Download NUR 2488 Mental Health Final Exam Questions and Answers and more Exams Nursing in PDF only on Docsity!
NUR 2488/ NUR2488: Mental Health Final
Exam Questions 2023/
The nurse is conducting discharge teaching for a client with schizophrenia who plans to live in a group home. Which statement is most indicative of the need for careful follow-up after discharge? a. Crickets are a good source of protein. b. I have not heard any voices for a week. c. Only my belief in God can help me. d. Sometimes I have a hard time sitting still - ANS C. Only my belief in God can help me. The most frequent cause of increased symptoms in psychotic clients is non- compliance with the medication regimen. If clients believe that "God alone" is going to heal them (C) then they may discontinue their medication, so (C) would pose the greatest threat to this client's prognosis. (A) would require further teaching, but is not as significant a statement as (C). (B) indicates an improvement in the client's condition. (D) may be a sign of anxiety that could improve with tx, but does not have the priority of (C). A child is brought to the ER with a broken arm. Because of other injuries, the nurse suspects the child may be a victim of abuse. When the nurse tries to give the child an injection, the child's mother becomes very loud and shouts, "I won't leave my son! Don't you touch him! You'll hurt my child!" What is the best interpretation of the mother's statements? The mother is a. regressing to an earlier behavior pattern. b. sublimating her anger. c. projecting her feelings onto the nurse. d. suppressing her fear. - ANS C. projecting her feelings onto the nurse.
Projection is attributing one's own thoughts, impulses, or behaviors onto another--it is the mother who is probably harming the child and she is attributing her actions to the nurse (C). The mother may be immature, but (A) is not the best description of her behavior. (B) is substituting a socially acceptable feeling for an unacceptable one. These are not socially acceptable feelings. The mother may be suppressing her fear (D) by displaying anger, but such an interpretation cannot be concluded from the data presented. An elderly female client with advanced dementia is admitted to the hospital with a fractured hip. The client repeatedly tells the staff, "Take me home. I want my Mommy." Which response is best for the nurse to provide? a. Orient the client to the time, place, and person. b. Tell the client that the nurse is there and will help her. c. Remind the client that her mother is no longer living. d. Explain the seriousness of her injury and need for hospitalization. - ANS B. Tell the client that the nurse is there and will help her. Those with dementia often refer to home or parents when seeking security and comfort. The nurse should use the techniques of "offering self" and "talking to the feelings" to provide reassurance (B). Clients with advanced dementia have permanent physiological changes in the brain (plaques and tangles) that prevent them from comprehending and retaining new information, so (A, C, and D) are likely to be of little use to this client and do not help the clients emotional needs. A 27 y/o F client is admitted to the psychiatric hospital with a dx of bipolar disorder, manic phase. She is demanding and active. Which intervention should the nurse include in this client's plan of care?
A 38 y/o F client is admitted with a dx of paranoid schizophrenia. When her tray is brought to her, she refuses to eat and tells the nurse, "I know you're trying to poison me with that food." Which response is most appropriate for the nurse to make? a. I'll leave your tray here. I am available if you need anything else. b. You're not being poisoned. Why do you think someone is trying to poison you? c. No one on this unit has ever died from poisoning. You're safe here. d. I will talk to your HCP about the possibility of changing your diet. - ANS A. I'll leave your tray here. I am available if you need anything else. (A) is the best choice cited. The nurse doesn't argue with the client nor demand that she eat, but offers support by agreeing to "be there if needed", e.g., to warm the food. (B and C) are arguing with the client's delusions, and (B) asks "why" which is usually not a good question for a psychotic client. (D) has nothing to do with the actual problem; i.e., the problem is not the diet (she thinks any food given to her is poisoned). A homeless person who is in the manic phase of bipolar disorder is admitted to the mental health unit. Which lab finding obtained on admission is most important for the nurse to report to the HCP? a. Decreased TSH level. b. Elevated liver function profile. c. Increased WBC count. d. Decreased Hct and Hgb levels. - ANS A. Decreased TSH level.
Hyperthyroidism causes an increased level of serum thyroid hormones (T3 and T4), which inhibits the release of TSH (A), so the client's manic behavior may be related to an endocrine disorder. (B, C, and D) are abnormal findings that are commonly found in the homeless population because of poor sanitation, poor nutrition, and the prevalence of substance abuse The nurse is planning discharge teaching for a male client with schizophrenia. The client insists that he is returning to his apartment, although the HCP informed him that he will be moving to a boarding home. What is the most important nursing dx for discharge planning? a. Ineffective denial r/t situational anxiety. b. Ineffective coping r/t inadequate support. c. Social isolation r/t difficult interactions. d. Self-care deficit r/t cognitive impairment. - ANS A. Ineffective denial r/t situational anxiety. The best nursing dx is (A) because the client is unable to acknowledge the move to a boarding home. (B, C, and D) are potential nursing diagnoses, but denial is most important because it is a defense mechanism that keeps the client from dealing with his feelings about living arrangements. A client who has been admitted to the psychiatric unit tells the nurse, "My problems are so bad that no one can help me." Which response is best for the nurse to make? a. How can I help? b. Things probably aren't as bad as they seem right now. c. Let's talk about what is right with your life.
