Mental health final exams (NSG MISC) 100Q with Verified Answers

Mental health final exams (NSG MISC) 100Q 100% Verified Answers 1 A nurse uses the SAD PERSONS scale to interview a patient. This tool provides data relevant to which of the following concepts? 2 A nurse is interacting with patients in a psychiatric unit. Which statements reflect use of therapeutic communication? Select all that apply. 3 A married couple has two biologic children who live with them as well as a child from the wife’s first marriage. What type of family is evident? 4 Which person would be most likely to experience sleep fragmentation? 5 A child diagnosed with attention deficit hyperactivity disorder will begin medication therapy. The nurse should prepare a plan to teach the family about which classification of medications? 6 A child diagnosed with attention deficit hyperactivity disorder (ADHD) shows hyperactivity, aggression, and impaired play. The health care provider prescribed amphetamine salts (Adderall). The nurse should monitor for which desired behavior? 7 A new psychiatric technician says, “Schizophrenia…schizotypal! What’s the difference?” The nurse’s response should include which information? 8 A nurse is caring for a patient taking a selective serotonin reuptake inhibitor (SSRI). When care planning, outcome criteria related to which goal is most appropriate? 9 A staff nurse completes orientation to a psychiatric unit. This nurse may expect an advanced practice nurse to perform which additional intervention? 10 A patient’s relationships are intense and unstable. The patient initially idealizes the significant other and then devalues him or her, resulting in frequent feelings of emptiness. This patient will benefit from interventions to develop which aspect of mental health? 11 A nurse is discussing culturally competent care at a nursing staff inservice. Which of the following information should the nurse include when discussing clients' cultures? 12 A patient diagnosed with schizophrenia says, “It’s beat. Time to eat. No room for the cat.” What type of verbalization is evident? 13 A nurse uses Maslow’s hierarchy of needs to plan care for a patient with mental illness. Which problem will receive priority? 14 As a nurse discharges a patient, the patient gives the nurse a card of appreciation made in an arts and crafts group. What is the nurse’s best action? 15 A nurse interacts with a newly hospitalized patient. Which of the following comments is most demonstrative of the nurse utilizing the communication technique of “offering self"? 16 Which prescription medication would the nurse expect to be prescribed for a patient diagnosed with a somatic symptom disorder? 17 A patient is fearful of riding on elevators. The therapist first rides an escalator with the patient. The therapist and patient then stand in an elevator with the door open for five minutes and later with the elevator door closed for five minutes. Which technique has the therapist used? 18 A nurse cares for a group of patients receiving various medications, including an MAO inhibitor, anti-convulsant, sedative-hypnotic, and 2nd generation anti-psychotic. The nurse will order a special diet for the patient who takes which medication? 19 A Puerto Rican American patient uses dramatic body language when describing emotional discomfort. Which analysis most likely explains the patient’s behavior? 20 A nurse assesses a patient with a tentative diagnosis of generalized anxiety disorder. Which question would be most appropriate for the nurse to ask? 21 A nurse is leading a family therapy session for a mother, father, and two adolescent siblings. Which of the following statements should the nurse recognize as an example of effective communication among family members? . 22 The exact cause of bipolar disorder has not been determined; which of the following provides the most accurate description of possible etiology? 23 A Mexican American patient puts a picture of the Virgin Mary on the bedside table. What is the nurse’s best action? 24 A nurse is caring for a client who has schizophrenia and is experiencing a variety of hallucinations. Which of the following hallucinations is the priority for the nurse to address? 25 A child known as the neighborhood bully says, “Nobody can tell me what to do.” After receiving a poor grade on a science project, this child secretly loaded a virus on the teacher’s computer. Which diagnosis is best supported by this data? oppositional defiant disorder. 26 Match the terms below with the appropriate description. Anxiety- Fear- Obsessions- Compulsions A feeling of apprehension, uncertainty, or dread resulting from a vague unspecified or unknown danger A reaction to a specific danger Thoughts, impulses or images that persist recur Ritualistic behaviors an individual feels driven to perform 27 Which assessment finding would cause the nurse to consider a child to be most at risk for the development of mental illness? 