Health Q&A | Mental Health Nursing
1. A nurse is assessing a client who has recently experienced a suicide
attempt. According to the risk factors for suicide, which of the following
clients is at the highest risk for completing suicide?
A) An adolescent female who overdosed on over-the-counter pain medication
B) A middle-aged male who used a firearm in the attempt
C) An older adult female with a history of depression
D) A young adult male who expressed suicidal ideation but has no plan
Correct Answer: A middle-aged male who used a firearm in the attempt
Rationale: Men are more successful in completing suicide than women, often
using more lethal means such as firearms. The risk of suicide also increases
with age, particularly among men. A middle-aged male using a firearm
combines high-risk gender, age, and method factors.
2. A nurse is caring for a client who has been diagnosed with major
depressive disorder and is prescribed a selective serotonin reuptake inhibitor
(SSRI). The client's family member expresses concern that the client seems
more anxious and agitated after starting the medication. Which of the
following is the most appropriate nursing response?
A) "This is a sign that the medication is not working and should be stopped
immediately."
B) "This is a common side effect that typically resolves, but the client should
be closely monitored for suicidal ideation."
C) "This means the client is having an allergic reaction and needs to be seen
by a provider."
D) "The client should take the medication only every other day to reduce
these symptoms."
,Correct Answer: "This is a common side effect that typically resolves, but the
client should be closely monitored for suicidal ideation."
Rationale: Antidepressants, especially SSRIs, can cause increased anxiety,
agitation, and suicidal ideation, particularly in the first few weeks of
treatment. This is a known side effect, and clients need close monitoring
during this period. The medication should not be stopped abruptly or taken
on an altered schedule.
3. A nurse is leading a group therapy session for clients with depression.
Which of the following statements by a client indicates an understanding of
cognitive behavioral therapy (CBT) as described in the course material?
A) "CBT focuses on how my childhood experiences shape my current
behaviors."
B) "CBT is based on the idea that my thoughts influence my feelings and
actions."
C) "CBT is primarily concerned with changing my unconscious conflicts."
D) "CBT is a type of therapy that uses medication to change my mood."
Correct Answer: "CBT is based on the idea that my thoughts influence my
feelings and actions."
Rationale: Cognitive behavioral therapy is based on the cognitive model,
which focuses on individual thoughts and behaviors to solve current
problems. The core belief is that thoughts come before feelings and actions.
It treats depression, anxiety, and other issues by changing a client's attitude
toward life experiences.
4. A client is exhibiting signs of panic-level anxiety. Which of the following
physiological responses is most consistent with this level of anxiety?
A) Mild finger tapping and fidgeting
B) Increased heart rate and respiratory rate
,C) Hyperventilation and tachycardia
D) Severe hyperactivity and dilated pupils
Correct Answer: Severe hyperactivity and dilated pupils
Rationale: Panic anxiety is the most severe level and is characterized by
severe hyperactivity, flight or immobility, dysfunction of speech, dilated
pupils, severe shakiness, and severe withdrawal. A fire in the house is an
example of a situation where panic anxiety may occur.
5. A nurse is planning care for a client who is experiencing a crisis. According
to the crisis intervention model, which of the following is the primary goal?
A) To explore the client's childhood experiences
B) To return the client to their pre-crisis level of functioning
C) To provide long-term psychotherapy
D) To prescribe psychotropic medication
Correct Answer: To return the client to their pre-crisis level of functioning
Rationale: The primary goal of crisis intervention is to help the client return
to their pre-crisis level of functioning. Crisis intervention is short-term and
focused on the immediate situation.
6. A mother is concerned about her ability to perform in her new role and
refuses to leave the postpartum unit. The nurse recognizes that this type of
crisis is most likely:
A) Precipitated by unexpected external stressors
B) Precipitated by preexisting psychopathology
C) Precipitated by an acute response to an external situational stressor
, D) Precipitated by normal life-cycle transitions that overwhelm the client
Correct Answer: Precipitated by normal life-cycle transitions that overwhelm
the client
Rationale: A maturational or developmental crisis is precipitated by normal
life-cycle transitions that overwhelm the client's ability to cope. The
postpartum period is a normal life transition that can be overwhelming for
some clients.
7. A client who has recently lost their job is brought to the emergency
department after an attempt to hang themselves. The client states, "I can't
function any longer under all this stress." The nurse identifies this as which
type of crisis?
A) Maturational/developmental crisis
B) Psychiatric emergency crisis
C) Anticipated life transition crisis
D) Traumatic stress crisis
Correct Answer: Psychiatric emergency crisis
Rationale: A suicide attempt is a psychiatric emergency. While the situation
involves stress and loss, the immediate concern is the client's life-
threatening behavior, making it a psychiatric emergency crisis.
8. A client is diagnosed with a somatic symptom disorder. When planning
care, which of the following is the most appropriate nursing action?
A) Avoid discussing social and personal problems
B) Focus interventions on the physical symptoms
C) Encourage the client to talk about feelings rather than physical complaints