NSG 309 Mental health final exams | 100% Guaranteed PASS | Already GRADED A+

1 A nurse uses the SAD PERSONS scale to interview a patient. This tool provides data relevant to which of the following concepts? suicide potential. 2 A nurse is interacting with patients in a psy chiatric unit. Which statements reflect use of therapeutic communication? Select all that apply. “Tell me more about that situation.” “I notice you are pacing a lot.” “I’ll stay with you a while.” 3 A married couple has two biologic children who live with them as well as a child from the wife’s first marriage. What type of family is evident? Blended 4 Which person would be most likely to experience sleep fragmentation? An obese adult 5 A child diagnosed with attention deficit hyperactivity disorder will begin medication therapy. The nurse should prepare a plan to teach the family about which classification of medications? Central nervous system stimulants 6 A child diagnosed with attention deficit hyperactivity disorder (ADHD) shows hyperactivity, aggression, and impaired play. The health care provider prescribed amphetamine salts (Adderall). The nurse should monitor for which desired behavior? Improved abilities to participate in cooperative play with other children 7 A new psychiatric technician says, “Schizophrenia…schizotypal! What’s the difference?” The nurse’s response should include which information? With schizotypal personality disorder, the person can be made aware of misinterpretations of reality. 8 A nurse is caring for a patient taking a selective serotonin reuptake inhibitor (SSRI). When care planning, outcome criteria related to which goal is most appropriate? improvement in depression. 9 A staff nurse completes orientation to a psychiatric unit. This nurse may expect an advanced practice nurse to perform which additional intervention? Prescribe psychotropic medication 10 A patient’s relationships are intense and unstable. The patient initially idealizes the significant other and then devalues him or her, resulting in frequent feelings of emptiness. This patient will benefit from interventions to develop which aspect of mental health? Fulfilling relationships 11 A nurse is discussing culturally competent care at a nursing staff inservice. Which of the following information should the nurse include when discussing clients' cultures? Nurses should focus on clients' cultures, rather than their ethnicity, when providing care. 12 A patient diagnosed with schizophrenia says, “It’s beat. Time to eat. No room for the cat.” What type of verbalization is evident? Associative looseness 13 A nurse uses Maslow’s hierarchy of needs to plan care for a patient with mental illness. Which problem will receive priority? The patient refuses to eat or bathe. 14 As a nurse discharges a patient, the patient gives the nurse a card of appreciation made in an arts and crafts group. What is the nurse’s best action? Recognize the effectiveness of the relationship and patient’s thoughtfulness. Accept the card. 15 A nurse interacts with a newly hospitalized patient. Which of the following comments is most demonstrative of the nurse utilizing the communication technique of “offering self"? “I’d like to sit with you for a while to help you get comfortable talking to me.” 16 Which prescription medication would the nurse expect to be prescribed for a patient diagnosed with a somatic symptom disorder? Antidepressant medications to treat underlying depression 17 A patient is fearful of riding on elevators. The therapist first rides an escalator with the patient. The therapist and patient then stand in an elevator with the door open for five minutes and later with the elevator door closed for five minutes. Which technique has the therapist used? Systematic desensitization 18 A nurse cares for a group of patients receiving various medications, including an MAO inhibitor, anti-convulsant, sedative-hypnotic, and 2nd generation anti-psychotic. The nurse will order a special diet for the patient who takes which medication? MAO Inhibitor 19 A Puerto Rican American patient uses dramatic body language when describing emotional discomfort. Which analysis most likely explains the patient’s behavior? The patient belongs to a culture in which dramatic body language is the norm. 20 A nurse assesses a patient with a tentative diagnosis of generalized anxiety disorder. Which question would be most appropriate for the nurse to ask? “Do you find it difficult to control your worrying?” 21 A nurse is leading a family therapy session for a mother, father, and two adolescent siblings. Which of the following statements should the nurse recognize as an example of effective communication among family members? "Can you tell me the reason you get upset each time I go to the mall?" . 22 The exact cause of bipolar disorder has not been determined; which of the following provides the most accurate description of possible etiology? Several factors, including genetics, are implicated. 