TEST BANK: PSYCHIATRIC-MENTAL HEALTH NURSING 10TH
EDITION VIDEBECK (CHAPTERS 1-24 COMPLETE)
Question 1
Which intervention is the priority for a client experiencing acute alcohol withdrawal?
A) Administering disulfiram
B) Monitoring for seizures and autonomic hyperactivity, and providing thiamine
and benzodiazepines as ordered
C) Initiating naltrexone therapy
D) Encouraging attendance at AA meetings
Rationale: Alcohol withdrawal can be life-threatening, with risk of seizures, delirium
tremens, and cardiovascular instability. Priority care includes monitoring vital signs,
seizure precautions, benzodiazepines for symptom control, and thiamine to prevent
Wernicke's encephalopathy. Disulfiram and naltrexone are for maintenance, not acute
withdrawal.
Question 2
,A nurse is caring for a client with major depressive disorder who states, "I just want to
sleep and never wake up." Which action should the nurse take first?
A) Document the statement and continue the assessment
B) Ask directly whether the client has thoughts of harming themselves and assess
for a suicide plan
C) Reassure the client that things will get better
D) Notify the provider after completing the full shift assessment
Rationale: Direct, nonjudgmental questioning about suicidal ideation is essential when a
client expresses hopelessness or a wish to die. Assessing intent, plan, and means
determines the level of safety intervention needed. Reassurance alone dismisses the
client's pain, and delaying notification places the client at risk.
Question 3
A nurse is assessing a client who was recently admitted to the psychiatric unit. The client
states, "I can't trust anyone here." Which nursing response best demonstrates
therapeutic communication?
A) "You'll learn to trust us eventually."
B) "It sounds like trusting people is difficult for you right now."
C) "Why don't you trust anyone?"
D) "Everyone here is here to help you."
Rationale: Restating and reflecting the client's feelings validates their experience without
judgment or false reassurance. "Why" questions can feel confrontational, and promising
future trust is unrealistic.
,Question 4
Which symptom is most characteristic of a panic attack?
A) Sudden onset of intense fear with palpitations, shortness of breath, and feelings
of impending doom
B) Gradual onset of low mood lasting several weeks
C) Flat affect with minimal verbal communication
D) Compulsive hand washing to reduce anxiety
Rationale: Panic attacks are characterized by abrupt, intense fear peaking within minutes,
accompanied by somatic symptoms such as palpitations, dyspnea, chest pain, and
derealization. Gradual low mood suggests depression, flat affect suggests negative
symptoms of schizophrenia, and compulsions suggest OCD.
Question 5
A client taking lithium carbonate reports increased urination and thirst. Which nursing
action is most appropriate?
A) Withhold the next dose and notify the provider immediately
B) Document the findings as expected side effects and encourage adequate fluid
intake
C) Restrict fluids to prevent dilutional hyponatremia
D) Encourage the client to increase sodium intake
Rationale: Polyuria and polydipsia are common, expected side effects of lithium related to
its effect on renal concentrating ability. Fluids should not be restricted. Sodium restriction
can raise lithium levels, so sodium intake should remain consistent rather than increased.
, Question 6
A nurse is establishing a therapeutic relationship with a newly admitted client. Which
action best demonstrates the orientation phase of the nurse-client relationship?
A) Evaluating progress toward mutually established goals
B) Introducing oneself, explaining the purpose of the relationship, and establishing
trust
C) Working together to solve problems and promote change
D) Summarizing accomplishments and ending the relationship
Rationale: The orientation phase involves introductions, explaining roles and
responsibilities, establishing trust, and identifying the client's needs. The working phase
focuses on problem-solving and change, and the termination phase involves evaluation
and closure.
Question 7
A client diagnosed with schizophrenia is experiencing delusions of persecution. Which
nursing intervention is most appropriate?
A) Present reality in a nonconfrontational manner and focus on the client's feelings
B) Argue with the client to correct the false belief
C) Reinforce the delusion to build trust
D) Change the subject whenever the delusion is mentioned
Rationale: Delusions are fixed false beliefs that cannot be argued away. The nurse should
acknowledge the client's feelings, present reality gently, and avoid reinforcing or arguing
with the delusion. Direct confrontation increases anxiety and distrust.
