Test Bank: Psychiatric and Mental Health Nursing for
Canadian Practice, 4th Edition by Austin - Chapters 1-35,
9781496384874 | Rationals Included
A 48-year-old Hispanic woman is seen by a psychiatric clinical nurse specialist after receiving a call by
her son. According to the son, since his father's death 7 months ago, his mother has lost 30 pounds
and can't sleep. During her initial visit, the patient states, 'My husband talks to me in his visits, but his
words make no sense to me. I don't understand what he wants me to do.' What is an appropriate
nursing diagnosis?
A. Ineffective denial
B. Bipolar mood disorder
C. Hyper-religiosity
D. Grieving - ANSWER: D. Grieving
(Rationale: Grieving may be characterized by weight loss, sleep disturbances, and messages from
beyond.)
Your neighbor's husband comes to talk to you. He says his wife has not left the house in 2 weeks, has
a flat mood, and has lost interest in her usual activities. You recognize these as the primary symptom
of
A. Depression
B. Schizophrenia
C. Suicidal ideation
D. Bipolar manic episodes - ANSWER: A. Depression
(Rationale: Depressed mood and anhedonia (loss of interest or pleasure in activities) are the primary
symptoms of major depression.)
Your patient is ready for discharge after a 30-day hospitalization for manic depression. About 30
minutes before his discharge, his roommates comes to you and says, "He is talking crazy." When you
ask the patient how he is feeling, he states, "I feel like Superman. I can do anything. I can fly home
today and then become a U.S. Senator." Which type of mania-relation symptoms is this patient
exhibiting?
A. Social
B. Cognitive
C. Behavioral
D. Perceptual - ANSWER: B. Cognitive
(Rationale: Cognitive symptoms include inflated self-esteem and grandiosity.)
You need to assess whether a patient hands a mood disorder is ready for discharge. Which statement
would indicate readiness for discharge?
A. "Right now, I can't bathe myself or dress myself, but I feel good about that."
B. "Going home will be fun, but if it isn't fun, I can always make my mother help or tell her to do so.
She better help me."
C. "I will take my medicines as I should and know to call the number you gave me if I have bad
thoughts."
D. "Taking care of myself is important, but it's okay if I don't want to do anything." - ANSWER: C. "I will
take my medicines as I should and know to call the number you gave me if I have bad thoughts."
(Rationale: Verbalization of a plan for help and demonstration of care are realistic discharge criteria.)
An angry patient is in the community room. She picks up a chair and uses it to hit another patient on
the head. When you come into the community room, what should your first response to the patient
holding the chair be?
A. "Are you crazy? Hitting people can hurt them!"
B. "Hitting others is unacceptable. Please put the chair completely down on the floor."
, C. "How would you like it if I hit you over the head with a chair?"
D. "You're in big trouble now. It's probably prison you are looking at!" - ANSWER: B. "Hitting others is
unacceptable. Please put the chair completely down on the floor."
(Rationale: Use words to indicate your lack of acceptance in the patient's behavior in as non
threatening tone or voice.)
A 22-year-old female is admitted to the unit following a suicide attempt. She has a 2-week history of
depression as well as a history of abusing multiple substances and anorexia nervosa. What is your first
nursing priority?
A. Socialization
B. Contracting for eating behavior
C. Safety
D. Administering the Back depression scale - ANSWER: C. Safety
(Rationale: Safety is the major principle underlying psychiatric nursing.)
Gerald was admitted to the psychiatric acute care unit because he stood in the center of a main two-
way street in his underwear and a t-shirt shouting, "I am being held against my will. I have personal
rights." Gerald was diagnosed with bipolar disorder, manic type. Which of the following interventions
will add to everyone's safety?
A. Having hectic surroundings
B. Have consistent unit routines
C. Minimize staff interventions
D. Medicate the patient only he has private health insurance - ANSWER: B. Having consistent unit
routines
(Rationale: Quiet environments with consistent routines will help calm patients and add to safety.)
Your patient has just been physically cleaned up after slicing his left arm 8 times. To show an
appropriate evaluative response, which of the following would be your best statement?
A. "I could care less if you cut yourself. It doesn't hurt me."
B. "If you wouldn't cut yourself, you would have a much happier life."
C. "You are lucky someone found you in time. Now you can help us make you better."
D. "The behavior of cutting is not acceptable." - ANSWER: D. "The behavior of cutting is not
acceptable."
(Rationale: Focus on the behavior, not the person. Be neutral, but not indifferent.)
A 22-year-old female was admitted to the mental health unit with major depression and suicidal
ideation. She has a history of cutting her wrists intermittently throughout the last 2 years. On days 1
and 2, the patient stays in her room and eats only 20% of her meals. On day 3, she eats 80% of her
meals and is talking to others in the group. The nurse should consider that the patient is
A. Showing improvement
B. Highly suicidal
C. Exhibiting mood swings
D. In need of electroshock therapy - ANSWER: A. Showing improvement
(Rationale: The patient improvement is based on increased socialization and increased appetite.)
A 21-year old patient has a diagnosis of schizophrenia and is stuporous, yet exhibits sudden, excessive
motor activity with repetitive sit-ups. What is this behavior called?
A. Delusional
B. Hallucinogenic
C. Paranoid
D. Catatonic - ANSWER: D. Catatonic
(Rationale: Catatonic schizophrenia occurs suddenly and includes motor immobility or excessive
motor activity.)
A 16-year-old girl is admitted for her first psychotic break. Her parents feel very guilty. What is your
best nursing response?
