Focus on Mental Health Exam Questions With Complete
Solutions
A client admitted to the mental health unit with depression is
unclean, has body odor, and is inappropriately dressed. An
accompanying family member is embarrassed about the client's
appearance. When planning care, it is most important for the
client and family member to understand that: Correct Answers
The nurse will help the client meet hygiene needs until the client
is able to do so
Rationale: Both the client and family need to know that the
nurse will assist the client until is able to resume self-care
activities. A client with depression has decreased energy and is
subject to psychomotor retardation, so, assistance is necessary.
Indicating that self-esteem needs to take priority over
appearance, that hygiene is not important, and that peer pressure
will soon have the client attending to hygiene needs are all
incorrect conclusions.
A client compulsively makes and remakes the bed numerous
times and often misses breakfast and some morning activities
because of this ritual. Which nursing action is appropriate?
Correct Answers Offering reflective feedback such as "I see
you made your bed several times. That takes a lot of energy."
Rationale: Reflective feedback lets the client know that the
nurse acknowledges the behavior and understands that it can be
very tiring. Verbalizing even tactful disapproval would increase
the client's anxiety and reinforce the need to perform the ritual.
Helping with the ritual is nontherapeutic and reinforces the
,behavior. Teaching the client about the role of neurotransmitters
in compulsive behavior does not focus on the client's feelings.
A client diagnosed with schizophrenia tells the nurse. "There are
voices outside the window telling me what to do all the time.
Can you hear them? What should I tell them?" How should the
nurse respond initially? Correct Answers "What are the voices
telling you?"
Rationale: The nurse should first assess the situation. When a
client is experiencing an auditory hallucination, it is important
initially to determine what the voices are saying or telling the
client to do. Suicidal or homicidal messages, if heard by the
client, necessitate the implementation of safety measures as a
priority. The incorrect options are inappropriate and do not
reinforce reality or provide important information to the nurse.
A client experienced the sudden onset of blindness, but
extensive testing revealed no organic reason that the client could
not see. The nurse later learned that the blindness developed
after the client witnessed a fire at a neighboring house in which
the family of three died. Which problem should the nurse
suspect? Correct Answers Conversion disorde
Rationale: A conversion disorder is an alteration or loss of a
physical function that cannot be explained by any known
pathophysiological mechanism. It is often an expression of a
psychological need or conflict. Psychosis is a state in which a
person's mental capacity to recognize reality, communicate, and
relate to others is impaired, thus interfering with the person's
capacity to deal with life demands. Repression is a coping
,mechanism in which unacceptable feelings are kept out of
awareness. A dissociative disorder is a disturbance or alteration
in the normally integrative functions of identity, memory, or
consciousness.
A client has a diagnosis of dependent personality disorder.
Which goal is most appropriate for this client? Correct Answers
Using the problem-solving process effectively
Rationale: The client with dependent personality disorder
exhibits an unusually strong need to be cared for and has
difficulty making personal choices and every day decisions in
fear of making the wrong decision. An appropriate goal would
be for the client to use the problem-solving process effectively
in everyday situations. The client described in the question does
not exhibit any suicidal traits, nor does he suffer from an
obsessive-compulsive personality disorder or an anxiety
disorder.
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? Correct
Answers The client initiates no aggressive acts for 30 minutes
after the release of two leg restraints
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.
A client hospitalized with schizophrenia says to the nurse, "Get
your goat. Go out and vote. Don't be a cut throat. Row your
boat." How should the nurse document the client's behavior?
Correct Answers Clang associations
Rationale: Repetition of words or phrases that are similar in
sound but in no other way, known as clang association, is an
assessment finding in some clients with schizophrenia. Clang
associations often take the form of rhyme. Echolalia, the
pathological repeating of another's word, is often seen in people
with catatonia. Word salad is a mixture of phrases that is
meaningless to the listener and perhaps to the speaker as well.
Thought broadcasting is the belief that others can know one's
thoughts.
A client hospitalized with severe depression is withdrawn and
exhibits poor motivation and concentration. Which activity
should the nurse plan for this client? Correct Answers Drawing
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.
