Mental Health Module 1
Nurse Dorothy is evaluating care of a client with schizophrenia; the nurse should keep
which point in mind?
A. Frequent reassessment is needed and is based on the client's response to treatment.
B. The family does not need to be included in the care because the client is an adult.
C. The client is too ill to learn about his illness.
D. Relapse is not an issue for a client with schizophrenia. - AnswerA. Frequent
reassessment is needed and is based on the client's response to treatment.
Gio told his nurse that the FBI is monitoring and recording his every movement and that
microphones have been plated in the unit walls. Which action would be the most
therapeutic response?
A. Confront the delusional material directly by telling Gio that this simply is not so.
B. Tell Gio that this must seem frightening to him but that you believe he is safe here.
C. Tell Gio to wait and talk about these beliefs in his one-on-one counseling sessions.
D. Isolate Gio when he begins to talk about these beliefs. - AnswerB. Tell Gio that this
must seem frightening to him but that you believe he is safe here.
The nurse must realize that these perceptions are very real to the client. Acknowledging
the client's feelings provides support; explaining how the nurse sees the situation in a
different way provides reality orientation
Which of the following client behaviors documented in Gio's chart would validate the
nursing diagnosis of Risk for other-directed violence?
A. Gio's description of being endowed with superpowers
B. Frequent angry outburst noted toward peers and staff
C. Refusal to eat cafeteria food
D. Refusal to join in group activities - AnswerB. Frequent angry outburst noted toward
peers and staff
Nurse Winona educates the family about symptom management for when the
schizophrenic client becomes upset or anxious. Which of the following would Nurse
Winona state is helpful?
A. Call the therapist to request a medication change.
B. Encourage the use of learned relaxation techniques.
C. Request that the client be hospitalized until the crisis is over.
D. Wait before the anxiety worsens before intervening. - AnswerB. Encourage the use
of learned relaxation techniques.
,The client with schizophrenia can learn relaxation techniques, which help reduce
anxiety. The family can be supportive and helpful by encouraging the client to use these
techniques.
Drogo who has had auditory hallucinations for many years tells Nurse Khally that the
voices prevent his participation in a social skills training program at the community
health center. Which intervention is most appropriate?
A. Let Drogo analyze the content of the voices.
B. Advise Drogo to participate in the program when the voices cease.
C. Advise Drogo to take his medications as prescribed.
D. Teach Drogo to use thought stopping techniques. - AnswerD. Teach Drogo to use
thought stopping techniques.
Clients with long-lasting auditory hallucinations can learn to use thought stopping
measures to accomplish tasks.
Jaime has a diagnosis of schizophrenia with negative symptoms. In planning care for
the client, Nurse Brienne would anticipate a problem with:
A. Auditory hallucinations.
B. Bizarre behaviors.
C. Ideas of reference.
D. Motivation for activities. - AnswerD. Motivation for activities.
In a client demonstrating negative symptoms of schizophrenia, avolition, or the lack of
motivation for activities, is a common problem.
A client tells the nurse that psychotropic medicines are dangerous and refuses to take
them. Which intervention should the nurse use first?
A. Ask the client about any previous problems with psychotropic medications.
B. Ask the client if an injection is preferable.
C. Insist that the client takes medication as prescribed.
D. Withhold the medication until the client is less suspicious - AnswerA. Ask the client
about any previous problems with psychotropic medications.
The nurse needs to clarify the client's previous experience with psychotropic medication
in order to understand the meaning of the client's statement.
Nurse Arya assesses for evidence of positive symptoms of schizophrenia in a newly
admitted client. Which of the following symptoms are considered positive evidence?
Select all that apply.
A. Anhedonia
B. Delusions
, C. Flat affect
D. Hallucinations
E. Loose associations
F. Social withdrawal - AnswerB, D, E
Nurse Isabelle enters the room of a client with a cognitive impairment disorder and asks
what day of the week it is; what the date, month, and year are; and where the client is.
The nurse is attempting to assess:
A. confabulation.
B. delirium.
C. orientation.
D. perseveration. - AnswerC. Orientation.
The initial, most basic assessment of a client with cognitive impairment involves
determining his level of orientation (awareness of time, place, and person).
A student nurse was asked which of the following best describes dementia. Which of
the following best describes the condition?
A. Memory loss occurring as part of the natural consequence of aging
B. Difficulty coping with physical and psychological change
C. Severe cognitive impairment that occurs rapidly
D. Loss of cognitive abilities, impairing ability to perform activities of daily living -
AnswerD. Loss of cognitive abilities, impairing ability to perform activities of daily living
The impaired ability to perform self-care is an important measure of a client's dementia
progression and loss of cognitive abilities. Difficulty or impaired ability to perform normal
activities of daily living, such as maintaining hygiene and grooming, toileting, making
meals, and maintaining a household, are significant indications of dementia. Slowing of
processes necessary for information retrieval is a normal consequence of aging.
However, the global statement that memory loss occurs as part of natural aging is not
true.
Which of the following will Nurse Dory use when communicating with a client who has
cognitive impairment.
A. Complete explanations with multiple details
B. Pictures or gestures instead of words
C. Stimulating words and phrases to capture the client's attention
D. Short words and simple sentences - AnswerD. Short words and simple sentences
Short words and simple sentences minimize client confusion and enhance
communication.
