PSYCHIATRIC
MENTAL HEALTH
NURSING (CHAPTER 1-24)
FINAL EXAM
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1
,1. Which behavior best demonstrates aggression?
a. Stomping away from the nurses' station, going to the day room, and grabbing a pool cue from a
patient standing by the pool table.
b. Bursting into tears, leaving the community meeting, and sitting on a bed hugging a pillow and
sobbing.
c. Telling the primary nurse, "I felt angry when you said I could not have a second helping at lunch."
d. Telling the medication nurse, "I am not going to take that or any other medication you try to give
me."
- CORRECT ANSWER -ANS: A
Aggression is harsh physical or verbal action that reflects rage, hostility, and the potential for
physical or verbal destructiveness. Aggressive behavior violates the rights of others. The incorrect
options do not feature violation of another's rights.
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 - CORRECT 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 - CORRECT ANSWER -ANS: D
The defining characteristics for Risk for other-directed violence include a history of being abused as a
2
,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. - CORRECT 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." - CORRECT 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. - CORRECT ANSWER -ANS: A
3
, 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." - CORRECT 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
c. Wish for revenge
d. Preoccupation with the incident - CORRECT ANSWER -ANS: C
The desire for revenge signals an urgent need for professional supervision to work through anger
and counter the aggressive feelings. The distracters are normal in a person who has been assaulted.
Nurses are usually relieved with crisis intervention and follow-up designed to give support, help the
individual regain a sense of control, and make sense of the event.
4
MENTAL HEALTH
NURSING (CHAPTER 1-24)
FINAL EXAM
High-Yield Qs & Answers with Feedback
This Exam Description:
High-Yield Qs
Answers with Feedback
Multiple Choices
Current Q&As
100% Guaranteed Pass
1
,1. Which behavior best demonstrates aggression?
a. Stomping away from the nurses' station, going to the day room, and grabbing a pool cue from a
patient standing by the pool table.
b. Bursting into tears, leaving the community meeting, and sitting on a bed hugging a pillow and
sobbing.
c. Telling the primary nurse, "I felt angry when you said I could not have a second helping at lunch."
d. Telling the medication nurse, "I am not going to take that or any other medication you try to give
me."
- CORRECT ANSWER -ANS: A
Aggression is harsh physical or verbal action that reflects rage, hostility, and the potential for
physical or verbal destructiveness. Aggressive behavior violates the rights of others. The incorrect
options do not feature violation of another's rights.
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 - CORRECT 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 - CORRECT ANSWER -ANS: D
The defining characteristics for Risk for other-directed violence include a history of being abused as a
2
,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. - CORRECT 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." - CORRECT 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. - CORRECT ANSWER -ANS: A
3
, 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." - CORRECT 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
c. Wish for revenge
d. Preoccupation with the incident - CORRECT ANSWER -ANS: C
The desire for revenge signals an urgent need for professional supervision to work through anger
and counter the aggressive feelings. The distracters are normal in a person who has been assaulted.
Nurses are usually relieved with crisis intervention and follow-up designed to give support, help the
individual regain a sense of control, and make sense of the event.
4
