Mental Health EAQs
What is the basic therapeutic tool used by the nurse to foster a client's psychologic coping?
1. self
2. milieu
3. helping process
4. client's intellect
1. self
The self is often the most important tool available to the nurse to help a client cope; to be therapeutic, the nurse must be present, actively listening, and attentive. The environment is important, but it is not the most basic tool. The
nurse fir
A client is admitted to the emergency department after ingesting a tricyclic antidepressant in an amount 30 times the daily recommended dose. What is the immediate treatment anticipated by the nurse?
1. Administration of physostigmine as soon as possible
3. Gastric Lavage
Gastric lavage with charcoal may help decrease the level of tricyclic antidepressant overdose. Supportive measures such as mechanical ventilation may be needed until
the medical crisis passes. Physostigmine salicylate was used in the pas
An older depressed person at an independent living facility constantly complains about her health problems to anyone who will listen. One day the client says, "I'm not going to any more activities. All these old crabby people do is talk about their proble
1. Projection
The client is assigning to others those feelings and emotions that are unacceptable to herself. Introjection
is treating something outside the self as if it is inside the self. Somatization is the unconscious transformation of anxiety into a
A nurse is assessing a client for the use of defense mechanisms. In the presence of which defense mechanism does the client express emotional conflicts through motor, sensory, or somatic disabilities?
1. Projection
2. Conversion
3. Dissociation
4. Compens
2. Conversion
The defense mechanism is called
conversion because the individual reduces emotional anxiety to a physical disability. Projection occurs when people assign their own unacceptable thoughts and feelings to others. With dissociation there is sep
A client has been diagnosed with generalized anxiety disorder [GAD]. Which behavior supports this diagnosis?
1. Making huge efforts to avoid "any kind of bug or spider"
2. Experiencing flashbacks to an event that involved a sexual attack
3. Spending
hours
3. Spending hours each day worrying about something "bad happening"
Using worrying as a coping mechanism is a behavior characteristic of GAD. Experiencing an accelerated heart rate and perfuse sweating for no apparent reason is consistent with a panic att
A mother and her three young children arrive at the mental health clinic. The woman says that she is seeking help in leaving her husband. She reports that he has been beating her for years but just started hitting the children. What is the best initial ac
1. answer
This emotionally charged topic should be discussed with the client in a confidential session; after the nurse has assessed the situation, the woman and the nurse can plan the family's future. Although a safe facility may be called, a determinati
The nurse is scheduled to be the co-leader of a therapy group being formed in the mental health clinic. When planning for the
first meeting, it is of primary importance that the nurse consider what?
1. Number of clients in the group
2. Needs of the client
2. answer
When planning a group, the nurse must ensure that clients have similar needs to promote relationships and interactions; diverse needs do not foster group process. Although important, the number of clients is not a primary consideration. Behavior
A nurse is planning to teach a client about self-care. What
level of anxiety will best enhance the client's learning abilities?
1. Mild
2. Panic
3. Severe
4. Moderate
1. answer
Mild anxiety motivates one to action, such as learning or making changes. Higher levels of anxiety tend to blur the individual's perceptions and interfere with functioning. Attention is severely reduced by panic. The perceptual field is greatly
A client is found to have a borderline personality disorder. What is a
realistic initial intervention for this client?
1. Establishing clear boundaries
2. Exploring job possibilities with the nurse
3. Initiating a discussion of feelings of being victimize
1. answer
Individuals with borderline personality disorder are impulsive and have difficulty identifying and respecting boundaries in relation to others. Exploration of this topic in a meaningful manner can be done only after an ongoing relationship has b
A client experiencing a tremendously stressful situation says, "My baby was diagnosed with terminal cancer 2 months ago. I'm either crying or walking around like I'm in a dream. I can't believe this is happening. What did we do to deserve something so hor
4. answer
Anticipatory grief is an intellectual and emotional response to a potential loss. Signs include a sense of disbelief and numbness. Emotions swing from sadness to anger. Individuals express the desire to avoid the
situation by running away and an
A nurse is conducting a group therapy session. Why is a group setting especially conducive to therapy?
1. It provides a new learning environment.
2. It decreases the focus on the individual.
3. It fosters one-on-one personal relationships.
4. It confronts
1. answer
The group setting provides an individual with the opportunity to learn that others share the same problems and needs. The group also provides
a safe arena in which new, healthier, more meaningful methods of relating to others can be explored. Th
A single mother of two children who recently lost her job because her company is downsizing comes to the emergency department. The woman does not know what to do and is in crisis. The most critical factor for the nurse to determine during crisis intervent
2. answer
Personal internal strengths and supportive individuals are critical to the
development of a crisis intervention plan; they must be explored with the client. Although developmental history information may be helpful, it is not essential; factors
A parent of a 13-year-old adolescent with recently diagnosed Hodgkin disease tells a nurse, "I don't want my child to know about the diagnosis." How should the nurse respond?
1. "It's best for your child to know the diagnosis."
2. "Did you know that the c
4. answer
Initiating
a conversation about the client's feelings does not prejudge the parent; it encourages communication. Stating that it is best for the child to know the diagnosis disregards the parent's feelings and cuts off further communication. Ask
A nurse in the mental health clinic concludes that a client is using confabulation when the client does what?
1. The flow of thoughts is interrupted.
2. Imagination is used to fill in memory gaps.
3. Speech flits from one topic
to another with no apparent
2. answer
Using imagination to fill in memory gaps is the definition of confabulation; it is a defense mechanism used by people experiencing memory deficits. Interruption of the flow of thoughts is the definition of thought blocking. Flitting of speech fr
A client in the mental health clinic who has been seeing a therapist for more than 6 months begins to talk and act like a therapist who is analyzing coworkers. What
defense mechanism does the nurse identify?
1. Undoing
2. Projection
3. Introjection
4. Int
3. answer
Introjection is treating something outside the self as if it is actually inside the self; it is unconsciously incorporating the wishes, values, and attitudes of another as if they were one's own. Undoing is taking some action to counteract or ma
A female nurse has been caring for a depressed 75-year-old woman who reminds her of her
grandmother. The nurse spends extra time with her every day and brings her home-baked cookies. What does the nurse's behavior reflect?
1. Affiliation
2. Displacement
3
4. answer
With countertransference the professional provider of care exhibits an emotional reaction to a client based on a previous relationship or on unconscious needs or conflicts. Affiliation is turning to others for support and help when stressed or c
What does a
psychiatric nurse identify as the primary purpose of the Diagnostic and Statistical Manual of Mental Disorders, fifth edition[DSM-5]?
1. Facilitate communication between researchers and clinicians.
2. Aid in teaching psychopathology to mental
4. answer
The prime purpose of the DSM-5 is to serve the clinician as a guide in identifying a client's mental health or psychiatric diagnosis. Although the DSM-5 is useful in facilitating communication, the teaching of
psychopathology, and the collection
A nurse is aware that a coworker's mother died 16 months ago. The coworker cries every time someone says the word "mother" and when the mother's name is mentioned. What does the nurse conclude about this behavior?
1. It is an expected response.
2. Most pe
3. answer
Crying is a release, but the individual should have developed effective coping mechanisms by this time. The coworker may need help with the
grieving process. Excessive crying 16 months after the death of a loved one is not an expected response.
The nurse should first discuss terminating the nurse-client relationship with a client during which phase?
1. Working phase, when the client initiates it
2. Orientation phase, when a contract is established
3. Working phase, when the client shows some pro
2. answer
When the nurse and client agree to work together, a contract should be
established and the length of the relationship should be discussed in terms of its ultimate termination. The client may discuss termination during the working phase; however,
When leading the first session of a newly formed group of clients in a mental health clinic, the nurse notes that group members frequently assume self-serving roles. What does the nurse understand about this?
