• Psychiatric Mental 09/07/2026
Health
Test Bank 2 for Varcarolis' Foundations of
Psychiatric Mental Health Nursing A Clinical,
9th Edition by Halter, 9780323697071,
Covering Chapters 1-36 | Includes Rationales
A 22-year-old male client is admitted to the emergency center following a suicide attempt. His records reveal that
this is his third suicide attempt in the past two years. He is conscious, but does not respond to verbal commands
for treatment. Which assessment finding should prompt the nurse to prepare the client for gastric lavage?
A) He ingested the drug 3 hours prior to admission to the emergency center.
B) The family reports that he took an entire bottle of acetaminophen (Tylenol).
C) He is unresponsive to instructions and is unable to cooperate with emetic therapy.
D) Those with repeated suicide attempts desire punishment to relieve their guilt. –
Correct Answer :Because the client is unable to follow instructions, emetic therapy would be very difficult to
implement and gastric lavage would be necessary (C). (A and B) should be considered in determining the course
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, • Psychiatric Mental 09/07/2026
Health
of treatment, but they are not the basis for determining if gastric lavage will be implemented. Medical
treatments should never be used as "punitive" measures (D).
Correct Answer(s): C
A 46-year-old female client has been on antipsychotic neuroleptics for the past three days. She has had a
decrease in psychotic behavior and appears to be responding well to the medication. On the fourth day, the
client's blood pressure increases, she becomes pale and febrile, and demonstrates muscular rigidity. Which
action should the nurse initiate?
A) Place the client on seizure precautions and monitor carefully.
B) Immediately transfer the client to ICU.
C) Describe the symptoms to the charge nurse and record on the client's chart.
D) No action is required at this time as these are known side effects of such drugs. –
Correct Answer :These symptoms are descriptive of neuroleptic malignant syndrome (NMS) which is an
extremely serious/life threatening reaction to neuroleptic drugs (B). The major symptoms of this syndrome are
fever, rigidity, autonomic instability, and encephalopathy. Respiratory failure, cardiovascular collapse,
arrhythmias, and/or renal failure can result in death. This is an EMERGENCY situation, and the client requires
immediate critical care. Seizure precautions (A) are not indicated in this situation. (C and D) do not consider the
seriousness of the situation.
Correct Answer(s): B
A young adult male client, diagnosed with paranoid schizophrenia, believes that world is trying poison him. What
intervention should the nurse include in this client's plan of care?
A) Remind the client that his suspicions are not true.
B) Ask one nurse to spend time with the client daily.
C) Encourage the client to participate in group activities.
D) Assign the client to a room closest to the activity room. –
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, • Psychiatric Mental 09/07/2026
Health
Correct Answer :A client with paranoid schizophrenia has difficulty with trust and developing a trusting
relationship with one nurse (B) is likely to be therapeutic for this client. (A) is argumentative. Stress increases
anxiety, and anxiety increases paranoid ideation; (C) would be too stressful and anxiety-promoting for a client
who is experiencing pathological suspicions. (D) also might increase anxiety and stress.
Correct Answer(s): B
The nurse should hold the next scheduled dose of a client's haloperidol (Haldol) based on which assessment
finding(s)?
A) Dizziness when standing.
B) Shuffling gait and hand tremors.
C) Urinary retention.
D) Fever of 102° F. –
Correct Answer :A fever (D) may indicate neuroleptic malignant syndrome (NMS), a potentially fatal
complication of antipsychotics. The healthcare provider should be contacted before administering the next dose
of Haldol. (A, B, and C) are all adverse effects of Haldol which can be managed.
Correct Answer(s): D
Within several days of hospitalization, a client is repeatedly washing the top of the same table. Which initial
intervention is best for the nurse to implement to help the client cope with anxiety related to this behavior?
A) Administer a prescribed PRN antianxiety medication.
B) Assist the client to identify stimuli that precipitates the ritualistic activity.
C) Allow time for the ritualistic behavior, then redirect the client to other activities.
D) Teach the client relaxation and thought stopping techniques.
