Mental health test bank EXAM 1 question and answers
Chapter 1. The Concept of Stress Adaptation
• A client diagnosed with obsessive-compulsive disorder is admitted to a psychiatric unit. The client
has an elaborate routine for toileting activities. Which would be an appropriate initial client outcome
during the first week of hospitalization?
A. The client will refrain from ritualistic behaviors during daylight hours.
B. The client will wake early enough to complete rituals prior to breakfast.
C. The client will participate in three unit activities by day 3.
D. The client will substitute a productive activity for rituals by day 1.
ANS: B
An appropriate initial client outcome is for the client to wake early enough to complete rituals prior to
breakfast. The nurse should also provide a structured schedule of activities and later in treatment
begin to gradually limit the time allowed for rituals.
• A nurse is providing discharge teaching to a client taking a benzodiazepine. Which client
statement would indicate a need for further follow-up instructions?
A. I will need scheduled bloodwork in order to monitor for toxic levels of this drug.
B. I wont stop taking this medication abruptly, because there could be serious complications.
C. I will not drink alcohol while taking this medication.
D. I wont take extra doses of this drug because I can become addicted.
ANS: A
The client indicates a need for additional information about taking benzodiazepines when stating the
need for blood work to monitor for toxic levels. No blood work is needed when taking a short-acting
benzodiazepine. The client should understand that taking extra doses of a benzodiazepine may result
in addiction and that the drug should not be taken in conjunction with alcohol.
• A client diagnosed with an obsessive-compulsive disorder spends hours bathing and grooming.
During a one-on-one interaction, the client discusses the rituals in detail but avoids any feelings that
the rituals generate. Which defense mechanism should the nurse identify?
A. Sublimation
B. Dissociation
C. Rationalization
D. Intellectualization
ANS: D
The nurse should identify that the client is using the defense mechanism of intellectualization when
discussing the rituals of obsessive-compulsive disorder in detail while avoiding discussion of feelings.
Intellectualization is an attempt to avoid expressing emotions associated with a stressful situation by
using the intellectual processes of logic, reasoning, and analysis.
,• A client is newly diagnosed with obsessive-compulsive disorder and spends 45 minutes
folding clothes and rearranging them in drawers. Which nursing intervention would best address
this clients problem?
A. Distract the client with other activities whenever ritual behaviors begin.
B. Report the behavior to the psychiatrist to obtain an order for medication dosage increase.
C. Lock the room to discourage ritualistic behavior.
D. Discuss the anxiety-provoking triggers that precipitate the ritualistic behaviors.
ANS: D
The nurse should discuss with the client the anxiety-provoking triggers that precipitate the
ritualistic behavior. If the client is going to be able to avoid the anxiety, he or she must first learn
to recognize precipitating factors. Attempting to distract the client, seeking medication increase,
and locking the clients room are not appropriate interventions because they do not help the
client recognize anxiety triggers.
• A nursing student questions an instructor regarding the order for fluvoxamine (Luvox), 300 mg
daily, for a client diagnosed with obsessive-compulsive disorder (OCD). Which instructor reply is
most accurate?
A. High doses of tricyclic medications will be required for effective treatment of OCD.
B. Selective serotonin reuptake inhibitor (SSRI) doses, in excess of what is effective for
treating depression, may be required for OCD.
C. The dose of Luvox is low due to the side effect of daytime drowsiness and nighttime insomnia.
D. The dosage of Luvox is outside the therapeutic range and needs to be questioned.
ANS: B
The most accurate instructor response is that SSRI doses in excess of what is effective for treating
depression may be required in the treatment of OCD. SSRIs have been approved by the U.S. Food and
Drug Administration for the treatment of OCD. Common side effects include headache, sleep
disturbances, and restlessness.
• A client presents in the emergency department with complaints of overwhelming anxiety. Which
of the following is a priority for the nurse to assess?
A. Risk for suicide
B. Cardiac status
C. Current stressors
D. Substance use history
ANS: B
Although all of the listed aspects of assessment are important, the priority is to evaluate cardiac status
since a person having an MI, CHF, or mitral valve prolapse can present with symptoms of anxiety.
• A client is prescribed alprazolam (Xanax) for acute anxiety. What client history should cause a
,nurse to question this order?
A. History of alcohol dependence
B. History of personality disorder
C. History of schizophrenia
D. History of hypertension
ANS: A
The nurse should question a prescription of alprazolam (Xanax) for acute anxiety if the client has a
history of alcohol dependence. Alprazolam is a benzodiazepine used in the treatment of anxiety and
has an increased risk for physiological dependence and tolerance. A client with a history of substance
abuse may be more likely to abuse other addictive substances and/or combine this drug with alcohol.
• Warrens college roommate actively resists going out with friends whenever they invite him. He
says he cant stand to be around other people and confides to Warren They wouldnt like me anyway.
Which disorder is Warrens roommate likely suffering from?
A. Agoraphobia
B. Mysophobia
C. Social anxiety disorder (social phobia)
D. Panic disorder
ANS: C
Social anxiety disorder is an excessive fear of social situations R/T fear that one might do something
embarrassing or be evaluated negatively by others.
