MENTAL HEALTH BASICS
IN NURSING
------Chapter-------- 1 Mental status
1. A charge nurse is discussing mental status examinations with a newly licensed nurse. Which of the
following statements by the newly licensed nurse indicates an understanding of the teaching? (SATA.)
A. "To assess cognitive ability, I should ask the client to count backward by sevens."
B. "To assess affect, I should observe the client's facial expression."
C."To assess language ability, I should instruct the client to write a sentence."
D."To assess remote memory, I should have the client repeat a list of objects."
E. "To assess the client's abstract thinking, I should ask the client to identify our most recent presidents." -
------ANSWER--1. A. Counting backward by 7s is an appropriate technique to assess a client's cognitive ability.
B. Observing a client's facial expression is appropriate when assessing affect.
C. Writing a sentence is an indication of language ability.
2. A nurse is planning care for a client who has a mental health disorder. Which of the following actions
should the nurse include as a psychobiological intervention?
A. Assist the client with systematic desensitization therapy.
B. Teach the client appropriate coping mechanisms.
C. Assess the client for comorbid health conditions.
D. Monitor the client for adverse effects of medications. - ------ANSWER--2. D. Monitoring for adverse effects
of medications is an example of a psychobiological intervention
3. A nurse in an outpatient mental health clinic is preparing to conduct an initial client interview. When
conducting the interview, which of the following actions should the nurse identify as the priority?
A. Coordinate holistic care with social services.
B. Identify the client's perception of her mental health status.
C. Include the client's family in the interview.
D. Teach the client about her current mental health disorder. - ------ANSWER--3. B. Identify the client's
perception of her mental health status.
Assessment is the priority action when using the
,nursing process approach to client care. Identifying the client's
perception of her mental health status provides important
information about the client's psychosocial history.
4. A nurse is told during change-of-shift report that a client is stuporous. When assessing the client, which of
the following findings
should the nurse expect?
A. The client arouses briefly in response to a sternal rub.
B. The client has a Glasgow Coma Scale score less than 7.
C. The client exhibits decorticate rigidity.
D. The client is alert but disoriented to time and place. - ------ANSWER--4. A. The client arouses briefly in
response to a sternal rub..
A client who is stuporous requires vigorous or painful stimuli to elicit a response.
5. A nurse is planning a peer group discussion about the Diagnostic
and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). WOTF information is appropriate to include
in the discussion? (SATA)
A. The DSM-5 includes client education handouts for mental health disorders.
B. The DSM-5 establishes diagnostic criteria for individual mental health disorders.
C. The DSM-5 indicates recommended pharmacological treatment
for mental health disorders.
D. The DSM-5 assists nurses in planning care for client's who have mental health disorders.
E. The DSM-5 indicates expected assessment findings of mental health disorders. - ------ANSWER--5. B. The
DSM-5 establishes diagnostic criteria for mental health disorders.
D. Nurses use the DSM-5 to plan, implement, and evaluate care for client's who have mental health
disorders.
E. The DSM-5 identifies expected findings for mental health disorders
------CHAPTER-------- 2 Legal and Ethical Issues
1. A nurse in an emergency mental health facility is caring for a group of clients. The nurse should identify
that which of the following clients requires a temporary emergency admission?
A. A client who has schizophrenia with delusions of grandeur
B. A client who has manifestations of depression and attempted
suicide a year ago
C. A client who has borderline personality disorder and assaulted a homeless man with a metal rod
, D. A client who has bipolar disorder and paces quickly around the room while talking to himself - ------
ANSWER--1. C. A client who has borderline personality disorder and assaulted a homeless man with a metal
rod
A client who is a current danger to self or others is a candidate for a temporary emergency admission.
2. A nurse decides to put a client who has a psychotic disorder in
seclusion overnight because the unit is very short-staffed, and the client frequently fights with other clients.
The nurse's actions are an example of which of the following torts?
A. Invasion of privacy
B. False imprisonment
C. Assault
D. Battery - ------ANSWER--2. B. False imprisonment
A civil wrong that violates a client's civil rights is a tort. In this case, it is false imprisonment, which is the
confining of a client to a specific area, such as a seclusion room, if the reason for such confinement is for the
convenience of staff.
3. A client tells a nurse, "Don't tell anyone, but I hid a sharp knife under my mattress in order to protect
myself from my roommate, who is always yelling at me and threatening me." Which of the following
actions should the nurse take?
A. Keep the client's communication confidential, but talk to the client
daily, using therapeutic communication to convince him to admit to hiding the knife.
B. Keep the client's communication confidential, but watch the client and his roommate closely.
C. Tell the client that this must be reported to the health care team because it concerns the health and safety
of the client and others.
D. Report the incident to the health care team, but do not inform the client of the intention to do so - ------
ANSWER--3. C. Tell the client that this must be reported to the health care team because it concerns the
health and safety of the client and others.
The information presented by the client is a serious safety issue that the nurse must report to the health care
team. Using the ethical principle of veracity, the student tells the client truthfully what must be done
regarding the issue.
4. A nurse is caring for a client who is in mechanical restraints. Which of the following statements should the
nurse include in the documentation? (SATA)
A. "Client ate most of his breakfast."
B. "Client was offered 8 oz of water every hr."
C."Client shouted obscenities at assistive personnel."
D."Client received chlorpromazine 15 mg by mouth at 1000."