23 A Mexican American patient puts a picture of the Virgin Mary on the bedside table. What is the nurse’s best action? Leave the picture where the patient placed it. 24 A nurse is caring for a client who has schizophrenia and is experiencing a variety of hallucinations. Which of the following hallucinations is the priority for the nurse to address? Command hallucination 25 A child known as the neighborhood bully says, “Nobody can tell me what to do.” After receiving a poor grade on a science project, this child secretly loaded a virus on the teacher’s computer. Which diagnosis is best supported by this data? oppositional defiant disorder. 26 Match the terms below with the appropriate description. Anxiety-A feeling of apprehension, uncertainty, or dread resulting from a vague unspecified or unknown danger Fear-A reaction to a specific danger Obsessions-Thoughts, impulses or images that persist recur Compulsions-Ritualistic behaviors an individual feels driven to perform 27 Which assessment finding would cause the nurse to consider a child to be most at risk for the development of mental illness? The child has been raised by a parent with chronic major depression. 28 Inpatient hospitalization for persons with mental illness is generally reserved for patients in which of the following situations? Patients who present a clear danger to self or others. 29 A nurse in an inpatient mental health unit is planning care for a client who is in restraints. Which of the following findings should indicate to the nurse that the client is ready to reintegrate into the unit? The client follows directions. 30 A community health nurse visits a family with four children. The father behaves angrily, finds fault with the oldest child, and asks twice, “Why are you such a stupid kid?” The wife says, “I have difficulty disciplining the children. It’s so frustrating.” Which comments by the nurse will facilitate an interview with these parents? Select all that apply. “Tell me how you discipline your children.” “How do you stop your baby from crying?” “Caring for four small children must be difficult.” 31 A nurse is assessing a client who has a new diagnosis of anorexia nervosa. Which of the following findings should the nurse expect? Bradycardia 32 Which nursing diagnosis is universally applicable for children diagnosed with autism spectrum disorders? Impaired social interaction related to difficulty relating to others 33 A charge nurse is conducting a staff education in-service about depressive disorders. Which of the following should the nurse identify as a risk factor for depression? Chronic Illness 34 A nurse is caring for a new client who exhibits manifestations of a major depressive episode. The provider states that she wants to rule out medical conditions which could also be linked to the findings. The nurse should expect diagnostic testing for which of the following medical conditions? Hypothyroidism 35 A nurse cares for a patient diagnosed with an opioid overdose. Which focused assessment has the highest priority? Respiratory 36 A nurse asks a patient diagnosed with schizophrenia, “What is meant by the old saying ‘You can’t judge a book by looking at the cover.’?” Which response by the patient indicates concrete thinking? “The table of contents tells what a book is about.” 37 An advanced practice nurse observes a novice nurse expressing irritability regarding a patient with a long history of alcoholism and suspects the new nurse is experiencing countertransference. Which comment by the new nurse confirms this suspicion? “My parents were alcoholics and often neglected our family.” 38 What is a nurse’s legal responsibility if child abuse or neglect is suspected? Report the suspicion according to state regulations. 39 A nurse is caring for a client who has bipolar disorder. The client states, “I feel like Superman. I can do anything. I can fly home today and then become a U.S. Senator.” Which of the following findings is this client exhibiting? Grandiosity 40 A 15-year-old ran away from home six times and was arrested for shoplifting. The parents told the court, “We can’t manage our teenager.” The adolescent is physically abusive to the mother and defiant with the father. Which diagnosis is supported by this adolescent’s behavior? Conduct disorder 41 A nurse is caring for a client who is experiencing acute manifestations of withdrawal from alcohol. Which of the following medications should the nurse expect to administer to the client? Diazepam 42 A nurse is discussing stress management techniques with a group of clients. Which of the following techniques mentioned by a client should the nurse recognize as the least effective? "I fix myself a pot of coffee when I get anxious." 43 A patient demonstrating behaviors associated with acute mania has been engaging in staff-splitting behaviors. Staff members are feeling defensive and fatigued. Which action will the staff take initially? Hold a staff meeting to discuss consistency and limit-setting approaches. 