Unit XIX: Mental Health Problems on the Adult Client

Question 1

The nurse is assigned to care for a client experiencing disturbed thought processes. The nurse is told that the client believes that their food id being poisoned. Which communication technique would the nurse plan to use to encourage the client to eat?
A. Open ended questions and silences
B. Focuses on self disclosure regarding food preferences
C. Stating the reasons that the client may not want to eat
D. Offering opinions about the necessity of adequate nutrition

Answer 1

A

Question 2

The nurse is assigned to care for a client admitted to the hospital after sustaining an injury from a house fire. The client attempted to save a neighbour involved in the fire but despite the clients efforts, the neighbour died. Which action would the nurse take to enable the client to work through the meaning of crisis?
A. Identifying the clients ability to function
B. Identifying the clients potential for self harm
C. Identifying about the clients feeling that may affect coping
D. Inquiring about the clients perception of the cause of the neighbours death

Answer 2

C

Question 3

The nurse is assisting with the data collection in a client admitted to the psychiatric unit. After review on the obtain data, the nurse would identify which as a PRIORITY concern?
A. Clients report of not eating or sleeping
B. Presence of bruises on the clients body
C. Clients reports if self-destructive thoughts
D. Family members is disapproving of the treatment

Answer 3

C

Question 4

Lab work is prescribed for the client who has been experiencing delusions. When the lab tech approaches the client to obtain a specimen of the clients blood, the client begins to shout, “you are all vampires. Let me out of here!” The nurse is present at the time would respond with which question or statement?
A. “The technician is not going to hurt you but is going to help”
B. “Are you fearful and think that the others may want to hurt you?”
C.” What makes you think that the technician wants to hurt you?”
D.”The technician will leave and come back later for your blood”

Answer 4

B

Question 5

An intoxicated client is brought to the ER by the police. The client is told that the primary health care provided will be in to see the client in about 30 minutes. The client becomes very loud and offensive and wants to be seen by the PHCP immediately. The nurse assisting to care for the client would take which appropriate nursing intervention?
A. Watch the behaviour escalate before intervening
B. Attempt to talk with the client to de-escalate the behaviour
C. Offer to take the client to an examination room until he or she can be treated
D. Informed the client that he or she will be asked to leave if the behaviour continues

Answer 5

C

Question 6

A client is admitted to the psychiatric unit for treatment of a psychiatric disorder. The client is at the locked door and is shouting “let me out! There is nothing wrong with me! I don’t belong here!” The nurse identifies this behaviour as which defence mechanism?
A. Denial
B. Projection
C.Regression
D. Rationalization

Answer 6

A

Question 7

A client says to the nurse, “I’m going to die, and I wish my family would stop hoping for a ‘cure’! I get so angry when they carry on like this! After all, I’m the one who is dying” Which therapeutic response would the nurse make to the client?
A. “Have you shared your feelings with your family?”
B. “I think we should talk more about your anger with your family”
C.”You’re feeling angry that your family continues to hope for you to be ‘cure’?”
D.”Well, it sounds like you’re pretty pessimistic. After all, years ago people died of pneumonia”

Answer 7

C

Question 8

The nurse in a psychiatric unit is assigned to care for a client admitted to the unit 2 days ago. During review of the clients record, the nurse notes that the admission was a voluntary one. Based on this type of admission, which would the nurse expect to note?
A. The client is angry and will refuse care
B. The client will participate in the treatment plan
C. The client will be very resistant to treatment measures
D. The client’s family will be very resistant to treatment

Answer 8

B

Question 9

The nurse enters a clients room and the client immediately demands to be released from the hospital. During review of the clients records, the nurse notes that the client was admitted 2 days ago for the treatment of an anxiety disordered that the admission was a voluntary one. The nurse reports the findings to the RN and expects that the RN will take which action?
A. call the clients family
B. Persuade the client to stay for a few more days
C. Contact the primary health care provider(PHCP)
D. Tell the client that discharge is not possible at this time

Answer 9

C

Question 10

A client is admitted to the psychiatric nursing unit. When collecting data from the client, the nurse notes that the client was admitted on an involuntary status. Based on this type of admission, which would the nurse be expected to note?
A. Client presents a harm to self
B. Client requested the admission
C. Client consented to the admission
D. Client provided written application to the facility for admission