1. Early group development involves these beha
1. answer
These
behaviors are a necessary phase of group development because they help members discover what they can expect from the leader and other members. It is inappropriate to assume at the first meeting that some clients will need to be switched t
A nurse is speaking with a client who was sexually abused as a child. The client does not know what constitutes inappropriate touch by another person. What issue will have to be addressed with this client?
1. Increased
libido
2. Phobic behavior
3. Boundar
3. answer
Clients who have experienced childhood sexual abuse will have difficulty being aware of their personal boundaries and maintaining appropriate boundaries for themselves and others. Clients who have experienced childhood sexual abuse tend to have
Personality disorders are identified in the DSM-V in clusters. How should the nurse describe the behaviors of an individual with a cluster A personality
disorder?
1. Odd and eccentric
2. Anxious and fearful
3. Dramatic and erratic
4. Hostile and impulsive
1. answer!
Cluster A includes paranoid, schizoid, and schizotypal personality disorders. These clients are odd and eccentric and use strange speech, are angry, and have impaired relationships. Cluster C includes avoidant, dependent, and obsessive-compulsi
A client who is to be discharged from an inpatient mental health facility is
referred to a mental health daycare center in the community. What should the nurse identify as the primary reason for this referral?
1. Improving social skills
2. Getting out of
3. answer
The daycare center provides the client with a therapeutic setting for a few hours each day during the transitional stage between hospital and total discharge. The goal is to maintain and enhance progress made during inpatient treatment. Daycare
In addition
to hallucinating, a client yells and curses throughout the day. What should the nurse do?
1. Ignore the client's behavior.
2. Isolate the client until the behavior stops.
3. Explain the meaning of the behavior to the client.
4. Seek to underst
4. Answer
All behavior has meaning; before planning intervention, the nurse must try to understand what the behavior means to the client. Ignoring behavior does little to alter it and may even cause further acting out.
Isolation may increase anxiety and p
A nurse understands that value clarification is a technique useful in therapeutic communication because initially it helps clients do what?
1. Become aware of their personal values
2. Gain information related to their needs
3. Make correct decisions relat
1. Answer
Value clarification is a technique that reveals individuals' values so the individuals become more aware of them and their effect on others.
Gaining information, making correct health decisions, and altering value systems to make them more socia
What should a nurse consider about the past experiences of clients who have immigrated to this country?
1. It affects all of their inherited traits.
2. There will be little impact on their lives today.
3. It is important that their values be assessed firs
3. Answer
Past experiences are important and must be recognized because they help
set the individual's values throughout life. Past experiences will not affect inherited traits. Past experiences play an important role in an individual's life. Nothing esta
Before discharge of an anxious client, the nurse should teach the family that anxiety can be recognized as what?
1. A totally unique feeling
2. Fears specifically related to the total environment
3. Consciously motivated actions, thoughts, and wishes
4. A
4.
Answer
Anxiety is a human response consisting of both physical and emotional changes that everyone experiences when faced with stressful situations. Anxiety is experienced to a greater or lesser degree by every person. The fear may be related to a spec
To provide appropriate psychosocial support to clients, a nurse must understand development across the life span. What theory is the nurse using in considering relationships and resulting behaviors as the central
factors that influence development?
1. Cog
3. Answer
The interpersonal theory of human development by Harry Stack Sullivan highlights interpersonal behaviors and relationships as the central factors influencing child and adolescent development across six "eras"; the need to satisfy social attachme
A married woman is brought to the emergency department of a local hospital. Her eyes are swollen shut, and she has a bruise on her neck. She reports that she is being beaten by her husband. How does the nurse expect the husband to behave when he arrives a
3. Abusers are often extremely charming to mask their abusive tendencies and convince the abused mate and others that change is possible. After an abusive episode there is often a "honeymoon" period because the tensions of the abuser have been released. A
A nurse in a hospice program cares for clients and family members who are coping with
imminent loss. What is the most important factor in predicting a person's potential reaction to grief?
1. Family interactions
2. Social support system
3 Emotional relati
4. How a person has handled grief in the past provides clues to how he or she will cope with grief in the present. Although family interactions, social support system, and emotional relationships are all important, none is the paramount predictor of a cli
According to
Erikson, what will an individual who fails to master the maturational crisis of adolescence most often do?
1 Rebel at parental orders.
2 Experience role confusion.
3 Experience interpersonal isolation.
4 Become a substance abuser.
2. According to Erikson, adolescents are struggling with identity versus role confusion. Rebellion against parental orders reflects part of the struggle for independence; it does not indicate failure to resolve the conflicts of adolescence. Adolescents te
A 68-year-old client who has metastatic carcinoma is told by the practitioner that death will occur within a month or two. Later the nurse enters the client's room and finds the client crying. Before responding, which factor should the nurse consider?
1 C
2. Crying is an expression of an emotion that, if not expressed, increases anxiety and tension; the increased anxiety and tension use additional psychic energy and hinder coping. Crying does not relieve depression, nor does it help a client face reality.
What is most important for a nurse to do when initially helping clients resolve a crisis situation?
1 Encourage socialization.
2 Meet dependency needs.
3 Support coping behaviors.
4 Involve them in a therapy group.
3. In a crisis situation, the individual frequently just needs support to regroup and re-establish the ability to cope. Socialization is part of recovery; this is not done during the initial stage of a crisis. Meeting dependency needs is not possible or r
Which psychotherapeutic theory uses hypnosis, dream interpretation, and free association as methods to release repressed feelings?
1 Behaviorist model
2 Psychoanalytic model
3 Psychobiologic model
4 Social-interpersonal model
2. The psychoanalytic model studies the unconscious and uses the strategies of hypnosis, dream interpretation, and free association to encourage the release of repressed feelings. The behaviorist model holds that the self and mental symptoms are learned b
An inpatient therapy group on a psychiatric unit has as its goal helping clients participate in life more fully by gaining insight and changing behavior. The nurse leader can best help the group achieve this goal by using a leadership style that is what?
1. A democratic and guiding leader stimulates and directs the group to assist it in developing its maximal potential by facilitating and balancing the group's forces. An autocratic and directing leader makes most of the decisions and controls the group, t
A psychiatric nurse is hired to work in the psychiatric emergency department of a large teaching hospital. While reviewing the manuals, the nurse reads, "People with mental health emergencies shall be triaged within 5 minutes of entering the emergency dep
1. Policies are statements that help define a course of action; what is to be done is stated in policies, and how a task or skill is to be performed is defined in a procedure manual. Standards of care are published by the American Nurses Association; they
A nurse is assessing a client with a diagnosis of primary insomnia. Which findings from the client's history may be the cause of this disorder? Select all that apply.
1. Chronic stress
2.
Severe anxiety
3. Generalized pain
4. Excessive caffeine
5. Chronic
Answer: 1,4,6
Acute or primary insomnia [1] [2] is caused by emotional or physical stress not related to the direct physiologic effects of a substance or illness. Excessive caffeine intake can cause disruptive sleep hygiene; caffeine is a stimulant that i
A nurse is assessing a client with the diagnosis of schizophrenia, undifferentiated type. What defense mechanisms
should the nurse anticipate that this client might use?
1. Projection
2. Repression
3. Regression
4. Conversion
Answer: 3
Regression is an unconscious defense mechanism that reduces anxiety by returning to behavior that was successful in earlier years. Regression commonly is used by clients with undifferentiated schizophrenia to reduce anxiety. Projection is the at
A 20-year-old homeless client at 38 weeks' gestation visits the prenatal clinic for the first time. She is accompanied by her 21-year-old boyfriend, who is the father of the baby. The nurse becomes concerned because as they sit in the waiting room, they a
Answer: Heroin
Research indicates that sneezing, yawning, and teary eyes are the first physical signs of withdrawal from heroin. Depression and irritability accompany withdrawal from cocaine. Restlessness, shakiness, hallucinations, and sometimes coma acc
A client in
the outpatient clinic is denying that he is addicted to alcohol. He tells the nurse that he is not an alcoholic and that it is his nagging wife who causes him to drink. What is the most therapeutic response by the nurse?