• A client has the following symptoms: preoccupation with imagined defect, verbalizations that are
out of proportion to actual physical abnormalities, and numerous visits to plastic surgeons to seek
relief. Which nursing diagnosis would best describe the problems evidenced by these symptoms?
A. Ineffective coping
B. Disturbed body image
C. Complicated grieving
D. Panic anxiety
ANS: B
The symptoms presented describe the DSM-5 diagnosis of body dysmorphic disorder, and the related
nursing diagnosis is disturbed body image.
A. How should a nurse best describe the major maladaptive client response to panic disorder?
B. Clients overuse medical care because of physical symptoms.
C. Clients use illegal drugs to ease symptoms.
D. Clients perceive having no control over life situations.
E. Clients develop compulsions to deal with anxiety.
, ANS: C
The major maladaptive client response to panic disorder is the perception of having no control over life
situations, which leads to nonparticipation in decision making and doubts regarding role performance.
• A client diagnosed with generalized anxiety states, I know the best thing for me to do now is to
just forget my worries. How should the nurse evaluate this statement?
A. The client is developing insight.
B. The clients coping skills are improving.
C. The client has a distorted perception of problem resolution.
D. The client is meeting outcomes and moving toward discharge.
ANS: C
This client has a distorted perception of how to deal with the problem of anxiety. Clients should be
encouraged to openly deal with anxiety and recognize the triggers that precipitate anxiety responses.
• A client is taking chlordiazepoxide (Librium) for generalized anxiety disorder symptoms. In
which situation should a nurse recognize that this client is at greatest risk for drug overdose?
A. When the client has a knowledge deficit related to the effects of the drug
B. When the client combines the drug with alcohol
C. When the client takes the drug on an empty stomach
D. When the client fails to follow dietary restrictions
ANS: B
Both Librium and alcohol are central nervous system depressants. In combination, these drugs have an
additive effect and can suppress the respiratory system, leading to respiratory arrest and death.
Multiple Response
• A college student has been diagnosed with generalized anxiety disorder (GAD). Which of
the following symptoms should a campus nurse expect this client to exhibit? Select all that
apply.
A. Fatigue
B. Anorexia
C. Hyperventilation
D. Insomnia
E. Irritability
ANS: A, D, E
The nurse should expect that a client diagnosed with GAD would experience fatigue, insomnia, and
irritability. GAD is characterized by chronic, unrealistic, and excessive anxiety and worry.
• A nurse is discussing treatment options with a client whose life has been negatively impacted
Chapter 1. The Concept of Stress Adaptation
• A client diagnosed with obsessive-compulsive disorder is admitted to a psychiatric unit. The client
has an elaborate routine for toileting activities. Which would be an appropriate initial client outcome
during the first week of hospitalization?
A. The client will refrain from ritualistic behaviors during daylight hours.
B. The client will wake early enough to complete rituals prior to breakfast.
C. The client will participate in three unit activities by day 3.
D. The client will substitute a productive activity for rituals by day 1.
ANS: B
An appropriate initial client outcome is for the client to wake early enough to complete rituals prior to
breakfast. The nurse should also provide a structured schedule of activities and later in treatment
begin to gradually limit the time allowed for rituals.
• A nurse is providing discharge teaching to a client taking a benzodiazepine. Which client
statement would indicate a need for further follow-up instructions?
A. I will need scheduled bloodwork in order to monitor for toxic levels of this drug.
B. I wont stop taking this medication abruptly, because there could be serious complications.
C. I will not drink alcohol while taking this medication.
D. I wont take extra doses of this drug because I can become addicted.
ANS: A
The client indicates a need for additional information about taking benzodiazepines when stating the
need for blood work to monitor for toxic levels. No blood work is needed when taking a short-acting
benzodiazepine. The client should understand that taking extra doses of a benzodiazepine may result
in addiction and that the drug should not be taken in conjunction with alcohol.
• A client diagnosed with an obsessive-compulsive disorder spends hours bathing and grooming.
During a one-on-one interaction, the client discusses the rituals in detail but avoids any feelings that
the rituals generate. Which defense mechanism should the nurse identify?
A. Sublimation
B. Dissociation
C. Rationalization
D. Intellectualization
ANS: D
The nurse should identify that the client is using the defense mechanism of intellectualization when
discussing the rituals of obsessive-compulsive disorder in detail while avoiding discussion of feelings.
Intellectualization is an attempt to avoid expressing emotions associated with a stressful situation by
using the intellectual processes of logic, reasoning, and analysis.
,• A client is newly diagnosed with obsessive-compulsive disorder and spends 45 minutes
folding clothes and rearranging them in drawers. Which nursing intervention would best address
this clients problem?