Answer 10

A

Question 11

Following a group therapy session, a client approaches the nurse and verbalizes a need for seclusion because of uncontrollable feelings. The nurse reports the findings to the RN and expects that the RN will take with action?
A. Call the clients family
B. Place the client in seclusion immediately
C. Inform the client that seclusion has not been prescribed
D. Get a written prescription for the primary health care provider(PHCP) and obtain an informed consent

Answer 11

D

Question 12

BThe nurse is providing care for a client admitted to the hospital with a diagnosis of anxiety order. The nurse is talking with the client, and the client says, “I have a secret that I want to tell you. You won’t tell anyone about it, will you?” Which is the appropriate nursing response?
A. “No, I won’t tell anyone”
B. “I cannot promise to keep a secret”
C. “If you tell me the secret, I will tell it to your doctor”
D. “If you tell me the secret, I will need to document it in your record”

Answer 12

B

Question 13

The nurse in the mental health unit reviews the therapeutic and non therapeutic communication techniques with a nursing student. Which are the therapeutic communication techniques? SELECT ALL THAT APPLY
A. Restating
B. Listening
C. Asking the client, “why?”
D. Maintaining neutral responses
E. Giving advice, approval, or disapproval
F. Providing acknowledgment and feedback

Answer 13

A,B,D,F

Question 14

The nurse is preparing a client for the termination phase of the nurse-client relationship. Which task would the nurse appropriately plan for during this phase?
A. Plan short term goals
B. Identify expected outcomes
C. Assist with making appropriate referrals
D. Assist with developing realistic solutions

Answer 14

C

Question 15

The psychiatric nurse is treated by a neighbour in a local grocery store. The neighbour says to the nurse, “How is carol during? She is my best friend and is seen at your clinical every week.” Which is the appropriate nursing response?
A. “I cannot discuss any client situation with you”
B. “I’m not suppose to discuss this, but because you are my neighbour, I can tell you that she us doing great!”
C. “You may want to know about Carol, so you need to ask her yourself so you can get the story first hand”
D. “I’m not suppose to discuss this, but because you are my neighbour, I can tell you that she really has some problems!”

Answer 15

A

Question 16

A client with delirium becomes agitated and confused at night. The BEST INITIAL intervention by the nurse is which action?
A. Move the client next to the nursing station
B. Use a night light and turn off the television
C. Keep the television and a soft light on during the night
D. Play soft music during the night and maintain a well-lit room

Answer 16

B

Question 17

The nurse is collecting data on a client who is actively hallucinating. Which nursing statement would be therapeutic at this time?
A. “I know you feel ‘they are out to get you’ but it is not true”
B. “I can hear the voice, and she wants you to come to dinner”
C. “Sometimes people hear things or voices others can’t hear”
D. “I talked to the voices you are hearing and they will not hurt you now”

Answer 17

C

Question 18

The nurse is caring for a client with a diagnosis of depression. The nurse monitors for signs of constipation and urinary retention, knowing that these problems are likely cause by which situation?
A. Poor dietary choices
B. Lack of exercise and poor diet
C. Inadequate dietary intake and dehydration
D. Psychomotor retardation and side effects of medication

Answer 18

D

Question 19

A client is admitted to the inpatient unit and is being considered for ECT. The client appears calm, but the family is hypervigilant and anxious. The child mother begin to cry and states, “My Childs brain will be destroyed. How can the doctored this?” The nurse would make which therapeutic response?
A. “Is sounds as though you need to speak to the psychiatrist”
B. “perhaps you’d like to see the ECT room and speak to the staff”
C. “Your child has decided to have this treatment. You should be supportive of the decision”
D. “It sounds as though you have some concerns about the ECT procedure. Why don’t we sit down together and discuss any concerns you may have?”

Answer 19

D

Question 20

Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behaviour? SELECT ALL THAT APPLY
A. Communicate expected behaviours to the client
B. Follow through about the consequences of behaviour in a non punitive manner
C. Ensure that the client knows that he or she is not in charge of the nursing unit
D. Assist the client with developing a means of setting limits on personal behaviour
E. Enforce rules and inform the client that he or she will not be allowed to attend therapy groups
F. Be clear with the client regarding the consequences of exceeding limits set regarding behaviour

