NURSING 309 Focus on Mental Health Questions and Answers 2020

A drunken client is awaiting treatment in the emergency department. The client becomes loud and aggressive when told that there will be a short delay before treatment. Which response by the nurse is therapeutic? A. Waiting until the behavior escalates before intervening B. Attempting to talk with the client to deescalate the behavior C. Informing the client, “You will be asked to leave if this behavior continues.” D. Offering to take the client to an examination room until treatment can be started Correct
Rationale: Safety of the client, other clients, and staff is of priority concern. Offering to take the client to an examination room until she is treated separates the client from others and provides a less stimulating environment where the client can maintain her dignity. Waiting until the behavior escalates before intervening is incorrect because it allows the client to become even more agitated and a threat to others. Attempting to talk with the client to deescalate behavior is not likely to be productive, because the client is intoxicated and her reasoning impaired. Informing the client that she will be asked to leave if the behavior continues would only further aggravate an already agitated individual.
Test-Taking Strategy: Use the process of elimination, specifically noting that the client is intoxicated. The correct option most directly addresses the situation and the behavior and feelings of the client. Review appropriate interventions for dealing with an intoxicated client if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Mental Health
Giddens Concepts: Clinical Judgment, Interpersonal Violence
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Violence
References: Hammond, B., & Zimmermann, P. (2013) Sheehy’s Manual of Emergency Care (7th ed., p. 514). St. Louis: Elsevier.
Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. p. 170). St. Louis: Saunders.
Awarded 1.0 points out of 1.0 possible points.
36.ID: 9
As the nurse prepares a client for a coronary artery bypass graft, the client asks, “Will I be OK?” Which response by the nurse is therapeutic? A. “I hope you’ll be fine.” B. “Let’s talk about how you’re feeling.” Correct C. “Don’t worry. You have an excellent surgeon.” D. “You need this surgery to avoid serious problems.”
Rationale: The correct response offers self and encourages the client to share feelings and fears. The incorrect options block communication and may increase the client’s anxiety. False reassurance is nontherapeutic. The client needs an opportunity to talk about the impending surgery.
Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. Note that the client is expressing a desire to discuss the surgery and its possible outcomes. The correct option addresses the client’s feelings and is an example of open-ended communication. Review therapeutic communication techniques if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Content Area: Mental Health
Giddens Concepts: Anxiety, Communication
HESI Concepts: Communication, Mood and Affect – Anxiety
Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. pp. 121-123, 177). St. Louis: Saunders.
Awarded 1.0 points out of 1.0 possible points.
37.ID: 8
A nurse prepares to care for a client with a diagnosis of Tourette syndrome. The medical record indicates that the client experiences motor tics. Which finding would the nurse expect to note during assessment of this client? A. Grunting sounds B. Tongue protrusion Correct C. Uttering of obscenities D. Consistent yelping sounds
Rationale: Tourette syndrome involves motor and verbal tics that cause marked distress and significant impairment of social and occupational function. Motor tics usually involve the head but may also involve the torso and limbs. The most common first symptom is a single tic, such as eye-blinking. Other motor tics include tongue protrusion, touching, squatting, hopping, skipping, retracing of steps, and twirling when walking. Vocal tics include words and sounds such as barks, grunts, yelps, clicks, snorts, sniffs, and coughs. Coprolalia, the uttering of obscenities, is present in some individuals with this disorder.
Test-Taking Strategy: Note the strategic phrase “motor tics” in the question. Using the process of elimination and eliminate the options that are comparable or alike — here, all of the incorrect options involve verbal behaviors. Review manifestations of this disorder if you had difficulty with this question.
Level of Cognitive Ability: Analyzing
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Assessment
Giddens Concepts: Clinical Judgment, Mood and Affect
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Mood and Affect
Content Area: Mental Health
Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. pp. 507-508). St. Louis: Saunders.
Awarded 1.0 points out of 1.0 possible points.
38.ID: 5
A nurse assesses a client with early-onset Alzheimer’s disease. The nurse asks the client, “How was your weekend?” The client responds by saying, “It was great. I discussed war campaigns with the president and had dinner at the White House.” Which defense mechanism is evident? A. Hiding B. Apraxia C. Perseveration D. Confabulation Correct
Rationale: Confabulation is a defense mechanism and an unconscious attempt to maintain self-esteem by providing information that is not true about an event or situation. Hiding is a form of denial and an unconscious protective defense against the terrifying possibility of losing one’s place in the world. Apraxia is characterized by the loss of purposeful movement in the absence of motor or sensory impairment. Perseveration is the repetition of phrases or behaviors.
Test-Taking Strategy: Focus on the subject, a defense mechanism, and the statement made by the client. Note the option that is not a defense mechanism (apraxia) and eliminate it. To select from the remaining options, focus on the statement of the client; this will direct you to the correct option. If you had difficulty with this question, review defense mechanisms and findings associated with dementia.
Level of Cognitive Ability: Understanding
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Analysis
Content Area: Mental Health
Giddens Concepts: Clinical Judgment, Cognition
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Cognition
Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. p. 346). St. Louis: Saunders.
Awarded 1.0 points out of 1.0 possible points.