A. Distract the client with other activities whenever ritual behaviors begin.
B. Report the behavior to the psychiatrist to obtain an order for medication dosage increase.
C. Lock the room to discourage ritualistic behavior.
D. Discuss the anxiety-provoking triggers that precipitate the ritualistic behaviors.
ANS: D
The nurse should discuss with the client the anxiety-provoking triggers that precipitate the
ritualistic behavior. If the client is going to be able to avoid the anxiety, he or she must first learn
to recognize precipitating factors. Attempting to distract the client, seeking medication increase,
and locking the clients room are not appropriate interventions because they do not help the
client recognize anxiety triggers.
• A nursing student questions an instructor regarding the order for fluvoxamine (Luvox), 300 mg
daily, for a client diagnosed with obsessive-compulsive disorder (OCD). Which instructor reply is
most accurate?
A. High doses of tricyclic medications will be required for effective treatment of OCD.
B. Selective serotonin reuptake inhibitor (SSRI) doses, in excess of what is effective for
treating depression, may be required for OCD.
C. The dose of Luvox is low due to the side effect of daytime drowsiness and nighttime insomnia.
D. The dosage of Luvox is outside the therapeutic range and needs to be questioned.
ANS: B
The most accurate instructor response is that SSRI doses in excess of what is effective for treating
depression may be required in the treatment of OCD. SSRIs have been approved by the U.S. Food and
Drug Administration for the treatment of OCD. Common side effects include headache, sleep
disturbances, and restlessness.
• A client presents in the emergency department with complaints of overwhelming anxiety. Which
of the following is a priority for the nurse to assess?
A. Risk for suicide
B. Cardiac status
C. Current stressors
D. Substance use history
ANS: B
Although all of the listed aspects of assessment are important, the priority is to evaluate cardiac status
since a person having an MI, CHF, or mitral valve prolapse can present with symptoms of anxiety.
• A client is prescribed alprazolam (Xanax) for acute anxiety. What client history should cause a
,nurse to question this order?
A. History of alcohol dependence
B. History of personality disorder
C. History of schizophrenia
D. History of hypertension
ANS: A
The nurse should question a prescription of alprazolam (Xanax) for acute anxiety if the client has a
history of alcohol dependence. Alprazolam is a benzodiazepine used in the treatment of anxiety and
has an increased risk for physiological dependence and tolerance. A client with a history of substance
abuse may be more likely to abuse other addictive substances and/or combine this drug with alcohol.
• Warrens college roommate actively resists going out with friends whenever they invite him. He
says he cant stand to be around other people and confides to Warren They wouldnt like me anyway.
Which disorder is Warrens roommate likely suffering from?
A. Agoraphobia
B. Mysophobia
C. Social anxiety disorder (social phobia)
D. Panic disorder
ANS: C
Social anxiety disorder is an excessive fear of social situations R/T fear that one might do something
embarrassing or be evaluated negatively by others.
• A client has the following symptoms: preoccupation with imagined defect, verbalizations that are
out of proportion to actual physical abnormalities, and numerous visits to plastic surgeons to seek
relief. Which nursing diagnosis would best describe the problems evidenced by these symptoms?
A. Ineffective coping
B. Disturbed body image
C. Complicated grieving
D. Panic anxiety
ANS: B
The symptoms presented describe the DSM-5 diagnosis of body dysmorphic disorder, and the related
nursing diagnosis is disturbed body image.
A. How should a nurse best describe the major maladaptive client response to panic disorder?
B. Clients overuse medical care because of physical symptoms.
C. Clients use illegal drugs to ease symptoms.
D. Clients perceive having no control over life situations.
E. Clients develop compulsions to deal with anxiety.
, ANS: C
The major maladaptive client response to panic disorder is the perception of having no control over life
situations, which leads to nonparticipation in decision making and doubts regarding role performance.
• A client diagnosed with generalized anxiety states, I know the best thing for me to do now is to
just forget my worries. How should the nurse evaluate this statement?
A. The client is developing insight.
B. The clients coping skills are improving.
C. The client has a distorted perception of problem resolution.
D. The client is meeting outcomes and moving toward discharge.
ANS: C
This client has a distorted perception of how to deal with the problem of anxiety. Clients should be
encouraged to openly deal with anxiety and recognize the triggers that precipitate anxiety responses.
• A client is taking chlordiazepoxide (Librium) for generalized anxiety disorder symptoms. In
which situation should a nurse recognize that this client is at greatest risk for drug overdose?
A. When the client has a knowledge deficit related to the effects of the drug
B. When the client combines the drug with alcohol
C. When the client takes the drug on an empty stomach
D. When the client fails to follow dietary restrictions
ANS: B
Both Librium and alcohol are central nervous system depressants. In combination, these drugs have an
additive effect and can suppress the respiratory system, leading to respiratory arrest and death.
Multiple Response
• A college student has been diagnosed with generalized anxiety disorder (GAD). Which of
the following symptoms should a campus nurse expect this client to exhibit? Select all that
apply.
A. Fatigue
B. Anorexia
C. Hyperventilation
D. Insomnia
E. Irritability
ANS: A, D, E
The nurse should expect that a client diagnosed with GAD would experience fatigue, insomnia, and
irritability. GAD is characterized by chronic, unrealistic, and excessive anxiety and worry.
• A nurse is discussing treatment options with a client whose life has been negatively impacted