44 A patient has blindness related to conversion (functional neurological) disorder. To help the patient eat, the nurse should implement which of the following interventions? expect the patient to feed self after explaining arrangement of the food on the tray. 45 An adolescent was arrested for prostitution and assault on a parent. The adolescent says, “I hate my parents. They focus all attention on my brother, who’s perfect in their eyes.” Which type of therapy might promote the greatest change in the adolescent’s behavior? Family therapy 46 An adult comes to the crisis clinic after termination from a job of 15 years. The patient says, “I don’t know what to do. How can I get another job? Who will pay the bills? How will I feed my family?” Which nursing diagnosis applies? Powerlessness 47 A nurse in an acute mental health facility is creating a plan of care for a new client who has histrionic personality disorder. Which of the following is the priority intervention for the nurse to make? Promote appropriate behavior during group therapy sessions. 48 Which central nervous system structure is most associated with anger and aggression? The Amygdala 49 A nurse finds a psychiatric advance directive in the medical record of a patient experiencing psychosis. The directive was executed during a period when the patient was stable and competent. Which of the following is the nurses best action? ensure that the directive is respected in treatment planning. 50 A patient taking both an SSRI & a MAOI develops muscle spasms, elevated BP, fever & sweating. Which adverse effect does the nurse suspect? Serotonin Syndrome 51 A patient presents to the emergency department with mixed psychiatric symptoms. The admission nurse suspects the symptoms may be the result of a medical problem. Lab results show elevated BUN (blood urea nitrogen) and creatinine. What is the nurse’s next best action? Assess the patient for a history of renal problems. 52 A pregnant woman describes a strong desire to ingest chalk at her prenatal appointment. She admits that several time she has eaten a few pieces. What disorder will the nurse suspect? Pica 53 A nurse set limits while interacting with a patient demonstrating behaviors associated with borderline personality disorder. The patient tells the nurse, “You used to care about me. I thought you were wonderful. Now I can see I was wrong. You’re evil.” This outburst can be documented using which of the following terms? splitting. 54 A person in the community asks, “People with mental illnesses went to state hospitals in earlier times. Why has that changed?” The nurse's best response would include which of the following? Select all that apply. -“Science has made significant improvements in drugs for mental illness, so now many persons may live in their communities.” -“There’s now a better selection of less restrictive treatment options available in communities to care for people with mental illness.” -“Federal legislation and payment for treatment of mental illness has shifted the focus to community rather than institutional settings.” 55 What individual point of view impacts our reaction to a stressor? Perception 56 A nurse encounters an unfamiliar psychiatric disorder on a new patient’s admission form. Which resource should the nurse consult to determine criteria used to establish this diagnosis? Diagnostic and Statistical Manual of Mental Disorders (DSM-5) 57 A nurse is caring for an adolescent who has a history of violent behavior and has asked the nurse to keep confidential information about the desire to kill several classmates and a school teacher. Which of the following responses by the nurse is appropriate to give? "I cannot promise that. I must share this information with other members of the team who are responsible for planning your care." 58 What information is conveyed by nursing diagnoses? Select all that apply. -Unmet patient needs currently present -Supporting data that validate the diagnoses -Probable causes that will be targets for nursing interventions 59 A patient would benefit from therapy in which peers as well as staff have a voice in determining patients’ privileges and psychoeducational topics. Which approach would be best? Milieu therapy 60 A nurse is preparing a client who has chronic anxiety for discharge from the psychiatric unit. Which of the following instructions should the nurse include in the client’s discharge plan? Identify anxiety-producing situations. 61 After celebrating the fortieth birthday, an individual becomes concerned with the loss of youthful appearance. What type of crisis has occurred? Maturational 62 A home health nurse is speaking to a group of acute care nurses about domestic violence. Which of the following statements by one of the acute care nurses indicates a need for clarification? "I have heard that abusers think of themselves as important and have high self esteem." 