.
Text page: 717

Question 74

The nurse providing end-of-life care will best engage in healthy self care by:

a. Adhering to the patient’s careplan once it has been created.
b. Being flexible in what you are willing/capable of doing for your patients.
c. Self reflecting on personal feelings/emotions often.
d. Remaining detached in order to provide effective care.

Answer 74

c. Self reflecting on personal feelings/emotions often.

Self reflection will encourage you to be aware of how your work is impacting you physically and emotionally.
Text page: 714

Question 75

A grieving wife tells the nurse “If his boss had not been so hard on him, he would not have had the heart attack. I will always blame his death on his job and that boss who rode him so hard and made him work so much overtime.” Which of the normal phenomena experienced during the mourning process does this statement exemplify?

a. Preoccupation with the deceased
b. Disorganization and depression
c. Anger
d. Guilt

Answer 75

c. Anger

Anger is exemplified in these statements in which the wife blames her husband’s boss for causing the husband’s heart attack.
Text page: 717

Question 76

Studies have shown that individuals contemplating end-of-life issues commonly fear

a. becoming a burden.
b. leaving money unspent.
c. being able to direct and control care.
d. the inability to display strong feelings toward family.

Answer 76

a. becoming a burden.

Individuals typically fear becoming a burden, being abandoned, being in pain, becoming impoverished, and becoming undignified in how they look and smell.
Text page: 711

Question 77

Which statement about palliative care could the nurse use to provide an explanation to a dying client and his or her family?

a. Palliation addresses emotional and spiritual pain to a greater degree than physical pain.
b. Palliation focuses on aggressive holistic comfort care when a cure is no longer a goal.
c. Clients receiving palliative care can expect no discomfort at the end of life.
d. Clients receiving palliative care will be released from end-of-life decisions.

Answer 77

b. Palliation focuses on aggressive holistic comfort care when a cure is no longer a goal.

Palliative care aggressively addresses physical, emotional, social, and spiritual pain when a cure is no longer a goal.
Text page: 708

Question 78

The most accurate way of describing nursing of the dying is that it is

a. facilitative.
b. directive.
c. structured.
d. stressful.

Answer 78

a. facilitative.

The nurse caring for a dying client must be more facilitative than directive if the client’s wishes are to be followed. Dying is an active process in which goals constantly require adjustment as the client’s physical and emotional states change.
Text page: 722

Question 79

The best approach to talking with a dying client about his or her future death is to

a. follow the client’s leads.
b. ask direct questions.
c. avoid the topic of dying.
d. talk about dying in indirect ways.

Answer 79

a. follow the client’s leads.

The client’s ability to face his or her death will vary from day to day or even hour to hour. The nurse must follow the client’s leads or risk confronting the client with unwanted information or, at other times, avoiding questions.
Text pages: 709, 710

Question 80

The two factors that seem to help dying clients and their families most are the ability to

a. have control and predict changes.
b. express anger and disconnect from emotion.
c. attend a bereavement group and vocalize negative feelings.
d. express guilt and establish a structured daily routine.

Answer 80

a. have control and predict changes.

Studies have provided information that can be of much value to nurses. Clients and their families prefer to retain control whenever possible and wish to predict and understand the changes that are taking place with the client and with themselves.
Text page: 708

Question 81

When the nurse transmits information to dying clients and their families, the process should include

a. a short session in which abbreviated information is given.
b. two sessions, one for the client and one for the family.
c. an initial session, a review session, and a time for questions.
d. oral and written information provided in at least six reiterations.

Answer 81

d. oral and written information provided in at least six reiterations.

Communication experts say that under stress, people need at least six reiterations to understand and retain new information.
Text page: 711

Question 82

The four gifts of resolving relationships are

a. forgiveness, love, gratitude, and farewell.
b. completion, closure, acceptance, and restitution.
c. recognition, review, emotion, and evaluation.
d. denial, bargaining, anger, and acceptance.

Answer 82

a. forgiveness, love, gratitude, and farewell.