28 Inpatient hospitalization for persons with mental illness is generally reserved for patients in which of the following situations? 29 A nurse in an inpatient mental health unit is planning care for a client who is in restraints. Which of the following findings should indicate to the nurse that the client is ready to reintegrate into the unit? 30 A community health nurse visits a family with four children. The father behaves angrily, finds fault with the oldest child, and asks twice, “Why are you such a stupid kid?” The wife says, “I have difficulty disciplining the children. It’s so frustrating.” Which comments by the nurse will facilitate an interview with these parents? Select all that apply. 31 A nurse is assessing a client who has a new diagnosis of anorexia nervosa. Which of the following findings should the nurse expect? 32 Which nursing diagnosis is universally applicable for children diagnosed with autism spectrum disorders? 33 A charge nurse is conducting a staff education in-service about depressive disorders. Which of the following should the nurse identify as a risk factor for depression? 34 A nurse is caring for a new client who exhibits manifestations of a major depressive episode. The provider states that she wants to rule out medical conditions which could also be linked to the findings. The nurse should expect diagnostic testing for which of the following medical conditions? 35 A nurse cares for a patient diagnosed with an opioid overdose. Which focused assessment has the highest priority? 36 A nurse asks a patient diagnosed with schizophrenia, “What is meant by the old saying ‘You can’t judge a book by looking at the cover.’?” Which response by the patient indicates concrete thinking? 37 An advanced practice nurse observes a novice nurse expressing irritability regarding a patient with a long history of alcoholism and suspects the new nurse is experiencing countertransference. Which comment by the new nurse confirms this suspicion? 38 What is a nurse’s legal responsibility if child abuse or neglect is suspected? 39 A nurse is caring for a client who has bipolar disorder. The client states, “I feel like Superman. I can do anything. I can fly home today and then become a U.S. Senator.” Which of the following findings is this client exhibiting? 40 A 15-year-old ran away from home six times and was arrested for shoplifting. The parents told the court, “We can’t manage our teenager.” The adolescent is physically abusive to the mother and defiant with the father. Which diagnosis is supported by this adolescent’s behavior? 41 A nurse is caring for a client who is experiencing acute manifestations of withdrawal from alcohol. Which of the following medications should the nurse expect to administer to the client? 42 A nurse is discussing stress management techniques with a group of clients. Which of the following techniques mentioned by a client should the nurse recognize as the least effective? 43 A patient demonstrating behaviors associated with acute mania has been engaging in staff-splitting behaviors. Staff members are feeling defensive and fatigued. Which action will the staff take initially? . 44 A patient has blindness related to conversion (functional neurological) disorder. To help the patient eat, the nurse should implement which of the following interventions? 45 An adolescent was arrested for prostitution and assault on a parent. The adolescent says, “I hate my parents. They focus all attention on my brother, who’s perfect in their eyes.” Which type of therapy might promote the greatest change in the adolescent’s behavior? 46 An adult comes to the crisis clinic after termination from a job of 15 years. The patient says, “I don’t know what to do. How can I get another job? Who will pay the bills? How will I feed my family?” Which nursing diagnosis applies? 47 A nurse in an acute mental health facility is creating a plan of care for a new client who has histrionic personality disorder. Which of the following is the priority intervention for the nurse to make? 48 Which central nervous system structure is most associated with anger and aggression? 49 A nurse finds a psychiatric advance directive in the medical record of a patient experiencing psychosis. The directive was executed during a period when the patient was stable and competent. Which of the following is the nurses best action? 50 A patient taking both an SSRI & a MAOI develops muscle spasms, elevated BP, fever & sweating. Which adverse effect does the nurse suspect? 51 A patient presents to the emergency department with mixed psychiatric symptoms. The admission nurse suspects the symptoms may be the result of a medical problem. Lab results show elevated BUN (blood urea nitrogen) and creatinine. What is the nurse’s next best action? 52 A pregnant woman describes a strong desire to ingest chalk at her prenatal appointment. She admits that several time she has eaten a few pieces. What disorder will the nurse suspect? 