1. "I don't think that
Answer: 2
The comment "Everyone is responsible for his own actions" encourages the client to accept responsibility and does not support denial as a defense mechanism. Although the comment "I don't think that your wife is the problem"
may be true, it may a
What is the greatest difficulty for nurses caring for the severely depressed client?
1 Client's lack of energy
2 Negative cognitive processes
3 Client's psychomotor retardation
4 Contagious quality of depression
Answer: 4
Depression is contagious; it affects the nurse as well as the client. The client's lack of energy does not make nursing care difficult. Intervening with the client's negative thinking is an
expected part of nursing care and does not create speci
A nurse in the mental health clinic is counseling a client with the diagnosis of depression. During the counseling session the client says, "Things always seem the same. They never change." The nurse suspects that the client is feeling hopeless. For what
Answer: 1
Clients who are depressed and feeling hopeless also tend to have inappropriate expressions of anger. Depressed clients frequently
have a diminished ability to think or concentrate. Preoccupation with delusions is usually associated with clients
What is a priority nursing intervention in the care of a drug-dependent mother and infant?
1. Supporting the mother's positive responses toward her infant
2. Requesting that family members share responsibility for infant care
3. Keeping the infant separat
Answer: 1
A nurse should attempt to support the mother-child
relationship; the mother is experiencing a developmental crisis while coping with drug addiction and possibly guilt. It is the client's right to decide who will share in the care of her child. T
When the nurse is managing the care of an acutely depressed client, which intervention demonstrates that the nurse recognizes the client's fundamental mental health need?
1. Role modeling a hopeful attitude regarding life and the future
2. Sharing that li
1. Role modeling has been shown to be an excellent tool in molding adaptive behavior. Depression affects the individual's ability to see hope in the future, and role modeling will help provide adaptation to similar feelings. Affirming that everyone has de
When planning care for a client who has just completed withdrawal from multiple-drug abuse, what reality in relation to the client should the nurse take into consideration?
1. Unable to give up drugs
2.
Unconcerned with reality
3. Unable to delay gratific
Answer: 3
A person with an addictive personality is unable to delay gratification; drugs help blur reality and ease frustration. Giving up drugs is possible but not easy; it requires a change in attitude and a deconditioning process. Users of drugs are co
An 8-year-old child is found to have oppositional defiant disorder. What behavior noted by the nurse supports this diagnosis?
1. Easily
distracted
2. Argues with adults
3. Lies to obtain favors
4. Initiates physical fights
Answer: 2
Oppositional defiant disorder is a repeated pattern of negativistic, disobedient, hostile, defiant behavior toward authority figures, usually exhibited before 8 years of age. Easy distraction, associated with attention deficit-hyperactivity diso
What characteristic of an adolescent girl suggests to the nurse that she has bulimia?
1 History
of gastritis
2 Positive self-concept
3 Excessively stained teeth
4 Frequent re-swallowing of food
Answer: 3
Dental enamel erosion occurs with repeated self-induced vomiting. History of gastritis is not associated with bulimia. Often body image is disturbed and there is low self-esteem. Habitual regurgitation of small amounts of undigested food [rumina
The nurse is interviewing a female adolescent with anorexia nervosa who is malnourished
and severely underweight. Which statement leads the nurse to conclude that the client is experiencing secondary gains from her behavior?
1. "I'm as big as a house."
2.
Answer: 3
The client's behavior has gotten attention for her; it provides a sense of power and control. "I'm as big as a house" reflects a disturbed perception about her body. Although clients with anorexia nervosa are concerned about social acceptance, p
A client has just been
admitted with the diagnosis of borderline personality disorder. There is a history of suicidal behavior and self-mutilation. What does the nurse remember is the main reason that clients use self-mutilation?
1. Control others
2. Expr
Answer: 2
Typically, recurrent self-mutilation is an expression of intense anger, helplessness, or guilt or is a form of self-punishment. Self-mutilation is used not to control others but for self-validation; also, it is a means of blocking
psychological
A client experiencing nonspecific, excessive, unpleasant feelings of being worried concerning one's safety likely is experiencing which mental health disorder?
1. Phobia
2. Panic disorder
3. Generalized anxiety disorder [GAD]
4. Posttraumatic stress disor
Answer: 3
Generalized anxiety disorder is the manifestation of both physical and cognitive symptoms of chronic or excessive anxiety/worry. A phobia is a fear of a
specific type of stimuli. Panic is an extreme stage of anxiety. Posttraumatic stress disorde
A nurse is considering Erikson's stages of psychosocial development while caring for a client. Which behavior is consistent with a problem involving trust versus mistrust?
1. Woman in an abusive relationship who refuses to leave the abuser
2. Man with par
Answer: 3
Trust is learned in infancy. Being parented by individuals who were not able to
consistently meet the client's basic physiologic and safety needs is likely to result in an inability to engage in healthy interpersonal relationships as an adult. T
A nurse is counseling a recently widowed client, who says, "His death has complicated my life even more than the hassles he caused when he was alive!" The nurse realizes the client is having difficulty with the grieving process and concludes that the rela
Answer: 3
If the relationship
was ambivalent, the surviving spouse now has feelings of both anger and guilt to resolve. A loving relationship evokes fewer feelings of guilt and is followed by a less complicated grieving process. The length of the relation
The nurse is leading a relapse-prevention group for clients who experience bipolar disorder manic episodes. Which strategies should the nurse teach to help prevent or identify impending relapse? Select all that apply.
1. Watch for changes in
libido.
2. Ke
Answer: 1,2,3,5
Increased sex drive often indicates the beginning of a manic episode. Changes in the eating pattern can trigger a manic episode. Changes in the sleeping pattern may increase anxiety and trigger a manic episode. An elevated, expansive, or i
A client with the diagnosis of schizophrenia refuses to eat meals. Which nursing action is mostbeneficial for this client?
1. Directing the client repeatedly to eat the
food
2. Explaining to the client the importance of eating
3. Waiting and allowing the
Answer: 4
By sitting with the client during mealtimes the nurse can evaluate how much the client is eating; this encourages the client to eat and begins the construction of a trusting relationship. Fewer distractions may help the client focus on eating. T
A client newly admitted to the psychiatric unit because of an acute psychotic episode is actively hallucinating. The admitting nurse has documented the content of the auditory hallucinations, which center on the theme of powerlessness. Later the primary n
Answer: 1
Once the content of the hallucination is known and it is not a command to harm the self or others, focusing on the hallucinations is not therapeutic; recognizing feelings, pointing out reality, and learning to use strategies to push aside halluc
A nurse on the psychiatric unit
concludes that the staff's approach to setting limits for a demanding, angry client is effective. What behavior by the client leads the nurse to this conclusion?
1. No longer calls the nursing staff for assistance
2. Unders
Answer: 4
Discussing concerns regarding the emotional condition that required hospitalization demonstrates that the client feels comfortable enough to discuss the problems that motivated the behavior. No longer calling the nursing staff for
assistance doe
A mental health nurse is admitting a client with anorexia nervosa. When obtaining the history and physical assessment, the nurse expects the client's condition to reveal which symptom?
1. Edema
2. Diarrhea
3. Amenorrhea
4. Hypertension
Answer: 3
Amenorrhea results from endocrine imbalances that occur when fat stores are depleted. The client is dehydrated; edema is not expected. Constipation, not diarrhea, may occur
because of lack of fiber in the diet. Hypotension, not hypertension, may
When being admitted to a mental health facility, a young male adult tells the nurse that the voices he hears frighten him. The nurse knows that clients tend to hallucinate more vividly at what point in their routine?