IN NURSING
------Chapter-------- 1 Mental status
1. A charge nurse is discussing mental status examinations with a newly licensed nurse. Which of the
following statements by the newly licensed nurse indicates an understanding of the teaching? (SATA.)
A. "To assess cognitive ability, I should ask the client to count backward by sevens."
B. "To assess affect, I should observe the client's facial expression."
C."To assess language ability, I should instruct the client to write a sentence."
D."To assess remote memory, I should have the client repeat a list of objects."
E. "To assess the client's abstract thinking, I should ask the client to identify our most recent presidents." -
------ANSWER--1. A. Counting backward by 7s is an appropriate technique to assess a client's cognitive ability.
B. Observing a client's facial expression is appropriate when assessing affect.
C. Writing a sentence is an indication of language ability.
2. A nurse is planning care for a client who has a mental health disorder. Which of the following actions
should the nurse include as a psychobiological intervention?
A. Assist the client with systematic desensitization therapy.
B. Teach the client appropriate coping mechanisms.
C. Assess the client for comorbid health conditions.
D. Monitor the client for adverse effects of medications. - ------ANSWER--2. D. Monitoring for adverse effects
of medications is an example of a psychobiological intervention
3. A nurse in an outpatient mental health clinic is preparing to conduct an initial client interview. When
conducting the interview, which of the following actions should the nurse identify as the priority?
A. Coordinate holistic care with social services.
B. Identify the client's perception of her mental health status.
C. Include the client's family in the interview.
D. Teach the client about her current mental health disorder. - ------ANSWER--3. B. Identify the client's
perception of her mental health status.
Assessment is the priority action when using the
,nursing process approach to client care. Identifying the client's
perception of her mental health status provides important
information about the client's psychosocial history.
4. A nurse is told during change-of-shift report that a client is stuporous. When assessing the client, which of
the following findings
should the nurse expect?
A. The client arouses briefly in response to a sternal rub.
B. The client has a Glasgow Coma Scale score less than 7.
C. The client exhibits decorticate rigidity.
D. The client is alert but disoriented to time and place. - ------ANSWER--4. A. The client arouses briefly in
response to a sternal rub..
A client who is stuporous requires vigorous or painful stimuli to elicit a response.
5. A nurse is planning a peer group discussion about the Diagnostic
and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). WOTF information is appropriate to include
in the discussion? (SATA)
A. The DSM-5 includes client education handouts for mental health disorders.
B. The DSM-5 establishes diagnostic criteria for individual mental health disorders.
C. The DSM-5 indicates recommended pharmacological treatment
for mental health disorders.
D. The DSM-5 assists nurses in planning care for client's who have mental health disorders.
E. The DSM-5 indicates expected assessment findings of mental health disorders. - ------ANSWER--5. B. The
DSM-5 establishes diagnostic criteria for mental health disorders.
D. Nurses use the DSM-5 to plan, implement, and evaluate care for client's who have mental health
disorders.
E. The DSM-5 identifies expected findings for mental health disorders
------CHAPTER-------- 2 Legal and Ethical Issues
1. A nurse in an emergency mental health facility is caring for a group of clients. The nurse should identify
that which of the following clients requires a temporary emergency admission?
A. A client who has schizophrenia with delusions of grandeur
B. A client who has manifestations of depression and attempted
suicide a year ago
C. A client who has borderline personality disorder and assaulted a homeless man with a metal rod
, D. A client who has bipolar disorder and paces quickly around the room while talking to himself - ------
ANSWER--1. C. A client who has borderline personality disorder and assaulted a homeless man with a metal
rod
A client who is a current danger to self or others is a candidate for a temporary emergency admission.
2. A nurse decides to put a client who has a psychotic disorder in
seclusion overnight because the unit is very short-staffed, and the client frequently fights with other clients.
The nurse's actions are an example of which of the following torts?
A. Invasion of privacy
B. False imprisonment
C. Assault
D. Battery - ------ANSWER--2. B. False imprisonment
A civil wrong that violates a client's civil rights is a tort. In this case, it is false imprisonment, which is the
confining of a client to a specific area, such as a seclusion room, if the reason for such confinement is for the
convenience of staff.
3. A client tells a nurse, "Don't tell anyone, but I hid a sharp knife under my mattress in order to protect
myself from my roommate, who is always yelling at me and threatening me." Which of the following
actions should the nurse take?
A. Keep the client's communication confidential, but talk to the client
daily, using therapeutic communication to convince him to admit to hiding the knife.
B. Keep the client's communication confidential, but watch the client and his roommate closely.
C. Tell the client that this must be reported to the health care team because it concerns the health and safety
of the client and others.
D. Report the incident to the health care team, but do not inform the client of the intention to do so - ------
ANSWER--3. C. Tell the client that this must be reported to the health care team because it concerns the
health and safety of the client and others.
The information presented by the client is a serious safety issue that the nurse must report to the health care
team. Using the ethical principle of veracity, the student tells the client truthfully what must be done
regarding the issue.
4. A nurse is caring for a client who is in mechanical restraints. Which of the following statements should the
nurse include in the documentation? (SATA)
A. "Client ate most of his breakfast."
B. "Client was offered 8 oz of water every hr."
C."Client shouted obscenities at assistive personnel."
D."Client received chlorpromazine 15 mg by mouth at 1000."