Nurse Dorothy is evaluating care of a client with schizophrenia; the nurse should keep
which point in mind?
A. Frequent reassessment is needed and is based on the client's response to treatment.
B. The family does not need to be included in the care because the client is an adult.
C. The client is too ill to learn about his illness.
D. Relapse is not an issue for a client with schizophrenia. - AnswerA. Frequent
reassessment is needed and is based on the client's response to treatment.
Gio told his nurse that the FBI is monitoring and recording his every movement and that
microphones have been plated in the unit walls. Which action would be the most
therapeutic response?
A. Confront the delusional material directly by telling Gio that this simply is not so.
B. Tell Gio that this must seem frightening to him but that you believe he is safe here.
C. Tell Gio to wait and talk about these beliefs in his one-on-one counseling sessions.
D. Isolate Gio when he begins to talk about these beliefs. - AnswerB. Tell Gio that this
must seem frightening to him but that you believe he is safe here.
The nurse must realize that these perceptions are very real to the client. Acknowledging
the client's feelings provides support; explaining how the nurse sees the situation in a
different way provides reality orientation
Which of the following client behaviors documented in Gio's chart would validate the
nursing diagnosis of Risk for other-directed violence?
A. Gio's description of being endowed with superpowers
B. Frequent angry outburst noted toward peers and staff
C. Refusal to eat cafeteria food
D. Refusal to join in group activities - AnswerB. Frequent angry outburst noted toward
peers and staff
Nurse Winona educates the family about symptom management for when the
schizophrenic client becomes upset or anxious. Which of the following would Nurse
Winona state is helpful?
A. Call the therapist to request a medication change.
B. Encourage the use of learned relaxation techniques.
C. Request that the client be hospitalized until the crisis is over.
D. Wait before the anxiety worsens before intervening. - AnswerB. Encourage the use
of learned relaxation techniques.
,The client with schizophrenia can learn relaxation techniques, which help reduce
anxiety. The family can be supportive and helpful by encouraging the client to use these
techniques.
Drogo who has had auditory hallucinations for many years tells Nurse Khally that the
voices prevent his participation in a social skills training program at the community
health center. Which intervention is most appropriate?
A. Let Drogo analyze the content of the voices.
B. Advise Drogo to participate in the program when the voices cease.
C. Advise Drogo to take his medications as prescribed.
D. Teach Drogo to use thought stopping techniques. - AnswerD. Teach Drogo to use
thought stopping techniques.
Clients with long-lasting auditory hallucinations can learn to use thought stopping
measures to accomplish tasks.
Jaime has a diagnosis of schizophrenia with negative symptoms. In planning care for
the client, Nurse Brienne would anticipate a problem with:
A. Auditory hallucinations.
B. Bizarre behaviors.
C. Ideas of reference.
D. Motivation for activities. - AnswerD. Motivation for activities.
In a client demonstrating negative symptoms of schizophrenia, avolition, or the lack of
motivation for activities, is a common problem.
A client tells the nurse that psychotropic medicines are dangerous and refuses to take
them. Which intervention should the nurse use first?
A. Ask the client about any previous problems with psychotropic medications.
B. Ask the client if an injection is preferable.
C. Insist that the client takes medication as prescribed.
D. Withhold the medication until the client is less suspicious - AnswerA. Ask the client
about any previous problems with psychotropic medications.
The nurse needs to clarify the client's previous experience with psychotropic medication
in order to understand the meaning of the client's statement.
Nurse Arya assesses for evidence of positive symptoms of schizophrenia in a newly
admitted client. Which of the following symptoms are considered positive evidence?
Select all that apply.
A. Anhedonia
B. Delusions
, C. Flat affect
D. Hallucinations
E. Loose associations
F. Social withdrawal - AnswerB, D, E
Nurse Isabelle enters the room of a client with a cognitive impairment disorder and asks
what day of the week it is; what the date, month, and year are; and where the client is.
The nurse is attempting to assess:
A. confabulation.
B. delirium.
C. orientation.
D. perseveration. - AnswerC. Orientation.
The initial, most basic assessment of a client with cognitive impairment involves
determining his level of orientation (awareness of time, place, and person).
A student nurse was asked which of the following best describes dementia. Which of
the following best describes the condition?
A. Memory loss occurring as part of the natural consequence of aging
B. Difficulty coping with physical and psychological change
C. Severe cognitive impairment that occurs rapidly
D. Loss of cognitive abilities, impairing ability to perform activities of daily living -
AnswerD. Loss of cognitive abilities, impairing ability to perform activities of daily living
The impaired ability to perform self-care is an important measure of a client's dementia
progression and loss of cognitive abilities. Difficulty or impaired ability to perform normal
activities of daily living, such as maintaining hygiene and grooming, toileting, making
meals, and maintaining a household, are significant indications of dementia. Slowing of
processes necessary for information retrieval is a normal consequence of aging.
However, the global statement that memory loss occurs as part of natural aging is not
true.
Which of the following will Nurse Dory use when communicating with a client who has
cognitive impairment.
A. Complete explanations with multiple details
B. Pictures or gestures instead of words
C. Stimulating words and phrases to capture the client's attention
D. Short words and simple sentences - AnswerD. Short words and simple sentences
Short words and simple sentences minimize client confusion and enhance
communication.
