N244 – Nursing Pharmacology – Mental Health Questions and Answers
As the nurse plans care for the schizophrenic client, it is important to understand the client's
developmental stage and ability to accept the disease.
Which nursing approach to administering an antianxiety agent to a client with acute severe
anxiety is most appropriate? Stay with the client until the medication becomes effective.
A client was admitted to a medical unit because the client suddenly experienced total deafness.
The client undergoes numerous testing to determine the cause of the deafness. All test results
are negative, and there seems to be no organic reason why this client cannot hear. On further
review of the client's record, the nurse notes that the client became deaf after witnessing a
murder. Based on this information and the results of the diagnostic tests, the nurse suspects
that the client may be experiencing: A conversion disorder
A conversion disorder is the alteration or loss of a physical function that cannot be explained by
any known pathophysiological mechanism. It is thought to be an expression of a psychological
need or conflict. In this scenario, the client witnessed a murder that was so psychologically
painful, the client became deaf. Psychosis is a state in which a person's mental capacity to
recognize reality, communicate, and relate to others is impaired, thus interfering with the
person's capacity to deal with life demands
A nurse is caring for a client who received electroconvulsive therapy (ECT) for a major
depressive disorder. On data collection, the nurse notes that the client's blood pressure is
elevated at 160/100 mm Hg. Based on this finding, the appropriate nursing action would be to:
Notify the registered nurse.
The major side effects of ECT are confusion, disorientation, and memory loss. An elevation in
blood pressure would not be an anticipated side effect and would be a cause for concern. If
hypertension occurred following ECT, the nurse would notify the registered nurse, who then
contacts the health care provider.
,A client is being seen at the primary care clinic for her annual gynecological examination. Which
client statements are most likely associated with potential intimate partner abuse? Select all
that apply. Bringing flowers after an abusive episode is part of the abuse cycle. Accusations
of affairs and jealousy are potentially abusive. Numerous bruises and trying to cover them up is
a symptom of a potentially abusive situation. Partners who have similar hobbies and passing
out after a drinking episode are not indicative of abusive situations
A nurse is caring for a client who verbalizes a need to increase her self-esteem. The nurse plans
to assist the client to achieve the goal of gaining self-esteem by encouraging the client to:
Maintain a well-groomed appearance.
The client may demonstrate an increased feeling of self-esteem through outward appearance.
A client arrives in the emergency department in a crisis state. The client demonstrates signs of
profound anxiety and is unable to focus on anything but the object of the crisis and the impact
on self. The initial data collection would focus on: The physical condition of the client
The initial nursing assessment of a client in a crisis state is the physical condition of the client,
the potential for self-harm, and the potential for harm to others. Once this has been
determined and appropriate interventions have been initiated, the nurse would then proceed
to care for the client.
A nurse is collecting data from a client in crisis and is determining the potential for self-harm.
Which of the following data would indicate that the client is a very high risk for suicide? The
client has an immediate plan for a suicide attempt.
The client presents a lethality potential if the client appears disorganized and impulsive. Clients
at higher risk include those with a history of a dual diagnosis of mental illness and substance
abuse, a personal or family history of suicide attempts, depression, alcoholism, or psychotic
episodes.
,A nurse has been closely observing a client who has been displaying aggressive behaviors. The
nurse observes that the behavior displayed by the client is escalating. Which of the following
nursing interventions is least likely to be helpful to this client at this time? Initiate
confinement measures.
During the escalation period, the client's behavior is moving toward loss of control. Nursing
actions include taking control, maintaining a safe distance, acknowledging behavior, moving the
client to a quiet area, and medicating the client if appropriate.
A nursing assistant is assigned to work with a nurse to care for a client who is at risk for suicide.
Which of these statements made by the nursing assistant indicates to the nurse that the
nursing assistant understands suicide? "Discussing suicide with a client is not harmful."
An open discussion of suicide will not encourage a client to make a decision to commit suicide
and will, in fact, often help prevent it.
