N3381 MENTAL HEALTH ACTUAL FINAL EXAM
QUESTIONS AND ANSWERS SURE A+
✔✔A client with a history of panic disorder comes to the emergency department and
states to the nurse, "Please help me. I think I'm having a heart attack." What is the
priority nursing action?
1.Assess the client's vital signs.
2.Identify the client's activity during the pain.
3.Assess for signs related to a panic disorder.
4.Determine the client's use of relaxation techniques. - ✔✔Assess the client's vital signs
Rationale:Clients with panic disorders experience acute physical symptoms, such as
chest pain and palpitations. The priority is to assess the client's physical condition to
rule out a physiological disorder. Therefore, options 2, 3, and 4 are not the priority.
✔✔Which is a primary behavior of a client diagnosed with antisocial personality
disorder?
1.Frequently expresses suicidal ideations
2.Leaves the dayroom when anyone else enters
3.Will take personal items from other clients' rooms
,4.Requires constant reassurance whenever required to make a decision - ✔✔Will take
personal items from other clients' rooms
Rationale:A central defining characteristic of the antisocial personality is disregard for
the rights and feelings of others. Taking the belongings of others would demonstrate
this characteristic. Although the remaining options describe behaviors that may on
occasion be exhibited by the client, none of these is the main characteristic of antisocial
personality disorder.
✔✔The nurse monitors a client diagnosed with anorexia nervosa understanding that the
client manages anxiety by which action?
1.Engaging in self-mutilating acts
2.Observing rigid rules and regulations
3.Always reverting to the independent role
4.Constantly striving to avoid making decisions - ✔✔Observing rigid rules and
regulations
Rationale:Clients with anorexia nervosa have the desire to please others. Rules and
rituals help them manage their anxiety. Their need to be correct or perfect interferes
with rational decision-making processes. These clients generally don't engage in self-
mutilation.
✔✔A client is admitted to the mental health unit with a diagnosis of depression. The
nurse should develop a plan of care for the client that includes which intervention?
1.Encouraging quiet reading and writing for the first few days 2.Identification of physical
activities that will provide exercise
3.No socializing activities until the client asks to participate in milieu 4.A structured
program of activities in which the client can participate - ✔✔A structured program of
activities in which the client can participate
Rationale:A client with depression often is withdrawn while experiencing difficulty
concentrating, loss of interest or pleasure, low energy, fatigue, and feelings of
worthlessness and poor self-esteem. The plan of care needs to provide successful
experiences in a stimulating yet structured environment. The remaining options are
either too "restrictive" or offer little or no structure and stimulation.
✔✔A depressed client on an inpatient unit says to the nurse, "My family would be better
off without me." Which is the nurse's best response?
1."Have you talked to your family about this?"
2."Everyone feels this way when they are depressed."
3."You will feel better once your medication begins to work."
,4."You sound very upset. Are you thinking of hurting yourself?" - ✔✔"You sound very
upset. Are you thinking of hurting yourself?"
Rationale:
A depressed client on an inpatient unit says to the nurse, "My family would be better off
without me." Which is the nurse's best response?
Rationale:Clients who are depressed may be at risk for suicide. It is critical for the nurse
to assess suicidal ideation and plan. The nurse should ask the client directly whether a
plan for self-harm exists. Options 1, 2, and 3 do not deal directly with the client's
feelings.
✔✔A moderately depressed client who was hospitalized 2 days ago suddenly begins
smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally
cured." Based on the client's behavior and statement, which intervention should the
nurse include in the plan?
1.Suggesting a reduction of medication
2.Allowing increased "in-room" activities
3.Increasing the level of suicide precautions
4.Allowing the client off-unit privileges as needed - ✔✔Increasing the level of suicide
precautions
Rationale:A client who is moderately depressed and has only been in the hospital 2
days is unlikely to have such a dramatic cure. When a depression suddenly lifts, it is
likely that the client may have made the decision to harm herself or himself. Suicide
precautions are necessary to keep the client safe. The remaining options are therefore
incorrect interpretations.
✔✔A depressed client verbalizes feelings of low self-esteem and self-worth typified by
statements such as "I'm such a failure. I can't do anything right." How should the nurse
plan to respond to the client's statement?
1.Reassure the client that things will get better.
2.Tell the client that this is not true and that we all have a purpose in life.
3.Identify recent behaviors or accomplishments that demonstrate the client's skills.
4.Remain with the client and sit in silence; this will encourage the client to verbalize
feelings. - ✔✔Identify recent behaviors or accomplishments that demonstrate the
client's skills.
