Test Bank For Foundations of Mental Health
Care All Chapters with Answers and
Rationals
A client with depression remains in bed most of the day, and declines activities. Which
nursing
problem has the greatest priority for this client?
A. Loss of interest in diversional activity.
B. Social isolation.
C. Refusal to address nutritional needs.
D. Low self-esteem - answersC
The RN is preparing medications for a client with bipolar disorder and notices that the
client
discontinued antipsychotic medication for several days. Which medication should also
be
discontinued?
a. Lithium. (Lithotabs)
b. Benzotropine (Cogentin).
c. Alprazolam (Xanax).
d. Magnesium (Milk of Magnesia) - answersB
The RN is teaching a client about the initiation of the prescribed abstinence therapy
using
disulfiram (Antabuse). What information should the client acknowledge understanding?
A. Completely abstain from heroin or cocaine use.
B. Remain alcohol free for 12 hours prior to the first dose.
C. Attend monthly meetings of alcoholics anonymous.
D. Admit to others that he is a substance user. - answersB
A male client with schizophrenia is admitted to the mental health unit after abruptly
stopping his
prescription for ziprasidone (Geodon) one month ago. Which question is most important
for the
RN to ask the client?
A. Have you lost interest in the things that you used to enjoy?
B. Is your ability to think or concentrate decreased?
C. How many continuous hours do you sleep at night?
D. Do you hear sounds or voices that others do not hear? - answersD
A female client requests that her husband be allowed to stay in the room during the
admission
assessment. When interviewing the client, the RN notes a discrepancy between the
client's
,verbal and nonverbal communication. What action does the RN take?
A. Pay close attention and document the nonverbal messages.
B. Ask the client's husband to interpret the discrepancy.
C. Ignore the nonverbal behavior and focus on the client's verbal messages.
D. Integrate the verbal and nonverbal messages and interpret them as one. - answersA
A male client approaches the RN with an angry expression on his face and raises his
voice,
saying "My roommate is the most selfish, self-centered, angry person I have ever met. If
he
loses his temper one more time with me, I am going to punch him out!" The RN
recognizes that
the client is using which defense mechanism?
A. Denial.
B. Projection.
C. Rationalization.
D. Splitting. - answersD
A mental health worker is caring for a client with escalating aggressive behavior. Which
action
by the MHW warrant immediate intervention by the RN?
A. Is attempting to physically restrain the patient.
B. Tells the client to go to the quiet area of the unit.
C. Is using a loid voice to talk to the client.
D. Remains at a distance of 4 feet from the client. - answersA
A client on the mental health unit is becoming more agitated, shouting at the staff, and
pacing in
the hallway. When the PRN medication is offered, the client refuses the medication and
defiantly
sits on the floor in the middle of the unit hallway. What nursing intervention should the
RN
implement first?
A. Transport of the client to the seclusion room.
B. Quietly approach the client with additional staff members.
C. Take other clients in the area to the client lounge.
D. Administer medication to chemically restrain the patient. - answersC
A male client with bipolar disorder who began taking lithium carbonate five days ago is
complaining of excessive thirst, and the RN finds him attempting to drink water from the
bathroom sink faucet. Which intervention should the RN implement?
A. Report the client's serum lithium level to the HCP.
B. Encourage the client to suck on hard candy to relieve the symptoms.
C. No action is needed since polydipsia is a common side effect.
D. Tell the client that drinking from the faucet is not allowed. - answersA
,During an annual physical by the occupational RN working in a corporate clinic, a male
employee tells the RN that is high-stress job is causing trouble in his personal life. He
further
explains that he often gets so angry while driving to and from work that he has
considered
"getting even" with other drivers. How should the RN respond?
A. "Anger is contagious and could result in major confrontation."
B. "Try not to let your anger cause you to act impulsively."
C. "Expressing your anger to a stranger could result in an unsafe situation."
D. "It sounds as if there are many situations that make you feel angry." - answersD
A client who has agoraphobia (a fear of crowds) is beginning desensitization with the
therapist,
and the RN is reinforcing the process. Which intervention has the highest priority for this
client's
plan of care?
A. Encourage substitution of positive thoughts and negative ones.
B. Establish trust by providing a calm, safe environment.
C. Progressively expose the client to larger crowds.
D. Encourage deep breathing when anxiety escalates in a crowd. - answersB
Which nursing actions are likely to help promote the self-esteem of a male client with
modern
depression?
