1
Essentials of Psychiatric Mental Health
Nursing
TEST BANK Essentials of Psychiatric
Mental Health Nursing 3: Concepts of
Care in Evidence-Based Practice (9th
Edition)— Verified 2025 Complete Q&A
Compilation
A female client with borderline personality disorder is admitted to the psychiatric unit. Initial
nursing assessment reveals that the client's wrists are scratched from a recent suicide
attempt. Based on this finding, the nurse should formulate a nursing diagnosis of:
A. Ineffective individual coping related to feelings of guilt
B. Situational low self-esteem related to feelings of loss of control
C. Risk for violence: Self-directed related to impulsive mutilating acts
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Essentials of Psychiatric Mental Health
D. Risk for violence: Directed toward other related to verbal threats – Nursing
Correct Answer :C. Risk for violence: Self-directed related to impulsive mutilating acts
Rationale:
The predominant behavior characteristic of the client with borderline personal out disorder is
impulsiveness, especially of a physically self-destructive sort. The observation that the client
has scratched wrists doesn't substantiate the other options.
A male client recently admitted to the hospital with sharp, substernal chest pain suddenly
complains of palpitations. The nurse notes a rise in the client's arterial blood pressure and a
heart rate of 144 beats/minute. On further questioning, the client admits to having used
cocaine recently after previously denying use of the drug. The nurse concludes that the client
is at high risk for which complication of cocaine use?
A. Coronary artery spasm
B. Bradyarrhythmias
C. Neuribehavioral deficits
D. Panic disorder –
Correct Answer :A. Coronary artery spasm
Rationale:
Cocaine use may cause such cardiac complications as coronary artery spasm, myocardial
infarction, dilated cardiomyopathy, acute heart failure, endocarditis, and sudden death.
Cocaine blocks reuptake of norepinephrine, epinephrine, and dopamine, causing an excess of
these neurotransmitters at postsynaptic receptor sites. Consequently, the drug is more likely
to cause tachyarrhythmias than bradyarrhythmias. Although neurobehavioral deficits are
common in neonates born to cocaine users, they are rare in adults. As craving for the drug
increases, a person who's addicted to cocaine typically experiences euphoria followed by
depression, not panic disorder.
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Essentials of Psychiatric Mental Health
Nursing
A male client is being admitted to the substance abuse unit for alcohol detoxification. As part
of the intake interview, the nurse asks him when he had his last alcoholic drink. He says that
he had his last drink 6 hours before admission. Based on this response, the nurse should
expect early withdrawal symptoms to:
A. Begin after 7 days
B. Not occur at all because the time period for their occurrence has passed
C. Begin anytime within the next 1-2 days
D. Begin within 2-7 days –
Correct Answer :C. Begin anytime within the next 1-2 days
Rationale:
Acute withdrawal symptoms from alcohol may begin 6 hours after the client has stopped
drinking and peak 1-2 days later. Delirium tremens may occur 2-4 days - even up to 7 days -
after the last drink.
The nurse is assigned to care for a client with anorexia nervosa. Initially, which nursing
intervention is most appropriate for this client?
A. Providing one-on-one supervision during meals and for 1 hour afterward
B. Letting the client ears with other clients to create a normal mealtime atmosphere
C. Trying to persuade the client to eat and thus restore nutritional balance
D. Giving the client as much time to eat as desired –
Correct Answer :A. Providing one-on-one supervision during meals and for 1 hour afterward
Rationale:
Because the client with anorexia nervosa, may discard food or induce vomiting in the
bathroom, the nurse should provide one-on-one supervision during meals and for 1 hour
afterward. Option B wouldn't be therapeutic because other clients may urge the client to eat
and give attention for not eating. Option C would reinforce control issues, which are central
, 4
Essentials of Psychiatric Mental Health
to this client's underlying psychological problem. Instead of giving the clientNursing
unlimited time to
eat, as in option D, the nurse should set limits and let the client know what is expected.
A female client begins to experience alcoholic hallucinosis. The nurse is aware that the best
nursing intervention at this time is:
A. Keeping the client restrained in bed
B. Checking the client's blood pressure every 15 minutes and offering juices
C. Providing a quiet environment and administering medications as needed and prescribed
D. Restraining the client and measuring blood pressure every 30 minutes –
Correct Answer :C. Providing a quiet environment and administering medications as needed
and prescribed
Rationale:
Manifestations of alcoholic hallucinosis are best treated by providing a quiet environment to
reduce stimulation and administering prescribed central nervous system depressants in
dosages that control symptom without causing oversedation. Although bed rest is indicated,
restraints are unnecessary unless the client poses a danger to himself or others. Also,
restrains may increase agitation and make the client feel trapped and helpless when
hallucinating. Offering juices is appropriate but measuring blood pressure every 15 minutes
would interrupt the client's rest. To avoid overstimulating the client, the nurse should check
blood pressure every 2 hours.
The nurse is aware that which assessment finding is most consistent with early alcohol
withdrawal?
