PSYCHIATRIC/MENTAL HEALTH NURSING |
Exam Review | 2024
A client in the mental health clinic has a phobia about closed spaces. Which desensitization
method should the nurse expect to be used successfully with this client? ** Answ ** Imagery
What treatment should a nurse anticipate will be prescribed for a client with severe, persistent,
intractable depression and suicidal ideation? ** Answ ** Electroconvulsive therapy
An older adult, accompanied by family members, is admitted to a long-term care facility with
symptoms of dementia. During the admission procedure the initial statement by the nurse most
helpful to this client is: ** Answ ** "Don't be afraid. I'm your nurse, and everyone here in the
hospital is here to help you."
An older depressed person at an independent living facility constantly complains about her
health problems to anyone who will listen. One day the client says, "I'm not going to any more
activities. All these old crabby people do is talk about their problems." What defense mechanism
does the nurse conclude that the client is using? ** Answ ** Projection
A client with alcohol dependence problem asks whether the nurse can see the bugs that are
crawling on the bed. What is the nurse's initial reply? ** Answ ** "No, I don't see any bugs."
A client is responding within an hour of receiving naloxone to combat respiratory depression
from an overdose of heroin. Why should a nurse continue to closely monitor this client's status?
** Answ ** Symptoms of the heroin overdose may return after the naloxone is metabolized.
A client tells the nurse, "The voices say I'll be safe only if I stay in this room, wear these clothes,
and avoid stepping on the cracks between the floor tiles." What is the best initial response by the
nurse? ** Answ ** "I understand that these voices are real to you, but I want you to know that
I don't hear them."
A parent of a 17-year-old girl who has been hospitalized for extremely disturbed acting-out
behavior leaves a gift for the daughter but says, "I'm too busy to visit today." The daughter
becomes upset and tearful after being given the message and opening the package. What does the
nurse conclude that the parent's actions represent? ** Answ ** Double-bind message
,A client with schizophrenia is admitted to a psychiatric unit. The client is talking while walking
in the hall, is unkempt, and obviously has not washed in several days. What should the nurse say
when trying to help this client shower? ** Answ ** "I'll help you take your shower now."
When a client is expressing severe anxiety by sobbing in the fetal position on her bed, the nurse's
priority is: ** Answ ** Ensuring a safe therapeutic milieu
A nurse is caring for several clients who are going through withdrawal from alcohol. The
primary reason for the ingestion of alcohol by clients with a history of alcohol abuse is that they:
** Answ ** Are dependent on it
A nurse is caring for a client with the diagnosis of alcohol withdrawal delirium. Which action is
most appropriate for the nurse to implement? ** Answ ** Assuring the client that the
symptoms are part of the withdrawal syndrome
A 30-year-old woman reports to the mental health clinic on the recommendation of her primary
health care provider. She has been unable to carry out everyday activities because of increased
pain in her lower back and legs. Numerous neurological and orthopedic workups indicate that
her symptoms seem excessive when compared with the physical problems shown on physical
examination and repeated MRIs and x-rays. She says that no one understands how difficult it has
been to care for her 32-year-old husband, who has an inoperable brain tumor and is undergoing
chemotherapy. In light of the history and symptoms, what disorder should the nurse suspect?
** Answ ** Conversion
A client is admitted to the hospital because of incapacitating obsessive-compulsive behavior. The
statement that best describes how clients with obsessive-compulsive behavior view this disorder
is: ** Answ ** "I know there's no reason to do these things, but I can't help myself."
A client with schizophrenia is demonstrating waxy flexibility. Which intervention is the best way
to manage the possible outcome of this behavior? ** Answ ** Passive range-of-motion
exercises three times a day for effective joint health
A client has been on the psychiatric unit for several days. The client arouses anxiety and
frustration in the staff and manipulates them so well that staff members are afraid to approach the
client. One morning the client shouts at the nurse, "You've worked it so I can't go for a walk with
the group today. You're as cunning as a fox. I hate you! Get out, or I'll hit you!" What is the best
response by the nurse? ** Answ ** "I don't like hearing your threats, but tell me more about
your feelings."
An adult client confides to a clinic nurse, "I fantasize about having sex with children, and I get
the urge to do it, too." What is the most appropriate response by the nurse? ** Answ **
Asking the client, "Have you ever acted on these thoughts?"