A male adolescent is admitted with bipolar disorder after being released from jail for assault with a deadly weapon. When the nurse asks the teen to identify his reason for the assault, he replies, "Because he made me mad!" Which goal is best for the nurse to include in the client's plan of care? The client will a. outline methods for managing anger. b. control impulsive actions toward self and others. c. verbalize feelings when anger occurs. d. recognize consequences for behaviors exhibited. - ANS B. control impulsive actions toward self and others. Those with bipolar disorder often exhibit poor impulse control, and the most important goal for this client at this time is to learn to control impulsive behavior (B) so that he can avert the social consequences related to such behaviors. (A, C, and D) are important goals but they don't address the acute issue of impulse control, which is necessary to reduce the likelihood of harming self or others. Based on non-compliance with the medication regimen, an adult client with a medical dx of substance abuse and schizophrenia was recently switched from oral fluphenazine HCl (Prolixin) to IM fluphenazine (Prolixin Decanoate). Which is most important to teach the client and family about this change in medication regimen? a. S/s of extrapyramidal effects (PS). b. Information about substance abuse and schizophrenia. c. The effects of alcohol and drug interaction. d. The availability of support groups for those with dual diagnoses. - ANS C. The effects of alcohol and drug interaction. Alcohol enhances the EPS side effects of Prolixin. The half-life of Prolixin PO is 8 hours, whereas the half-life of Prolixin Decanoate IM is 2-4 weeks. That means the side effects of drinking alcohol are far more severe when the client drinks alcohol after taking the long-acting Prolixin Decanoate IM. (A, B, and D) provide valuable
information and should be included in the client/family teaching but the don't have the priority of (C). Within several days of hospitalization, a client is repeatedly washing the top of the same table. Which initial intervention is best for the nurse to implement to help the client cope with anxiety related to this behavior? a. Administer a prescribed PRN antianxiety medication. b. Assist the client to identify stimuli that precipitates the ritualistic activity. c. Allow time for the ritualistic behavior, then redirect the client to other activities. d. Teach the client relaxation and thought stopping techniques. - ANS C. Allow time for the ritualistic behavior, then redirect the client to other activities. Initially the nurse should allow time for the ritual (C) to prevent anxiety. (A) may help reduce the client's anxiety, but will not prevent ritualistic behavior resulting from the clients ineffective coping ability. (B) is a long-term goal of individual therapy, but isn't directly related to controlling the behavior at this time. (D) lists techniques that can be used to assist the client in learning new ways of interrupting obsessive thoughts and resulting ritualistic behavior as tx progresses. Physical examination of a 6 y/o reveals several bite marks in various locations on his body. X-ray examination reveals healed fractures of the ribs. The mother tells the nurse that her child is always having accidents. Which initial response by the nurse would be most appropriate? a. I need to inform the HCP about your child's tendency to be accident prone. b. Tell me more specifically about your child's accidents.
When preparing a teaching plan for a client who is to be discharged with a prescription for lithium carbonate (Lithonate), it is important for the nurse to include which instruction? a. It may take 3-4 weeks to achieve therapeutic effects. b. Keep your dietary salt intake consistent. c. Avoid eating aged cheese and chicken liver. d. Eat foods high in fiber such as whole grain breads. - ANS B. Keep your dietary salt intake consistent. Lithium's effectiveness is influenced by salt intake (B). Too much salt causes more lithium to be excreted, thereby decreasing the effectiveness of the drug. Too little salt causes less lithium to be excreted, potentially resulting in toxicity. (A, C, and D) are not specific instructions pertinent to teaching about lithium carbonate (Lithonate). The nurse is planning the care of a 32 y/o M client with acute depression. Which nursing intervention best helps this client deal with his depression? a. Ensure that the client's day is filled with group activities. b. Assist the client in exploring feelings of shame, anger, and guilt. c. Allow the client to initiate and determine activities of daily living. d. Encourage the client to explore the rationale for his depression. - ANS B. Assist the client in exploring feelings of shame, anger, and guilt. Depression is associated with feelings of shame, anger, and guilt. Exploring such feelings is an important nursing intervention for the depressed client (B). If the client's day is filled with group activities (A) he might not have the opportunity to explore these feelings. (C) is a good intervention for the chronically depressed client who exhibits vegetative signs of depression. (D) is essentially asking the client "why" he is depressed--avoid "why's" disguised as "rationale".