53 A nurse set limits while interacting with a patient demonstrating behaviors associated with borderline personality disorder. The patient tells the nurse, “You used to care about me. I thought you were wonderful. Now I can see I was wrong. You’re evil.” This outburst can be documented using which of the following terms? 54 A person in the community asks, “People with mental illnesses went to state hospitals in earlier times. Why has that changed?” The nurse's best response would include which of the following? Select all that apply. 55 What individual point of view impacts our reaction to a stressor? 56 A nurse encounters an unfamiliar psychiatric disorder on a new patient’s admission form. Which resource should the nurse consult to determine criteria used to establish this diagnosis? 57 A nurse is caring for an adolescent who has a history of violent behavior and has asked the nurse to keep confidential information about the desire to kill several classmates and a school teacher. Which of the following responses by the nurse is appropriate to give? 58 What information is conveyed by nursing diagnoses? Select all that apply. 59 A patient would benefit from therapy in which peers as well as staff have a voice in determining patients’ privileges and psychoeducational topics. Which approach would be best? 60 A nurse is preparing a client who has chronic anxiety for discharge from the psychiatric unit. Which of the following instructions should the nurse include in the client’s discharge plan? 61 After celebrating the fortieth birthday, an individual becomes concerned with the loss of youthful appearance. What type of crisis has occurred? 62 A home health nurse is speaking to a group of acute care nurses about domestic violence. Which of the following statements by one of the acute care nurses indicates a need for clarification? 63 A nurse is caring for a young adult client following the sudden death of his wife. The client feels paralyzed in his ability to cope with work and family responsibilities. Which of the following types of crisis is the client experiencing? 64 Which of the following comorbidities are associated with an increased risk of anger/aggression? (select all that apply) 65 A nurse is caring for a client who has a depressive disorder. The client states, “I just can’t feel any happiness or joy in life.” Which of the following terms should the nurse use when documenting this finding? 66 A nurse is assessing a client who is experiencing chronic stress. Which of the following findings should the nurse expect? 67 A rape victim tells the emergency nurse, “I feel so dirty. Help me take a shower before I get examined.” What are the nurses next appropriate actions? (select all that apply) . 68 A nurse is teaching a client who has bipolar disorder about lithium. Which of the following statements should the nurse include in the teaching? 69A nurse works with a child who is sad and irritable because the child’s parents are divorcing. Why is establishing a therapeutic alliance with this child a priority? 70 A nurse is caring for a client who requires a crisis intervention for acute anxiety. Which of the following actions is the highest priority? 71 A nurse is teaching a community education course about the physical complications related to substance use disorder. Which of the following findings should the nurse identify as the primary cause of liver cirrhosis? 72 Before assessing a new patient, a nurse is told by another health care worker, “I know that patient. No matter how hard we work, there isn’t much improvement by the time of discharge.” What is the nurse’s responsibility in this situation? 73 A nurse on a mental health unit is caring for clients who have various depressive disorders. The nurse should identify which of the following client diagnoses as presenting the greatest risk for suicide? 74 A patient diagnosed with depersonalization disorder tells the nurse, “It’s starting again. I feel as though I’m going to float away.” Which intervention would be most appropriate at this point? 75 A patient diagnosed with bipolar disorder has an unstable mood, aggressiveness, agitation, talkativeness, and irritability. The nurse expects the health care provider to prescribe a medication from which group? 76 Shift work, especially night shift and rotating shifts, are a common cause of what sleep-related disorder? 77 A nurse interviews a patient abducted and raped at gunpoint by an unknown assailant. The patient says, “I can’t talk about it. Nothing happened. I have to forget.” What is the patient’s present coping strategy? 78 A nurse manager is providing staff education about working with clients who have a history of anger and aggression. Which of the following information should the nurse include in the teaching? (Select all that apply.) 