1. Before meals
2. After going to bed
Answer: 2
Auditory hallucinations are most troublesome when environmental stimuli are diminished and there are few
competing distractions. Before meals, during group activities, and during television watching are all times of relatively high, competing en
When planning for a client's care during the detoxification phase of acute alcohol withdrawal, what need should the nurse anticipate?
1. Checking on the client frequently
2. Keeping the client's room lights dim
3. Addressing the client in a loud, clear vo
Answer: 1
During detoxification frequent
checks help ensure safety and prevent suicide, which is a real threat. Bright light is preferable to dim light because it minimizes shadows that may contribute to misinterpretation of environmental stimuli [illusio
What childhood problem has legal as well as emotional aspects and cannot be ignored?
1. School phobia
2. Fear of animals
3. Fear of monsters
4. Sleep disturbances
Answer: 1
School phobia is a disorder that cannot legally be
ignored for long because children must attend school. It requires intervention to alleviate the separation anxiety and promote the child's increasing independence. Fear of animals and monsters a
A client with a history of chronic alcoholism is admitted to the mental health unit. What does the nurse identify as the cause of a client's use of confabulation?
1. Ideas of grandeur
2. Need to get attention
3. Marked loss of memory
4. Difficulty accepti
Answer: 3
Alcoholic clients have loss of memory and adapt to this by unconsciously filling in with false information areas that cannot be remembered. Ideas of grandeur do not occur in this disease.
A nurse is caring for a client with an obsessive-compulsive disorder. What is the basis for the obsessions and compulsions?
1. Unconscious control of unacceptable feelings
2. Conscious use of this method to punish themselves
3. Acceptance of voices that
t
Answer: 1
In carrying out the compulsive ritual the client unconsciously tries to control anxiety by avoiding acting on unacceptable feelings and impulses. The client does not consciously use this method to punish herself. Hallucinations are not part of t
A client in the psychiatric hospital is attempting to communicate by stating, "Sky, flower, angry, green, opposite, blanket." The nurse recognizes what term as describing this type of
communication?
1. Echolalia
2. Word salad
3. Confabulation
4. Flight of
Answer: 2
Word salad is an incoherent mixture of words. Echolalia is a pathologic repetition of another's words or phrases. Confabulation is the unconscious filling in of memory gaps with imagined or untrue experiences. Flight of ideas is a speech pattern
For which clinical indication should a nurse observe a child in whom autism is suspected?
1. Lack of eye
contact
2. Crying for attention
3. Catatonia-like rigidity
4. Engaging in parallel play
Answer: 1
Children with autism usually have a pervasive impairment of reciprocal social interaction. Lack of eye contact is a typical behavior associated with autism. Crying for attention, rigidity, and parallel play are not indicative of autism.
An older adult is admitted for evaluation of anemia and unsteady gait. While obtaining a health history, the
nurse notes that the client seems to make up stories to fill in for memory lapses. How should the nurse document what the client is doing?
1. Lyin
Answer 4:
Confabulation is the filling in of memory gaps as a protective mechanism. Lying is false or dishonest behavior that is conscious and deliberate and is used in an attempt to deceive or mislead; there is no evidence of this behavior. Denying is a
A nurse is planning care for a client with substance-induced persisting dementia resulting from long-term alcohol use. Which nutritional problem, in addition to the effect of alcohol on brain tissue, has contributed to substance-induced persisting dementi
Answer: 2
Substance-induced persistent dementia is caused by a prolonged deficiency of vitamin B1 [thiamine] and the direct toxic effect of alcohol on brain tissue. Increase in serotonin, reduction in iron intake, and malabsorption of riboflavin are probl
Within a few hours of alcohol withdrawal the nurse should assess the client for the presence of what symptoms?
1. Irritability and tremors
2. Yawning and convulsions
3. Disorientation and paranoia
4. Fever and profuse diaphoresis
Answer: 1
Alcohol is a central nervous system depressant; irritability and tremors are the body's neurological adaptation to the withdrawal of alcohol. Tachycardia, irritability, and tremors are the early signs of
withdrawal and will appear 24 to 48 hours
The nurse is caring for a client with vascular dementia. What does the nurse identify as the cause of this problem?
1. A long history of inadequate nutrition
2. Disruptions in cerebral blood flow, resulting in thrombi or emboli
3. A delayed response to se
Answer: 2
Vascular dementia results from the sudden closure of the lumen of arterioles, causing infarction of the brain tissue in the affected
area. Inadequate nutrition may be one of the factors that bring about a general decline of health; however, ther
A nurse is assessing a child with suspected autism. At what age does the nurse determine that the signs of autism initially may be evident?
1. 2 years
2. 6 years
3. 6 months
4. 1 to 3 months
Answer: 1
By 2 years of age the child should demonstrate an interest in others, communicate verbally, and possess the ability to learn
from the environment. Before the age when these skills develop, autism is difficult to diagnose. Usually by 3 years the
A 24-year-old woman states that she no longer enjoys any of the activities that she once found fun and pleasurable, such as socializing, sports, and hobbies. What term should the nurse use to describe this condition?
1. Anergia
2. Anhedonia
3. Grandiosity
Answer: 2
Anhedonia is the inability to experience pleasure in
events or activities that once were enjoyable. Anergia is lethargy and a decreased level of energy. Grandiosity is a symptom seen during manic episodes in which an individual displays an infla
A nurse is caring for a client with a somatoform disorder. What should the nurse anticipate that this client will do?
1. Write down conversations to facilitate the recall of information.
2. Monopolize conversations about the anxiety being experienced.
3.
Answer: 3
Clients with somatoform disorders are preoccupied with the symptoms that are being experienced and usually do not want to talk about their emotions or relate them to their current situation. Clients with somatoform disorders do not seek opportun
During an interview of a client with a diagnosis of bipolar I disorder, manic episode, what does the nurse expect the client to demonstrate?
1 Flight of ideas
2 Ritualistic behaviors
3Associative
looseness
4 Auditory hallucinations
Answer: 1
Flight of ideas is a fragmented, pressured, nonsequential pattern of speech typically used during a manic episode. Ritualistic behaviors are repetitive, purposeful, and intentional behaviors that are carried out in a stereotyped fashion; they ar
A nurse has been assigned to care for a client with the diagnosis of obsessive-compulsive disorder [OCD]. Before providing care for this client, what should
the nurse remember about clients with OCD?
1. Are unaware that the ritual serves no purpose
2. Can
Answer: 4
The repeated thought or act defends the client against even higher, more severe levels of anxiety. Clients usually do recognize that the ritual serves little or no purpose. Rituals are usually followed rigidly; setting limits on or altering a ri
A nurse is counseling clients who are attending an alcohol rehabilitation program. Which
substance poses the greatest risk of addiction for these clients?
1. Heroin
2. Cocaine
3. Nicotine
4. Marijuana
Answer: 3
Although polysubstance abuse is common, clients undergoing rehabilitation from alcohol dependence are more likely to use or develop a dependence on nicotine, another legal substance, than on an illegal substance such as heroin, cocaine, or marij
What defense mechanism should the nurse anticipate that a client with
the diagnosis of schizophrenia, undifferentiated type, will most often exhibit?
1. Projection
2. Regression
3. Repression
4. Rationalization
Answer: 2
Regression is the defense mechanism that is commonly used by clients with schizophrenia, undifferentiated type, to reduce anxiety by returning to earlier behavior. Projection is an organized defense used by clients with schizophrenia, paranoid t
A client who has been admitted with a
diagnosis of schizophrenia says to the nurse, "Yes, it's March. March is Little Women. That's literal, you know." What do these statements illustrate?
1. Echolalia
2. Neologisms
3. Flight of ideas
4. Loosening of asso
Answer: 4
Loose associations are thoughts that are presented without the logical connections that are usually necessary for the listener to interpret the message. Echolalia is the purposeless repetition of words spoken by others or repetition of
overheard
A client with a history of drug abuse begins group therapy. After attending the first meeting the client says to the nurse, "It helps to know that I'm not the only one with this type of problem." What concept does this statement reflect?