39.ID: 4
A nurse reviews the record of a client and notes that the client experiences flashbacks. Which of the following conditions is most often associated with flashbacks? A. Schizophrenia B. Anxiety disorder C. Hallucinogenic drug use Correct D. Obsessive-compulsive disorder
Rationale: Flashbacks, a common effect of hallucinogenic drugs, are transitory recurrences in perceptual disturbance caused by a person’s earlier hallucinogenic drug experiences. They occur when the person is in a drug-free state. Visual distortions, time expansion, loss of ego boundaries, and intense emotions may occur. The experience of flashbacks is also characteristic of posttraumatic stress disorder. They do not occur in schizophrenia or obsessivecompulsive disorder. Anxiety disorder is a term that encompasses posttraumatic stress disorder as one of its components.
Test-Taking Strategy: Focus on the subject, flashbacks. Recalling that flashbacks occur with the use of hallucinogenic drugs will direct you to the correct option. Review the characteristics of flashbacks if you had difficulty with this question.
Level of Cognitive Ability: Understanding
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Mental Health
Giddens Concepts: Mood and Affect, Psychosis
HESI Concepts: Cognition – Psychosis, Mood and Affect
Reference: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., p. 449). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
40.ID: 9
After an attack in a park while jogging, a client experiences posttraumatic stress disorder. The client, visibly anxious, tells the nurse that she now avoids all exercise and parks but says, “I don’t want to feel this way.” Which response by the nurse is appropriate? A. “I know it’s difficult now, but try not to worry so much.” B. “Everything will be all right if you just give it more time.” C. “I can see that you’re upset about this. Let’s talk some more about it.” Correct D. “Why don’t you just go jogging in a park and get it out of your system?”
Rationale: The therapeutic response encourages the client’s expressions of feelings by indicating that the nurse is aware of the client’s feelings and promoting continued communication. Each of the incorrect options neither acknowledges the client’s concerns nor encourages further communication. Giving advice and false reassurance are not therapeutic techniques.
Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. The correct option is the only option that addresses the client’s feelings. Review these techniques if you had difficulty with this question
Level of Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Content Area: Mental Health
Giddens Concepts: Communication, Interpersonal Violence
HESI Concepts: Communication, Violence
Reference: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., p. 224). St. Louis: Mosby.
Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. pp. 121-123). St. Louis: Saunders.
Awarded 1.0 points out of 1.0 possible points.
41.ID: 6
A client hospitalized in a mental health unit is restrained after becoming extremely violent. Which finding indicates to the nurse that the client can be removed from the restraints? A. The client dozes after a sedative is administered B. The client apologizes and says, “It won’t happen again.” C. The client divulges all of the reasons for the violent behavior D. The client initiates no aggressive acts for 30 minutes after the release of two leg restraints Correct
Rationale: The best indicator that the client’s behavior is under control is when the client refrains from aggression after partial release from the restraints. Generally a structured reintegration, begun by reducing a client's four-point restraints to two-point restraints, is initiated. If the client continues to exhibit nonaggressive behavior, the remaining restraints are removed. The incorrect options are not indicators that the client’s behavior is under control.
Test-Taking Strategy: Use the process of elimination noting the subject, removal of restraints. Noting the words “no aggressive acts” will direct you to the correct option. Review the procedure for the use of restraints if you had difficulty with this question.
Level of Cognitive Ability: Evaluating
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Evaluation
Content Area: Mental Health
Giddens Concepts: Interpersonal Violence, Safety
HESI Concepts: Safety, Violence
Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. pp. 468-469, 472). St. Louis: Saunders.
Awarded 1.0 points out of 1.0 possible points.
42.ID: 0
A client with bipolar disorder has been hospitalized for 4 days. Today in group therapy the client offered helpful suggestions in regard to another client’s problem. The nurse concludes that the client’s behavior is representative of: A. Acting out B. Manipulation C. Improvement Correct D. Attention-seeking
Rationale: The behavior demonstrated by the client is appropriate during hospitalization. There is no evidence in the question that the client is acting out (which is an attention-seeking behavior), being manipulative, or seeking attention.
Test-Taking Strategy: Focus on the data presented in the question. Eliminate the options that are comparable or alike (acting out and attention-seeking). To select from the remaining options, focus on the data in the question, which will direct you to the correct option. Review the signs of improvement in a hospitalized client if you had difficulty with this question.
Level of Cognitive Ability: Understanding
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Analyzing
Content Area: Mental Health
Giddens Concepts: Clinical Judgment, Mood and Affect
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Mood and Affect
Reference: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., p. 316). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
43.ID: 0
A client says to the nurse, “My cancer is going to shorten my life, so I’m making a will that leaves my money to charity. Do you think I can get into heaven that way?” Which response by the nurse is therapeutic? A. “I don’t believe that giving away money will help a person get into heaven.” B. “I don’t believe in heaven, but it certainly seems like a good plan if it exists.” C. “You feel that a charitable contribution will get you into heaven if your cancer ends your life?” Correct D. “You’re going to live a long healthy life because your cancer was caught early and the cure rate is high.”
