Saunders Mental Health Questions
1073. A client in a long-term care facility who had multiple sclerosis is embarrassed about the
need to use a wheelchair and the muscle spasms that are readily visible in her legs. Which
approach is therapeutic in assisting the client to cope?
1. Keep the client in her room as much as possible .
2. Assist the client with all activities of daily living (ADLs).
3. Tell the client that many of the people in the facility have these same sorts of problems.
4. Encourage and praise perseverance in performing ADLs, and assist the client to dress and
groom daily. - ANS 4. Encourage and praise perseverance in performing ADLs, and assist the
client to dress and groom daily
1074. The nurse uses which approach when caring for a client with a diagnosis of acute
undifferentiated schizophrenia?
1. Repeatedly points out inconsistencies in the client's communication .
2. Allows the client to set his or her own treatment goals for the plan of care.
3. Lets the client act out initially and uses the quiet room and restraints as needed.
4. Provides assistance with grooming and nutrition until the client's thinking is cleared. - ANS 4.
Provides assistance with grooming and nutrition until the client's thinking is cleared
1075. A client is admitted to the mental health unit after a suicide attempt by hanging. The
nurse's most important aspect of care is to maintain client safety. The is best accomplished by
which action?
1. Requesting that a peer remain with the client at all times.
2. Removing the client's clothing and placing the client in a hospital gown.
3. Assigning a staff member to the client who will remain with the client at all times.
4. Admitting the client to a seclusion room where all potentially dangerous articles are removed.
- ANS 3. Assigning a staff member to the client who will remain with the client at all times
1076. The nurse providing end-of-life care to a Muslim client understands that which practice is
accurate regarding end-of-life care?
1. The client's head should be positioned below the body.
2. Discussions about death are usually welcomed and open.
3. A same-gendered Muslim should handle the body if possible.
4. Stopping medical treatment is allowed if permitted by the family. - ANS 3. A same-gendered
Muslim should handle the body if possible.
1077. On admission assessment, the nurse is obtaining subjective data about a client's sexual
and reproductive status. The client states, "I don't want to discuss this; it's private and personal."
Which response by the nurse is most therapeutic?
,1. "I'd hate being asked these sorts of questions too, but it's a necessary part of providing you
with the best care."
2. "This is difficult for you to speak about, but I need this information from you in order to
perform a complete assessment."
3. "I am a professional registered nurse, and , as such, I'll have you know that all your
information is certainly kept confidential."
4. " I know that some of these questions are difficult for you, but, as a professional nurse, I am
obligated to respect your confidentiality." - ANS 4. " I know that some of these questions are
difficult for you, but, as a professional nurse, I am obligated to respect your confidentiality."
1078. The nurse should include which information in the nursing plan of care for a client with
obsessive-compulsive disorder (OCD)? Select all that apply.
1. The medical diagnosis of the client.
2. Individualized goals and objectives.
3. Attendance at group therapy sessions.
4. Self-care measures to improve hygiene.
5. Interruption of all compulsive behaviors. - ANS 2. Individualized goals and objectives.
3. Attendance at group therapy sessions.
4. Self-care measures to improve hygiene.
1079. A client asks the nurse to explain what milieu therapy is. The nurse responds, knowing
that the primary focus of milieu therapy can be best described by which statement?
1. Changing behavior through crisis intervention.
2. A cognitive approach to changing client behavior.
3. Providing a safe, therapeutic environment for clients.
4. A behavioral approach to changing behavior appropriately. - ANS 3. Providing a safe,
therapeutic environment for clients.
1080. An older adult client states to the nurse, "Lately I'm getting forgetful about things. Do you
think I'm getting Alzheimer's disease?" Which response by the nurse is most therapeutic?
1. "Oh, I'm certain it's not Alzheimer's disease because everyone forgets things sometimes."
2. " No, I don't think we really need to discuss this because I' sure it is just normal aging."
3. " Although it's not unusual to experience some lapses of memory, let's discuss your
concerns."
4. " I am so forgetful, too. I never needed lists of things that I had to do, but that changed as I
got older." - ANS 3. " Although it's not unusual to experience some lapses of memory, let's
discuss your concerns."
1081. A client in the mental health unit believes that the food is being poisoned. Which
intervention(s) would be helpful when attempting to encourage the client to eat? Select all that
apply.
1. Use open-ended questions to encourage client dialogue.
2. Offer opinions about the necessity for adequate nutrition.
3. Focus on the client's self-disclosure about food preferences.
, 4. Identify the reasons that the client had for not wanting to eat.