A. Heart rate of 120-140 beats/minute
B. Heart rate of 50-60 beats/minute
C. Blood pressure of 100/70 mmHg
D. Blood pressure of 140/80 mmHg –
Correct Answer :A. Heart rate of 120-140 beats/minute
Essentials of Psychiatric Mental Health
Nursing
TEST BANK Essentials of Psychiatric
Mental Health Nursing 3: Concepts of
Care in Evidence-Based Practice (9th
Edition)— Verified 2025 Complete Q&A
Compilation
A female client with borderline personality disorder is admitted to the psychiatric unit. Initial
nursing assessment reveals that the client's wrists are scratched from a recent suicide
attempt. Based on this finding, the nurse should formulate a nursing diagnosis of:
A. Ineffective individual coping related to feelings of guilt
B. Situational low self-esteem related to feelings of loss of control
C. Risk for violence: Self-directed related to impulsive mutilating acts
, 2
Essentials of Psychiatric Mental Health
D. Risk for violence: Directed toward other related to verbal threats – Nursing
Correct Answer :C. Risk for violence: Self-directed related to impulsive mutilating acts
Rationale:
The predominant behavior characteristic of the client with borderline personal out disorder is
impulsiveness, especially of a physically self-destructive sort. The observation that the client
has scratched wrists doesn't substantiate the other options.
A male client recently admitted to the hospital with sharp, substernal chest pain suddenly
complains of palpitations. The nurse notes a rise in the client's arterial blood pressure and a
heart rate of 144 beats/minute. On further questioning, the client admits to having used
cocaine recently after previously denying use of the drug. The nurse concludes that the client
is at high risk for which complication of cocaine use?
A. Coronary artery spasm
B. Bradyarrhythmias
C. Neuribehavioral deficits
D. Panic disorder –
Correct Answer :A. Coronary artery spasm
Rationale:
Cocaine use may cause such cardiac complications as coronary artery spasm, myocardial
infarction, dilated cardiomyopathy, acute heart failure, endocarditis, and sudden death.
Cocaine blocks reuptake of norepinephrine, epinephrine, and dopamine, causing an excess of
these neurotransmitters at postsynaptic receptor sites. Consequently, the drug is more likely
to cause tachyarrhythmias than bradyarrhythmias. Although neurobehavioral deficits are
common in neonates born to cocaine users, they are rare in adults. As craving for the drug
increases, a person who's addicted to cocaine typically experiences euphoria followed by
depression, not panic disorder.
, 3
Essentials of Psychiatric Mental Health
Nursing
A male client is being admitted to the substance abuse unit for alcohol detoxification. As part
of the intake interview, the nurse asks him when he had his last alcoholic drink. He says that
he had his last drink 6 hours before admission. Based on this response, the nurse should
expect early withdrawal symptoms to:
A. Begin after 7 days
B. Not occur at all because the time period for their occurrence has passed
C. Begin anytime within the next 1-2 days
D. Begin within 2-7 days –
Correct Answer :C. Begin anytime within the next 1-2 days
Rationale:
Acute withdrawal symptoms from alcohol may begin 6 hours after the client has stopped
drinking and peak 1-2 days later. Delirium tremens may occur 2-4 days - even up to 7 days -
after the last drink.
The nurse is assigned to care for a client with anorexia nervosa. Initially, which nursing
intervention is most appropriate for this client?
A. Providing one-on-one supervision during meals and for 1 hour afterward
B. Letting the client ears with other clients to create a normal mealtime atmosphere
C. Trying to persuade the client to eat and thus restore nutritional balance
D. Giving the client as much time to eat as desired –
Correct Answer :A. Providing one-on-one supervision during meals and for 1 hour afterward
Rationale:
Because the client with anorexia nervosa, may discard food or induce vomiting in the
bathroom, the nurse should provide one-on-one supervision during meals and for 1 hour
afterward. Option B wouldn't be therapeutic because other clients may urge the client to eat
and give attention for not eating. Option C would reinforce control issues, which are central
, 4
Essentials of Psychiatric Mental Health
to this client's underlying psychological problem. Instead of giving the clientNursing
unlimited time to
eat, as in option D, the nurse should set limits and let the client know what is expected.
A female client begins to experience alcoholic hallucinosis. The nurse is aware that the best
nursing intervention at this time is:
A. Keeping the client restrained in bed
B. Checking the client's blood pressure every 15 minutes and offering juices
C. Providing a quiet environment and administering medications as needed and prescribed
D. Restraining the client and measuring blood pressure every 30 minutes –
Correct Answer :C. Providing a quiet environment and administering medications as needed
and prescribed
Rationale:
Manifestations of alcoholic hallucinosis are best treated by providing a quiet environment to
reduce stimulation and administering prescribed central nervous system depressants in
dosages that control symptom without causing oversedation. Although bed rest is indicated,
restraints are unnecessary unless the client poses a danger to himself or others. Also,
restrains may increase agitation and make the client feel trapped and helpless when
hallucinating. Offering juices is appropriate but measuring blood pressure every 15 minutes
would interrupt the client's rest. To avoid overstimulating the client, the nurse should check
blood pressure every 2 hours.
The nurse is aware that which assessment finding is most consistent with early alcohol
withdrawal?
A. Heart rate of 120-140 beats/minute
B. Heart rate of 50-60 beats/minute
C. Blood pressure of 100/70 mmHg
D. Blood pressure of 140/80 mmHg –
Correct Answer :A. Heart rate of 120-140 beats/minute
