ESSENTIALS OF PSYCHIATRIC
MENTAL EXAM SCRIPT WITH
CORRECT ANSWERS
⩥ 2. Which scenario predicts the highest risk for directing violent
behavior toward others?
a. Major depression with delusions of worthlessness
b. Obsessive-compulsive disorder; performing many rituals
c. Paranoid delusions of being followed by alien monsters
d. Completing alcohol withdrawal and beginning a rehabilitation
program. Answer: ANS: C
The correct answer illustrates the greatest disruption of ability to
perceive reality accurately. People who feel persecuted may strike out
against those believed to be persecutors. The patients identified in the
distracters have better reality-testing ability.
⩥ 3. A patient is hospitalized after an arrest for breaking windows in the
home of a former domestic partner. The history reveals childhood abuse
by a punitive parent, torturing family pets, and an arrest for disorderly
conduct. Which nursing diagnosis has priority?
a. Risk for injury
b. Posttrauma response
,c. Disturbed thought processes
d. Risk for other-directed violence. Answer: ANS: D
The defining characteristics for Risk for other-directed violence include
a history of being abused as a child, having committed other violent acts,
and demonstrating poor impulse control. The defining characteristics for
the other diagnoses are not present in this scenario.
⩥ 4. A confused older adult patient in a skilled care facility is in bed
sleeping. The nurse enters the room quietly and touches the bed to see if
it is wet. The patient awakens and hits the nurse in the face. Which
statement best explains the patient's action?
a. Older adult patients often demonstrate exaggerations of behaviors
used earlier in life.
b. Crowding in skilled care facilities increases individual tendencies
toward violence.
c. The patient interpreted the health care worker's behavior as potentially
harmful.
d. This patient learned violent behavior by watching other patients act
out.. Answer: ANS: C
Confused patients are not always able to evaluate accurately the actions
of others. This patient behaved as though provoked by the intrusive
actions of the staff member.
⩥ 5. A patient is pacing the hall near the nurses' station, swearing loudly.
An appropriate initial intervention for the nurse would be to address the
patient by name and say:
,a. "Hey, what's going on?"
b. "Please quiet down immediately."
c. "I'd like to talk with you about how you're feeling right now."
d. "You must go to your room and try to get control of yourself.".
Answer: ANS: C
Intervention should begin with an analysis of the patient and situation.
With this response, the nurse is attempting to hear the patient's feelings
and concerns, which leads to the next step of planning an intervention.
⩥ 6. A patient was responding to auditory hallucinations earlier in the
morning. The patient approaches the nurse, shaking a fist and shouting,
"Back off!" and then goes into the day room. As the nurse follows the
patient into the day room, the nurse should:
a. make sure adequate physical space exists between the nurse and the
patient.
b. move into a position that allows the patient to be close to the door.
c. maintain one arm's length distance from the patient.
d. sit down in a chair near the patient.. Answer: ANS: A
Making sure space is present between the nurse and the patient avoids
invading the patient's personal space. Personal space needs increase
when a patient feels anxious and threatened. Allowing the patient to
block the nurse's exit from the room is not wise. Closeness may be
threatening to the patient and provoke aggression. Sitting is inadvisable
until further assessment suggests the patient's aggression is abating. One
arm's length is inadequate space.
, ⩥ 7. An intramuscular dose of antipsychotic medication needs to be
given to a patient who is becoming increasingly more aggressive. The
patient is in the day room. The nurse should enter the day room:
a. and say, "Would you like to come to your room and take some
medication your doctor prescribed for you?"
b. accompanied by three staff members and say, "Please come to your
room so I can give you some medication that will help you feel more
comfortable."
c. and place the patient in a basket-hold and then say, "I am going to take
you to your room to give you an injection of medication to calm you."
d. accompanied by a male nursing assistant and tell the patient, "You can
come to your room willingly so I can give you this medication, or the
aide and I will take you there.". Answer: ANS: B
A patient gains feelings of security if he or she sees that others are
present to help with control. The nurse gives a simple direction, honestly
states what is going to happen, and reassures the patient that the
intervention will be helpful. This positive approach assumes that the
patient can act responsibly and will maintain control. Physical control
measures should be used only as a last resort.
