UNIT VII MENTAL HEALTH TEST BANK
QUIZ Q&A
Which of the following are effective interventions that a nurse should utilize when
caring for an inpatient client who expresses anger inappropriately? Select all that
apply.
A. Maintain a calm demeanor.
B. Clearly delineate the consequences of the behavior.
C. Use therapeutic touch to convey empathy.
D. Set limits on the behavior.
E. Teach the client to avoid I statements related to expression of feelings. - Answer-
ANSWER: A, B, D
RATIONALE: The nurse should determine that when working with an inpatient client
who expresses anger inappropriately, it is important to maintain a calm demeanor,
clearly define the consequences, and set limits on the behavior. The use of
therapeutic touch may not be appropriate and could escalate the clients anger.
A nurse discovers a clients suicide note that details the time, place, and means to
commit suicide. What should be the priority nursing intervention and the rationale for
this action?
A. Administering lorazepam (Ativan) prn, because the client is angry about the
discovery of the note
B. Establishing room restrictions, because the clients threat is an attempt to
manipulate the staff
C. Placing this client on one-to-one suicide precautions, because the more specific
the plan, the more likely the client will attempt suicide
D. Calling an emergency treatment team meeting, because the clients threat must be
addressed - Answer-ANSWER: C
RATIONALE: The priority nursing action should be to place this client on one-to-one
suicide precautions, because the more specific the plan, the more likely the client will
attempt suicide. The appropriate nursing diagnosis for this client would be risk for
suicide.
During the planning of care for a suicidal client, which correctly written outcome
should be a nurses first priority?
A. The client will not physically harm self.
B. The client will express hope for the future by day 3.
C. The client will establish a trusting relationship with the nurse.
D. The client will remain safe during the hospital stay. - Answer-ANSWER: D
RATIONALE: The nurses priority should be that the client will remain safe during the
hospital stay. Client safety should always be the nurses priority. The A answer
choice is incorrectly written. Correctly written outcomes must be client focused,
,measurable, and realistic and contain a time frame. Without a time frame, an
outcome cannot be correctly evaluated.
A client diagnosed with major depressive disorder with psychotic features hears
voices commanding self- harm. The client refuses to commit to developing a plan for
safety. What should be the nurses priority intervention at this time?
A. Obtaining an order for locked seclusion until client is no longer suicidal
B. Conducting 15-minute checks to ensure safety
C. Placing the client on one-to-one observation while monitoring suicidal ideations
D. Encouraging client to express feelings related to suicide - Answer-ANS: C
RATIONALE: The nurses priority intervention when a client hears voices
commanding self-harm is to place the client on one-to-one observation while
continuing to monitor suicidal ideation.
A client with a history of three suicide attempts has been taking fluoxetine (Prozac)
for 1 month. The client suddenly presents with a bright affect, rates mood at 9/10,
and is much more communicative. Which action should be the nurses priority at this
time?
A. Give the client off-unit privileges as positive reinforcement.
B. Encourage the client to share mood improvement in group.
C. Increase frequency of client observation.
D. Request that the psychiatrist reevaluate the current medication protocol. -
Answer-ANSWER: C
RATIONALE: The nurse should be aware that a sudden increase in mood rating and
change in affect could indicate that the client is at risk for suicide and client
observation should be more frequent. Suicide risk may occur early during treatment
with antidepressants. The return of energy may bring about an increased ability to
act out self- destructive behaviors prior to attaining the full therapeutic effect of the
antidepressant medication.
A nurse recently admitted a client to an inpatient unit after a suicide attempt. A
health-care provider orders amitriptyline (Elavil) for the client. Which intervention
related to this medication should be initiated to maintain this clients safety upon
discharge?
A. Provide a 6-month supply of Elavil to ensure long-term compliance.
B. Provide a 1-week supply of Elavil with refills contingent on follow-up
appointments.
C. Provide a pill dispenser as a memory aid.
D. Provide education regarding the avoidance of foods containing tyramine. -
Answer-ANSWER: B
RATIONALE: The health-care provider should provide a 1-week supply of Elavil with
refills contingent on follow-up appointments as an appropriate intervention to
maintain the clients safety. Tricyclic antidepressants have a narrow therapeutic
, range and can be used in overdose to commit suicide. Distributing limited amounts
of the medication decreases this potential.