A nurse is assigned to care for a client who is suicidal. The appropriate nursing intervention in
dealing with this client during this crisis is to: Provide authority, action, and participation.
A crisis is an acute, time-limited state of disequilibrium resulting from situational,
developmental, or societal sources of stress
A nurse employed in a psychiatric unit receives a client assignment for the day. Which of the
following clients assigned to the nurse is at the highest risk for committing suicide? A client
with severe depression and cancer
The individual at highest risk for suicide is the individual with a terminal illness. Other high-risk
groups include adolescents, drug abusers, and those individuals with social problems, recent
losses, few or no social supports, and a history of suicide attempts and a suicide plan.
, A hospitalized client who recently experienced the loss of a spouse is grieving. The client
progresses well and is approaching discharge. Which of the following is an appropriate outcome
for this client? The client verbalizes stages of grief and plans to attend a community grief
group.
The question is focused on grieving.
Which data indicates to the nurse that a client may be experiencing ineffective coping?
Constantly neglects personal grooming
Rationale: Coping mechanisms are behaviors that are used to decreased stress and anxiety. In
response to a death, ineffective coping is manifested by an extreme behavior that in some
instances may be harmful to the individual, physically, psychologically, or both. Option 1 is
indicative of a behavior that identifies an ineffective coping behavior as part of the grieving
process.
Which client is most likely at risk to become a victim of elder abuse? A 90-year-old woman
with advanced Parkinson's disease
Elder abuse is widespread and occurs among all subgroups of the population. It includes
physical and psychological abuse, the misuse of property, and the violation of rights. The typical
abuse victim is a woman of advanced age with few social contacts and at least one physical or
mental impairment that limits her ability to perform activities of daily living. In addition, the
client usually lives alone or with the abuser and depends on the abuser for care.
Which data collection finding would indicate the possibility of the sexual abuse of a child?
Swelling of the genitals
A nurse is assigned to care for a client who is experiencing disturbed thought processes. The
nurse is told that the client believes that the food is being poisoned. Which communication
As the nurse plans care for the schizophrenic client, it is important to understand the client's
developmental stage and ability to accept the disease.
Which nursing approach to administering an antianxiety agent to a client with acute severe
anxiety is most appropriate? Stay with the client until the medication becomes effective.
A client was admitted to a medical unit because the client suddenly experienced total deafness.
The client undergoes numerous testing to determine the cause of the deafness. All test results
are negative, and there seems to be no organic reason why this client cannot hear. On further
review of the client's record, the nurse notes that the client became deaf after witnessing a
murder. Based on this information and the results of the diagnostic tests, the nurse suspects
that the client may be experiencing: A conversion disorder
A conversion disorder is the alteration or loss of a physical function that cannot be explained by
any known pathophysiological mechanism. It is thought to be an expression of a psychological
need or conflict. In this scenario, the client witnessed a murder that was so psychologically
painful, the client became deaf. Psychosis is a state in which a person's mental capacity to
recognize reality, communicate, and relate to others is impaired, thus interfering with the
person's capacity to deal with life demands
A nurse is caring for a client who received electroconvulsive therapy (ECT) for a major
depressive disorder. On data collection, the nurse notes that the client's blood pressure is
elevated at 160/100 mm Hg. Based on this finding, the appropriate nursing action would be to:
Notify the registered nurse.
The major side effects of ECT are confusion, disorientation, and memory loss. An elevation in
blood pressure would not be an anticipated side effect and would be a cause for concern. If
hypertension occurred following ECT, the nurse would notify the registered nurse, who then
contacts the health care provider.
,A client is being seen at the primary care clinic for her annual gynecological examination. Which
client statements are most likely associated with potential intimate partner abuse? Select all
that apply. Bringing flowers after an abusive episode is part of the abuse cycle. Accusations
of affairs and jealousy are potentially abusive. Numerous bruises and trying to cover them up is
a symptom of a potentially abusive situation. Partners who have similar hobbies and passing
out after a drinking episode are not indicative of abusive situations
A nurse is caring for a client who verbalizes a need to increase her self-esteem. The nurse plans
to assist the client to achieve the goal of gaining self-esteem by encouraging the client to:
Maintain a well-groomed appearance.
