UNIT III MENTAL HEALTH TEST BANK
(ALL ANSWERS) WITH VERIFIED
ANSWERS
A preschool child is admitted to a psychiatric unit with the diagnosis autistic spectrum
disorder. To help the child feel more secure on the unit, which intervention should a
nurse include in this clients plan of care?
1. Encourage and reward peer contact.
2. Provide consistent caregivers.
3. Provide a variety of safe daily activities.
4. Maintain close physical contact throughout the day. - Answer-ANS: 2
Rationale: The nurse should provide consistent caregivers as part of the plan of care
for a child diagnosed with autistic spectrum disorder. Children diagnosed with autistic
spectrum disorder have an inability to trust. Providing consistent caregivers allows
the client to develop trust and a sense of security.
A preschool child diagnosed with autistic spectrum disorder has been engaging in
constant head-banging behavior. Which nursing intervention is appropriate?
1. Place client in restraints until the aggression subsides.
2. Sedate the client with neuroleptic medications.
3. Hold clients head steady and apply a helmet.
4. Distract the client with a variety of games and puzzles. - Answer-ANS: 3
Rationale: The most appropriate intervention for head banging is to hold the client's
head steady and apply a helmet. The helmet is the least restrictive intervention and
will serve to protect the client's head from injury.
When planning care for a client, which medication classification should a nurse
recognize as effective in the treatment of Tourettes syndrome?
1. Neuroleptic medications
2. Anti-manic medications
3. Tricyclic antidepressant medications
4. Monoamine oxidase inhibitor medications - Answer-ANS: 1
Rationale: The nurse should recognize that neuroleptic (antipsychotic) medications
are effective in the treatment of Tourette's syndrome. These medications are used to
reduce the severity of tics and are most effective when combined with psychosocial
therapy.
Which behavioral approach should a nurse use when caring for children diagnosed
with disruptive behavior disorders?
1. Involving parents in designing and implementing the treatment process
2. Reinforcing positive actions to encourage repetition of desirable behaviors
3. Providing opportunities to learn appropriate peer interactions
4. Administering psychotropic medications to improve quality of life - Answer-ANS: 2
Rationale: The nurse should reinforce positive actions to encourage repetition of
desirable behaviors when caring for children diagnosed with disruptive behavior
disorder. Behavior therapy is based on the concepts of classical conditioning and
operant conditioning.
,A child diagnosed with severe autistic spectrum disorder has the nursing diagnosis
disturbed personal identity. Which outcome would best address this client diagnosis?
1. The client will name own body parts as separate from others by day five.
2. The client will establish a means of communicating personal needs by discharge.
3. The client will initiate social interactions with caregivers by day four.
4. The client will not harm self or others by discharge. - Answer-ANS: 1
Rationale: An appropriate outcome for this client is to name own body parts as
separate from others. The nurse should assist the client in the recognition of
separateness during self-care activities, such as dressing and feeding. The long-
term goal for disturbed personal identity is for the client to develop an ego identity.
A nursing instructor presents a case study in which a three-year-old child is in
constant motion and is unable to sit still during story time. She asks a student to
evaluate this childs behavior. Which student response indicates an appropriate
evaluation of the situation?
1. This childs behavior must be evaluated according to developmental norms.
2. This child has symptoms of attention deficit-hyperactivity disorder.
3. This child has symptoms of the early stages of autistic disorder.
4. This childs behavior indicates possible symptoms of oppositional defiant disorder.
- Answer-ANS: 1
Rationale: The students evaluation of the situation is appropriate when indicating a
need for the client to be evaluated according to developmental norms. The DSM-5
indicates that emotional problems exist if the behavioral manifestations are not age-
appropriate, deviate from cultural norms, or create deficits or impairments in adaptive
functioning.
A client has an IQ of 47. Which nursing diagnosis best addresses a client problem
associated with this degree of IDD?