A female client refuses to take an oral hypoglycemic agent because she believes that the drug is being administered as part of an elaborate plan by the Mafia to harm her. Which nursing intervention is most important to include in this clients plan of care? a. Reassure the client that no one will harm her while she is in the hospital. b. Ask the healthcare provider to give the client the medication. c. Explain that the diabetic medication is important to take. d. Reassess client's mental status for thought processes and content. - ANS D. Reassess client's mental status for thought processes and content. The most important intervention is to reassess the client's mental status (D) and to take further action based on the findings of this assessment. Attempting to reassure the client (A) is in effect arguing with the client's delusions and could escalate an already anxious situation. Collaborating about diabetic care (B and C) is not likely to help change the client's false beliefs. A male client is admitted to a mental health unit on Friday afternoon and is very upset on Sunday because he has not had the opportunity to talk with the healthcare provider. Which response is best for the nurse to provide this client? a. Let me call and leave a message for your HCP. b. The HCP should be here on Monday morning. c. How can I help answer your questions. d. What concerns do you have at this time? - ANS A. Let me call and leave a message for your HCP. It is best for the nurse to call the HCP (A) because clients have the right to information about their tx. Suggesting that the HCP will be available the following
b. The nurse should confirm any suspicions of child abuse with the HCP before reporting to the authorities. c. The nurse should report any case of suspected child abuse to the nurse in charge. d. The nurse should note in the client's record any suspicions of child abuse so that a history of such suspicions can be tracked. - ANS C. The nurse should report any case of suspected child abuse to the nurse in charge. It is the nurse's legal responsibility to report all suspected cases of child abuse. Notifying the charge nurse starts the legal reporting process (C). A 72 y/o F client is admitted to the psych unit with a diagnosis of major depression. Which statement by the client should be of greatest concern to the nurse and require further assessment. a. I will die if my cat dies. b. I don't feel like eating this morning. c. I just went to my friend's funeral. d. Don't you have more important things to do? - ANS A. I will die if my cat dies. Sometimes a client will use an analogy to describe themselves and (A) would be an indication for conducting a suicide assessment. (B) would have a variety of etiologies, and while further assessment is indicated, this statement doesn't indicate potential suicide. Normal grief process differs from depression and at this client's age peer/cohort deaths are more frequent so (C) would be within normal limits. (D) is an expression of low self-esteem typical of depression. (B, C, and D) are examples of decreased energy and mood levels which would negate suicide ideation at this time
A client with bipolar disorder on the mental health unit becomes loud, and shouts at one of the nurses, "You fat tub of lard! Get something done around here!" What is the best initial action for the nurse to take? a. Have the orderly escort the client to his room. b. Tell the client his HCP will be notified if he continues to be verbally abusive. c. Redirect the client's energy by asking him to tidy the recreation room. d. Call the HCP to obtain a prescription for a sedative. - ANS C. Redirect the client's energy by asking him to tidy the recreation room. Distracting the client or reducing his energy (C) prevents further escalation of the inappropriate behavior. (A) could result in escalating the abuse and unnecessarily involve another staff member in the abusive situation. (B) is a threat and is using a health team member (HCP) as the threat. (D) may be indicated if the behavior escalates, but at this time the best initial action is (C). A 52 y/o M client is the ICU has been oriented suddenly becomes disoriented and fearful. Assessment of VS and other physical parameters reveal no significant change and the nurse formulates the diagnosis, "Confusion related to ICU psychosis." Which intervention is best to implement. a. Move all machines away from the client's immediate area. b. Attempt to allay the client's fears by explaining the etiology of his condition. c. Cluster care so that brief periods of rest can be scheduled during the day. d. Extend visitation times for family and friends. - ANS C. Cluster care so that brief periods of rest can be scheduled during the day. The critical care environment confronts clients with an environment which provides stressors heightened by treatment modalities that may provide lifesaving. These stressors can result in isolation and confusion. The best intervention is to provide the client with rest periods (C). (A) is not practical --the machinery is often lifesaving. The client is not ready for (B). Although family and
e. Observe and encourage food and fluid intake. f. Encourage mild exercise and short walks on the unit. - ANS A. Permit rest periods as needed. B. Speaking slowly and simply. D. Allow the client extra time to complete tasks. E. Observe and encourage food and fluid intake. F. Encourage mild exercise and short walks on the unit. (A, B, D, E, and F) should be included in this clients plan of care because these measures promote the clients comfort and well-being. Neurovegetative symptoms accompany the mood disorder of depression and include physiological disruptions such as anorexia, constipation, sleep disturbance, and psychomotor retardation. Suicidal ideation (C) doesn't usually accompany the neurovegetative state because the client doesn't have the energy or high level of anxiety associated with a suicide attempt. A male client with mental illness and substance dependency tells the mental health nurse that he has started using illegal drugs again and wants to seek treatment. Since he has a dual diagnosis, which person is best for the nurse to refer this client to first? a. The ER nurse b. His case manager c. The clinic HCP d. His support group sponsor - ANS B. His case manager The case manager (B) is responsible for coordinating community services and since this client has a dual diagnosis this is the best person to describe available treatment options. (A) is unnecessary unless the client experiences behaviors that threatened his safety or the safety of others. (C and D) might also be useful, but it is most important at this time that a treatment program be coordinated to meet this clients needs.