5. Offer the client food in closed containers, such as in cans that have to be opened. - ANS 1.
Use open-ended questions to encourage client dialogue.
5. Offer the client food in closed containers, such as in cans that have to be opened.
1082. The spouse of a client who abuses alcohol states, " I wish I could just get out of this
situation and far away from my spouse." Which response by the nurse is therapeutic?
1. " What aspects of this situation are most difficult for you?"
2. " In order to ensure your safety, it's probably best that you leave."
3. "Maybe you should make this decision when your spouse is stable."
4. "I don't think that's what is best for you or your spouse now. Besides, where would you go?" -
ANS 1. " What aspects of this situation are most difficult for you?"
1083. A crisis center nurse receives a telephone call from
a client who states that he wants to kill himself and that he had a bottle of sleeping pills in from
of him. What is the appropriate nursing action?
1. Keep the client talking, and allow him to ventilate his feelings.
2. Use therapeutic communication techniques, especially the reflection of feelings.
3. Insist that the client give you his name and address so that you can get the police there
immediately.
4. Keep the client talking, and signal another staff member to trace the call so that appropriate
help can be sent. - ANS 4. Keep the client talking, and signal another staff
member to trace the call so that appropriate help can be sent.
1084. Which description(s) are characteristic(s) of a crisis state for a client. Select all that apply.
1. A client's response to a crisis is individualized.
2. A crisis state will always last from 3 to 5 days.
3. A crisis state does not mean that the individual has a mental illness.
4. Presenting symptoms in a crisis situation are similar for all individuals.
5. A crisis state indicates that the individual is suffering from an emotional illness. - ANS 1. A
client's response to a crisis is individualized.
3. A crisis state does not mean that the individual has a mental illness.
1085. A client with a leg amputation is upset about his appearance. The nurse intends to
address which most closely associated psychosocial problem?
1. inability to be mobile.
2. Isolating self from others.
3. Inability to tolerate activity.
4. Concern about body persona. - ANS 4. Concern about body persona.
1086. The nurse is preparing to care for a client who witnessed her mother being shot by an
unknown attacker. The nurse interprets that the client is demonstrating behavior that indicates
denial if which finding is noted?
1. The client is calm, cooperative, and reserved.
1073. A client in a long-term care facility who had multiple sclerosis is embarrassed about the
need to use a wheelchair and the muscle spasms that are readily visible in her legs. Which
approach is therapeutic in assisting the client to cope?
1. Keep the client in her room as much as possible .
2. Assist the client with all activities of daily living (ADLs).
3. Tell the client that many of the people in the facility have these same sorts of problems.
4. Encourage and praise perseverance in performing ADLs, and assist the client to dress and
groom daily. - ANS 4. Encourage and praise perseverance in performing ADLs, and assist the
client to dress and groom daily
1074. The nurse uses which approach when caring for a client with a diagnosis of acute
undifferentiated schizophrenia?
1. Repeatedly points out inconsistencies in the client's communication .
2. Allows the client to set his or her own treatment goals for the plan of care.
3. Lets the client act out initially and uses the quiet room and restraints as needed.
4. Provides assistance with grooming and nutrition until the client's thinking is cleared. - ANS 4.
Provides assistance with grooming and nutrition until the client's thinking is cleared
1075. A client is admitted to the mental health unit after a suicide attempt by hanging. The
nurse's most important aspect of care is to maintain client safety. The is best accomplished by
which action?
1. Requesting that a peer remain with the client at all times.
2. Removing the client's clothing and placing the client in a hospital gown.
3. Assigning a staff member to the client who will remain with the client at all times.
4. Admitting the client to a seclusion room where all potentially dangerous articles are removed.
- ANS 3. Assigning a staff member to the client who will remain with the client at all times
1076. The nurse providing end-of-life care to a Muslim client understands that which practice is
accurate regarding end-of-life care?
1. The client's head should be positioned below the body.
2. Discussions about death are usually welcomed and open.
3. A same-gendered Muslim should handle the body if possible.
4. Stopping medical treatment is allowed if permitted by the family. - ANS 3. A same-gendered
Muslim should handle the body if possible.
1077. On admission assessment, the nurse is obtaining subjective data about a client's sexual
and reproductive status. The client states, "I don't want to discuss this; it's private and personal."
Which response by the nurse is most therapeutic?
,1. "I'd hate being asked these sorts of questions too, but it's a necessary part of providing you
with the best care."