1. Risk for injury R/T self-mutilation
2. Altered social interaction R/T non-adherence to social convention
3. Altered verbal communication R/T delusional thinking
4. Social isolation R/T severely decreased gross motor skills - Answer-ANS: 2
Rationale: The appropriate nursing diagnosis associated with this degree of IDD is
altered social interaction R/T non-adherence to social convention. A client with an IQ
of 47 would be diagnosed with moderate intellectual developmental disorder and
may also experience some limitations in speech communications.
A physician orders methylphenidate (Ritalin) for a child diagnosed with ADHD. Which
information about this medication should the nurse provide to the parents?
1. If one dose of Ritalin is missed, double the next dose.
2. Administer Ritalin to the child after breakfast.
3. Administer Ritalin to the child just prior to bedtime.
4. A side effect of Ritalin is decreased ability to learn. - Answer-ANS: 2
Rationale: The nurse should instruct the parents to administer Ritalin to the child
after breakfast. Ritalin is a central nervous system stimulant and can cause
decreased appetite. Central nervous system stimulants can also temporarily interrupt
growth and development.
,Which should be the priority nursing intervention when caring for a child diagnosed
with conduct disorder?
1. Modify environment to decrease stimulation and provide opportunities for quiet
reflection.
2. Convey unconditional acceptance and positive regard.
3. Recognize escalating aggressive behavior and intervene before violence occurs.
4. Provide immediate positive feedback for appropriate behaviors. - Answer-ANS: 3
Rationale: The priority nursing intervention when caring for a child diagnosed with
conduct disorder should be to recognize escalating aggressive behavior and to
intervene before violence occurs. This intervention serves to keep the client as well
as others safe, which is the priority nursing concern.
A mother questions the decreased effectiveness of methylphenidate (Ritalin),
prescribed for her childs ADHD. Which nursing response best addresses the
mothers concern?
1. The physician will probably switch from Ritalin to a central nervous system
stimulant.
2. The physician may prescribe an antihistamine with the Ritalin to improve
effectiveness.
3. Your child has probably developed a tolerance to Ritalin and may need a higher
dosage.
4. Your child has developed sensitivity to Ritalin and may be exhibiting an allergy. -
Answer-ANS: 3
Rationale: The nurse should explain to the mother that the child has probably
developed a tolerance to Ritalin and may need a higher dosage. Methylphenidate is
a central nervous system stimulant, and tolerance can develop rapidly. Physical and
psychological dependence can also occur.
After studying the DSM-5 criteria for oppositional defiant disorder (ODD), which listed
symptom would a student nurse recognize?
1. Arguing and annoying older sibling over the past year
2. Angry and resentful behavior over a three-month period
3. Initiating physical fights for more than 18 months
4. Arguing with authority figures for more than six months - Answer-ANS: 4
Rationale: The DSM-5 rules out the diagnosis of ODD when only siblings are
involved in argumentative interactions. Angry and resentful behavior over more than
six months, not three months, would be considered a symptom of ODD. Initiating
physical fights is a symptom of conduct disorder, not ODD. Arguing with authority
figures for more than six months is listed by the DSM-5 as a symptom for the
diagnosis of ODD.
Which of the following risk factors, if noted during a family history assessment,
should a nurse associate with the development of IDD? (Select all that apply.)
1. A family history of Tay-Sachs disease
2. Childhood meningococcal infection
3. Deprivation of nurturance and social contact
4. History of maternal multiple motor and verbal tics
5. A diagnosis of maternal major depressive disorder - Answer-ANS: 1, 2, 3
Rationale: The nurse should recognize a family history of Tay-Sachs disease,
childhood meningococcal infections, and deprivation of nurturance and social contact
, as risk factors that would predispose a child to IDD. There are five major
predisposing factors of IDD: hereditary factors, early alterations in embryonic
development, pregnancy and perinatal factors, medical conditions acquired in
infancy or childhood, and environmental influences and other mental disorders.
Which of the following findings should a nurse identify that would contribute to a
clients development of ADHD? (Select all that apply.)
1. The clients father was a smoker.
2. The client was born 7 weeks premature.
3. The client is lactose intolerant.
4. The client has a sibling diagnosed with ADHD.
5. The client has been diagnosed with dyslexia. - Answer-ANS: 2, 4
Rationale: The nurse should identify that premature birth and having a sibling
diagnosed with ADHD would predispose a client to the development of ADHD.