1. Altruism
2. Ca
Answer: 3
Universality is the sense that one is not alone in any situation; one purpose of group therapy is to share feelings and gain support from others with similar thoughts and
feelings. Altruism in group therapy is giving support, insight, and reassu
What is the priority nursing intervention for a forgetful, disoriented client with the diagnosis of dementia of the Alzheimer type?
1. Restricting gross motor activity
2. Preventing further deterioration
3. Keeping the client oriented to time
4. Managing
Answer: 4
Clients with Alzheimer disease require external controls to minimize the danger of injury caused by
lack of judgment. The staff should not prevent all gross motor activity; the client needs to use the muscles, or atrophy will occur. Further dete
A client with a prolonged history of chronic schizophrenia, paranoid type, shows the nurse a small plastic keychain and says that it provides protection from evil forces. The client then quickly hides the keychain, yelling, "Don't take it away from me; it
Answer: 1
The keychain poses no threat to the
client or others. It increases the client's sense of security and decreases anxiety. There is no evidence to indicate that the keychain poses any risk; removing it at this time will increase the client's anxie
During the first month in a nursing home, an older client with dementia demonstrates numerous disruptive behaviors related to disorientation and cognitive impairment. What should the nurse take into consideration when planning care?
1. Client's orientatio
Answer: 3
Additional information must be collected to determine what may be precipitating the disruptive behavior. Clients with cognitive impairment may have difficulty controlling behaviors and may need the environment to provide the structure needed to
The clients on a mental health unit go on a supervised day trip to a baseball game. When returning to the bus, a client with a narcissistic personality disorder insists on leaving the group to get an autograph from a player. What is the most appropriate r
Answer: 3
Informing the client in a matter-of-fact tone indicates that negotiation is unacceptable. Holding the client by the arm is an inappropriate use of force. The nurse should contact the police if the client continues to refuse to leave. Raising the
When a disturbed client who has a history of using neologisms says to the nurse, "My lacket huss kelong mon," how should the nurse
respond?
1. Trying to learn the language of the client
2. Telling the client that these words cannot be understood
3. Commun
Answer: 2
Telling the client that these words are not understood is a simple statement that provides feedback and points out reality. Neologisms have symbolic meaning only for the client. Although communicating in simple terms should be done, it does not
A client has the diagnosis of histrionic personality disorder.
Which behavior should the nurse expect when assessing this client?
1. Boastful and egotistical
2. Rigid and perfectionistic
3. Extroverted and dramatic
4. Aggressive and manipulative
Answer: 3
Clients with histrionic personality disorder draw attention to themselves, are vain, and demonstrate emotionality and attention-seeking behavior. Boastful and egotistical behaviors are typical of clients with the diagnosis of narcissistic person
A
client is admitted to the mental health unit with the diagnosis of major depressive disorder. Which statement alerts the nurse to the possibility of a suicide attempt?
1. "I don't feel too good today."
2. "I feel much better; today is a lovely day."
3.
Answer: 2
A rapid mood upswing and psychomotor change may signal that the client has made a decision and has developed a plan for suicide. "I don't feel too good today"; "I feel a little better, but it probably won't
last"; and "I'm really tired today, so
A client's severe anxiety and panic are often considered "contagious." What action should be taken when a nurse's personal feelings of anxiety are increasing?
1. Refocusing the conversation to more pleasant topics
2. Saying to the client, "Calm down. You'
Answer: 3
The nurse who is anxious should leave the situation after ensuring continuity of care; the client will be aware of the nurse's anxiety, and
the nurse's presence will be nonproductive and nontherapeutic. The client will probably sense the nurse's
What response from the nurse demonstrates an understanding of hallucinating behavior by a client?
1. Asking, "What are the voices telling you to do?"
2. Calmly noting that the "rat on the floor" is really a stuffed toy
3. Allowing the family to bring prep
Answer: 1
A hallucination involves false perceptions of sensory stimuli that may
be visual, auditory, tactile, or olfactory. Hearing voices is a common hallucination, and it is appropriate for the nurse to clarify exactly what the client is hearing. When
A client who has severe anxiety starts to cry while talking with the nurse. The client is so upset that the crying becomes uncontrollable. What is the best response by the nurse?
1. "Talking about your problem is upsetting you."
2. "It's okay to cry; I'll
Answer:
2
Telling the client that it is alright to cry and offering to stay presents a nonjudgmental attitude that recognizes the client's needs. Pointing out the obvious is unnecessary and not therapeutic. Telling the client that it's good to get it out
A severely depressed client is to have electroconvulsive therapy [ECT]. What should a nurse include when discussing this therapy with the client?
1. Sleep will be induced and the treatment will not cause pain.
2. The
treatment is totally safe with the new
Answer: 1
Clients fear ECT because they think it will be painful. If they are reassured that they will be asleep and will feel no pain, there will be less anxiety. No treatment requiring anesthesia is totally safe. Clients may not realize their own fears
A client is not responding to antidepressant medications for treatment of major depression with suicidal ideation. After learning about electroconvulsive therapy [ECT], the client discusses the advantages and disadvantages with the primary nurse. The nurs
Answer: 3
Impaired memory is an expected side effect of the therapy. Succinylcholine prevents the external manifestations of a tonic-clonic seizure, thereby minimizing fractures and dislocations. The therapy begins to elicit results in two or three treatm
A client with a history of schizophrenia attends the mental health clinic for a regularly scheduled group therapy session. The client arrives agitated and exhibits behaviors that indicate that the client is hearing voices. When a nurse begins to walk towa
Answer: 1
A firm approach prevents anxiety transference and provides structure and control for a client who is out of control. A passive approach for a client who may be out of control does not provide structure, which may increase the client's anxiety. A
A depressed client is brought
to the emergency department after taking an overdose of a sedative. After lavage the client says, "Let me die. I'm no good." What is the most appropriate response by the nurse?
1. "Tell me why you did this."
2. "You must have
Answer: 2
Identifying and showing understanding of the client's feelings by giving feedback help establish a therapeutic relationship and promote exploration of feelings. Asking why the client attempted suicide is too direct; it does not allow the
client
A client with bipolar I disorder, manic episode, is admitted to the mental health unit of a community hospital. When developing an initial plan of care for this client, what should the nurse plan to do?
1. Increase the client's gym time.
2. Isolate the cl
Answer: 3
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. The hyperactivity of mania
creates an increased need for calories. Although the client needs to ex
A nurse is caring for an adolescent who has anorexia nervosa. The nutritional treatment of anorexia is composed of several guidelines. Which guidelines should the nurse emphasize? Select all that apply.
1. Increasing high-fiber foods
2. Eating just three
Answer: 3,4,5
Food intake should be increased by approximately 200 calories weekly. A gradual increase allows the
client to adapt emotionally and physically to the increased volume. Thirty minutes is sufficient time for eating. Extended mealtimes place ex
A delusional client is actively hallucinating and worried about being stalked by a terrorist group. What defense mechanism does the nurse identify as the most prominent in this situation?
1. Splitting
2. Undoing
3. Projection
4. Sublimation
Answer: 3
Projection is the common defense mechanism
found in delusions. Projection is attributing to others one's own unacceptable feelings, impulses, or thoughts. Splitting is when the individual fails to integrate the positive and negative qualities of
The parents of an adolescent who is experiencing posttraumatic stress disorder have decided to care for their child at home. What is the priority intervention that the home health nurse must include in the plan of care?
1. Encouraging the parents to keep
Answer 3
The client will tend to avoid emotional attachment to significant others, because this is a common way to protect the self from the experience of potential future losses. The priority at this time is to have family members develop an understandin
A nurse is preparing a teaching plan for a client who is to undergo electroconvulsive therapy. What instructions should the nurse include?