During a one-to-one session with a client, the client states, Nothing will ever get
better, and Nobody can help me. Which nursing diagnosis is most appropriate for a
nurse to assign to this client at this time?
A. Powerlessness R/T altered mood AEB client statements
B. Risk for injury R/T altered mood AEB client statements
C. Risk for suicide R/T altered mood AEB client statements
D. Hopelessness R/T altered mood AEB client statements - Answer-ANSWER: D
RATIONALE: The clients statements indicate the problem of hopelessness. Prior to
assigning either risk for injury or risk for suicide, a further evaluation of the clients
suicidal ideations and intent would be necessary.
The treatment team is making a discharge decision regarding a previously suicidal
client. Which client assessment information should a nurse recognize as contributing
to the teams decision?
A. No previous admissions for major depressive disorder
B. Vital signs stable; no psychosis noted
C. Able to comply with medication regimen; able to problem-solve life issues
D. Able to participate in a plan for safety; family agrees to constant observation -
Answer-ANSWER: D
RATIONALE: Participation in a plan of safety and constant family observation will
decrease the risk for self-harm. All other answer choices are not directly focused on
suicide prevention and safety.
A college student who was nearly raped while jogging completes a series of
appointments with a rape crisis nurse. At the final session, which client statement
most clearly suggests that the goals of crisis intervention have been met?
A. You've really been helpful. Can I count on you for continued support?
B. I don't work out anymore.
C. I'm really glad I didn't go home. It would have been hard to come back.
D. I carry mace when I jog. It makes me feel safe and secure. - Answer-ANSWER: D
RATIONALE: The nurse should evaluate that the client who has developed adaptive
coping strategies has achieved the goals of crisis intervention.
A despondent client, who has recently lost her husband of 30 years, tearfully states,
I'll feel a lot better if I sell my house and move away. Which nursing reply is most
appropriate?
A. I'm confident you know whats best for you.
B. This may not be the best time for you to make such an important decision.
C. Your children will be terribly disappointed.
D. Tell me why you want to make this change. - Answer-ANSWER: B
QUIZ Q&A
Which of the following are effective interventions that a nurse should utilize when
caring for an inpatient client who expresses anger inappropriately? Select all that
apply.
A. Maintain a calm demeanor.
B. Clearly delineate the consequences of the behavior.
C. Use therapeutic touch to convey empathy.
D. Set limits on the behavior.
E. Teach the client to avoid I statements related to expression of feelings. - Answer-
ANSWER: A, B, D
RATIONALE: The nurse should determine that when working with an inpatient client
who expresses anger inappropriately, it is important to maintain a calm demeanor,
clearly define the consequences, and set limits on the behavior. The use of
therapeutic touch may not be appropriate and could escalate the clients anger.
A nurse discovers a clients suicide note that details the time, place, and means to
commit suicide. What should be the priority nursing intervention and the rationale for
this action?
A. Administering lorazepam (Ativan) prn, because the client is angry about the
discovery of the note
B. Establishing room restrictions, because the clients threat is an attempt to
manipulate the staff
C. Placing this client on one-to-one suicide precautions, because the more specific
the plan, the more likely the client will attempt suicide
D. Calling an emergency treatment team meeting, because the clients threat must be
addressed - Answer-ANSWER: C
RATIONALE: The priority nursing action should be to place this client on one-to-one
suicide precautions, because the more specific the plan, the more likely the client will
attempt suicide. The appropriate nursing diagnosis for this client would be risk for
suicide.
During the planning of care for a suicidal client, which correctly written outcome
should be a nurses first priority?
A. The client will not physically harm self.
B. The client will express hope for the future by day 3.
C. The client will establish a trusting relationship with the nurse.
D. The client will remain safe during the hospital stay. - Answer-ANSWER: D
RATIONALE: The nurses priority should be that the client will remain safe during the
hospital stay. Client safety should always be the nurses priority. The A answer
choice is incorrectly written. Correctly written outcomes must be client focused,
,measurable, and realistic and contain a time frame. Without a time frame, an
outcome cannot be correctly evaluated.