The charge nurse is collaborating with the nursing staff about the plan of care for a client who is very depressed. What is the most important intervention to implement during the first 48 hours after the client's admission to the unit? a. Monitor appetite and observe intake at meals. b. Maintain safety in the client's milieu. c. Provide ongoing, supportive contact. d. Encourage participation in activities. - ANS B. Maintain safety in the client's milieu. The most important reason for closely observing a depressed client immediately after admission is to maintain safety (B) since suicide is a risk with depression. (A, C, and D) are all important interventions but safety is the priority. A 35 y/o M client on the psych ward of a general hospital believes that someone is trying to poison him. The nurse understands that a client's delusions are most likely related to his a. early childhood experiences involving authority issues. b. anger about being hospitalized. c. neurobiological disorder. d. phobic fear of food. - ANS C. neurobiological disorder. Psychotic clients have difficulty with trust and have neurobiological disorder (C). Nursing care should be directed at building trust and promoting positive self- esteem. Activities with limited concentration and no competition should be encourages tin order to build self-esteem. (A, B, and D) aren't specifically related to the development of delusions.
a. Risk for injury r/t suicidal ideation b. Risk for injury r/t alcohol detoxification c. Knowledge deficit r/t ineffective coping d. Health seeking behaviors r/t personal crisis - ANS B. Risk for injury r/t alcohol detoxification. The most important nursing diagnosis is r/t alcohol detoxification (B) because the client has elevated vitals, a sign of alcohol detoxification. Maintaining client safety r/t (A) should be addressed after giving the client Ativan for elevated vitals secondary to alcohol withdrawal. (C and D) can be addressed when immediate needs for safety are met. A 25 y/o F client has been particularly restless and the nurse finds her trying to leave the psych unit. She tells the nurse, "Please let me go! I must leave because the secret police are after me." Which response is best for the nurse to make? a. No one is after you, you're safe here. b. You'll feel better after you have rested. c. I know you must feel lonely and frightened. d. Come with me to your room and I will sit with you. - ANS D. Come with me to your room and I will sit with you. (D) is the best response because it offers support without judgment or demands. (A) is arguing with the client's delusion. (B) is offering false reassurance. (C) is a violation of therapeutic communication in that the nurse is telling the client how she feels (frightened and lonely) rather than allowing the client to describe her own feelings. Hallucinating and/or delusional clients are not capable of discussing their feelings, particularly when they perceive a crisis.
The community health nurse talks to a male client who has bipolar disorder. The client explains that he sleeps 4-5 hours a night and is working with his partner to start two new businesses and build an empire. The client stopped taking his medications several days ago. What nursing problem has the highest priority? a. Excessive work activity. b. Decreased need for sleep. c. Medication management. d. Inflated self-esteem - ANS C. Medication management. The most important nursing problem is medication management © because compliance with the medication regimen will help prevent hospitalization. The client is also exhibiting signs of (A, B, and C); however, these problems don't have the priority of medication management. A woman brings her 48 y/o husband to the outpatient psych unit and describes his behavior to the admitting nurse. She states that he has been sleepwalking, can't remember who he is, and exhibits multiple personalities. The nurse knows that these behaviors are often associated with a. dissociative disorder b. obsessive-compulsive disorder c. panic disorder d. post-traumatic stress syndrome - ANS A. dissociative disorder Sleepwalking, amnesia, and multiple personalities are examples of detaching emotional conflict from one's consciousness, which is the definition of a dissociative disorder (A). (B) is characterized by persistent, recurrent intrusive thoughts or urges (obsessions) that are unwilled and cannot be ignored, and provoke impulsive acts (compulsions) such as handwashing. (C) is an acute attack of anxiety characterized by personality disorganization. (D) is re-experiencing a