1. Void just before the procedure.
2. Wear cotton clothing
during the procedure.
3. Sleep for several hours after th
Answer: 1
During the expected seizure the client may become incontinent. The client will awaken 20 to 30 minutes after the procedure. Although the client will be groggy and confused, there is no requirement that the client sleep for several hours. The cli
A nurse is interviewing an 8-year-old girl who has been admitted to the pediatric unit. Which statement by the child needs to be
explored?
1. "Wow! This place has bright colors."
2. "Is my mother allowed to visit me tonight?"
3. "Those boys are so cute. I
Answer: 3
An 8-year-old child should be more concerned with same-gender relationships. A child who demonstrates a strong attraction to opposite-gender relations should be questioned further to explore the possibility of sexual abuse. A statement such as
What is the most important information for a nurse to teach
to prevent relapse in a client with a psychiatric illness?
1. The need to develop a close support system
2. The need to create a stress-free environment
3. The need to refrain from activities tha
Answer: 4
Following the prescribed medication regimen is important because side effects and denial of illness may cause clients to stop taking their medications; this is a common cause of relapse or recurrence of symptoms. Although a close support system
A local business owner asks the mental health nurse to talk with employees about the principles of maintaining mental health in today's world. What is the nurse's primary intervention before planning the approach or content for the discussion?
1. Arrangin
Answer: 4
Beginning at the learner's level of understanding and including the learner in the planning foster acceptance and stimulate motivation. Arranging for speakers who can help the employees is premature. An
outline of topics to be included should be
The nurse is caring for an 84-year-old man admitted with a diagnosis of severe Alzheimer dementia. In the admission assessment, the nurse notes that the client can no longer recognize familiar objects such as his glasses and toothbrush. What is the best t
Answer: 2
Agnosia is the term used to describe the loss of sensory ability to recognize familiar sounds and objects, as well as loved ones or even parts
of the affected individual's body. Amnesia is the term for the impairment of memory both recent and re
The nurse manager is observing the performance of a nursing assistant. Which behavior by the nursing assistant toward a client reflects a boundary violation?
1. Offering advice to the client
2. Providing false reassurance
3. Accepting a gift from the clie
3. A boundary violation occurs when a provider of care goes beyond the established therapeutic relationship standard and enters into a personal or social relationship with a client, such as with accepting a gift from the client. Offering advice is inadequ
A 16-year-old boy with a diagnosis of adolescent adjustment disorder and his family are beginning family therapy. What is the best initial nursing approach?
1. Setting long-term goals for the family
2. Letting the client express his feelings first
3. Havi
Answer:
4
Family therapy must include the whole family. Each member must be considered not just individually from his or her perspective but also as a member of the whole. Identification of the problem by the people involved is the priority. The family, n
Which statement best explains the focus of a therapeutic milieu management?
1. Management of a therapeutic milieu is a nursing responsibility.
2.The nurse-patient relationship is dependent upon therapeutic milieu
management.
3. Milieu management creates a
Answer: 3
The focus of a therapeutic milieu is the creation and maintenance of an environment that supports and benefits a client toward achieving therapeutic goals. That management of a therapeutic milieu is a nursing responsibility, the nurse-patient re
A nurse is planning to teach a class of nursing assistants how to compare the behaviors of psychotic clients with the behaviors of people who function
acceptably in society. What type of behavior is considered acceptable?
1. When defense mechanisms are ra
Answer: 3
An accepted practice in some parts of the world may be considered unacceptable behavior in others [e.g., pica]. Every person needs relief from tension from time to time and makes use of defense mechanisms to accomplish this. If the behavior is a
A client who was sexually assaulted 3 hours ago comes to the emergency department of the
hospital. The priority is for the staff to help the client feel what?
1. Loved
2. Believed
3. Protected
4. Accepted
Answer: 3
Safety and security are basic needs that assume significance immediately after a sexual assault. Although all people have a need to belong and be loved, these are not priorities at this time and are not responsibilities of the staff. Although be
A client who is being discharged with severe facial scarring from
burns tells the nurse, "I've saved some oxycodone, and when I get home I'm going to take all of them. Don't tell anyone." What is the best response by the nurse?
1. "Are you going to kill y
Answer: 1
A direct assessment is necessary to determine whether the client is contemplating suicide. The client already has stated that the nurse should not tell anyone; reeliciting this information will only serve to delay further investigation and inter
The
client repeatedly performs ritualistic behaviors throughout the day to limit anxious feelings. How does the nurse characterize these behaviors?
1. Obsessions
2. Compulsions
3. Under personal control
4. Related to rebelliousness
Answer: 2
A compulsion is an uncontrollable, persistent urge to perform an act repetitively to relieve anxiety. An obsession is a persistent idea, thought, or impulse that cannot be eliminated from consciousness with logical reasoning. The
urge to perform
When planning interventions to help a client with bipolar I disorder, manic episode, meet rest and sleep needs, what must the nurse remember about the manic client?
1. Experiences few sleep pattern disturbances
2. Requires less sleep than the average pers
Answer: 3
Manic individuals readily respond to environmental cues. Increased stimulation increases activity; decreased stimulation decreases activity. Sleep pattern
disturbances characteristically occur because of psychomotor activity. All individuals req
One morning a client tells the nurse, "My legs are turning to rubber because I have an incurable disease called schizophrenia." What is this statement an example of?
1. Hallucinations
2. Paranoid thinking
3. Depersonalization
4. Autistic verbalization
Answer: 3
The state in which the client feels unreal or believes that parts of the body are
distorted is known as depersonalization or loss of personal identity. This is not an example of a hallucination; a hallucination is a sensory experience for which
A client who has a long history of alcoholism has not worked for the past 10 years. When the nurse asks about daily activities the client responds, "I currently work in the office of a local construction company." Which mental mechanism should the nurse s
Answer: 4
Confabulation is often
used by people with alcoholism to cover lapses of memory that occur with Korsakoff syndrome; it is an unconscious means of self-protection. Regression is a return to a prior stage of development as a way to cope with stres
The nurse is interviewing the family about the onset of problems in a young client with the diagnosis of schizophrenia. In what stage of development does the nurse expect that the client's difficulties with reality testing began?
1. Puberty
2.
Adolescence
Answer: 2
The usual age of onset of schizophrenia is adolescence or early adulthood. Signs and symptoms usually do not appear earlier in life.
An executive assistant experiences an overwhelming impulse to count and arrange the rubber bands and paper clips in his desk. The client feels that something dreadful will occur if the ritual is not carried out. Considering the client's symptoms, what doe
Answer: 2
Serving to
control anxiety resulting from unconscious impulses is the psychoanalytical explanation for the development of obsessive-compulsive symptomatology. Compulsive rituals commonly result in interference with activities of daily living, an
A client is admitted to the mental health unit with the diagnosis of anorexia nervosa. What typical signs and symptoms of anorexia nervosa does the nurse expect the client to exhibit?
1. Slow pulse, mild weight loss, and
alopecia
2. Compulsive behaviors,
Answer: 3
In anorexia nervosa, weight loss is excessive [15% of expected weight]; nutritional deficiencies result in amenorrhea and a distended abdomen. Although pulse irregularities and alopecia are associated with anorexia, weight loss is excessive, not
During a home visit to an older adult, the nurse observes a change in behavior and suspects delirium. The nurse assesses the client for one of several
conditions that may have precipitated the delirium. Select all that apply.
1. Infection
2. Dementia
3. D
Answer: 3,4
Infections, especially urinary tract infections in older clients, may cause delirium because they may become systemic. A memory aid for recalling the causes of delirium is DELIRIUMS: Drugs, Emotional factors, Low arterial oxygen level, Infecti
During the intake interview at a mental health clinic, a client in withdrawal reveals to the nurse long-term, high-dose cocaine use. Which signs and symptoms support the conclusion that the client has been abusing cocaine for a prolonged time? Select all
Answer: 1, 5
Although cocaine is an alkaloid stimulant, depressant effects such as a decreased mood, hypotension, and psychomotor retardation are associated with long-term, high-dose use. Cocaine is a stimulant, and euphoria, loss of appetite, and impaire
A 5-foot 5-inch
[165 cm] 15-year-old girl who weighs 80 lb [36.3 kg] is admitted to a mental health facility with a diagnosis of anorexia nervosa. The nurse recognizes what factor as the most likely cause of her problem?