Rationale: The correct option involves the therapeutic communication technique of reflection, in which the ideas of the client are presented back to the client for the client to consider. It is employed when a client asks the nurse for approval or judgment because it helps the nurse intervene with a nonjudgmental response. The client is expressing concern, and, although the illness may be cured, it is vital to actively listen and to be sensitive to expression of concerns and fear. The incorrect options give an opinion, express approval, use false reassurance, or offer advice and lectures to the client, all of which are closedended techniques that do not facilitate expressions of feelings.
Test-Taking Strategy: Use your knowledge of therapeutic communication techniques and remember to focus on the client’s feelings. This will direct you to the correct option. Review these techniques if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Content Area: Mental Health
Giddens Concepts: Communication, Coping
HESI Concepts: Communication, Stress and Coping – Caregiving
Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. pp. 121-123). St. Louis: Saunders.
Awarded 1.0 points out of 1.0 possible points.
44.ID: 6
A nurse is providing medication instructions to a client who is starting disulfiram. Which statements by the client indicate that the client understands the information? Select all that apply. A. “It’s important to take this medication every day.” Correct B. “Painting my living room will be a good distraction.” C. “I need to check the labels on over-the-counter medications carefully.” Correct D. “If I take this medication and drink alcohol, I’ll feel sick within 8 hours.” E. “It’s important to take this medication when I have the urge to start drinking.”
Rationale: Disulfiram can help motivated clients avoid impulsive drinking of alcohol because it interacts with alcohol, resulting in unpleasant physical effects. The medication must be taken daily and is often administered under supervision. The medication reaction begins minutes to a half-hour after alcohol use, and the effects — facial flushing, headache, neck pain, tachycardia, decreased blood pressure, sweating, nausea and vomiting, and respiratory distress — may last for as long as 2 hours. The client should avoid “hidden” sources of alcohol in foods and other medications. The client should also avoid inhaling fumes from alcohol-containing substances such as wood stain, paint, and furniture-stripping products.
Test-Taking Strategy: Specific knowledge regarding disulfiram (Antabuse) therapy is needed to answer this question. Also use general medication guidelines to answer correctly. Remember that this medication interacts with alcohol. Review information on disulfiram if you had difficulty with this question.
Level of Cognitive Ability: Evaluating
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Pharmacology
Giddens Concepts: Client Education, Safety
HESI Concepts: Safety, Teaching and Learning/Patient Education
Reference: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., p. 462). St. Louis: Mosby.
Awarded 2.0 points out of 2.0 possible points.
45.ID: 4
A nurse counsels a client with an alcohol disorder and the client’s spouse. The spouse says, “I’ve covered up the drinking because I made a commitment to our marriage, but now our children won’t come to visit.” The nurse should refer the spouse to a support group for: A. Alcoholics B. Caregivers C. Codependents Correct D. Substance abusers
Rationale: The description of the spouse’s behavior indicates that the spouse is codependent. Codependence involves overly responsible behavior; that is, doing for another person what that person could be doing for himself or herself. The incorrect options identify addicted people, not people connected to the addict, and a person who is involved with caring for an addicted significant other on a daily basis.
Test-Taking Strategy: Focus on the data in the question and note that the spouse exhibits a pattern of overly responsible (codependent) behavior. This will direct you to the correct option. Review support groups if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Mental Health
Giddens Concepts: Addiction, Clinical Judgment
HESI Concepts: Clinical Decision-Making/Clinical Judgment, BehaviorsAddiction
Reference: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., pp. 450-451, 465). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
46.ID: 2
A client hospitalized with severe depression is withdrawn and exhibits poor motivation and concentration. Which activity should the nurse plan for this client? A. Drawing Correct B. Cooking class C. Dance therapy D. Small-group discussions
Rationale: When a client is severely depressed, the client should be involved in activities that require little concentration and have no elements of being “right” or “wrong.” As the client’s condition improves, the client may become involved in activities with small groups, such as cooking class, dance therapy, and small group discussions.
Test-Taking Strategy: Use the process of elimination. Eliminate the options that are comparable or alike in that they involve activities with small groups. Review care of the client with severe depression if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Planning
Content Area: Mental Health
Giddens Concepts: Caregiving, Mood and Affect
HESI Concepts: Mood and Affect, Stress and Coping – Caregiving
Reference: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., pp. 315, 373). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
47.ID: 2
A nurse cares for a severely depressed client who is mute. Which comment by the nurse to the client is appropriate? A. “Are you having trouble talking?” B. “Everyone feels sad once in a while.” C. “There are many new pictures on the wall.” Correct D. “Things will look up for you, just wait and see.”
Rationale: When a client is not ready to talk, direct questions may raise the client’s anxiety level. Pointing to commonalities in the environment draws the client into, and reinforces, reality. The nurse should avoid platitudes, which tend to minimize the client’s feelings and can increase feelings of guilt and worthlessness. The nurse also should avoid statements that provide false reassurance.
Test-Taking Strategy: Use the process of elimination and note that the client is mute. Eliminate the option in which the nurse asks the client a question, because this may increase the client’s anxiety level. Next eliminate the nontherapeutic responses. Review care of the client who is mute if you have difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation