Mental Health 2 Exam 1 Practice
Questions 2024-2025
A client has a score of two on the Clinical Institute Withdrawal Assessment of Alcohol
Scale (CIWA-AR) for orientation and clouding of sensorium. What does the nurse
interpret from the score?
1. The client is disoriented regarding place.
2. The client is uncertain about the date.
3. The client is disoriented for more than 2 calendar days.
4. The client is disoriented for not more than 2 calendar days. - ANS 4. The client is
disoriented for not more than 2 calendar days.
Rationales
Option 1:
If the client is disoriented regarding place, then the score would be four for orientation
and clouding of sensorium on the CIWA-AR scale.
Option 2:
If the client is uncertain about the date, then the score would be one for orientation and
clouding of sensorium on a CIWA-AR scale.
Option 3:
If the client is disoriented for more than 2 calendar days, then the scoring would be
three for orientation and clouding of sensorium on a CIWA-AR scale.
Option 4:
If the client is disoriented for not more than 2 calendar days, then the scoring would be
two for orientation and clouding of sensorium on a CIWA-AR scale.
[Page reference: 431]
What are the anticholinergic side effects associated with novel antipsychotic
medications? Select all that apply.
1. Tremors
2. Drowsiness
3. Weight loss
4. Bradycardia
5. Hypertension - ANS 1. Tremors
Rationales
Option 1:
Novel antipsychotic medications may cause tremors as a side effect. This is because of
their anticholinergic effect on the motor control of the body.
,Option 2:
Novel antipsychotic medications may cause insomnia as an anticholinergic side effect.
Option 3:
Novel antipsychotic medications may cause weight gain as a side effect.
Option 4:
Novel antipsychotic medications may cause tachycardia as a side effect.
Option 5:
Novel antipsychotic medications are not associated with hypertension, but may cause
drops in blood pressure while changing postures, i.e., postural hypotension.
[Page reference: 485]
What personality traits is the nurse likely to find in a client who is addicted to opioids?
Select all that apply. [Page reference: 402]
1. Hyperactivity
2. Low self-esteem
3. Histrionic behaviors
4. Frequent depression
5. Ineffective communication - ANS 2. Low self-esteem
5. Ineffective communication
Option 1:
A client addicted to opioids becomes passive and remains inactive due to the
depressive effect of opioids on the central nervous system.
Option 2:
A client addicted to opioids will verbalize statements reflecting low self-esteem.
Option 3:
A client who is addicted to opioids may show antisocial personality traits but not
histrionic personality.
Option 4:
Frequent depression is observed in clients who are addicted to opioids due to the
inhibitory effect on the central nervous system.
Option 5:
A client who is addicted to opioids will have the inability to communicate effectively due
to social impairment.
What are the negative symptoms of schizophrenia? Select all that apply. [Page
reference: 471]
1. Delusions
2. Magical thinking
3. Pacing and rocking
4. Associative looseness
5. Emotional ambivalence - ANS 5. Emotional ambivalence
Option 1:
, Delusions are the false beliefs that are inconsistent with the client's intelligence or
cultural background. It is a positive symptom of schizophrenia.
Option 2:
The client with magical thinking believes that his or her thoughts or behaviors have
control over specific situations or people.
Option 3:
Pacing and rocking is one of the positive symptoms of schizophrenia, in which the client
performs backward and forward swaying of the trunk from the hips while sitting.
Option 4:
Associative looseness is the condition in which the client is unaware that the topics are
unconnected. It is a positive symptom of schizophrenia.
Option 5:
Emotional ambivalence refers to the coexistence of opposite emotions toward the same
object, person, or situation. It is a negative symptom of schizophrenia.
A client with schizophrenia says to the nurse, "A divine voice coming from space is
always telling me to go to New York." What is the best response of the nurse in this
situation? [Page reference: 469]
1. "What else do they tell you?"
2. "I don't think what you are saying is true."
3. "Maybe they are real, but don't listen to them and try to avoid them."
4. "Even though the voices are real to you, I am unable to hear any voices speaking." -
ANS 4. "Even though the voices are real to you, I am unable to hear any voices
speaking."
Option 1:
The nurse should never refer to the auditory hallucinations of the client with the words
such as "they" or "those." This is because these words do not imply validation to the
client's beliefs, and the client may feel rejected.
Option 2:
The nurse should not express doubtfulness towards the client's words. This may lead
the client to distrust the nurse.
Option 3:
The nurse should refrain from instructing the client to not listen to the voices. Instead,
the nurse should provide an explanation to the client in a nonthreatening manner.
Option 4:
The nurse should refer to the auditory hallucinations of the client as "the voices" to help
validate them for the client. This helps to make the client believe that the nurse is
honest and to accept that the voices are unreal.