EDITION VIDEBECK (CHAPTERS 1-24 COMPLETE)
Question 1
Which intervention is the priority for a client experiencing acute alcohol withdrawal?
A) Administering disulfiram
B) Monitoring for seizures and autonomic hyperactivity, and providing thiamine
and benzodiazepines as ordered
C) Initiating naltrexone therapy
D) Encouraging attendance at AA meetings
Rationale: Alcohol withdrawal can be life-threatening, with risk of seizures, delirium
tremens, and cardiovascular instability. Priority care includes monitoring vital signs,
seizure precautions, benzodiazepines for symptom control, and thiamine to prevent
Wernicke's encephalopathy. Disulfiram and naltrexone are for maintenance, not acute
withdrawal.
Question 2
,A nurse is caring for a client with major depressive disorder who states, "I just want to
sleep and never wake up." Which action should the nurse take first?
A) Document the statement and continue the assessment
B) Ask directly whether the client has thoughts of harming themselves and assess
for a suicide plan
C) Reassure the client that things will get better
D) Notify the provider after completing the full shift assessment
Rationale: Direct, nonjudgmental questioning about suicidal ideation is essential when a
client expresses hopelessness or a wish to die. Assessing intent, plan, and means
determines the level of safety intervention needed. Reassurance alone dismisses the
client's pain, and delaying notification places the client at risk.
Question 3
A nurse is assessing a client who was recently admitted to the psychiatric unit. The client
states, "I can't trust anyone here." Which nursing response best demonstrates
therapeutic communication?
A) "You'll learn to trust us eventually."
B) "It sounds like trusting people is difficult for you right now."
C) "Why don't you trust anyone?"
D) "Everyone here is here to help you."
Rationale: Restating and reflecting the client's feelings validates their experience without
judgment or false reassurance. "Why" questions can feel confrontational, and promising
future trust is unrealistic.
,Question 4
Which symptom is most characteristic of a panic attack?
A) Sudden onset of intense fear with palpitations, shortness of breath, and feelings
of impending doom
B) Gradual onset of low mood lasting several weeks
C) Flat affect with minimal verbal communication
D) Compulsive hand washing to reduce anxiety
Rationale: Panic attacks are characterized by abrupt, intense fear peaking within minutes,
accompanied by somatic symptoms such as palpitations, dyspnea, chest pain, and
derealization. Gradual low mood suggests depression, flat affect suggests negative
symptoms of schizophrenia, and compulsions suggest OCD.
Question 5
A client taking lithium carbonate reports increased urination and thirst. Which nursing
action is most appropriate?
A) Withhold the next dose and notify the provider immediately
B) Document the findings as expected side effects and encourage adequate fluid
intake
C) Restrict fluids to prevent dilutional hyponatremia
D) Encourage the client to increase sodium intake
Rationale: Polyuria and polydipsia are common, expected side effects of lithium related to
its effect on renal concentrating ability. Fluids should not be restricted. Sodium restriction
can raise lithium levels, so sodium intake should remain consistent rather than increased.
, Question 6
A nurse is establishing a therapeutic relationship with a newly admitted client. Which
action best demonstrates the orientation phase of the nurse-client relationship?
A) Evaluating progress toward mutually established goals
B) Introducing oneself, explaining the purpose of the relationship, and establishing
trust
C) Working together to solve problems and promote change
D) Summarizing accomplishments and ending the relationship
Rationale: The orientation phase involves introductions, explaining roles and
responsibilities, establishing trust, and identifying the client's needs. The working phase
focuses on problem-solving and change, and the termination phase involves evaluation
and closure.
Question 7
A client diagnosed with schizophrenia is experiencing delusions of persecution. Which
nursing intervention is most appropriate?
A) Present reality in a nonconfrontational manner and focus on the client's feelings
B) Argue with the client to correct the false belief
C) Reinforce the delusion to build trust
D) Change the subject whenever the delusion is mentioned
Rationale: Delusions are fixed false beliefs that cannot be argued away. The nurse should
acknowledge the client's feelings, present reality gently, and avoid reinforcing or arguing
with the delusion. Direct confrontation increases anxiety and distrust.