A client diagnosed with major depressive disorder with psychotic features hears
voices commanding self- harm. The client refuses to commit to developing a plan for
safety. What should be the nurses priority intervention at this time?
A. Obtaining an order for locked seclusion until client is no longer suicidal
B. Conducting 15-minute checks to ensure safety
C. Placing the client on one-to-one observation while monitoring suicidal ideations
D. Encouraging client to express feelings related to suicide - Answer-ANS: C
RATIONALE: The nurses priority intervention when a client hears voices
commanding self-harm is to place the client on one-to-one observation while
continuing to monitor suicidal ideation.
A client with a history of three suicide attempts has been taking fluoxetine (Prozac)
for 1 month. The client suddenly presents with a bright affect, rates mood at 9/10,
and is much more communicative. Which action should be the nurses priority at this
time?
A. Give the client off-unit privileges as positive reinforcement.
B. Encourage the client to share mood improvement in group.
C. Increase frequency of client observation.
D. Request that the psychiatrist reevaluate the current medication protocol. -
Answer-ANSWER: C
RATIONALE: The nurse should be aware that a sudden increase in mood rating and
change in affect could indicate that the client is at risk for suicide and client
observation should be more frequent. Suicide risk may occur early during treatment
with antidepressants. The return of energy may bring about an increased ability to
act out self- destructive behaviors prior to attaining the full therapeutic effect of the
antidepressant medication.
A nurse recently admitted a client to an inpatient unit after a suicide attempt. A
health-care provider orders amitriptyline (Elavil) for the client. Which intervention
related to this medication should be initiated to maintain this clients safety upon
discharge?
A. Provide a 6-month supply of Elavil to ensure long-term compliance.
B. Provide a 1-week supply of Elavil with refills contingent on follow-up
appointments.
C. Provide a pill dispenser as a memory aid.
D. Provide education regarding the avoidance of foods containing tyramine. -
Answer-ANSWER: B
RATIONALE: The health-care provider should provide a 1-week supply of Elavil with
refills contingent on follow-up appointments as an appropriate intervention to
maintain the clients safety. Tricyclic antidepressants have a narrow therapeutic
, range and can be used in overdose to commit suicide. Distributing limited amounts
of the medication decreases this potential.
During a one-to-one session with a client, the client states, Nothing will ever get
better, and Nobody can help me. Which nursing diagnosis is most appropriate for a
nurse to assign to this client at this time?
A. Powerlessness R/T altered mood AEB client statements
B. Risk for injury R/T altered mood AEB client statements
C. Risk for suicide R/T altered mood AEB client statements
D. Hopelessness R/T altered mood AEB client statements - Answer-ANSWER: D
RATIONALE: The clients statements indicate the problem of hopelessness. Prior to
assigning either risk for injury or risk for suicide, a further evaluation of the clients
suicidal ideations and intent would be necessary.
The treatment team is making a discharge decision regarding a previously suicidal
client. Which client assessment information should a nurse recognize as contributing
to the teams decision?
A. No previous admissions for major depressive disorder
B. Vital signs stable; no psychosis noted
C. Able to comply with medication regimen; able to problem-solve life issues
D. Able to participate in a plan for safety; family agrees to constant observation -
Answer-ANSWER: D
RATIONALE: Participation in a plan of safety and constant family observation will
decrease the risk for self-harm. All other answer choices are not directly focused on
suicide prevention and safety.
A college student who was nearly raped while jogging completes a series of
appointments with a rape crisis nurse. At the final session, which client statement
most clearly suggests that the goals of crisis intervention have been met?
A. You've really been helpful. Can I count on you for continued support?
B. I don't work out anymore.
C. I'm really glad I didn't go home. It would have been hard to come back.
D. I carry mace when I jog. It makes me feel safe and secure. - Answer-ANSWER: D
RATIONALE: The nurse should evaluate that the client who has developed adaptive
coping strategies has achieved the goals of crisis intervention.
A despondent client, who has recently lost her husband of 30 years, tearfully states,
I'll feel a lot better if I sell my house and move away. Which nursing reply is most
appropriate?
A. I'm confident you know whats best for you.
B. This may not be the best time for you to make such an important decision.
C. Your children will be terribly disappointed.
D. Tell me why you want to make this change. - Answer-ANSWER: B