What suggestions will the nurse provide to a client about the management of illness
related to substance abuse? Select all that apply. [Page reference: 440]
1. Progressive relaxation techniques
Questions 2024-2025
A client has a score of two on the Clinical Institute Withdrawal Assessment of Alcohol
Scale (CIWA-AR) for orientation and clouding of sensorium. What does the nurse
interpret from the score?
1. The client is disoriented regarding place.
2. The client is uncertain about the date.
3. The client is disoriented for more than 2 calendar days.
4. The client is disoriented for not more than 2 calendar days. - ANS 4. The client is
disoriented for not more than 2 calendar days.
Rationales
Option 1:
If the client is disoriented regarding place, then the score would be four for orientation
and clouding of sensorium on the CIWA-AR scale.
Option 2:
If the client is uncertain about the date, then the score would be one for orientation and
clouding of sensorium on a CIWA-AR scale.
Option 3:
If the client is disoriented for more than 2 calendar days, then the scoring would be
three for orientation and clouding of sensorium on a CIWA-AR scale.
Option 4:
If the client is disoriented for not more than 2 calendar days, then the scoring would be
two for orientation and clouding of sensorium on a CIWA-AR scale.
[Page reference: 431]
What are the anticholinergic side effects associated with novel antipsychotic
medications? Select all that apply.
1. Tremors
2. Drowsiness
3. Weight loss
4. Bradycardia
5. Hypertension - ANS 1. Tremors
Rationales
Option 1:
Novel antipsychotic medications may cause tremors as a side effect. This is because of
their anticholinergic effect on the motor control of the body.
,Option 2:
Novel antipsychotic medications may cause insomnia as an anticholinergic side effect.
Option 3:
Novel antipsychotic medications may cause weight gain as a side effect.
Option 4:
Novel antipsychotic medications may cause tachycardia as a side effect.
Option 5:
Novel antipsychotic medications are not associated with hypertension, but may cause
drops in blood pressure while changing postures, i.e., postural hypotension.
[Page reference: 485]
What personality traits is the nurse likely to find in a client who is addicted to opioids?
Select all that apply. [Page reference: 402]
1. Hyperactivity
2. Low self-esteem
3. Histrionic behaviors
4. Frequent depression
5. Ineffective communication - ANS 2. Low self-esteem
5. Ineffective communication
Option 1:
A client addicted to opioids becomes passive and remains inactive due to the
depressive effect of opioids on the central nervous system.
Option 2:
A client addicted to opioids will verbalize statements reflecting low self-esteem.
Option 3:
A client who is addicted to opioids may show antisocial personality traits but not
histrionic personality.
Option 4:
Frequent depression is observed in clients who are addicted to opioids due to the
inhibitory effect on the central nervous system.
Option 5:
A client who is addicted to opioids will have the inability to communicate effectively due
to social impairment.
What are the negative symptoms of schizophrenia? Select all that apply. [Page
reference: 471]
1. Delusions
2. Magical thinking
3. Pacing and rocking
4. Associative looseness
5. Emotional ambivalence - ANS 5. Emotional ambivalence
Option 1:
, Delusions are the false beliefs that are inconsistent with the client's intelligence or
cultural background. It is a positive symptom of schizophrenia.
Option 2:
The client with magical thinking believes that his or her thoughts or behaviors have
control over specific situations or people.
Option 3:
Pacing and rocking is one of the positive symptoms of schizophrenia, in which the client
performs backward and forward swaying of the trunk from the hips while sitting.
Option 4:
Associative looseness is the condition in which the client is unaware that the topics are
unconnected. It is a positive symptom of schizophrenia.
Option 5:
Emotional ambivalence refers to the coexistence of opposite emotions toward the same
object, person, or situation. It is a negative symptom of schizophrenia.
A client with schizophrenia says to the nurse, "A divine voice coming from space is
always telling me to go to New York." What is the best response of the nurse in this
situation? [Page reference: 469]
1. "What else do they tell you?"
2. "I don't think what you are saying is true."
3. "Maybe they are real, but don't listen to them and try to avoid them."
4. "Even though the voices are real to you, I am unable to hear any voices speaking." -
ANS 4. "Even though the voices are real to you, I am unable to hear any voices
speaking."
Option 1:
The nurse should never refer to the auditory hallucinations of the client with the words
such as "they" or "those." This is because these words do not imply validation to the
client's beliefs, and the client may feel rejected.
Option 2:
The nurse should not express doubtfulness towards the client's words. This may lead
the client to distrust the nurse.
Option 3:
The nurse should refrain from instructing the client to not listen to the voices. Instead,
the nurse should provide an explanation to the client in a nonthreatening manner.
Option 4:
The nurse should refer to the auditory hallucinations of the client as "the voices" to help
validate them for the client. This helps to make the client believe that the nurse is
honest and to accept that the voices are unreal.
What suggestions will the nurse provide to a client about the management of illness
related to substance abuse? Select all that apply. [Page reference: 440]
1. Progressive relaxation techniques
