NUR 220 Mental Health
1. A charge nurse overhears another nurse talking with a client who has schizophrenia.
Suddenly the client yells, "I am the devil. I am God. Open the gate for me!" Which of the
following replies by the nurse requires intervention by the charge nurse?
A) Tell me who you are
B) I dont understand. Can you tell me what that means?
C) Are you saying that you are both good and bad?
D) There is no gate.
Answer
D) There is no gate
2. A nurse in a psychiatric unit is caring for a client who is being admitted involuntarily after
attacking a neighbor. The nurse knows that the client can be kept in the hospital after the 72-hour
hold is over if the client
A) is a danger to herself or others.
B) is unwilling to accept that treatment is needed.
C) does not have anyone that she could stay with.
D) is financially incapable of paying for prescription medications.
Answer
A) Is a danger to herself or others
3. A nurse in the ED is caring for a client taking haldol for the past 3 months. The client's
temperature is 102 F, BP 150/110, and has tachycardia. The nurse should know that these
indicate a diagnosis of
A) agranulocytosis
B) neuroleptic malignant syndrome (NMS)
C) hypertensive crisis
D) tardive dyskinesia
Answer
B) neuroleptic malignant syndrome (NMS)
,4. A nurse is admitting a client who has multiple trauma after a motor vehicle accident. Shortly
after admission her husband arrives. He is distraught and blames himself for the accident.
Which of the following is an appropriate nursing response?
A) Don't worry about that. Your wife will be fine.
B) I think you should calm down a little before you see your wife.
C) Why do you think the accident was your fault?
D) Tell me more about your feelings about what happened to your wife.
Answer
D) Tell me more about your feelings about what happened to your wife.
5. A nurse is assessing a client receiving treatment for schizophrenia with the typical
antipsychotic fluphenazine (Prolixin) for 12 months. The nurse observes fine, fasciculating
tongue movements and associates this finding
with which of the following?
A) A drug-food reaction to grapefruit juice
B) The client has missed several doses of medication
C) Early symptoms of neuroleptic malignant syndrome (NMS)
D) Early symptoms of tardive dyskinesia (TD)
Answer
D) Early symptoms of tardive dyskinesia (TD)
6. A nurse is assessing an adolescent client with anorexia. Which of the following client
statements is a sign of cognitive distortion?
a) I like to cut my food into small portions
b) I really need to get in shape
c) If I eat one piece of candy, I may as well eat ten.
d) I can't afford to gain weight.
Answer
c) If I eat one piece of candy, I may as well eat ten.
7. A nurse is assessing for the presence of extrapyramidal side effects (EPSs) in a client taking
, chlorpromazine (Thorazine). Which of the following findings should the nurse recognize as
EPSs? Select all that apply.
a) Muscle contractions of the neck
b) Fidgeting behavior
c) Fluctuating vital signs
d) Impaired gait
e) Sexual dysfunction
Answer
a) Muscle contractions of the neck
b) Fidgeting behavior
d) Impaired gait
8. A nurse is caring for a client admitted with acute psychosis, being treated with haloperidol
(Haldol.) The nurse should suspect tardive dyskinesia as an adverse reaction when the client
exhibits which of the following? Select all that apply.
a) Urinary retention and constipation
b) Tongue twisting and lip smacking
c) Fine hand tremors and pill rolling
d) Facial grimacing and eye blinking
e) Extreme sedation and lethargy
f) Repetitive involuntary movements
Answer
b) Tongue twisting and lip smacking
d) Facial grimacing and eye blinking
f) Repetitive involuntary movements
9. A nurse is caring for a client in an urgent care center with traumatic injuries following an
assault. She sits quietly and calmly in the exam room. The nurse should recognize this behavior
as which of the following?
a) Denial
b) Displacement
c) Introjection
1. A charge nurse overhears another nurse talking with a client who has schizophrenia.
Suddenly the client yells, "I am the devil. I am God. Open the gate for me!" Which of the
following replies by the nurse requires intervention by the charge nurse?
A) Tell me who you are
B) I dont understand. Can you tell me what that means?
C) Are you saying that you are both good and bad?
D) There is no gate.
Answer
D) There is no gate
2. A nurse in a psychiatric unit is caring for a client who is being admitted involuntarily after
attacking a neighbor. The nurse knows that the client can be kept in the hospital after the 72-hour
hold is over if the client
A) is a danger to herself or others.
B) is unwilling to accept that treatment is needed.
C) does not have anyone that she could stay with.
D) is financially incapable of paying for prescription medications.
Answer
A) Is a danger to herself or others
3. A nurse in the ED is caring for a client taking haldol for the past 3 months. The client's
temperature is 102 F, BP 150/110, and has tachycardia. The nurse should know that these
indicate a diagnosis of
A) agranulocytosis
B) neuroleptic malignant syndrome (NMS)
C) hypertensive crisis
D) tardive dyskinesia
Answer
B) neuroleptic malignant syndrome (NMS)
,4. A nurse is admitting a client who has multiple trauma after a motor vehicle accident. Shortly
after admission her husband arrives. He is distraught and blames himself for the accident.
Which of the following is an appropriate nursing response?
A) Don't worry about that. Your wife will be fine.
B) I think you should calm down a little before you see your wife.
C) Why do you think the accident was your fault?
D) Tell me more about your feelings about what happened to your wife.
Answer
D) Tell me more about your feelings about what happened to your wife.
5. A nurse is assessing a client receiving treatment for schizophrenia with the typical
antipsychotic fluphenazine (Prolixin) for 12 months. The nurse observes fine, fasciculating
tongue movements and associates this finding
with which of the following?
A) A drug-food reaction to grapefruit juice
B) The client has missed several doses of medication
C) Early symptoms of neuroleptic malignant syndrome (NMS)
D) Early symptoms of tardive dyskinesia (TD)
Answer
D) Early symptoms of tardive dyskinesia (TD)
6. A nurse is assessing an adolescent client with anorexia. Which of the following client
statements is a sign of cognitive distortion?
a) I like to cut my food into small portions
b) I really need to get in shape
c) If I eat one piece of candy, I may as well eat ten.
d) I can't afford to gain weight.
Answer
c) If I eat one piece of candy, I may as well eat ten.
7. A nurse is assessing for the presence of extrapyramidal side effects (EPSs) in a client taking
, chlorpromazine (Thorazine). Which of the following findings should the nurse recognize as
EPSs? Select all that apply.
a) Muscle contractions of the neck
b) Fidgeting behavior
c) Fluctuating vital signs
d) Impaired gait
e) Sexual dysfunction
Answer
a) Muscle contractions of the neck
b) Fidgeting behavior
d) Impaired gait
8. A nurse is caring for a client admitted with acute psychosis, being treated with haloperidol
(Haldol.) The nurse should suspect tardive dyskinesia as an adverse reaction when the client
exhibits which of the following? Select all that apply.
a) Urinary retention and constipation
b) Tongue twisting and lip smacking
c) Fine hand tremors and pill rolling
d) Facial grimacing and eye blinking
e) Extreme sedation and lethargy
f) Repetitive involuntary movements
Answer
b) Tongue twisting and lip smacking
d) Facial grimacing and eye blinking
f) Repetitive involuntary movements
9. A nurse is caring for a client in an urgent care center with traumatic injuries following an
assault. She sits quietly and calmly in the exam room. The nurse should recognize this behavior
as which of the following?
a) Denial
b) Displacement
c) Introjection