1. A desire to control her life
2.
Answer: 1
Eating and weight loss become the means of control to decrease anxiety related to perfectionist thinking. Controlling one's self within the family seems to be more important than peer group acceptance. Although it is true
that the media celebrat
What is a primary component of the nursing plan of care for a client with the diagnosis of anorexia nervosa?
1.Observing the client after meals
2.Weighing the client before meals
3. Measuring the client's fluid balance
4. Limiting the client's interaction
Answer: 1
Observing the client after meals is the only way the nurse can be certain that the client does not engage in purging. Weighing will not help the nurse
assess the client's electrolyte or nutritional status. An accurate intake and output record is
A 13-year-old student visits the school nurse numerous times over the course of several weeks. The student has reported, "I worry about my parents because I don't want them to get a divorce. They tell me that they're happy, but I can't stop worrying. I'm
Answer: 3
The data presented reflect generalized anxiety disorder [GAD], which includes three or more
of these adaptations: uncontrollable worry, restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbances. The cr
What characteristic of the environment is most therapeutic for clients with the diagnosis of bulimia nervosa?
1. Controlling
2. Empathetic
3. Focused on food
4. Based on realistic limits
answer: 4
Realistic guidelines reduce anxiety, increase feelings of security, and increase
adherence to the therapeutic regimen. A controlling environment sets up a power struggle between these clients and the nurse. These clients need realistic rules and
A nurse plans to give greater responsibility for self-control to clients with a long history of alcohol abuse who are about to enter a detoxification program. What should the nurse plan to do?
1. Tell them about the detoxification program.
2. Help them ad
Answer: 2
The client must
learn to develop and use more healthful coping mechanisms if drinking is to be stopped; the responsibility lies with the client because the client must do the changing. Telling the clients about the detoxification program will te
The husband of a woman who gave birth to a baby 2 weeks ago calls the postpartum unit at the hospital, seeking assistance for his wife. He reports that he found his wife in bed and that the baby was wet, dirty, and crying in the crib. He says, "She says s
Answer: 4
The inability to care for herself or her infant is a significant sign that the wife is depressed and in need of immediate intervention. The wife, not the husband, is the priority at this time. The wife has an emotional, not physiologic, problem
What developmental task should the nurse consider when caring for toddlers?
1.Trust
2. Industry
3. Autonomy
4. Identification
Answer: 3
Testing the
self both physically and psychologically occurs during the toddler stage, after trust has been achieved. Trust is the task of infancy. The task of industry is accomplished between the ages of 6 and 12 years. Identification is not a d
A nurse at the mental health clinic is counseling a client who has lost three jobs and four roommates in the last 6 months. The client states that sometimes he or she has problems interacting with people. What is the most appropriate response by the nurse
Answer: 4
The response "Tell me more about some of the specific problem you've experienced with these people" invites the client to explore interpersonal problems more fully while showing interest in what the client is communicating. Past experiences may
A client comes to the crisis center because her spouse has stated that he wants a divorce. The client states that she is angry and feels rejected. What should the nurse
encourage the client to do to cope with this emotional trauma?
1. Use other defense me
Answer: 4
Coping mechanisms, such as venting anger, may help the client address the feelings of rejection. Defense mechanisms are usually subconscious and not under a person's control; specific coping approaches should be explored. Avoidance is a defense
What should the nurse's approach be when when working with clients who use manipulative, socially
acting-out behaviors?
1.Strict, punishing, and restrictive
2. Sincere, cautious, and consistent
3. Supportive, accepting, and friendly
4. Sympathetic, nurtur
Answer: 2
A sincere, cautious, and consistent attitude limits this type of individual's ability to manipulate both situations and staff members. A strict, punishing, and restrictive approach may create a power struggle and limit the development of a thera
A mental health nurse is
participating in a therapy group. The nurse concludes that the group has reached the working stage when the members do what?
1. Appear happy in their group interactions.
2. Focus on a variety of needs and concerns.
3. Say what is
Answer: 2
Focusing on a variety of needs and concerns is typical of the working stage of the group; trust has been established, and a willingness to discuss any problems or needs is present. Satisfaction with group interactions may occur at
any stage; sat
In response to a question posed during a group meeting, the nurse explains that the superego is that part of the self that says what?
1."I like what I want."
2. "I want what I want."
3. "I shouldn't want that."
4. "I can wait for what I want.
Answer: 3
Conscience and a sense of right and wrong are expressed in the superego, which acts to counterbalance the id's desire for immediate gratification. "I like what I want" does
not reflect any part of the self. "I want what I want" is the id seeking
A 13-year-old girl is brought to the emergency department by her mother, who tells the nurse that she just found out that her daughter has been sexually abused by her grandfather for almost 2 years. What is the nurse's priority intervention?
1.Keeping the
Answer: 3
Victims of sexual abuse need to feel safe and accepted when discussing their histories. The nurse's primary
responsibility is toward the child, not the family. The story should initially be accepted as true. The nurse's primary responsibility is
Which outcome best demonstrates a healthcare institution's commitment to providing a supportive environment for its psychiatric nursing staff?
1. Psychiatric nursing units are well staffed with qualified personnel.
2. The psychiatric units are equipped wi
Answer: 3
A supportive nursing environment is one
that fosters and supports open, honest communication among all disciplines involved in a client's care. This demonstrates respect for the professional psychiatric nurses and their influence on client healt
What conflict associated with Erikson's psychosocial stages of development should the nurse remember when caring for a client who is 30 years of age?
1.Integrity versus despair
2. Intimacy versus isolation
3. Industry versus inferiority
4. Identity
versus
Answer: 2
The major task of the young adult is to develop close, sharing relationships that may include a sexual partnership; the person develops a sense of belonging and avoids isolation. During the integrity-versus-despair stage, the adjusted older adul
In the care of a withdrawn, reclusive psychotic client, the priority goal is for the client to develop what?
1.Trust
2. Self-worth
3. A sense of identity
4. An ability to
socialize
Answer: 1
Trust is basic to all therapies; without trust a therapeutic relationship cannot be established. The development of self-worth is a long-term goal; developing trust is the priority. There is nothing to indicate that the client does not have a se
A 3-year-old child is brought to the emergency department by the mother, who reports that her child fell down the stairs and sustained injuries to the right arm and leg. During the physical assessment the nurse identifies a number of old bruises on the ch
Answer: 3
The response "Show me how you fell down the stairs" will allow the child to show what happened; it removes the pressure of verbalization. Children have difficulty answering "why" questions; asking why the child fell may add to the guilty feeling
The nurse is caring for a client experiencing a crisis. What role is most important for the nurse to assume when
providing therapeutic crisis intervention?
1.Passive listener
2. Friendly advisor
3. Active participant
4. Participant observer
Answer: 3
To intervene in a crisis, the nurse must assume a direct, active role because the client's ability to cope is lessened and help is needed to solve problems. Being a passive listener is insufficient to help the client. Being a friendly advisor ca
A young client who has become a mother for the first time is showing signs of being anxious about her new parenting role. With the nurse's encouragement, she joins the new mothers' support group at the local YMCA. What kind of prevention does this activit
Answer: 1
Primary prevention is directed toward health promotion and prevention of problems. Tertiary prevention is focused on rehabilitation and the reduction of residual effects of illness. Secondary prevention is related to early detection and treatmen
A client with emotional problems is being discharged from a psychiatric unit. What should the nurse encourage the client to do?