A. Ask the client what his long term goals are.
B. Discuss the challenges of his medical condition.
C. Include the client in determining treatment protocol.
D. Encourage the client to engage in recreational therapy.
E. Provide opportunities for the client to discuss his concerns. - answersADE
A male client is admitted to the psychiatric unit for recurrent negative symptoms of
chronic
schizophrenia and medication adjustment of Risperidone (Risperdal). When the client
walks to
the nurse's station in a laterally contracted position, he states that something has made
his body
contort into a monster. What action should the RN take?
A. Medicate the client with the prescribed antipsychotic thioridazine (Mellaril).
B. Offer the client a prescribed physical therapy hot pack for muscle spasms.
C. Direct client to occupational therapy to distract him from somatic complaints.
D. Administer the prescribed anticholinergic benztropine (Cogentin) for dystonia. -
answersD
A client is admitted to the mental health unit and reports taking extra antianxiety
medication
, because, "I'm so stressed out. I just want to go to sleep." The RN should plan one-on-
one
observation of the client based on which statement?
A. "What should I do? Nothing seems to help."
B. "I have been so tired lately and needed to sleep."
C. "I really think that I don't need to be here."
D. "I don't want to walk. Nothing matters anymore. - answersD
A male hospital employee is pushed out the way by a female employee because of an
oncoming
gurney. The pushed employee becomes very angry and swings at the female
employee. Both
employees are referred for counseling with the staff psychiatric RN. Which factor in the
pushed
employee's history is most related to the reaction that occurred?
A. Is worried about losing his job to a woman.
B. Tortured animals as a child.
C. Was physically abused by his mother.
D. Hates to be touched by anyone. - answersC
The RN documents the mental status of a female client who has been hospitalized for
several
days by court order. The client states, "I don't need to be here" and tells the RN that she
believes
the television talks to her. The RN should document these assessment findings in which
section
of the mental status exam/
A. Level of concentration.
B. Insight and judgement.
C. Remote memory.
D. Mood and affect. - answersB
A client is admitted to the mental health unit reports shortness of breath and dizziness.
The client
tells the RN, "I feel like I'm going to die". Which nursing problem should the RN include
in this
client's plan of care?
A. Mood disturbance.
B. Moderate anxiety.
C. Altered thoughts.
D. Social isolation. - answersB
A female client who is wearing dirty clothes and has foul body odor, comes to the clinic
reporting feeling scared because she is being stalked. What action is most important for
the RN
to take?
Care All Chapters with Answers and
Rationals
A client with depression remains in bed most of the day, and declines activities. Which
nursing
problem has the greatest priority for this client?
A. Loss of interest in diversional activity.
B. Social isolation.
C. Refusal to address nutritional needs.
D. Low self-esteem - answersC
The RN is preparing medications for a client with bipolar disorder and notices that the
client
discontinued antipsychotic medication for several days. Which medication should also
be
discontinued?
a. Lithium. (Lithotabs)
b. Benzotropine (Cogentin).
c. Alprazolam (Xanax).
d. Magnesium (Milk of Magnesia) - answersB
The RN is teaching a client about the initiation of the prescribed abstinence therapy
using
disulfiram (Antabuse). What information should the client acknowledge understanding?
A. Completely abstain from heroin or cocaine use.
B. Remain alcohol free for 12 hours prior to the first dose.
C. Attend monthly meetings of alcoholics anonymous.
D. Admit to others that he is a substance user. - answersB
A male client with schizophrenia is admitted to the mental health unit after abruptly
stopping his
prescription for ziprasidone (Geodon) one month ago. Which question is most important
for the
RN to ask the client?
A. Have you lost interest in the things that you used to enjoy?
B. Is your ability to think or concentrate decreased?
C. How many continuous hours do you sleep at night?
D. Do you hear sounds or voices that others do not hear? - answersD
A female client requests that her husband be allowed to stay in the room during the
admission
assessment. When interviewing the client, the RN notes a discrepancy between the
client's
,verbal and nonverbal communication. What action does the RN take?
A. Pay close attention and document the nonverbal messages.
B. Ask the client's husband to interpret the discrepancy.
C. Ignore the nonverbal behavior and focus on the client's verbal messages.
D. Integrate the verbal and nonverbal messages and interpret them as one. - answersA
A male client approaches the RN with an angry expression on his face and raises his
voice,
saying "My roommate is the most selfish, self-centered, angry person I have ever met. If
he
loses his temper one more time with me, I am going to punch him out!" The RN
recognizes that
the client is using which defense mechanism?
A. Denial.
B. Projection.
C. Rationalization.
D. Splitting. - answersD
A mental health worker is caring for a client with escalating aggressive behavior. Which
action
by the MHW warrant immediate intervention by the RN?
