Psychiatric/Mental Health Review Exam - Questions, Answers and Rationales

Psychiatric/Mental Health Review Exam - Questions, Answers and Rationales An adolescent has been admitted for evaluation of excessive weight loss over several months. When assessing the client, what data gathered by the nurse would be most important to support a diagnosis of anorexia nervosa? Select all that apply 1. Dehydration 2. Poor appetite 3. Amenorrhea 4. Tachycardia 5. Muscle loss 6. Constipation Rationale: 1., 3., 5., and 6. CORRECT: The client has lost excessive weight over several months, indicating possibly early stages of anorexia nervosa. In the initial stages of starvation, skin becomes very dry and dehydrated. A client suffering from starvation is experiencing a loss of both food and fluids. Not only does the skin provide evidence of dehydration, but hair and nails will also be dry and brittle. This visible sign would be readily noticed by the nurse. (3) The client eventually develops amenorrhea. As the body begins to deteriorate from the effects of starvation, many normal body functions also decrease, or even cease. In women, amenorrhea develops as the normal monthly cycle slows, and finally stops. In fact, many individuals who recover from anorexia nervosa often have difficulty getting pregnant after that. (5) As weight decreases, muscle mass and strength is lost. As weight is lost, fatty tissue also decreases. Eventually, as muscles atrophy, the client will lose muscle mass, appearing quite skeletal. The client still perceives excessive body weight, though the nurse would visibly see atrophy. (6) Poor intake of fiber or fluids can also lead to increased constipation. When the human body is denied proper food and fluids, the gastrointestinal system responds by becoming sluggish. Constipation can become very serious, as waste products are not being eliminated by the body. 2. INCORRECT: With anorexia nervosa clients, the normal appetite still exists but the individual refuses to acknowledge the need to eat. The client will continue to resist the appetite in order to lose weight. 4. INCORRECT: Although the client may begin to experience arrhythmias, the pulse is not consistently tachycardic. The client may also experience episodes of bradycardia, especially at rest. The client with mania has repeatedly interrupted group session with the counselor. The client explains that they already know this information about family roles and paces around the room. What should the nurse do at this time? 1. Ask the client to take a walk with you and make another pot of coffee. 2. Ask the client to reflect on their behavior to determine if it is appropriate. 3. Ask the group to tell the client how they feel when they are interrupted. 4. Tell the client to perform jumping jacks and count out loud. Rationale: 1. Correct: Yes, get them away from the group and do something purposeful. Purposeful activities help the client use energy and focus on something. Distractibility is the nurse's most effective tool. 2. Incorrect: That is embarrassing and humiliating to the client. Singling out the client during group activity, does not fix the problem. This may lead to arguing and escalate the client's mania. 3. Incorrect: Sometimes this will be helpful during times of therapy, but the client is manic at this time. They may not believe them. Also, the client may be aggressive toward other group members. 4. Incorrect: This is getting them active, but the group will be interrupted by this behavior. Do not let the client continue with this attention seeking behavior. Remove the client from the group activity. The purpose of the group is to work toward a common goal. The client performing jumping jacks is not working toward a common goal. The nurse is caring for a client who presents to the mental health unit following a violent altercation with the spouse. The client has numerous bruises on the face, chest, and back. There is one laceration where spouse "came at me" with a knife. At this time, what is most likely to be the mood of the perpetrator in this situation? 1. Extreme anger 2. Anxiety 3. Kindness 4. Irritability There are 3 phases: tension building, acute battering (explosion), and honeymoon phase. Rationale: 3. Correct: The perpetrator has completed the acute battering phase and has now likely entered the honeymoon phase with extreme kindness and acts of love. The attacker is now calm after the tension has been released. You may witness remorseful and apologetic behaviors like bringing gifts and promises of love. 1. Incorrect: The anger phase is likely over after the attacker has beaten the victim. The extreme anger exhibited during the acute battering stage. The abuser releases the built-up anger and tension by brutal and uncontrollable beatings. After the beating, the client is calm and described as "in shock" or having amnesia of the event. 2. Incorrect: The tension or anxiety would be felt during the tension-building phase. This tension building stage and is characterized by minor incidents like pushing, shoving and verbal abuse. During this time the abused spouse may accept the abuse for fear of it getting worse so the abuser rationalizes that the behavior is acceptable. The abuser may even turn to alcohol and drugs to curb the anger. 