2. "This is difficult for you to speak about, but I need this information from you in order to
perform a complete assessment."
3. "I am a professional registered nurse, and , as such, I'll have you know that all your
information is certainly kept confidential."
4. " I know that some of these questions are difficult for you, but, as a professional nurse, I am
obligated to respect your confidentiality." - ANS 4. " I know that some of these questions are
difficult for you, but, as a professional nurse, I am obligated to respect your confidentiality."
1078. The nurse should include which information in the nursing plan of care for a client with
obsessive-compulsive disorder (OCD)? Select all that apply.
1. The medical diagnosis of the client.
2. Individualized goals and objectives.
3. Attendance at group therapy sessions.
4. Self-care measures to improve hygiene.
5. Interruption of all compulsive behaviors. - ANS 2. Individualized goals and objectives.
3. Attendance at group therapy sessions.
4. Self-care measures to improve hygiene.
1079. A client asks the nurse to explain what milieu therapy is. The nurse responds, knowing
that the primary focus of milieu therapy can be best described by which statement?
1. Changing behavior through crisis intervention.
2. A cognitive approach to changing client behavior.
3. Providing a safe, therapeutic environment for clients.
4. A behavioral approach to changing behavior appropriately. - ANS 3. Providing a safe,
therapeutic environment for clients.
1080. An older adult client states to the nurse, "Lately I'm getting forgetful about things. Do you
think I'm getting Alzheimer's disease?" Which response by the nurse is most therapeutic?
1. "Oh, I'm certain it's not Alzheimer's disease because everyone forgets things sometimes."
2. " No, I don't think we really need to discuss this because I' sure it is just normal aging."
3. " Although it's not unusual to experience some lapses of memory, let's discuss your
concerns."
4. " I am so forgetful, too. I never needed lists of things that I had to do, but that changed as I
got older." - ANS 3. " Although it's not unusual to experience some lapses of memory, let's
discuss your concerns."
1081. A client in the mental health unit believes that the food is being poisoned. Which
intervention(s) would be helpful when attempting to encourage the client to eat? Select all that
apply.
1. Use open-ended questions to encourage client dialogue.
2. Offer opinions about the necessity for adequate nutrition.
3. Focus on the client's self-disclosure about food preferences.
, 4. Identify the reasons that the client had for not wanting to eat.
5. Offer the client food in closed containers, such as in cans that have to be opened. - ANS 1.
Use open-ended questions to encourage client dialogue.
5. Offer the client food in closed containers, such as in cans that have to be opened.
1082. The spouse of a client who abuses alcohol states, " I wish I could just get out of this
situation and far away from my spouse." Which response by the nurse is therapeutic?
1. " What aspects of this situation are most difficult for you?"
2. " In order to ensure your safety, it's probably best that you leave."
3. "Maybe you should make this decision when your spouse is stable."
4. "I don't think that's what is best for you or your spouse now. Besides, where would you go?" -
ANS 1. " What aspects of this situation are most difficult for you?"
1083. A crisis center nurse receives a telephone call from
a client who states that he wants to kill himself and that he had a bottle of sleeping pills in from
of him. What is the appropriate nursing action?
1. Keep the client talking, and allow him to ventilate his feelings.
2. Use therapeutic communication techniques, especially the reflection of feelings.
3. Insist that the client give you his name and address so that you can get the police there
immediately.
4. Keep the client talking, and signal another staff member to trace the call so that appropriate
help can be sent. - ANS 4. Keep the client talking, and signal another staff
member to trace the call so that appropriate help can be sent.
1084. Which description(s) are characteristic(s) of a crisis state for a client. Select all that apply.
1. A client's response to a crisis is individualized.
2. A crisis state will always last from 3 to 5 days.
3. A crisis state does not mean that the individual has a mental illness.
4. Presenting symptoms in a crisis situation are similar for all individuals.
5. A crisis state indicates that the individual is suffering from an emotional illness. - ANS 1. A
client's response to a crisis is individualized.
3. A crisis state does not mean that the individual has a mental illness.
1085. A client with a leg amputation is upset about his appearance. The nurse intends to
address which most closely associated psychosocial problem?
1. inability to be mobile.
2. Isolating self from others.
3. Inability to tolerate activity.
4. Concern about body persona. - ANS 4. Concern about body persona.
1086. The nurse is preparing to care for a client who witnessed her mother being shot by an
unknown attacker. The nurse interprets that the client is demonstrating behavior that indicates
denial if which finding is noted?
1. The client is calm, cooperative, and reserved.