A client in the mental health unit points to another client and
says to the nurse, "He's been working with the Taliban, pouring
Solutions
A client admitted to the mental health unit with depression is
unclean, has body odor, and is inappropriately dressed. An
accompanying family member is embarrassed about the client's
appearance. When planning care, it is most important for the
client and family member to understand that: Correct Answers
The nurse will help the client meet hygiene needs until the client
is able to do so
Rationale: Both the client and family need to know that the
nurse will assist the client until is able to resume self-care
activities. A client with depression has decreased energy and is
subject to psychomotor retardation, so, assistance is necessary.
Indicating that self-esteem needs to take priority over
appearance, that hygiene is not important, and that peer pressure
will soon have the client attending to hygiene needs are all
incorrect conclusions.
A client compulsively makes and remakes the bed numerous
times and often misses breakfast and some morning activities
because of this ritual. Which nursing action is appropriate?
Correct Answers Offering reflective feedback such as "I see
you made your bed several times. That takes a lot of energy."
Rationale: Reflective feedback lets the client know that the
nurse acknowledges the behavior and understands that it can be
very tiring. Verbalizing even tactful disapproval would increase
the client's anxiety and reinforce the need to perform the ritual.
Helping with the ritual is nontherapeutic and reinforces the
,behavior. Teaching the client about the role of neurotransmitters
in compulsive behavior does not focus on the client's feelings.
A client diagnosed with schizophrenia tells the nurse. "There are
voices outside the window telling me what to do all the time.
Can you hear them? What should I tell them?" How should the
nurse respond initially? Correct Answers "What are the voices
telling you?"
Rationale: The nurse should first assess the situation. When a
client is experiencing an auditory hallucination, it is important
initially to determine what the voices are saying or telling the
client to do. Suicidal or homicidal messages, if heard by the
client, necessitate the implementation of safety measures as a
priority. The incorrect options are inappropriate and do not
reinforce reality or provide important information to the nurse.
A client experienced the sudden onset of blindness, but
extensive testing revealed no organic reason that the client could
not see. The nurse later learned that the blindness developed
after the client witnessed a fire at a neighboring house in which
the family of three died. Which problem should the nurse
suspect? Correct Answers Conversion disorde
Rationale: A conversion disorder is an alteration or loss of a
physical function that cannot be explained by any known
pathophysiological mechanism. It is often an expression of a
psychological need or conflict. Psychosis is a state in which a
person's mental capacity to recognize reality, communicate, and
relate to others is impaired, thus interfering with the person's
capacity to deal with life demands. Repression is a coping
,mechanism in which unacceptable feelings are kept out of
awareness. A dissociative disorder is a disturbance or alteration
in the normally integrative functions of identity, memory, or
consciousness.
A client has a diagnosis of dependent personality disorder.
Which goal is most appropriate for this client? Correct Answers
Using the problem-solving process effectively
Rationale: The client with dependent personality disorder
exhibits an unusually strong need to be cared for and has
difficulty making personal choices and every day decisions in
fear of making the wrong decision. An appropriate goal would
be for the client to use the problem-solving process effectively
in everyday situations. The client described in the question does
not exhibit any suicidal traits, nor does he suffer from an
obsessive-compulsive personality disorder or an anxiety
disorder.
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? Correct
Answers The client initiates no aggressive acts for 30 minutes
after the release of two leg restraints
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.
A client hospitalized with schizophrenia says to the nurse, "Get
your goat. Go out and vote. Don't be a cut throat. Row your
boat." How should the nurse document the client's behavior?
Correct Answers Clang associations
Rationale: Repetition of words or phrases that are similar in
sound but in no other way, known as clang association, is an
assessment finding in some clients with schizophrenia. Clang
associations often take the form of rhyme. Echolalia, the
pathological repeating of another's word, is often seen in people
with catatonia. Word salad is a mixture of phrases that is
meaningless to the listener and perhaps to the speaker as well.
Thought broadcasting is the belief that others can know one's
thoughts.
A client hospitalized with severe depression is withdrawn and
exhibits poor motivation and concentration. Which activity
should the nurse plan for this client? Correct Answers Drawing
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.
A client in the mental health unit points to another client and
says to the nurse, "He's been working with the Taliban, pouring