4. Incorrect: Irritability would be demonstrated during the tension-building phase. An elderly client is to be ambulated for the first time following a hip replacement. The client refuses to get out of bed, indicating an extreme fear of falling. What statement by the nurse is most therapeutic? 1. "Don't be afraid because I will not let you fall." 2. "Your doctor says you must walk twice today." 3. "I'll get another nurse to help so you won't fall." 4. "What worries you most about getting out of bed?" Rationale: 4. CORRECT: The nurse needs to focus on the client's psychological as well as physical needs. An open-ended question or statement encourages the client to elaborate and share concerns that the nurse needs to address. It would be inappropriate to force the client to participate in an activity that causes extreme fear and distress. 1. INCORRECT: The nurse is dismissing the client's right to experience a specific emotion, rather than actively seeking the reason behind those feelings. The nurse is not utilizing appropriate communication techniques. 2. INCORRECT: This tactless response focuses on the orders provided by the primary healthcare provider, rather than the client's expressed concerns. Such a comment by the nurse is non-therapeutic because it ignores the client's psychological needs. 3. INCORRECT: Although the nurse offers a solution to the client, there is no chance for the client to verbalize feelings and concerns. It is more important to present the client with the therapeutic opportunity to discuss fears. The nurse is working on the inpatient mental health unit and determines that one of the clients has suicidal thoughts. The nurse initiates suicide precautions. Which rationale best validates the action? 1. The client has the right to a safe care environment. 2. The nurse may be sued for malpractice if injury occurs. 3. All clients on mental health units are placed on suicide precautions. 4. Clients are most likely to act on suicidal thoughts when energy is low. Rationale: 1. Correct: Verbalizing suicidal thoughts is a risk factor for client suicide. Safety must be maintained while the client is in this vulnerable state. The nurse identifies client at risk of suicide and intervenes to prevent harm for those identified as being at risk. 2. Incorrect: Client safety is the primary issue here. 3. Incorrect: This is not a true statement. All clients have the right to a safe environment; however, not all clients on the mental health unit are placed on suicide precautions. Only clients identified at risk for suicide are placed on suicide precautions. 4. Incorrect: This is an untrue statement. Clients are likely to act on suicidal thoughts as energy levels improve. The issue here is client safety, and the client's right to a safe environment. The school nurse has been observing a 13 year-old student during the past few months as the student has steadily lost weight. Which assessment finding would be the best indication of the beginning of an eating disorder? 1. Clothing size has decreased by 2 sizes. 2. Student eats most meals with peers. 3. Client reports a fear of gaining weight. 4. Diet consists mostly of fruit or raw vegetables. Rationale: 3. Correct: An adolescent reporting a fear of gaining weight may indicate the beginning of an eating disorder. This is the best indicator of an eating disorder. 1. Incorrect: A decrease in clothing size does not indicate a problem. It may be an indicator of an eating disorder but in itself does not mean there is an eating disorder. 2. Incorrect: A client with an eating disorder may eat alone, or not at all. Eating with peers shows the feeling of acceptance which is not usually present with an eating disorder. 4. Incorrect: Eating snacks of fruit and vegetables is a healthy behavior. This alone does not contribute to an eating disorder. Also, it says the diet is "mostly" fruit and vegetables. A client in the manic phase of bipolar disorder is constantly walking around the day room and refuses to sit down to eat the spaghetti and meatballs sent by the kitchen. Which food should the nurse request from dietary? 1. Carrots and apples 2. Donuts 3. Pepperoni pizza sticks 4. Strawberry pastry Rationale: 3. Correct: High protein, high calorie, nutritious finger foods are required when the client will not sit down to eat. This client needs food they can eat "on the go" because they are burning more calories in this phase of bipolar disorder. 1. Incorrect: Although nutritious, these foods are not high calorie or high protein. 2. Incorrect: Donuts are high in calories but do not have high nutritional value. 4. Incorrect: Pasties are also high in calories but do not have high nutritional value. They are also not very easy to eat "on the go" The family of an elderly client are concerned about emotional well-being since the loss of the spouse two years ago. What alternative therapy could the nurse recommend for this client?