Research indicates evidence of genetic influences in the etiology of ADHD. Studies
also indicate that environmental influences, such as lead exposure and diet, can be
linked with the development of ADHD.
The DSM-5 criteria for ODD specifies that: A persistent pattern of angry/irritable
mood, argumentative/defiant behavior, or vindictiveness must be evident and last at
least ______________ months. - Answer-ANS: six
Rationale: A persistent pattern of angry/irritable mood, argumentative/defiant
behavior, or vindictiveness must be evident and last at least six months according to
the DSM-5 criteria for the diagnosis of ODD.
A client has recently been placed in a long-term care facility, because of marked
confusion and inability to perform most activities of daily living (ADLs). Which nursing
intervention is most appropriate to maintain the clients self-esteem?
1. Leave the client alone in the bathroom to test ability to perform self-care.
2. Assign a variety of caregivers to increase potential for socialization.
3. Allow client to choose between two different outfits when dressing for the day.
4. Modify the daily schedule often to maintain variety and decrease boredom. -
Answer-ANS: 3
Rationale: The most appropriate nursing intervention to maintain this client's self-
esteem is to allow the client to choose between two different outfits when dressing
for the day. The nurse should also provide appropriate supervision to keep the client
safe, maintain consistency of caregivers, and maintain a structured daily routine to
minimize confusion.
A son, who recently brought his extremely confused parent to a nursing home for
admission, reports feelings of guilt. Which is the appropriate nursing response?
1. Support groups are held here on Mondays for children of residents in similar
situations.
2. You did what you had to do. I wouldnt feel guilty if I were you.
3. Support groups are available to low-income families.
4. Your parent is doing just fine. Well take very good care of him. - Answer-ANS: 1
Rationale: The most appropriate response by the nurse is to offer support to the son
by presenting available support groups. Caregivers can often experience negative
emotions and guilt. Release of these emotions can serve to prevent caregivers from
developing psychopathology such a depression.
(ALL ANSWERS) WITH VERIFIED
ANSWERS
A preschool child is admitted to a psychiatric unit with the diagnosis autistic spectrum
disorder. To help the child feel more secure on the unit, which intervention should a
nurse include in this clients plan of care?
1. Encourage and reward peer contact.
2. Provide consistent caregivers.
3. Provide a variety of safe daily activities.
4. Maintain close physical contact throughout the day. - Answer-ANS: 2
Rationale: The nurse should provide consistent caregivers as part of the plan of care
for a child diagnosed with autistic spectrum disorder. Children diagnosed with autistic
spectrum disorder have an inability to trust. Providing consistent caregivers allows
the client to develop trust and a sense of security.
A preschool child diagnosed with autistic spectrum disorder has been engaging in
constant head-banging behavior. Which nursing intervention is appropriate?
1. Place client in restraints until the aggression subsides.
2. Sedate the client with neuroleptic medications.
3. Hold clients head steady and apply a helmet.
4. Distract the client with a variety of games and puzzles. - Answer-ANS: 3
Rationale: The most appropriate intervention for head banging is to hold the client's
head steady and apply a helmet. The helmet is the least restrictive intervention and
will serve to protect the client's head from injury.
When planning care for a client, which medication classification should a nurse
recognize as effective in the treatment of Tourettes syndrome?
1. Neuroleptic medications
2. Anti-manic medications
3. Tricyclic antidepressant medications
4. Monoamine oxidase inhibitor medications - Answer-ANS: 1
Rationale: The nurse should recognize that neuroleptic (antipsychotic) medications
are effective in the treatment of Tourette's syndrome. These medications are used to
reduce the severity of tics and are most effective when combined with psychosocial
therapy.
Which behavioral approach should a nurse use when caring for children diagnosed
with disruptive behavior disorders?