Answer 20

A,B,D,F

Question 21

The nurse is preparing for the hospital discharge pf a client with a history of command hallucinations to harm self or others. The nurse instructs the club about interventions for hallucinations and anxiety and determines that the client understands the interventions when the client makes which statement?
A. “My medications won’t make me anxious”
B. “I’ll go to a support group and talk so that I won’t hurt anyone”
C. “I won’t get anion or hear things if I get enough sleep and eat well”
D.”I can call my therapist when I’m hallucinating so I can talk about my feelings and plans and not hurt anyone”

Answer 21

D

Question 22

The nurse observes that a client is psychotic, pacing, and agitated and is making aggressive gestures. The clients speech pattern is rapid, and the client’s effect is belligerent. Based on these observations, which is the nurses IMMEDIATE PRIORITY of care?
A. Provide safety for the client and other clients on the unit
B. Provide the clients on the unit with a sense of comfort and safety
C. Assist the staff with caring for the client in a controlled environment
D. Offer the client a less-stimulating are to calm down and gain control

Answer 22

A

Question 23

The nurse is caring for a client diagnoses with catatonic stupor. The client is lying on the bed with the body pulled into a fetal position. Which is the appropriate nursing action?
A. Ask direct questions to encourage talking
B. Leave the client alone and intermittent check on them
C. Sit beside the client in silence and verbalize occasional open-ended questions
D.Take the client into the dayroom with other clients so they can help watch him

Answer 23

C

Question 24

A mother of a teenage client with an anxiety disorder is concerned about her daughters progress during discharge. She states that her daughter “stashes food, eats all the wrong things that make her hyperactive” and “hangs out with the wrong crowd.” While helping the mother prepare for her daughters discharge, the nurse would make which suggestion?
A. The mother should restrict her daughters socializing time with her friends
B. The mother should restrict the amount of chocolate and caffeine products in the home
C. The mother should keep her daughter out of school until she can adjust to the school environment
D. The mother should consider taking time off of work to help her daughter adjust to the home environment

Answer 24

B

Question 25

A client is unwilling to leave the house for fear of “doing something crazy in public.” Because of this fear, the client remains homebound except when accompanied outside by the spouse. The spouse asks the nurse, “ What is the name of my wife’s disorder?” Which answer would the nurse give to the spouse?
A. Agoraphobia
B. Hematophobia
C. Claustrophobia
D. Hypochondriasis

Answer 25

A

Question 26

A client reports that crying spells have been a major problem over the past several weeks and that the doctor said depression is probably the reason. The nurse observes that the client is sitting slumped in the chair, and the clothes that the client is wearing do not fit well. The nurse interprets that further data collection would focus on which assessment?
A. Weight loss
B. Sleep pattern
C. Medication compliance
D. Onset of crying spells

Answer 26

A

Question 27

A client was admitted to a medical unit with acute blindness. Many tests are performed, and there seems to be no organic reason why this client cannot see. The nurse later learns the client became blind after witnessing a hit and run crash in which a family of three was killed. The nurse suspects that the client may be experiencing which diagnosis?
A. Psychosis
B. Repression
C. Conversion disorder
D. Dissociative disorder

Answer 27

C

Question 28

S manic client announces to everyone in the dayroom the a stripper is coming to perform that evening. When the psychiatric nurse’s aid firmly states that the clients behaviour is not appropriate, the manic client becomes verbally abusive and threatens physical violence to the nurses aide. Based on the analysis of this situation, the nurse determines that the appropriate action would be which intervention
A. Escort the manic client to his or her room
B. Orient the client to time, place, and person
C. Tell the client that the behaviour is not appropriate
D. Tell the client that smoking privileges are revoked for 24 hours

Answer 28

A

Question 29

The nurse notes documentation in a clients record that the client is experiencing delusions of persecution. The nurse recognizes that these types of delusions are characteristic of which thoughts?
A. The false belief that one is a very powerful person
B. The false belief that one is a very important person
C. The false belief that one partner is being unfaithful
D. The false belief that one is being singled out for harm by others

Answer 29

D

Question 30

A client who is diagnosed with pedophilia and recently been paroled as a sex offender says, “I’m in treatment and have served my time. Now this group has posters all over the neighbourhood with my photograph and details of my crime.” Which is the appropriate response by the nurse?
A. “When children are hurt the way you hurt them, people want you isolated.”
B. “Your are lucky it doesn’t escalate into something pretty scary after your crime”
C. “You understand that people fear for their children, but you’re feeling unfairly treated?”
D. “You seem angry, but you have committed serious crimes against several children, so your neighbours are frightened”

Answer 30

C