79 A nurse assesses a patient who reports a 3-week history of depression and periods of uncontrolled crying. The patient says, “My business is bankrupt, and I was served with divorce papers.” Which subsequent statement by the patient alerts the nurse to a concealed suicidal message? 80 An adolescent diagnosed with an impulse control disorder said, “I just want to die. I spend all my time getting even with people who have done wrong to me.” When asked about a suicide plan, the adolescent replied, “I’ll jump from the bridge near my home. My father threw kittens off that bridge, and they died because they couldn’t swim.” Which of the following is the appropriate suicide risk rating? 81 In a team meeting a nurse says, “I’m concerned about whether we are behaving ethically by using restraint to prevent one patient from self-mutilation, while the care plan for another self-mutilating patient requires one-on-one supervision.” Which ethical principle most clearly applies to this situation? 82 A health care provider prescribed depot injections every 3 weeks at the clinic for a patient with a history of medication noncompliance. For this plan to be successful, which factor will be of critical importance? 83 A nurse is assessing the suicide risk of a group of clients on a mental health unit. Which of the following clients should the nurse identify as having a risk factor for a suicide attempt? 84 The nurse assesses an adult who is socially withdrawn and hoards. Which nursing diagnoses most likely apply to this individual? Select all that apply. 85 A nurse can best address factors of critical importance to successful community treatment by assessing elements of a biopsychosocial assessment including which of the following? (Select all that apply.) 86 Shortly after the parents announced that they were divorcing, a 15-year-old became truant from school and assaulted a friend. The adolescent told the school nurse, “I’d rather stay in my room and listen to music. It’s easier than thinking about what is happening in my family.” Which nursing diagnosis is most applicable? 87 A cruel and abusive person often uses rationalization to explain the behavior. Which comment demonstrates use of this defense mechanism? 88 A child has a history of multiple hospitalizations for recurrent systemic infections. The child is not improving in the hospital, despite aggressive treatment. Factitious disorder by proxy is suspected. Which nursing interventions are appropriate? Select all that apply. 89 A patient diagnosed with depression begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy. The nurse should provide information to the patient and family about which of the following home care concepts? 90 A nurse is caring for a client who has been diagnosed with obsessive compulsive disorder (OCD) and is constantly picking up after others in the day room. The nurse should recognize that the client uses this behavior to do which of the following? 91 Four teenagers died in an automobile accident. One week later, which behavior by the parents of these teenagers most clearly demonstrates resilience? 92 A nurse explains to the family of a mentally ill patient how a nurse-patient relationship differs from social relationships. Which is the best explanation? 93 A parent became unemployed 6 months ago. The parent has subsequently been verbally abusive toward the spouse and oldest child. The child ran away twice, and the spouse has become depressed. What is the most appropriate nursing diagnosis for this family? 94 A patient has smoked two packs of cigarettes daily for many years. When the patient tries to reduce smoking, anxiety, craving, poor concentration, and headache occur. Which term best describes this scenario? 95 A patient reports, “I am overwhelmed by stress.” Which question by the nurse would be most important to use in the initial assessment of this the patient? 96 A patient who has been hospitalized for 3 days with a serious mental illness says, “I’ve got to get out of here and back to my job. I get 60 to 80 messages a day, and I’m getting behind on my email correspondence.” What is this patient’s perspective about health and illness? 97 A patient tells the nurse, “Everyone says we should sleep 8 hours a night. I can only sleep 6 hours, no matter how hard I try. Am I doing harm to my body?” Which of the following is the nurse’s best response? 98 A patient being admitted to the eating disorders unit has a yellow cast to the skin and fine, downy hair over the trunk. The patient weighs 70 pounds; height is 5 feet 4 inches. The patient says, “I won’t eat until I look thin.” Which of the following is the priority initial nursing diagnosis? 99 A nurse in the clinic has a full appointment schedule. A Hispanic American patient arrives at 1230 for a 1000 appointment. A Native American patient does not keep an appointment at all. What understanding will improve the nurse’s planning? 100 A nurse is performing an admission assessment for a client who has schizophrenia. Which of the following findings should the nurse identify as a negative symptom?