1. Involving parents in designing and implementing the treatment process
2. Reinforcing positive actions to encourage repetition of desirable behaviors
3. Providing opportunities to learn appropriate peer interactions
4. Administering psychotropic medications to improve quality of life - Answer-ANS: 2
Rationale: The nurse should reinforce positive actions to encourage repetition of
desirable behaviors when caring for children diagnosed with disruptive behavior
disorder. Behavior therapy is based on the concepts of classical conditioning and
operant conditioning.
,A child diagnosed with severe autistic spectrum disorder has the nursing diagnosis
disturbed personal identity. Which outcome would best address this client diagnosis?
1. The client will name own body parts as separate from others by day five.
2. The client will establish a means of communicating personal needs by discharge.
3. The client will initiate social interactions with caregivers by day four.
4. The client will not harm self or others by discharge. - Answer-ANS: 1
Rationale: An appropriate outcome for this client is to name own body parts as
separate from others. The nurse should assist the client in the recognition of
separateness during self-care activities, such as dressing and feeding. The long-
term goal for disturbed personal identity is for the client to develop an ego identity.
A nursing instructor presents a case study in which a three-year-old child is in
constant motion and is unable to sit still during story time. She asks a student to
evaluate this childs behavior. Which student response indicates an appropriate
evaluation of the situation?
1. This childs behavior must be evaluated according to developmental norms.
2. This child has symptoms of attention deficit-hyperactivity disorder.
3. This child has symptoms of the early stages of autistic disorder.
4. This childs behavior indicates possible symptoms of oppositional defiant disorder.
- Answer-ANS: 1
Rationale: The students evaluation of the situation is appropriate when indicating a
need for the client to be evaluated according to developmental norms. The DSM-5
indicates that emotional problems exist if the behavioral manifestations are not age-
appropriate, deviate from cultural norms, or create deficits or impairments in adaptive
functioning.
A client has an IQ of 47. Which nursing diagnosis best addresses a client problem
associated with this degree of IDD?
1. Risk for injury R/T self-mutilation
2. Altered social interaction R/T non-adherence to social convention
3. Altered verbal communication R/T delusional thinking
4. Social isolation R/T severely decreased gross motor skills - Answer-ANS: 2
Rationale: The appropriate nursing diagnosis associated with this degree of IDD is
altered social interaction R/T non-adherence to social convention. A client with an IQ
of 47 would be diagnosed with moderate intellectual developmental disorder and
may also experience some limitations in speech communications.
A physician orders methylphenidate (Ritalin) for a child diagnosed with ADHD. Which
information about this medication should the nurse provide to the parents?
1. If one dose of Ritalin is missed, double the next dose.
2. Administer Ritalin to the child after breakfast.
3. Administer Ritalin to the child just prior to bedtime.
4. A side effect of Ritalin is decreased ability to learn. - Answer-ANS: 2
Rationale: The nurse should instruct the parents to administer Ritalin to the child
after breakfast. Ritalin is a central nervous system stimulant and can cause
decreased appetite. Central nervous system stimulants can also temporarily interrupt
growth and development.
,Which should be the priority nursing intervention when caring for a child diagnosed
with conduct disorder?
1. Modify environment to decrease stimulation and provide opportunities for quiet
reflection.
2. Convey unconditional acceptance and positive regard.
3. Recognize escalating aggressive behavior and intervene before violence occurs.
4. Provide immediate positive feedback for appropriate behaviors. - Answer-ANS: 3
Rationale: The priority nursing intervention when caring for a child diagnosed with
conduct disorder should be to recognize escalating aggressive behavior and to
intervene before violence occurs. This intervention serves to keep the client as well
as others safe, which is the priority nursing concern.
A mother questions the decreased effectiveness of methylphenidate (Ritalin),
prescribed for her childs ADHD. Which nursing response best addresses the
mothers concern?
1. The physician will probably switch from Ritalin to a central nervous system
stimulant.
2. The physician may prescribe an antihistamine with the Ritalin to improve
effectiveness.
3. Your child has probably developed a tolerance to Ritalin and may need a higher
dosage.