Rationale:Feelings of low self-esteem and worthlessness are common symptoms of a
depressed client. An effective plan of care to enhance the client's personal self-esteem
is to provide experiences for the client that are challenging but that will not be met with
failure. Reminders of the client's past accomplishments or personal successes are ways
to interrupt the client's negative self-talk and distorted cognitive view of self. Options 1
and 2 give advice and devalue the client's feelings. Silence may be interpreted as
agreement.
, ✔✔The nurse should plan which goals of the termination stage of group development?
Select all that apply.
1. The group evaluates the experience.
2. The real work of the group is accomplished.
3. Group interaction involves superficial conversation.
4. Group members become acquainted with one another.
5. Some structuring of group norms, roles, and responsibilities takes place.
6.The group explores members' feelings about the group and the impending separation.
- ✔✔The group evaluates the experience.
The group explores members' feelings about the group and the impending separation.
Rationale:The stages of group development include the initial stage, the working stage,
and the termination stage. During the initial stage, the group members become
acquainted with one another, and some structuring of group norms, roles, and
responsibilities takes place. During the initial stage, group interaction involves
superficial conversation. During the working stage, the real work of the group is
accomplished. During the termination stage, the group evaluates the experience and
explores members' feelings about the group and the impending separation.
✔✔A client is preparing to attend a Gamblers Anonymous meeting for the first time. The
nurse should tell the client that which is the first step in this 12-step program?
1.Admitting to having a problem
2.Substituting other activities for gambling
3.Stating that the gambling will be stopped
4.Discontinuing relationships with people who gamble - ✔✔Admitting to having a
problem
Rationale:The first step in the 12-step program is to admit that a problem exists.
Substituting other activities for gambling may be a strategy but it is not the first step.
The remaining options are not realistic strategies for the initial step in a 12-step
program.
✔✔What is the most appropriate nursing action to help manage a manic client who is
monopolizing a group therapy session?
1.Ask the client to leave the group for this session only.
2.Refer the client to another group that includes other manic clients. 3.Tell the client to
stop monopolizing in a firm but compassionate manner.
4.Thank the client for the input, but inform the client that others now need a chance to
contribute. - ✔✔Thank the client for the input, but inform the client that others now need
a chance to contribute.
QUESTIONS AND ANSWERS SURE A+
✔✔A client with a history of panic disorder comes to the emergency department and
states to the nurse, "Please help me. I think I'm having a heart attack." What is the
priority nursing action?
1.Assess the client's vital signs.
2.Identify the client's activity during the pain.
3.Assess for signs related to a panic disorder.
4.Determine the client's use of relaxation techniques. - ✔✔Assess the client's vital signs
Rationale:Clients with panic disorders experience acute physical symptoms, such as
chest pain and palpitations. The priority is to assess the client's physical condition to
rule out a physiological disorder. Therefore, options 2, 3, and 4 are not the priority.
✔✔Which is a primary behavior of a client diagnosed with antisocial personality
disorder?
1.Frequently expresses suicidal ideations
2.Leaves the dayroom when anyone else enters
3.Will take personal items from other clients' rooms
,4.Requires constant reassurance whenever required to make a decision - ✔✔Will take
personal items from other clients' rooms
Rationale:A central defining characteristic of the antisocial personality is disregard for
the rights and feelings of others. Taking the belongings of others would demonstrate
this characteristic. Although the remaining options describe behaviors that may on
occasion be exhibited by the client, none of these is the main characteristic of antisocial
personality disorder.
✔✔The nurse monitors a client diagnosed with anorexia nervosa understanding that the
client manages anxiety by which action?
1.Engaging in self-mutilating acts
2.Observing rigid rules and regulations
3.Always reverting to the independent role
4.Constantly striving to avoid making decisions - ✔✔Observing rigid rules and
regulations
Rationale:Clients with anorexia nervosa have the desire to please others. Rules and
rituals help them manage their anxiety. Their need to be correct or perfect interferes
with rational decision-making processes. These clients generally don't engage in self-
mutilation.
✔✔A client is admitted to the mental health unit with a diagnosis of depression. The
nurse should develop a plan of care for the client that includes which intervention?
1.Encouraging quiet reading and writing for the first few days 2.Identification of physical
activities that will provide exercise
3.No socializing activities until the client asks to participate in milieu 4.A structured
program of activities in which the client can participate - ✔✔A structured program of
activities in which the client can participate
Rationale:A client with depression often is withdrawn while experiencing difficulty
concentrating, loss of interest or pleasure, low energy, fatigue, and feelings of
worthlessness and poor self-esteem. The plan of care needs to provide successful
experiences in a stimulating yet structured environment. The remaining options are
either too "restrictive" or offer little or no structure and stimulation.
