NUR 2459 • Mental Health Chapter Review
questions and answers
. A client is brought to the emergency department by a family member
who reports that the client stopped taking mood stabilizer medication a
few months ago and is now agitated, pacing, demanding, and speaking
very loudly. Her family member reports that she eats very little, is losing
weight, and almost never sleeps. What is the priority nursing diagnosis?
a. Imbalanced nutrition: Less than body requirements related to not
eating
b. Risk for injury related to hyperactivity
c. Disturbed sleep patt Ans✓✓✓ b. Risk for injury related to
hyperactivity
. A client who has been taking sertraline (Zoloft) 50 mg PO bid for
depression tells the nurse, "I've been on this medication for almost a
week and I don't feel a bit better." What is the most appropriate
response by the nurse?
a. "Cheer up. You have so much to be happy about."
b. "Sometimes it takes a few weeks for the medicine to bring about an
improvement in symptoms."
c. "I'll report that to the physician. Maybe he will order something
different."
d. "Try not to dwell Ans✓✓✓ b. "Sometimes it takes a few weeks for
the medicine to bring about an improvement in symptoms."
,. A client whose husband died 6 months ago is given a diagnosis of
major depressive disorder. She says to the nurse, "I start feeling angry
that Harold died and left me all alone; he should have stopped smoking
years ago! But then I start feeling guilty for feeling that way." What is
an appropriate response by the nurse?
a. "Yes, he should have stopped smoking. Then he probably wouldn't
have gotten lung cancer."
b. "I can understand how you must feel."
c. "Those feelings are a no Ans✓✓✓ c. "Those feelings are a normal
part of the grief response."
. A client with neurocognitive disease due to Alzheimer's disease is
admitted to the hospital. Which of the following actions by the nurse is
a priority?
a. Ensuring that she receives food she likes to prevent hunger
b. Ensuring that the environment is safe to prevent injury
c. Ensuring that she meets the other patients to prevent social isolation
d. Ensuring that she takes care of her own ADLs to prevent dependence
Ans✓✓✓ b. Ensuring that the environment is safe to prevent injury
A client admitted to the inpatient detoxification program for alcohol
withdrawal approaches the nurse complaining of nausea and feeling
shaky. The nurse notices that the client has hand tremors and appears
diaphoretic. Which of these nursing interventions is a priority?
a. Check the client's temperature.
, b. Send a urine sample to the laboratory for a random drug screen.
c. Ask the client if there is anything that he is particularly stressed
about.
d. Administer prn benzodiazepine that was orde Ans✓✓✓ d.
Administer prn benzodiazepine that was ordered for management of
withdrawal symptoms.
A client admitted to the inpatient psychiatric unit with bipolar disorder
tells the nurse, "I need to sit in on change-of-shift report because I have
been appointed director of this unit." Which action by the nurse
demonstrates the best clinical judgment at this point?
a. Invite the client to sit in on the change-of-shift report, but do not
share any confidential client information.
b. Instruct the client that this is not permitted and redirect the client to
other unit activities that are av Ans✓✓✓ b. Instruct the client that this
is not permitted and redirect the client to other unit activities that are
available.
A client comes into the emergency department stating that he is
"crashing" and feels like he'd "be better off dead." Which of these
nursing interventions is a priority?
a. Instruct the client not to worry; these are temporary signs of
withdrawal and should go away in a few days.
b. Request an order for amphetamines to ease the client's withdrawal
symptoms.
c. Assess the client's risk for suicide.
questions and answers
. A client is brought to the emergency department by a family member
who reports that the client stopped taking mood stabilizer medication a
few months ago and is now agitated, pacing, demanding, and speaking
very loudly. Her family member reports that she eats very little, is losing
weight, and almost never sleeps. What is the priority nursing diagnosis?
a. Imbalanced nutrition: Less than body requirements related to not
eating
b. Risk for injury related to hyperactivity
c. Disturbed sleep patt Ans✓✓✓ b. Risk for injury related to
hyperactivity
. A client who has been taking sertraline (Zoloft) 50 mg PO bid for
depression tells the nurse, "I've been on this medication for almost a
week and I don't feel a bit better." What is the most appropriate
response by the nurse?
a. "Cheer up. You have so much to be happy about."
b. "Sometimes it takes a few weeks for the medicine to bring about an
improvement in symptoms."
c. "I'll report that to the physician. Maybe he will order something
different."
d. "Try not to dwell Ans✓✓✓ b. "Sometimes it takes a few weeks for
the medicine to bring about an improvement in symptoms."
,. A client whose husband died 6 months ago is given a diagnosis of
major depressive disorder. She says to the nurse, "I start feeling angry
that Harold died and left me all alone; he should have stopped smoking
years ago! But then I start feeling guilty for feeling that way." What is
an appropriate response by the nurse?
a. "Yes, he should have stopped smoking. Then he probably wouldn't
have gotten lung cancer."
b. "I can understand how you must feel."
c. "Those feelings are a no Ans✓✓✓ c. "Those feelings are a normal
part of the grief response."
. A client with neurocognitive disease due to Alzheimer's disease is
admitted to the hospital. Which of the following actions by the nurse is
a priority?
a. Ensuring that she receives food she likes to prevent hunger
b. Ensuring that the environment is safe to prevent injury
c. Ensuring that she meets the other patients to prevent social isolation
d. Ensuring that she takes care of her own ADLs to prevent dependence
Ans✓✓✓ b. Ensuring that the environment is safe to prevent injury
A client admitted to the inpatient detoxification program for alcohol
withdrawal approaches the nurse complaining of nausea and feeling
shaky. The nurse notices that the client has hand tremors and appears
diaphoretic. Which of these nursing interventions is a priority?
a. Check the client's temperature.
, b. Send a urine sample to the laboratory for a random drug screen.
c. Ask the client if there is anything that he is particularly stressed
about.
d. Administer prn benzodiazepine that was orde Ans✓✓✓ d.
Administer prn benzodiazepine that was ordered for management of
withdrawal symptoms.
A client admitted to the inpatient psychiatric unit with bipolar disorder
tells the nurse, "I need to sit in on change-of-shift report because I have
been appointed director of this unit." Which action by the nurse
demonstrates the best clinical judgment at this point?
a. Invite the client to sit in on the change-of-shift report, but do not
share any confidential client information.
b. Instruct the client that this is not permitted and redirect the client to
other unit activities that are av Ans✓✓✓ b. Instruct the client that this
is not permitted and redirect the client to other unit activities that are
available.
A client comes into the emergency department stating that he is
"crashing" and feels like he'd "be better off dead." Which of these
nursing interventions is a priority?
a. Instruct the client not to worry; these are temporary signs of
withdrawal and should go away in a few days.
b. Request an order for amphetamines to ease the client's withdrawal
symptoms.
c. Assess the client's risk for suicide.