4. Your child has developed sensitivity to Ritalin and may be exhibiting an allergy. -
Answer-ANS: 3
Rationale: The nurse should explain to the mother that the child has probably
developed a tolerance to Ritalin and may need a higher dosage. Methylphenidate is
a central nervous system stimulant, and tolerance can develop rapidly. Physical and
psychological dependence can also occur.
After studying the DSM-5 criteria for oppositional defiant disorder (ODD), which listed
symptom would a student nurse recognize?
1. Arguing and annoying older sibling over the past year
2. Angry and resentful behavior over a three-month period
3. Initiating physical fights for more than 18 months
4. Arguing with authority figures for more than six months - Answer-ANS: 4
Rationale: The DSM-5 rules out the diagnosis of ODD when only siblings are
involved in argumentative interactions. Angry and resentful behavior over more than
six months, not three months, would be considered a symptom of ODD. Initiating
physical fights is a symptom of conduct disorder, not ODD. Arguing with authority
figures for more than six months is listed by the DSM-5 as a symptom for the
diagnosis of ODD.
Which of the following risk factors, if noted during a family history assessment,
should a nurse associate with the development of IDD? (Select all that apply.)
1. A family history of Tay-Sachs disease
2. Childhood meningococcal infection
3. Deprivation of nurturance and social contact
4. History of maternal multiple motor and verbal tics
5. A diagnosis of maternal major depressive disorder - Answer-ANS: 1, 2, 3
Rationale: The nurse should recognize a family history of Tay-Sachs disease,
childhood meningococcal infections, and deprivation of nurturance and social contact
, as risk factors that would predispose a child to IDD. There are five major
predisposing factors of IDD: hereditary factors, early alterations in embryonic
development, pregnancy and perinatal factors, medical conditions acquired in
infancy or childhood, and environmental influences and other mental disorders.
Which of the following findings should a nurse identify that would contribute to a
clients development of ADHD? (Select all that apply.)
1. The clients father was a smoker.
2. The client was born 7 weeks premature.
3. The client is lactose intolerant.
4. The client has a sibling diagnosed with ADHD.
5. The client has been diagnosed with dyslexia. - Answer-ANS: 2, 4
Rationale: The nurse should identify that premature birth and having a sibling
diagnosed with ADHD would predispose a client to the development of ADHD.
Research indicates evidence of genetic influences in the etiology of ADHD. Studies
also indicate that environmental influences, such as lead exposure and diet, can be
linked with the development of ADHD.
The DSM-5 criteria for ODD specifies that: A persistent pattern of angry/irritable
mood, argumentative/defiant behavior, or vindictiveness must be evident and last at
least ______________ months. - Answer-ANS: six
Rationale: A persistent pattern of angry/irritable mood, argumentative/defiant
behavior, or vindictiveness must be evident and last at least six months according to
the DSM-5 criteria for the diagnosis of ODD.
A client has recently been placed in a long-term care facility, because of marked
confusion and inability to perform most activities of daily living (ADLs). Which nursing
intervention is most appropriate to maintain the clients self-esteem?
1. Leave the client alone in the bathroom to test ability to perform self-care.
2. Assign a variety of caregivers to increase potential for socialization.
3. Allow client to choose between two different outfits when dressing for the day.
4. Modify the daily schedule often to maintain variety and decrease boredom. -
Answer-ANS: 3
Rationale: The most appropriate nursing intervention to maintain this client's self-
esteem is to allow the client to choose between two different outfits when dressing
for the day. The nurse should also provide appropriate supervision to keep the client
safe, maintain consistency of caregivers, and maintain a structured daily routine to
minimize confusion.
A son, who recently brought his extremely confused parent to a nursing home for
admission, reports feelings of guilt. Which is the appropriate nursing response?
1. Support groups are held here on Mondays for children of residents in similar
situations.
2. You did what you had to do. I wouldnt feel guilty if I were you.
3. Support groups are available to low-income families.
4. Your parent is doing just fine. Well take very good care of him. - Answer-ANS: 1
Rationale: The most appropriate response by the nurse is to offer support to the son
by presenting available support groups. Caregivers can often experience negative
emotions and guilt. Release of these emotions can serve to prevent caregivers from
developing psychopathology such a depression.