63 A nurse is caring for a young adult client following the sudden death of his wife. The client feels paralyzed in his ability to cope with work and family responsibilities. Which of the following types of crisis is the client experiencing? Situational 64 Which of the following comorbidities are associated with an increased risk of anger/aggression? (select all that apply) Traumatic Brain Injuries (TBIs) Personality Disorders Dementia 65 A nurse is caring for a client who has a depressive disorder. The client states, “I just can’t feel any happiness or joy in life.” Which of the following terms should the nurse use when documenting this finding? Anhedonia 66 A nurse is assessing a client who is experiencing chronic stress. Which of the following findings should the nurse expect? Viral Infection 67 A rape victim tells the emergency nurse, “I feel so dirty. Help me take a shower before I get examined.” What are the nurses next appropriate actions? (select all that apply) explain that bathing destroys evidence. offer the victim a shower after evidence is collected. 68 A nurse is teaching a client who has bipolar disorder about lithium. Which of the following statements should the nurse include in the teaching? "We will monitor your lithium levels closely while you are taking this medication." 69A nurse works with a child who is sad and irritable because the child’s parents are divorcing. Why is establishing a therapeutic alliance with this child a priority? Acceptance and trust convey feelings of security to the child. 70 A nurse is caring for a client who requires a crisis intervention for acute anxiety. Which of the following actions is the highest priority? Protecting the client from injury 71 A nurse is teaching a community education course about the physical complications related to substance use disorder. Which of the following findings should the nurse identify as the primary cause of liver cirrhosis? Alcohol 72 Before assessing a new patient, a nurse is told by another health care worker, “I know that patient. No matter how hard we work, there isn’t much improvement by the time of discharge.” What is the nurse’s responsibility in this situation? assess the patient based on data collected from all sources. 73 A nurse on a mental health unit is caring for clients who have various depressive disorders. The nurse should identify which of the following client diagnoses as presenting the greatest risk for suicide? Major depressive disorder 74 A patient diagnosed with depersonalization disorder tells the nurse, “It’s starting again. I feel as though I’m going to float away.” Which intervention would be most appropriate at this point? Engage the patient in a physical activity such as exercise. 75 A patient diagnosed with bipolar disorder has an unstable mood, aggressiveness, agitation, talkativeness, and irritability. The nurse expects the health care provider to prescribe a medication from which group? Mood stabilizers 76 Shift work, especially night shift and rotating shifts, are a common cause of what sleep-related disorder? Circadian Rhythm Sleep Disorder 77 A nurse interviews a patient abducted and raped at gunpoint by an unknown assailant. The patient says, “I can’t talk about it. Nothing happened. I have to forget.” What is the patient’s present coping strategy? Denial 78 A nurse manager is providing staff education about working with clients who have a history of anger and aggression. Which of the following information should the nurse include in the teaching? (Select all that apply.) Avoid wearing necklaces during client care Know the layout of the facility Provide immediate verbal feedback for escalating behavior 79 A nurse assesses a patient who reports a 3-week history of depression and periods of uncontrolled crying. The patient says, “My business is bankrupt, and I was served with divorce papers.” Which subsequent statement by the patient alerts the nurse to a concealed suicidal message? “I have a plan that will fix everything.” 80 An adolescent diagnosed with an impulse control disorder said, “I just want to die. I spend all my time getting even with people who have done wrong to me.” When asked about a suicide plan, the adolescent replied, “I’ll jump from the bridge near my home. My father threw kittens off that bridge, and they died because they couldn’t swim.” Which of the following is the appropriate suicide risk rating? High 81 In a team meeting a nurse says, “I’m concerned about whether we are behaving ethically by using restraint to prevent one patient from self-mutilation, while the care plan for another self-mutilating patient requires one-on-one supervision.” Which ethical principle most clearly applies to this situation? Justice 82 A health care provider prescribed depot injections every 3 weeks at the clinic for a patient with a history of medication noncompliance. For this plan to be successful, which factor will be of critical importance? The availability of transportation to the clinic 83 A nurse is assessing the suicide risk of a group of clients on a mental health unit. Which of the following clients should the nurse identify as having a risk factor for a suicide attempt? A client who usually acts impulsively. 