The four gifts are forgiveness, love, gratitude, and farewell. When expressed to a terminally ill client by a significant other they precipitate a healing shift in relationships.
Text page: 712

Question 83

Which statement would be evaluated as indicating risk for unsuccessful work of mourning?

a. “He was a wreck when his brother died. He cried several times. It took months before he acted like his old self.”
b. “I remember the good times we had together as well as the rough days we went through before she died.”
c. “She was so strong. She didn’t shed a tear when anyone was around. Even now she just acts as though nothing different has happened.”
d. “She went through a stage where she was very angry at the doctors and nurses who were not able to save her husband’s life.”

Answer 83

c. “She was so strong. She didn’t shed a tear when anyone was around. Even now she just acts as though nothing different has happened.”

Crying is expected during the acute stage of grieving. A person who is unable to cry may have difficulty in successfully completing the work of mourning.
Text page: 718

Question 84

The client most at risk for dying in pain is

a. an executive who is used to being in power.
b. an immigrant whose culture is stoic regarding death.
c. a 4-year-old.
d. An Alzheimer’s patient.

Answer 84

d. An Alzheimer’s patient.

Characteristics of the Alzheimer’s client including dementia will pose increased risk of untreated pain.
Text page: 720

Question 85

A client has been admitted for hospice care. The health care team who planned his care advise him to have radiation therapy to shrink a chest tumor and allow him to breathe more easily. The client does not wish to undergo this treatment. How will this controversy be resolved?

a. The client’s wishes will prevail.
b. The recommendation of the health care team will be taken.
c. A consultant will be called in to give a definitive opinion.
d. The dispute will be settled by the ethics committee.

Answer 85

a. The client’s wishes will prevail.

The hospice principle supports client control and choice.
Text page: 708

Question 86

A client tells the nurse that her relationship with her terminally ill mother has seldom been a harmonious, loving one. She states she wishes things could have been different. The nurse could explain to the client the use of

a. the Four Gifts.
b. premourning.
c. anticipatory grieving.
d. recognition of a transcendent realm.

Answer 86

a. the Four Gifts.

The four gifts refer to simple tools for identifying distress and expressing it in a healthy way by making use of forgiveness, expression of love, gratitude, and saying farewell.
Text page: 712

Question 87

A client appears to be in denial regarding the seriousness of his diagnosis of lung cancer. He is likely to begin to accept the impact of the situation when:

a. his physician begins to discuss treatment modalities.
b. he begins to experience the full symptomology of his cancer.
c. experiences the physical pain of his cancer.
d. his family accepts the seriousness of the situation.

Answer 87

b. he begins to experience the full symptomology of his cancer.

As the symptoms and acute crises repeat over time, the individual then begins to accept the seriousness of the situation.
Text page: 699

Question 88

An important reason for nurses to identify coexisting or resulting anxiety and anxiety disorders among their clients is

a. anxiety can be transmitted interpersonally.
b. anxiety is a major factor contributing to medical noncompliance.
c. anxiety leads to development of additional somatic symptoms.
d. anxiety disorder is a risk factor for development of cerebrovascular disease.

Answer 88

d. anxiety disorder is a risk factor for development of cerebrovascular disease.

Cohen and associates found that those with anxiety disorders had a significantly higher relative risk of developing a medical disease compared with the control group.
Text page: 698

Question 89

A client has a history of heavy smoking and heavy alcohol use. He is divorced, has two grown children, is a member of a prominent church, and is president of the local chamber of commerce. He has been given the diagnosis of laryngeal cancer and told that removal of the larynx is recommended. He tells the nurse “This is the end for me. I won’t be able to talk. I won’t be able to sell advertising promotions. I won’t be able to chair meetings. I’ll be good for nothing.” The nurse who hears this can hypothesize that the client would be an excellent candidate for

a. cognitive therapy.
b. guided imagery.
c. acupressure.
d. biofeedback.

Answer 89

a. cognitive therapy.

