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NUR220 – Mental Health Complete
Questions and Correct Detailed Answers
1. A charge nurse overhears another nurse talking with a client who has
schizophrenia. Suddenly the client yells, "I am the devil. I am God. Open the
gate for me!" Which of the following replies by the nurse requires
intervention by the charge nurse?
A) Tell me who you are
B) I dont understand. Can you tell me what that means?
C) Are you saying that you are both good and bad?
D) There is no gate.
ANSWER: D) There is no gate
2. A nurse in a psychiatric unit is caring for a client who is being admitted
involuntarily after attacking a neighbor. The nurse knows that the client can
be kept in the hospital after the 72-hour hold is over if the client
A) is a danger to herself or others.
B) is unwilling to accept that treatment is needed.
C) does not have anyone that she could stay with.
D) is financially incapable of paying for prescription medications.
ANSWER: A) Is a danger to herself or others
3. A nurse in the ED is caring for a client taking haldol for the past 3 months.
The client's temperature is 102 F, BP 150/110, and has tachycardia. The nurse
should know that these indicate a diagnosis of
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A) agranulocytosis
B) neuroleptic malignant syndrome (NMS)
C) hypertensive crisis
D) tardive dyskinesia
ANSWER: B) neuroleptic malignant syndrome (NMS)
4. A nurse is admitting a client who has multiple trauma after a motor vehicle
accident. Shortly after admission her husband arrives. He is distraught and
blames himself for the accident. Which of the following is an appropriate
nursing response?
A) Don't worry about that. Your wife will be fine.
B) I think you should calm down a little before you see your wife.
C) Why do you think the accident was your fault?
D) Tell me more about your feelings about what happened to your wife.
ANSWER: D) Tell me more about your feelings about what happened to your
wife.
5. A nurse is assessing a client receiving treatment for schizophrenia with the
typical antipsychotic fluphenazine (Prolixin) for 12 months. The nurse
observes fine, fasciculating tongue movements and associates this finding with
which of the following?
A) A drug-food reaction to grapefruit juice
B) The client has missed several doses of medication
C) Early symptoms of neuroleptic malignant syndrome (NMS)
D) Early symptoms of tardive dyskinesia (TD)
, 3
ANSWER: D) Early symptoms of tardive dyskinesia (TD)
6. A nurse is assessing an adolescent client with anorexia. Which of the
following client statements is a sign of cognitive distortion?
a) I like to cut my food into small portions
b) I really need to get in shape
c) If I eat one piece of candy, I may as well eat ten.
d) I can't afford to gain weight.
ANSWER: c) If I eat one piece of candy, I may as well eat ten.
7. A nurse is assessing for the presence of extrapyramidal side effects (EPSs)
in a client taking chlorpromazine (Thorazine). Which of the following findings
should the nurse recognize as EPSs? Select all that apply.
a) Muscle contractions of the neck
b) Fidgeting behavior
c) Fluctuating vital signs
d) Impaired gait
e) Sexual dysfunction
ANSWER: a) Muscle contractions of the neck
b) Fidgeting behavior
d) Impaired gait
8. A nurse is caring for a client admitted with acute psychosis, being treated
with haloperidol (Haldol.) The nurse should suspect tardive dyskinesia as an
NUR220 – Mental Health Complete
Questions and Correct Detailed Answers
1. A charge nurse overhears another nurse talking with a client who has
schizophrenia. Suddenly the client yells, "I am the devil. I am God. Open the
gate for me!" Which of the following replies by the nurse requires
intervention by the charge nurse?
A) Tell me who you are
B) I dont understand. Can you tell me what that means?
C) Are you saying that you are both good and bad?
D) There is no gate.
ANSWER: D) There is no gate
2. A nurse in a psychiatric unit is caring for a client who is being admitted
involuntarily after attacking a neighbor. The nurse knows that the client can
be kept in the hospital after the 72-hour hold is over if the client
A) is a danger to herself or others.
B) is unwilling to accept that treatment is needed.
C) does not have anyone that she could stay with.
D) is financially incapable of paying for prescription medications.
ANSWER: A) Is a danger to herself or others
3. A nurse in the ED is caring for a client taking haldol for the past 3 months.
The client's temperature is 102 F, BP 150/110, and has tachycardia. The nurse
should know that these indicate a diagnosis of
,2
A) agranulocytosis
B) neuroleptic malignant syndrome (NMS)
C) hypertensive crisis
D) tardive dyskinesia
ANSWER: B) neuroleptic malignant syndrome (NMS)
4. A nurse is admitting a client who has multiple trauma after a motor vehicle
accident. Shortly after admission her husband arrives. He is distraught and
blames himself for the accident. Which of the following is an appropriate
nursing response?
A) Don't worry about that. Your wife will be fine.
B) I think you should calm down a little before you see your wife.
C) Why do you think the accident was your fault?
D) Tell me more about your feelings about what happened to your wife.
ANSWER: D) Tell me more about your feelings about what happened to your
wife.
5. A nurse is assessing a client receiving treatment for schizophrenia with the
typical antipsychotic fluphenazine (Prolixin) for 12 months. The nurse
observes fine, fasciculating tongue movements and associates this finding with
which of the following?
A) A drug-food reaction to grapefruit juice
B) The client has missed several doses of medication
C) Early symptoms of neuroleptic malignant syndrome (NMS)
D) Early symptoms of tardive dyskinesia (TD)
, 3
ANSWER: D) Early symptoms of tardive dyskinesia (TD)
6. A nurse is assessing an adolescent client with anorexia. Which of the
following client statements is a sign of cognitive distortion?
a) I like to cut my food into small portions
b) I really need to get in shape
c) If I eat one piece of candy, I may as well eat ten.
d) I can't afford to gain weight.
ANSWER: c) If I eat one piece of candy, I may as well eat ten.
7. A nurse is assessing for the presence of extrapyramidal side effects (EPSs)
in a client taking chlorpromazine (Thorazine). Which of the following findings
should the nurse recognize as EPSs? Select all that apply.
a) Muscle contractions of the neck
b) Fidgeting behavior
c) Fluctuating vital signs
d) Impaired gait
e) Sexual dysfunction
ANSWER: a) Muscle contractions of the neck
b) Fidgeting behavior
d) Impaired gait
8. A nurse is caring for a client admitted with acute psychosis, being treated
with haloperidol (Haldol.) The nurse should suspect tardive dyskinesia as an