In her eighth month of pregnancy, a 24-year-old client is brought to the hospital by the police,
who were called when she barricaded herself in a ladies' restroom of a restaurant. During
admission the client shouts, "Don't come near me! My stomach is filled with bombs, and I'll
, blow up this place if anyone comes near me." The nurse concludes that the client is exhibiting:
** Answ ** Delusional thinking
A client who is on the third day of detoxification therapy becomes agitated and restless. What are
the signs and symptoms that indicate impending alcohol withdrawal delirium? (Select all that
apply.) ** Answ ** Diaphoresis
Tachycardia
Hypertension
A client is lonely and extremely depressed, and the health care provider prescribes a tricyclic
antidepressant. The client asks the nurse what the medication will do. What is the best response
by the nurse? ** Answ ** "The medication will increase your appetite and make you feel
better."
A client with a diagnosis of panic disorder who had a panic attack on the previous day says to the
nurse, "That was a terrible feeling I had yesterday. I'm so afraid to talk about it." What is the
most therapeutic response by the nurse? ** Answ ** "What were you doing yesterday when
you first noticed the feeling?"
A client believes that doorknobs are contaminated and refuses to touch them except with a paper
tissue. What nursing intervention will be most therapeutic for this client? ** Answ **
Supplying the client with tissues to maintain function until the anxiety eases
A man is admitted to the psychiatric unit after attempting suicide. The client's history reveals that
his first child died of sudden infant death syndrome 2 years ago, that he has been unable to work
since the death of the child, and that he has attempted suicide before. When talking with the
nurse he says, "I hear my son telling me to come over to the other side." What should the nurse
conclude that the client is experiencing? ** Answ ** Command hallucination
A nurse recalls that language development in the autistic child resembles: ** Answ **
Echolalia
What is a therapeutic nursing action in the care of a depressed client? ** Answ ** Sitting
down next to the client at frequent intervals
A nurse is caring for a client who uses ritualistic behavior. What common antiobsessional
medication does the nurse anticipate will be prescribed? ** Answ ** Fluvoxamine (Luvox)
A client is found to have a borderline personality disorder. What behavior does the nurse
consider is most typical of these clients? ** Answ ** Impulsive
An older adult with a diagnosis of delirium on the mental health unit begins acting out while in
the dayroom. What is the initial nursing intervention? ** Answ ** Giving the client one
simple direction at a time in a firm low-pitched voice
Exam Review | 2024
A client in the mental health clinic has a phobia about closed spaces. Which desensitization
method should the nurse expect to be used successfully with this client? ** Answ ** Imagery
What treatment should a nurse anticipate will be prescribed for a client with severe, persistent,
intractable depression and suicidal ideation? ** Answ ** Electroconvulsive therapy
An older adult, accompanied by family members, is admitted to a long-term care facility with
symptoms of dementia. During the admission procedure the initial statement by the nurse most
helpful to this client is: ** Answ ** "Don't be afraid. I'm your nurse, and everyone here in the
hospital is here to help you."
An older depressed person at an independent living facility constantly complains about her
health problems to anyone who will listen. One day the client says, "I'm not going to any more
activities. All these old crabby people do is talk about their problems." What defense mechanism
does the nurse conclude that the client is using? ** Answ ** Projection
A client with alcohol dependence problem asks whether the nurse can see the bugs that are
crawling on the bed. What is the nurse's initial reply? ** Answ ** "No, I don't see any bugs."
A client is responding within an hour of receiving naloxone to combat respiratory depression
from an overdose of heroin. Why should a nurse continue to closely monitor this client's status?
** Answ ** Symptoms of the heroin overdose may return after the naloxone is metabolized.
A client tells the nurse, "The voices say I'll be safe only if I stay in this room, wear these clothes,
and avoid stepping on the cracks between the floor tiles." What is the best initial response by the
nurse? ** Answ ** "I understand that these voices are real to you, but I want you to know that
I don't hear them."
A parent of a 17-year-old girl who has been hospitalized for extremely disturbed acting-out
behavior leaves a gift for the daughter but says, "I'm too busy to visit today." The daughter
becomes upset and tearful after being given the message and opening the package. What does the
nurse conclude that the parent's actions represent? ** Answ ** Double-bind message
,A client with schizophrenia is admitted to a psychiatric unit. The client is talking while walking
in the hall, is unkempt, and obviously has not washed in several days. What should the nurse say
when trying to help this client shower? ** Answ ** "I'll help you take your shower now."