Cognitive therapy could be helpful by assisting him to test negative assumptions and arrive at a more balanced picture of life after surgery.
Text page: 702

Question 90

At a recent clinic visit a client was diagnosed with fibromyalgia. At this visit she tells the nurse that she spends considerable time on the Internet seeking information about her illness. The nurse can correctly assume that this activity

a. reduces her anxiety.
b. offers emotional expression.
c. defends against emotional arousal.
d. is a predictor of further emotional upheaval.

Answer 90

a. reduces her anxiety.

Learning about one’s illness reduces anxiety. Keeping anxiety at a manageable level helps the client understand options and make informed decisions.
Text page: 593

Question 91

Which is an important factor to assess before developing a treatment plan for a client who is HIV positive?

a. Are the individuals in the client’s network available and reliable?
b. Will the client be compliant with treatment recommendations?
c. Is the client willing to abstain from sexual expression?
d. Is the client afraid of experiencing pain?

Answer 91

a. Are the individuals in the client’s network available and reliable?

Social support can buffer the effects of physical and psychological stress.
Text page: 594

Question 92

The nurse caring for a client with newly diagnosed type 2 diabetes mellitus makes the assessment that the client is depressed. The nurse knows that depression may lift without treatment but opts to discuss the use of selective serotonin reuptake inhibitors with the physician. The rationale for this action is

a. depression is a risk factor for medical noncompliance.
b. diabetic clients who are depressed are at high risk for suicide.
c. selective serotonin reuptake inhibitors are particularly effective for clients with endocrine disorders.
d. diabetes further distorts the endocrine imbalance associated with depression.

Answer 92

a. depression is a risk factor for medical noncompliance.

A study by DiMatteo and colleagues found that the odds are three times greater that depressed clients will be noncompliant with medical treatment recommendations than will nondepressed clients.
Text page: 596

Question 93

A 72-year-old client lives with her son and daughter-in-law. She gives them the money from her monthly Social Security check to help with household expenses. When her daughter-in-law mismanages the household finances, she demands that the client give her extra money from a small savings account. The client writes the check because she fears that her family will make her live elsewhere if she doesn’t “help out.” The nurse who hears this should assess it as

a. neglect.
b. physical violence.
c. psychological abuse.
d. financial maltreatment.

Answer 93

d. financial maltreatment.

Financial maltreatment occurs when the perpetrator takes financial advantage of the elderly person, often through the use of subtle threats of what unpleasant or frightening outcome will occur if the elder does not supply funds.
Text page: 592

Question 94

When the nurse interviews an adult victim of abuse the best approach is to be

a. confrontational.
b. gentle and direct.
c. direct and professional.
d. sympathetic and outraged.

Answer 94

c. direct and professional.

Expressing strong emotion does not help the victim. A direct, honest, and professional manner of asking questions produces the best results.
Text page: 590

Question 95

When treatment for injuries sustained during an incident of abuse is sought from the primary physician, the client is receiving

a. primary prevention.
b. secondary prevention.
c. tertiary prevention.
d. stop-gap therapy.

Answer 95

b. secondary prevention.

Secondary prevention is synonymous with treatment.
Text page: 602

Question 96

A desirable goal for the perpetrator of violence against a developmentally delayed child would be that the client will

a. Understand the impact of violence on the child with 2 days.
b. attend anger management training sessions within 2 weeks.
c. state that he or she is considering attending a group for child abusers by [date].
d. express anger and aggression toward significant other rather than the child by [date].

Answer 96

b. attend anger management training sessions within 2 weeks.

Perpetrators of violence need help learning how to manage anger. A structured group is an excellent way to provide this teaching.
Text page: 597

Question 97

The nurse has referred a battered woman to the battered women’s shelter and believes the woman left the emergency department to go there. An hour later the woman’s husband comes to the emergency department and pleads with the nurse to tell him his wife’s whereabouts. The nurse should

a. refuse to provide any information.
b. give him the telephone number, but not the address, of the shelter.
c. inform him that no information can be given for a minimum of 24 hours.
d. call law enforcement to arrest the husband for the assault and battery of his wife.