Canadian Practice, 4th Edition by Austin - Chapters 1-35,
9781496384874 | Rationals Included
A 48-year-old Hispanic woman is seen by a psychiatric clinical nurse specialist after receiving a call by
her son. According to the son, since his father's death 7 months ago, his mother has lost 30 pounds
and can't sleep. During her initial visit, the patient states, 'My husband talks to me in his visits, but his
words make no sense to me. I don't understand what he wants me to do.' What is an appropriate
nursing diagnosis?
A. Ineffective denial
B. Bipolar mood disorder
C. Hyper-religiosity
D. Grieving - ANSWER: D. Grieving
(Rationale: Grieving may be characterized by weight loss, sleep disturbances, and messages from
beyond.)
Your neighbor's husband comes to talk to you. He says his wife has not left the house in 2 weeks, has
a flat mood, and has lost interest in her usual activities. You recognize these as the primary symptom
of
A. Depression
B. Schizophrenia
C. Suicidal ideation
D. Bipolar manic episodes - ANSWER: A. Depression
(Rationale: Depressed mood and anhedonia (loss of interest or pleasure in activities) are the primary
symptoms of major depression.)
Your patient is ready for discharge after a 30-day hospitalization for manic depression. About 30
minutes before his discharge, his roommates comes to you and says, "He is talking crazy." When you
ask the patient how he is feeling, he states, "I feel like Superman. I can do anything. I can fly home
today and then become a U.S. Senator." Which type of mania-relation symptoms is this patient
exhibiting?
A. Social
B. Cognitive
C. Behavioral
D. Perceptual - ANSWER: B. Cognitive
(Rationale: Cognitive symptoms include inflated self-esteem and grandiosity.)
You need to assess whether a patient hands a mood disorder is ready for discharge. Which statement
would indicate readiness for discharge?
A. "Right now, I can't bathe myself or dress myself, but I feel good about that."
B. "Going home will be fun, but if it isn't fun, I can always make my mother help or tell her to do so.
She better help me."
C. "I will take my medicines as I should and know to call the number you gave me if I have bad
thoughts."
D. "Taking care of myself is important, but it's okay if I don't want to do anything." - ANSWER: C. "I will
take my medicines as I should and know to call the number you gave me if I have bad thoughts."
(Rationale: Verbalization of a plan for help and demonstration of care are realistic discharge criteria.)
An angry patient is in the community room. She picks up a chair and uses it to hit another patient on
the head. When you come into the community room, what should your first response to the patient
holding the chair be?
A. "Are you crazy? Hitting people can hurt them!"
B. "Hitting others is unacceptable. Please put the chair completely down on the floor."
, C. "How would you like it if I hit you over the head with a chair?"
D. "You're in big trouble now. It's probably prison you are looking at!" - ANSWER: B. "Hitting others is
unacceptable. Please put the chair completely down on the floor."
(Rationale: Use words to indicate your lack of acceptance in the patient's behavior in as non
threatening tone or voice.)
A 22-year-old female is admitted to the unit following a suicide attempt. She has a 2-week history of
depression as well as a history of abusing multiple substances and anorexia nervosa. What is your first
nursing priority?
A. Socialization
B. Contracting for eating behavior
C. Safety
D. Administering the Back depression scale - ANSWER: C. Safety
(Rationale: Safety is the major principle underlying psychiatric nursing.)
Gerald was admitted to the psychiatric acute care unit because he stood in the center of a main two-
way street in his underwear and a t-shirt shouting, "I am being held against my will. I have personal
rights." Gerald was diagnosed with bipolar disorder, manic type. Which of the following interventions
will add to everyone's safety?
A. Having hectic surroundings
B. Have consistent unit routines
C. Minimize staff interventions
D. Medicate the patient only he has private health insurance - ANSWER: B. Having consistent unit
routines
(Rationale: Quiet environments with consistent routines will help calm patients and add to safety.)
Your patient has just been physically cleaned up after slicing his left arm 8 times. To show an
appropriate evaluative response, which of the following would be your best statement?
A. "I could care less if you cut yourself. It doesn't hurt me."
B. "If you wouldn't cut yourself, you would have a much happier life."
C. "You are lucky someone found you in time. Now you can help us make you better."
D. "The behavior of cutting is not acceptable." - ANSWER: D. "The behavior of cutting is not
acceptable."
(Rationale: Focus on the behavior, not the person. Be neutral, but not indifferent.)
A 22-year-old female was admitted to the mental health unit with major depression and suicidal
ideation. She has a history of cutting her wrists intermittently throughout the last 2 years. On days 1
and 2, the patient stays in her room and eats only 20% of her meals. On day 3, she eats 80% of her
meals and is talking to others in the group. The nurse should consider that the patient is
A. Showing improvement
B. Highly suicidal
C. Exhibiting mood swings
D. In need of electroshock therapy - ANSWER: A. Showing improvement
(Rationale: The patient improvement is based on increased socialization and increased appetite.)
A 21-year old patient has a diagnosis of schizophrenia and is stuporous, yet exhibits sudden, excessive
motor activity with repetitive sit-ups. What is this behavior called?
A. Delusional
B. Hallucinogenic
C. Paranoid
D. Catatonic - ANSWER: D. Catatonic
(Rationale: Catatonic schizophrenia occurs suddenly and includes motor immobility or excessive
motor activity.)
A 16-year-old girl is admitted for her first psychotic break. Her parents feel very guilty. What is your
best nursing response?