84 The nurse assesses an adult who is socially withdrawn and hoards. Which nursing diagnoses most likely apply to this individual? Select all that apply. Ineffective home maintenance Chronic low self-esteem Risk for injury 85 A nurse can best address factors of critical importance to successful community treatment by assessing elements of a biopsychosocial assessment including which of the following? (Select all that apply.) housing adequacy. family and support systems. income adequacy and stability. substance abuse history and current use. 86 Shortly after the parents announced that they were divorcing, a 15-year-old became truant from school and assaulted a friend. The adolescent told the school nurse, “I’d rather stay in my room and listen to music. It’s easier than thinking about what is happening in my family.” Which nursing diagnosis is most applicable? Ineffective coping related to adjustment to changes in family relationships 87 A cruel and abusive person often uses rationalization to explain the behavior. Which comment demonstrates use of this defense mechanism? “That person should not have provoked me.” 88 A child has a history of multiple hospitalizations for recurrent systemic infections. The child is not improving in the hospital, despite aggressive treatment. Factitious disorder by proxy is suspected. Which nursing interventions are appropriate? Select all that apply. Keep careful, detailed records of visitation and untoward events. Encourage family members to visit in groups of two or three. Interact with the patient frequently during visiting hours. 89 A patient diagnosed with depression begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy. The nurse should provide information to the patient and family about which of the following home care concepts? reporting increased suicidal thoughts. 90 A nurse is caring for a client who has been diagnosed with obsessive compulsive disorder (OCD) and is constantly picking up after others in the day room. The nurse should recognize that the client uses this behavior to do which of the following? Decrease anxiety to a tolerable level. 91 Four teenagers died in an automobile accident. One week later, which behavior by the parents of these teenagers most clearly demonstrates resilience? The parents who create a scholarship fund at their child’s high school. 92 A nurse explains to the family of a mentally ill patient how a nurse-patient relationship differs from social relationships. Which is the best explanation? “The focus is on the patient. Problems are discussed by the nurse and patient, but solutions are implemented by the patient.” 93 A parent became unemployed 6 months ago. The parent has subsequently been verbally abusive toward the spouse and oldest child. The child ran away twice, and the spouse has become depressed. What is the most appropriate nursing diagnosis for this family? Disabled family coping related to insecurity secondary to loss of family income 94 A patient has smoked two packs of cigarettes daily for many years. When the patient tries to reduce smoking, anxiety, craving, poor concentration, and headache occur. Which term best describes this scenario? substance addiction. 95 A patient reports, “I am overwhelmed by stress.” Which question by the nurse would be most important to use in the initial assessment of this the patient? “Tell me about the kinds of things you do to reduce or cope with your stress 96 A patient who has been hospitalized for 3 days with a serious mental illness says, “I’ve got to get out of here and back to my job. I get 60 to 80 messages a day, and I’m getting behind on my email correspondence.” What is this patient’s perspective about health and illness? Western, biomedical 97 A patient tells the nurse, “Everyone says we should sleep 8 hours a night. I can only sleep 6 hours, no matter how hard I try. Am I doing harm to my body?” Which of the following is the nurse’s best response? “If you function well with 6 hours of sleep, you are a short sleeper. That’s normal for some people.” 98 A patient being admitted to the eating disorders unit has a yellow cast to the skin and fine, downy hair over the trunk. The patient weighs 70 pounds; height is 5 feet 4 inches. The patient says, “I won’t eat until I look thin.” Which of the following is the priority initial nursing diagnosis? Imbalanced nutrition: less than body requirements related to self-starvation 99 A nurse in the clinic has a full appointment schedule. A Hispanic American patient arrives at 1230 for a 1000 appointment. A Native American patient does not keep an appointment at all. What understanding will improve the nurse’s planning? These patients are members of cultural groups that have a different view of time. 100 A nurse is performing an admission assessment for a client who has schizophrenia. Which of the following findings should the nurse identify as a negative symptom? Affective flattening Show Less