1. Go back to regular activities.
2. Enroll in an aftercare program.
3. Call the unit whenever she is upset.
4. Find a group th
Answer: 2
Close follow-up and continued monitoring of medication, behavior, and emotional state are necessary to enable the client to maintain a positive behavioral change. Returning to regular activities
depends on what the client's regular activities we
A nurse greets a client who has been experiencing delusions of persecution and auditory hallucinations by saying, "Good evening. How are you?" The client, who has been referring to himself as "the man," answers, "The man is bad." Of what is this an exampl
Answer: 1
Speaking in the third person reflects poor ego boundaries and dissociation from the real self. Transference is the movement of
emotional energy and feelings that one has for one person to another person. Displacement is an attempt to reduce anxi
A widow of 6 months is brought to a psychiatric hospital. During the assessment interview the client avoids eye contact, responds in a low voice, and is tearful. What is the best initial approach by the nurse?
1. "You'll find that you'll get better faster
Answer: 4
The response "I know that this is difficult, but as soon as
we're finished I'll take you to your room" should limit anxiety; it identifies the client's feelings and tells the client what will happen in the immediate future. "You'll find that you
What should a nurse recognize that a client who uses the defense mechanism of sublimation is doing?
1.Acting out in reverse something already done or thought
2. Returning to an earlier, less mature stage of development
3. Channeling unacceptable impulses
Answer:
3
The individual using sublimation attempts to fulfill desires by selecting a socially appropriate activity rather than one that is socially unacceptable. Acting out in reverse something already done or thought is reaction formation. Returning to
A nurse is caring for a preschool-aged child with a history of physical and sexual abuse. What type of therapy will be the most advantageous for this child?
1.Play
2. Group
3. Family
4. Psychodrama
Answer: 1
It will be most effective for the child to play out feelings; when feelings are allowed to surface, the child can then learn to face them by controlling, accepting, or abandoning them. Group, family, and psychodrama therapies are not child-speci
A 15-year-old client is brought to the high school health office by two of her friends, who report, "We think she just took a handful of pills." The adolescent appears alert and refuses to speak. The
school nurse's initial response should be to do what?
1
Answer: 2
Asking the client is the most direct approach to ascertaining whether pills were ingested; the client will usually respond to this type of direct question. Asking the friends where she got the pills does not provide useful information. Calling t
A clinic nurse observes a 2-year-old client sitting alone, rocking and staring at a small, shiny top that she is spinning. Later the father relates his concerns, stating, "She pushes me away. She doesn't speak, and she only shows feelings when I take her
Answer: 3
The nurse provides support in a nonjudgmental way by sharing information and observations about the child. This child exhibits symptoms of autism, which is not attributable to the actions of the parents. Asking the father about his relationship
A nurse is teaching a group of recently hired staff members about conscious
and unconscious defense mechanisms that are used to defend the self against anxiety. What is an example of a conscious defense mechanism that the nurse should include?
1. Undoing
Answer: 3
Suppression is a conscious measure used as a defense against anxiety; the affected person intentionally avoids thinking about disturbing problems, wishes, feelings, or experiences. Undoing is an unconscious defense mechanism; it is the use of wo
A reasonable
short-term outcome for clients who are functioning below the optimal level of mental health is to help them become better able to do what?
1. Understand the dynamics behind their inadequate interpersonal relations.
2. Confront their inadequac
Answer: 3
The ability to discuss feelings about others and life situations is necessary for positive mental health. Understanding interpersonal dynamics, confronting inadequacies, and taking actions to increase satisfaction in
relationships are all long-t
A nurse on the psychiatric unit is planning a discharge conference with a client and the client's family. What is the priority nursing action that should be included in the discharge plan?
1. Obtaining a more complete family history
2. Teaching the client
Answer: 4
Evaluation and termination are the foci of a discharge planning conference; it is important for the nurse to assist the family in viewing the
hospitalization as a learning experience. A more complete family history should have been obtained befo
A college student visits the health center and describes anxiety about having to declare an academic major. What developmental conflict, according to Erikson, is this client still attempting to resolve?
1. Initiative versus guilt
2. Integrity versus despa
Answer: 4
The client is demonstrating a search for self and has not resolved the
developmental conflict of adolescence, identity versus role confusion. Initiative versus guilt is the developmental conflict of early childhood. Integrity versus despair is t
According to Erikson, a person's adjustment to the period of senescence will depend largely on the adjustment the individual made to which developmental stage?
1. Trust versus mistrust
2. Industry versus inferiority
3. Generativity versus stagnation
4. Id
Answer:
3
Erikson theorized that how well people adapt to the present stage depends on how well they adapted to the stage immediately preceding it�in this instance, adulthood. Trust versus mistrust, industry versus inferiority, and identity versus role co
A nurse completes the assessment of a female client who cannot function because of an impending divorce. What is the most effective nursing intervention for this client at this time?
1. Helping her identify
precipitating factors
2. Assisting her in explor
Answer: 2
Intervention is aimed at restoring equilibrium by helping the client develop new ways to cope and assisting with the exploration of available support systems. Identification of the precipitating factors should have taken place during the assessm
A nurse educator is leading a class on supporting middle-aged adults who are experiencing midlife crises. What should the nurse include as the
most significant factor in the development of this type of crisis?
1. The perception of their life situation
2.
Answer: 1
The most significant factor in either precipitating or avoiding a crisis is not the events, but how the individual perceives them. Changes in roles may occur, but, again, the individual's perception of these changes is most influential. The anti
After speaking with the parents of a child dying of leukemia, the primary
healthcare provider gives a verbal do-not-resuscitate order but refuses to put it in writing. What should the nurse do?
1. Follow the order as given by the primary healthcare provid
Answer: 4
Determining whether the family is in accord with the primary healthcare provider while following hospital policy verifies family and provider agreement and uses institutional policy developed by the ethics committee. Neither the nurse nor the nu
During a
therapy group session, a female client begins to cry and tells the other group members that her husband has told her that he wants a divorce. What is the most appropriate initial response by the nurse?
1. Observing how the group responds to her s
Answer: 1
The nurse should not intervene at this time because the client made the statement to the group. Initially the nurse should observe how the group responds to the client's statement. Next the nurse should nurture a
supportive response by group mem
A young child in whom sexual abuse is suspected asks the nurse, "Did I do something bad?" What is the mosttherapeutic response by the nurse?
1. "Do you think you did something bad?"
2. "Who said that you did something bad?"
3. "What do you mean by somethi
Answer: 3
"What do you mean by something bad?" elicits further clarification of what the child means by "bad." The nurse must determine what the child
means by the word "bad" before reflecting the term back to the child. "Who said that you did something b
According to Erikson, a child's increased vulnerability to anxiety in response to separation or pending separation from significant others results from failure to complete a developmental stage. What does the nurse call this stage?
1. Trust
2. Identity
3.
Answer: 1
Without the development of trust, the child has little confidence that
the significant other will return; separation is considered abandonment by the child. Without identity, the individual will have a problem forming a social role and a sense o
A nurse understands that autism is a form of a pervasive developmental disorder [PDD]. Which factor unique to autism differentiates it from other forms of PDD?
1. Less severe linguistic handicaps
2. Early onset, before 36 months of age
3. The only form th
Answer:
2
Autism impairs bonding and communication and therefore becomes apparent early in life. Autism involves both delayed and deviant linguistic problems. About 25% of children with autism have a seizure disorder. Autism may, and often does, include c
A public health nurse routinely performs health screenings in the local senior citizen center. What concept about older adults is essential for the nurse to remember when working with these clients?
1. Reviewing the
past is depressing.
2. Stimulating new
Answer: 4
Optimal health is central to optimal retirement; with good health, objectives and goals are more likely to be achieved. Reviewing the past is an essential part of the life review that older adults must engage in to eventually reach integrity. Th