- Correct Answer :Initially, the nurse should allow time for the ritual (C) to prevent anxiety. (A) may help reduce
the client's anxiety, but will not prevent ritualistic behavior resulting from the client's ineffective coping ability.
(B) is a long-term goal of individual therapy, but is not directly related to controlling the behavior at this time. (D)
lists techniques that can be used to assist the client in learning new ways of interrupting obsessive thoughts and
resulting ritualistic behavior as treatment progresses.
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, • Psychiatric Mental 09/07/2026
Health
Correct Answer(s): C
A 72-year-old female client is admitted to the psychiatric unit with a diagnosis of major depression. Which
statement by the client should be of greatest concern to the nurse and require further assessment?
A) I will die if my cat dies.
B) I don't feel like eating this morning.
C) I just went to my friend's funeral.
D) Don't you have more important things to do? –
Correct Answer :Sometimes a client will use an analogy to describe themselves, and (A) would be an indication
for conducting a suicide assessment. (B) could have a variety of etiologies, and while further assessment is
indicated, this statement does not indicate potential suicide. Normal grief process differs from depression, and
at this client's age peer/cohort deaths are more frequent, so (C) would be within normal limits. (D) is an
expression of low self-esteem typical of depression. (B, C, and D) are examples of decreased energy and mood
levels which would negate suicide ideation at this time.
Correct Answer(s): A
The nurse is conducting discharge teaching for a client with schizophrenia who plans to live in a group home.
Which statement is most indicative of the need for careful follow-up after discharge?
A) Crickets are a good source of protein.
B) I have not heard any voices for a week.
C) Only my belief in God can help me.
D) Sometimes I have a hard time sitting still. - Correct Answer :The most frequent cause of increased symptoms
in psychotic clients is non-compliance with the medication regimen. If clients believe that "God alone" is going to
heal them (C), then they may discontinue their medication, so (C) would pose the greatest threat to this client's
prognosis. (A) would require further teaching, but is not as significant a statement as (C). (B) indicates an
improvement in the client's condition. (D) may be a sign of anxiety that could improve with treatment, but does
not have the priority of (C).
Correct Answer(s): C
P 4
Health
Test Bank 2 for Varcarolis' Foundations of
Psychiatric Mental Health Nursing A Clinical,
9th Edition by Halter, 9780323697071,
Covering Chapters 1-36 | Includes Rationales
A 22-year-old male client is admitted to the emergency center following a suicide attempt. His records reveal that
this is his third suicide attempt in the past two years. He is conscious, but does not respond to verbal commands
for treatment. Which assessment finding should prompt the nurse to prepare the client for gastric lavage?
A) He ingested the drug 3 hours prior to admission to the emergency center.
B) The family reports that he took an entire bottle of acetaminophen (Tylenol).
C) He is unresponsive to instructions and is unable to cooperate with emetic therapy.
D) Those with repeated suicide attempts desire punishment to relieve their guilt. –
Correct Answer :Because the client is unable to follow instructions, emetic therapy would be very difficult to
implement and gastric lavage would be necessary (C). (A and B) should be considered in determining the course
P 1
, • Psychiatric Mental 09/07/2026
Health
of treatment, but they are not the basis for determining if gastric lavage will be implemented. Medical
treatments should never be used as "punitive" measures (D).
Correct Answer(s): C
A 46-year-old female client has been on antipsychotic neuroleptics for the past three days. She has had a
decrease in psychotic behavior and appears to be responding well to the medication. On the fourth day, the
client's blood pressure increases, she becomes pale and febrile, and demonstrates muscular rigidity. Which
action should the nurse initiate?
A) Place the client on seizure precautions and monitor carefully.
B) Immediately transfer the client to ICU.
C) Describe the symptoms to the charge nurse and record on the client's chart.
D) No action is required at this time as these are known side effects of such drugs. –
Correct Answer :These symptoms are descriptive of neuroleptic malignant syndrome (NMS) which is an
extremely serious/life threatening reaction to neuroleptic drugs (B). The major symptoms of this syndrome are
fever, rigidity, autonomic instability, and encephalopathy. Respiratory failure, cardiovascular collapse,
arrhythmias, and/or renal failure can result in death. This is an EMERGENCY situation, and the client requires
immediate critical care. Seizure precautions (A) are not indicated in this situation. (C and D) do not consider the
seriousness of the situation.