When a client is expressing severe anxiety by sobbing in the fetal position on her bed, the nurse's
priority is: ** Answ ** Ensuring a safe therapeutic milieu
A nurse is caring for several clients who are going through withdrawal from alcohol. The
primary reason for the ingestion of alcohol by clients with a history of alcohol abuse is that they:
** Answ ** Are dependent on it
A nurse is caring for a client with the diagnosis of alcohol withdrawal delirium. Which action is
most appropriate for the nurse to implement? ** Answ ** Assuring the client that the
symptoms are part of the withdrawal syndrome
A 30-year-old woman reports to the mental health clinic on the recommendation of her primary
health care provider. She has been unable to carry out everyday activities because of increased
pain in her lower back and legs. Numerous neurological and orthopedic workups indicate that
her symptoms seem excessive when compared with the physical problems shown on physical
examination and repeated MRIs and x-rays. She says that no one understands how difficult it has
been to care for her 32-year-old husband, who has an inoperable brain tumor and is undergoing
chemotherapy. In light of the history and symptoms, what disorder should the nurse suspect?
** Answ ** Conversion
A client is admitted to the hospital because of incapacitating obsessive-compulsive behavior. The
statement that best describes how clients with obsessive-compulsive behavior view this disorder
is: ** Answ ** "I know there's no reason to do these things, but I can't help myself."
A client with schizophrenia is demonstrating waxy flexibility. Which intervention is the best way
to manage the possible outcome of this behavior? ** Answ ** Passive range-of-motion
exercises three times a day for effective joint health
A client has been on the psychiatric unit for several days. The client arouses anxiety and
frustration in the staff and manipulates them so well that staff members are afraid to approach the
client. One morning the client shouts at the nurse, "You've worked it so I can't go for a walk with
the group today. You're as cunning as a fox. I hate you! Get out, or I'll hit you!" What is the best
response by the nurse? ** Answ ** "I don't like hearing your threats, but tell me more about
your feelings."
An adult client confides to a clinic nurse, "I fantasize about having sex with children, and I get
the urge to do it, too." What is the most appropriate response by the nurse? ** Answ **
Asking the client, "Have you ever acted on these thoughts?"
In her eighth month of pregnancy, a 24-year-old client is brought to the hospital by the police,
who were called when she barricaded herself in a ladies' restroom of a restaurant. During
admission the client shouts, "Don't come near me! My stomach is filled with bombs, and I'll
, blow up this place if anyone comes near me." The nurse concludes that the client is exhibiting:
** Answ ** Delusional thinking
A client who is on the third day of detoxification therapy becomes agitated and restless. What are
the signs and symptoms that indicate impending alcohol withdrawal delirium? (Select all that
apply.) ** Answ ** Diaphoresis
Tachycardia
Hypertension
A client is lonely and extremely depressed, and the health care provider prescribes a tricyclic
antidepressant. The client asks the nurse what the medication will do. What is the best response
by the nurse? ** Answ ** "The medication will increase your appetite and make you feel
better."
A client with a diagnosis of panic disorder who had a panic attack on the previous day says to the
nurse, "That was a terrible feeling I had yesterday. I'm so afraid to talk about it." What is the
most therapeutic response by the nurse? ** Answ ** "What were you doing yesterday when
you first noticed the feeling?"
A client believes that doorknobs are contaminated and refuses to touch them except with a paper
tissue. What nursing intervention will be most therapeutic for this client? ** Answ **
Supplying the client with tissues to maintain function until the anxiety eases
A man is admitted to the psychiatric unit after attempting suicide. The client's history reveals that
his first child died of sudden infant death syndrome 2 years ago, that he has been unable to work
since the death of the child, and that he has attempted suicide before. When talking with the
nurse he says, "I hear my son telling me to come over to the other side." What should the nurse
conclude that the client is experiencing? ** Answ ** Command hallucination
A nurse recalls that language development in the autistic child resembles: ** Answ **
Echolalia
What is a therapeutic nursing action in the care of a depressed client? ** Answ ** Sitting
down next to the client at frequent intervals
A nurse is caring for a client who uses ritualistic behavior. What common antiobsessional
medication does the nurse anticipate will be prescribed? ** Answ ** Fluvoxamine (Luvox)
A client is found to have a borderline personality disorder. What behavior does the nurse
consider is most typical of these clients? ** Answ ** Impulsive
An older adult with a diagnosis of delirium on the mental health unit begins acting out while in
the dayroom. What is the initial nursing intervention? ** Answ ** Giving the client one
simple direction at a time in a firm low-pitched voice