The client may demonstrate an increased feeling of self-esteem through outward appearance.
A client arrives in the emergency department in a crisis state. The client demonstrates signs of
profound anxiety and is unable to focus on anything but the object of the crisis and the impact
on self. The initial data collection would focus on: The physical condition of the client
The initial nursing assessment of a client in a crisis state is the physical condition of the client,
the potential for self-harm, and the potential for harm to others. Once this has been
determined and appropriate interventions have been initiated, the nurse would then proceed
to care for the client.
A nurse is collecting data from a client in crisis and is determining the potential for self-harm.
Which of the following data would indicate that the client is a very high risk for suicide? The
client has an immediate plan for a suicide attempt.
The client presents a lethality potential if the client appears disorganized and impulsive. Clients
at higher risk include those with a history of a dual diagnosis of mental illness and substance
abuse, a personal or family history of suicide attempts, depression, alcoholism, or psychotic
episodes.
,A nurse has been closely observing a client who has been displaying aggressive behaviors. The
nurse observes that the behavior displayed by the client is escalating. Which of the following
nursing interventions is least likely to be helpful to this client at this time? Initiate
confinement measures.
During the escalation period, the client's behavior is moving toward loss of control. Nursing
actions include taking control, maintaining a safe distance, acknowledging behavior, moving the
client to a quiet area, and medicating the client if appropriate.
A nursing assistant is assigned to work with a nurse to care for a client who is at risk for suicide.
Which of these statements made by the nursing assistant indicates to the nurse that the
nursing assistant understands suicide? "Discussing suicide with a client is not harmful."
An open discussion of suicide will not encourage a client to make a decision to commit suicide
and will, in fact, often help prevent it.
A nurse is assigned to care for a client who is suicidal. The appropriate nursing intervention in
dealing with this client during this crisis is to: Provide authority, action, and participation.
A crisis is an acute, time-limited state of disequilibrium resulting from situational,
developmental, or societal sources of stress
A nurse employed in a psychiatric unit receives a client assignment for the day. Which of the
following clients assigned to the nurse is at the highest risk for committing suicide? A client
with severe depression and cancer
The individual at highest risk for suicide is the individual with a terminal illness. Other high-risk
groups include adolescents, drug abusers, and those individuals with social problems, recent
losses, few or no social supports, and a history of suicide attempts and a suicide plan.
, A hospitalized client who recently experienced the loss of a spouse is grieving. The client
progresses well and is approaching discharge. Which of the following is an appropriate outcome
for this client? The client verbalizes stages of grief and plans to attend a community grief
group.
The question is focused on grieving.
Which data indicates to the nurse that a client may be experiencing ineffective coping?
Constantly neglects personal grooming
Rationale: Coping mechanisms are behaviors that are used to decreased stress and anxiety. In
response to a death, ineffective coping is manifested by an extreme behavior that in some
instances may be harmful to the individual, physically, psychologically, or both. Option 1 is
indicative of a behavior that identifies an ineffective coping behavior as part of the grieving
process.
Which client is most likely at risk to become a victim of elder abuse? A 90-year-old woman
with advanced Parkinson's disease
Elder abuse is widespread and occurs among all subgroups of the population. It includes
physical and psychological abuse, the misuse of property, and the violation of rights. The typical
abuse victim is a woman of advanced age with few social contacts and at least one physical or
mental impairment that limits her ability to perform activities of daily living. In addition, the
client usually lives alone or with the abuser and depends on the abuser for care.
Which data collection finding would indicate the possibility of the sexual abuse of a child?
Swelling of the genitals
A nurse is assigned to care for a client who is experiencing disturbed thought processes. The
nurse is told that the client believes that the food is being poisoned. Which communication