⩥ 8. After an assault by a patient, a nurse has difficulty sleeping, startles
easily, and is preoccupied with the incident. The nurse says, "I dread
facing potentially violent patients." Which response would be the most
urgent reason for this nurse to seek supervision?
a. Startle reactions
b. Difficulty sleeping
MENTAL EXAM SCRIPT WITH
CORRECT ANSWERS
⩥ 2. Which scenario predicts the highest risk for directing violent
behavior toward others?
a. Major depression with delusions of worthlessness
b. Obsessive-compulsive disorder; performing many rituals
c. Paranoid delusions of being followed by alien monsters
d. Completing alcohol withdrawal and beginning a rehabilitation
program. Answer: ANS: C
The correct answer illustrates the greatest disruption of ability to
perceive reality accurately. People who feel persecuted may strike out
against those believed to be persecutors. The patients identified in the
distracters have better reality-testing ability.
⩥ 3. A patient is hospitalized after an arrest for breaking windows in the
home of a former domestic partner. The history reveals childhood abuse
by a punitive parent, torturing family pets, and an arrest for disorderly
conduct. Which nursing diagnosis has priority?
a. Risk for injury
b. Posttrauma response
,c. Disturbed thought processes
d. Risk for other-directed violence. Answer: ANS: D
The defining characteristics for Risk for other-directed violence include
a history of being abused as a child, having committed other violent acts,
and demonstrating poor impulse control. The defining characteristics for
the other diagnoses are not present in this scenario.
⩥ 4. A confused older adult patient in a skilled care facility is in bed
sleeping. The nurse enters the room quietly and touches the bed to see if
it is wet. The patient awakens and hits the nurse in the face. Which
statement best explains the patient's action?
a. Older adult patients often demonstrate exaggerations of behaviors
used earlier in life.
b. Crowding in skilled care facilities increases individual tendencies
toward violence.
c. The patient interpreted the health care worker's behavior as potentially
harmful.
d. This patient learned violent behavior by watching other patients act
out.. Answer: ANS: C
Confused patients are not always able to evaluate accurately the actions
of others. This patient behaved as though provoked by the intrusive
actions of the staff member.
⩥ 5. A patient is pacing the hall near the nurses' station, swearing loudly.
An appropriate initial intervention for the nurse would be to address the
patient by name and say:
,a. "Hey, what's going on?"
b. "Please quiet down immediately."
c. "I'd like to talk with you about how you're feeling right now."
d. "You must go to your room and try to get control of yourself.".
Answer: ANS: C
Intervention should begin with an analysis of the patient and situation.
With this response, the nurse is attempting to hear the patient's feelings
and concerns, which leads to the next step of planning an intervention.
⩥ 6. A patient was responding to auditory hallucinations earlier in the
morning. The patient approaches the nurse, shaking a fist and shouting,
"Back off!" and then goes into the day room. As the nurse follows the
patient into the day room, the nurse should:
a. make sure adequate physical space exists between the nurse and the
patient.
b. move into a position that allows the patient to be close to the door.
c. maintain one arm's length distance from the patient.
d. sit down in a chair near the patient.. Answer: ANS: A
Making sure space is present between the nurse and the patient avoids
invading the patient's personal space. Personal space needs increase
when a patient feels anxious and threatened. Allowing the patient to
block the nurse's exit from the room is not wise. Closeness may be
threatening to the patient and provoke aggression. Sitting is inadvisable
until further assessment suggests the patient's aggression is abating. One
arm's length is inadequate space.
, ⩥ 7. An intramuscular dose of antipsychotic medication needs to be
given to a patient who is becoming increasingly more aggressive. The
patient is in the day room. The nurse should enter the day room:
a. and say, "Would you like to come to your room and take some
medication your doctor prescribed for you?"
b. accompanied by three staff members and say, "Please come to your
room so I can give you some medication that will help you feel more
comfortable."
c. and place the patient in a basket-hold and then say, "I am going to take
you to your room to give you an injection of medication to calm you."
d. accompanied by a male nursing assistant and tell the patient, "You can
come to your room willingly so I can give you this medication, or the
aide and I will take you there.". Answer: ANS: B
A patient gains feelings of security if he or she sees that others are
present to help with control. The nurse gives a simple direction, honestly
states what is going to happen, and reassures the patient that the
intervention will be helpful. This positive approach assumes that the
patient can act responsibly and will maintain control. Physical control
measures should be used only as a last resort.
⩥ 8. After an assault by a patient, a nurse has difficulty sleeping, startles
easily, and is preoccupied with the incident. The nurse says, "I dread
facing potentially violent patients." Which response would be the most
urgent reason for this nurse to seek supervision?
a. Startle reactions
b. Difficulty sleeping