Answer 97

a. refuse to provide any information.

The nurse must respect the client’s right to confidentiality. Whether the questioner asks pleadingly or in a demanding way, the answer must be the same.
Text pages: 597, 598

Question 98

A person experiencing violence from a spouse may feel trapped in a detrimental relationship. Which of the following would be the most likely symptom that the woman would report as an attempt to escape the situation?

a. The client relates that she is taking alcohol as a way to escape.
b. The client states she has recently become more aggressive toward her husband so that she will not be physically beaten by him.
c. The client states that she has recently made a suicide attempt.
d. The client states she needs help because when she calls the police to arrest her husband but they do nothing.

Answer 98

c. The client states that she has recently made a suicide attempt.

A person experiencing violence may feel so trapped in a detrimental relationship, yet so desperate to get out, that suicide may seem the only answer. A suicide attempt may be the presenting symptom in the emergency department. At least 10% of abused women attempt suicide. The other reports are not realistic for a woman who is being abused.
Text pages: 588 and 594

Question 99

A 4-year-old child is seen in a well-child clinic. He tells the nurse “I’m a bad boy. I’m not worth a second look.” The nurse gently questions the boy and his mother and learns that the boy’s father constantly browbeats the child. He tells him he’s worthless and puts down all his efforts. He also shouts verbal threats whenever the boy misbehaves. This situation can be assessed as

a. neglect.
b. physical maltreatment.
c. emotional violence.
d. harsh parenting.

Answer 99

c. emotional violence.

Emotional violence occurs when the child’s self-esteem is attacked. It is as devastating to the child as physical abuse.
Text page: 592

Question 100

When a nurse has reason to suspect that a child is being abused, what action should he or she take?

a. Call the local police to report it
b. Follow agency policy for reporting
c. Confront the parent or parents
d. Interrogate the child to obtain proof

Answer 100

b. Follow agency policy for reporting

Nurses are mandated reporters of child abuse. They must follow the rules set forth by the state regarding the steps to take to report child abuse.
Text page: 597

Question 101

The nurse is caring for a patient who exhibits disorganized thinking and delusions. The patient repeatedly states, “I hear voices of aliens trying to contact me.” The nurse should recognize this presentation as which type of major depressive disorder?

a. Catatonic
b. Atypical
c. Melancholic
d. Psychotic

Answer 101

d. Psychotic

Question 102

Which patient statement indicates learned helplessness?

a. “I am a horrible person.”
b. “Everyone in the world is just out to get me.”
c. “It’s all my fault that my husband left me for another woman.”
d. “I hate myself”

Answer 102

c. “It’s all my fault that my husband left me for another woman.”

Question 103

The nurse is planning care for a patient with depression who will be discharged to home soon. What aspect of teaching should be the priority on the nurse’s discharge plan of care?

a. Pharmacological teaching
b. Safety risk
c. Awareness of symptoms increasing depression
d. The need for interpersonal contact

Answer 103

b. Safety risk

Question 104

The nurse is reviewing orders given for a patient with depression. Which order should the nurse question?

a. A low starting does of a tricyclic antidepressant
b. An SSRI given initially with an MAOI
c. Electroconvulsive therapy to treat suicidal thoughts
d. Elavil to address the patient’s agitation

Answer 104

b. An SSRI given initially with an MAOI

Question 105

A female patient tells the nurse that he would like to begin taking St. John’s wort for depression. What teaching should the nurse provide?

a. “St. John’s wort should be taken several hours after your other antidepressant.”
b. “St. John’s wort has generally been shown to be effective in treating depression.”
c. “This supplement is safe to take if you are pregnant.”
d. “St. John’s wort is regulated by the FDA, so you can be assured of its safety.”

Answer 105

b. “St. John’s wort has generally been shown to be effective in treating depression.”