✔✔A depressed client on an inpatient unit says to the nurse, "My family would be better
off without me." Which is the nurse's best response?
1."Have you talked to your family about this?"
2."Everyone feels this way when they are depressed."
3."You will feel better once your medication begins to work."
,4."You sound very upset. Are you thinking of hurting yourself?" - ✔✔"You sound very
upset. Are you thinking of hurting yourself?"
Rationale:
A depressed client on an inpatient unit says to the nurse, "My family would be better off
without me." Which is the nurse's best response?
Rationale:Clients who are depressed may be at risk for suicide. It is critical for the nurse
to assess suicidal ideation and plan. The nurse should ask the client directly whether a
plan for self-harm exists. Options 1, 2, and 3 do not deal directly with the client's
feelings.
✔✔A moderately depressed client who was hospitalized 2 days ago suddenly begins
smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally
cured." Based on the client's behavior and statement, which intervention should the
nurse include in the plan?
1.Suggesting a reduction of medication
2.Allowing increased "in-room" activities
3.Increasing the level of suicide precautions
4.Allowing the client off-unit privileges as needed - ✔✔Increasing the level of suicide
precautions
Rationale:A client who is moderately depressed and has only been in the hospital 2
days is unlikely to have such a dramatic cure. When a depression suddenly lifts, it is
likely that the client may have made the decision to harm herself or himself. Suicide
precautions are necessary to keep the client safe. The remaining options are therefore
incorrect interpretations.
✔✔A depressed client verbalizes feelings of low self-esteem and self-worth typified by
statements such as "I'm such a failure. I can't do anything right." How should the nurse
plan to respond to the client's statement?
1.Reassure the client that things will get better.
2.Tell the client that this is not true and that we all have a purpose in life.
3.Identify recent behaviors or accomplishments that demonstrate the client's skills.
4.Remain with the client and sit in silence; this will encourage the client to verbalize
feelings. - ✔✔Identify recent behaviors or accomplishments that demonstrate the
client's skills.
Rationale:Feelings of low self-esteem and worthlessness are common symptoms of a
depressed client. An effective plan of care to enhance the client's personal self-esteem
is to provide experiences for the client that are challenging but that will not be met with
failure. Reminders of the client's past accomplishments or personal successes are ways
to interrupt the client's negative self-talk and distorted cognitive view of self. Options 1
and 2 give advice and devalue the client's feelings. Silence may be interpreted as
agreement.
, ✔✔The nurse should plan which goals of the termination stage of group development?
Select all that apply.
1. The group evaluates the experience.
2. The real work of the group is accomplished.
3. Group interaction involves superficial conversation.
4. Group members become acquainted with one another.
5. Some structuring of group norms, roles, and responsibilities takes place.
6.The group explores members' feelings about the group and the impending separation.
- ✔✔The group evaluates the experience.
The group explores members' feelings about the group and the impending separation.
Rationale:The stages of group development include the initial stage, the working stage,
and the termination stage. During the initial stage, the group members become
acquainted with one another, and some structuring of group norms, roles, and
responsibilities takes place. During the initial stage, group interaction involves
superficial conversation. During the working stage, the real work of the group is
accomplished. During the termination stage, the group evaluates the experience and
explores members' feelings about the group and the impending separation.
✔✔A client is preparing to attend a Gamblers Anonymous meeting for the first time. The
nurse should tell the client that which is the first step in this 12-step program?
1.Admitting to having a problem
2.Substituting other activities for gambling
3.Stating that the gambling will be stopped
4.Discontinuing relationships with people who gamble - ✔✔Admitting to having a
problem
Rationale:The first step in the 12-step program is to admit that a problem exists.
Substituting other activities for gambling may be a strategy but it is not the first step.
The remaining options are not realistic strategies for the initial step in a 12-step
program.
✔✔What is the most appropriate nursing action to help manage a manic client who is
monopolizing a group therapy session?
1.Ask the client to leave the group for this session only.
2.Refer the client to another group that includes other manic clients. 3.Tell the client to
stop monopolizing in a firm but compassionate manner.
4.Thank the client for the input, but inform the client that others now need a chance to
contribute. - ✔✔Thank the client for the input, but inform the client that others now need
a chance to contribute.