Correct Answer(s): B
A young adult male client, diagnosed with paranoid schizophrenia, believes that world is trying poison him. What
intervention should the nurse include in this client's plan of care?
A) Remind the client that his suspicions are not true.
B) Ask one nurse to spend time with the client daily.
C) Encourage the client to participate in group activities.
D) Assign the client to a room closest to the activity room. –
P 2
, • Psychiatric Mental 09/07/2026
Health
Correct Answer :A client with paranoid schizophrenia has difficulty with trust and developing a trusting
relationship with one nurse (B) is likely to be therapeutic for this client. (A) is argumentative. Stress increases
anxiety, and anxiety increases paranoid ideation; (C) would be too stressful and anxiety-promoting for a client
who is experiencing pathological suspicions. (D) also might increase anxiety and stress.
Correct Answer(s): B
The nurse should hold the next scheduled dose of a client's haloperidol (Haldol) based on which assessment
finding(s)?
A) Dizziness when standing.
B) Shuffling gait and hand tremors.
C) Urinary retention.
D) Fever of 102° F. –
Correct Answer :A fever (D) may indicate neuroleptic malignant syndrome (NMS), a potentially fatal
complication of antipsychotics. The healthcare provider should be contacted before administering the next dose
of Haldol. (A, B, and C) are all adverse effects of Haldol which can be managed.
Correct Answer(s): D
Within several days of hospitalization, a client is repeatedly washing the top of the same table. Which initial
intervention is best for the nurse to implement to help the client cope with anxiety related to this behavior?
A) Administer a prescribed PRN antianxiety medication.
B) Assist the client to identify stimuli that precipitates the ritualistic activity.
C) Allow time for the ritualistic behavior, then redirect the client to other activities.
D) Teach the client relaxation and thought stopping techniques.
- Correct Answer :Initially, the nurse should allow time for the ritual (C) to prevent anxiety. (A) may help reduce
the client's anxiety, but will not prevent ritualistic behavior resulting from the client's ineffective coping ability.
(B) is a long-term goal of individual therapy, but is not directly related to controlling the behavior at this time. (D)
lists techniques that can be used to assist the client in learning new ways of interrupting obsessive thoughts and
resulting ritualistic behavior as treatment progresses.
P 3
, • Psychiatric Mental 09/07/2026
Health
Correct Answer(s): C
A 72-year-old female client is admitted to the psychiatric unit with a diagnosis of major depression. Which
statement by the client should be of greatest concern to the nurse and require further assessment?
A) I will die if my cat dies.
B) I don't feel like eating this morning.
C) I just went to my friend's funeral.
D) Don't you have more important things to do? –
Correct Answer :Sometimes a client will use an analogy to describe themselves, and (A) would be an indication
for conducting a suicide assessment. (B) could have a variety of etiologies, and while further assessment is
indicated, this statement does not indicate potential suicide. Normal grief process differs from depression, and
at this client's age peer/cohort deaths are more frequent, so (C) would be within normal limits. (D) is an
expression of low self-esteem typical of depression. (B, C, and D) are examples of decreased energy and mood
levels which would negate suicide ideation at this time.
Correct Answer(s): A
The nurse is conducting discharge teaching for a client with schizophrenia who plans to live in a group home.
Which statement is most indicative of the need for careful follow-up after discharge?
A) Crickets are a good source of protein.
B) I have not heard any voices for a week.
C) Only my belief in God can help me.
D) Sometimes I have a hard time sitting still. - Correct Answer :The most frequent cause of increased symptoms
in psychotic clients is non-compliance with the medication regimen. If clients believe that "God alone" is going to
heal them (C), then they may discontinue their medication, so (C) would pose the greatest threat to this client's
prognosis. (A) would require further teaching, but is not as significant a statement as (C). (B) indicates an
improvement in the client's condition. (D) may be a sign of anxiety that could improve with treatment, but does
not have the priority of (C).
Correct Answer(s): C
P 4