A. Is attempting to physically restrain the patient.
B. Tells the client to go to the quiet area of the unit.
C. Is using a loid voice to talk to the client.
D. Remains at a distance of 4 feet from the client. - answersA
A client on the mental health unit is becoming more agitated, shouting at the staff, and
pacing in
the hallway. When the PRN medication is offered, the client refuses the medication and
defiantly
sits on the floor in the middle of the unit hallway. What nursing intervention should the
RN
implement first?
A. Transport of the client to the seclusion room.
B. Quietly approach the client with additional staff members.
C. Take other clients in the area to the client lounge.
D. Administer medication to chemically restrain the patient. - answersC
A male client with bipolar disorder who began taking lithium carbonate five days ago is
complaining of excessive thirst, and the RN finds him attempting to drink water from the
bathroom sink faucet. Which intervention should the RN implement?
A. Report the client's serum lithium level to the HCP.
B. Encourage the client to suck on hard candy to relieve the symptoms.
C. No action is needed since polydipsia is a common side effect.
D. Tell the client that drinking from the faucet is not allowed. - answersA
,During an annual physical by the occupational RN working in a corporate clinic, a male
employee tells the RN that is high-stress job is causing trouble in his personal life. He
further
explains that he often gets so angry while driving to and from work that he has
considered
"getting even" with other drivers. How should the RN respond?
A. "Anger is contagious and could result in major confrontation."
B. "Try not to let your anger cause you to act impulsively."
C. "Expressing your anger to a stranger could result in an unsafe situation."
D. "It sounds as if there are many situations that make you feel angry." - answersD
A client who has agoraphobia (a fear of crowds) is beginning desensitization with the
therapist,
and the RN is reinforcing the process. Which intervention has the highest priority for this
client's
plan of care?
A. Encourage substitution of positive thoughts and negative ones.
B. Establish trust by providing a calm, safe environment.
C. Progressively expose the client to larger crowds.
D. Encourage deep breathing when anxiety escalates in a crowd. - answersB
Which nursing actions are likely to help promote the self-esteem of a male client with
modern
depression?
A. Ask the client what his long term goals are.
B. Discuss the challenges of his medical condition.
C. Include the client in determining treatment protocol.
D. Encourage the client to engage in recreational therapy.
E. Provide opportunities for the client to discuss his concerns. - answersADE
A male client is admitted to the psychiatric unit for recurrent negative symptoms of
chronic
schizophrenia and medication adjustment of Risperidone (Risperdal). When the client
walks to
the nurse's station in a laterally contracted position, he states that something has made
his body
contort into a monster. What action should the RN take?
A. Medicate the client with the prescribed antipsychotic thioridazine (Mellaril).
B. Offer the client a prescribed physical therapy hot pack for muscle spasms.
C. Direct client to occupational therapy to distract him from somatic complaints.
D. Administer the prescribed anticholinergic benztropine (Cogentin) for dystonia. -
answersD
A client is admitted to the mental health unit and reports taking extra antianxiety
medication
, because, "I'm so stressed out. I just want to go to sleep." The RN should plan one-on-
one
observation of the client based on which statement?
A. "What should I do? Nothing seems to help."
B. "I have been so tired lately and needed to sleep."
C. "I really think that I don't need to be here."
D. "I don't want to walk. Nothing matters anymore. - answersD
A male hospital employee is pushed out the way by a female employee because of an
oncoming
gurney. The pushed employee becomes very angry and swings at the female
employee. Both
employees are referred for counseling with the staff psychiatric RN. Which factor in the
pushed
employee's history is most related to the reaction that occurred?
A. Is worried about losing his job to a woman.
B. Tortured animals as a child.
C. Was physically abused by his mother.
D. Hates to be touched by anyone. - answersC
The RN documents the mental status of a female client who has been hospitalized for
several
days by court order. The client states, "I don't need to be here" and tells the RN that she
believes
the television talks to her. The RN should document these assessment findings in which
section
of the mental status exam/
A. Level of concentration.
B. Insight and judgement.
C. Remote memory.
D. Mood and affect. - answersB
A client is admitted to the mental health unit reports shortness of breath and dizziness.
The client
tells the RN, "I feel like I'm going to die". Which nursing problem should the RN include
in this
client's plan of care?
A. Mood disturbance.
B. Moderate anxiety.
C. Altered thoughts.
D. Social isolation. - answersB
A female client who is wearing dirty clothes and has foul body odor, comes to the clinic
reporting feeling scared because she is being stalked. What action is most important for
the RN
to take?
