PSYCHIATRIC MENTAL HEALTH NURSING QUESTIONS AND ANSWERS 100% CORRECT.

"Around 2:30 in the afternoon is the best time to visit." - ANSWERS-An older client with a diagnosis of dementia is living in a long-term care facility. The client's daughter, who lives 300 miles away, calls the unit to speak to the nurse about her upcoming visit. What should the nurse say in response to her question about the best time of day to visit? ."Don't be afraid. I'm your nurse, and everyone here in the hospital is here to help you." - ANSWERS-An older adult, accompanied by family members, is admitted to a long-term care facility with symptoms of dementia. During the admission procedure the initial statement by the nurse most helpful to this client is: ."Every time I turn around the kid is falling over something." "I can't understand it. He didn't have a problem using the stairs without my help before this." - ANSWERS-A 2½-year-old child is admitted for treatment of injuries supposedly sustained in a fall down a flight of stairs. Child abuse is suspected. What statements might the nurse expect from a parent who engages in child abuse? (Select all that apply.) ."Everyone has a bed. This one is yours." - ANSWERS-A male client with the diagnosis of a bipolar disorder, depressed episode, is found lying on the floor in his room in the psychiatric unit. He states, "I don't deserve a comfortable bed; give it to someone else." The best response response by the nurse is: ."Everyone is responsible for his own actions." - ANSWERS-A client in the outpatient clinic is denying that he is addicted to alcohol. He tells the nurse that he is not an alcoholic and that it is his nagging wife who causes him to drink. What is the most therapeutic response by the nurse? ."Have you ever felt bad or guilty about your drinking?" - ANSWERS-A nurse uses the CAGE screening test for alcoholism to determine an individual's potential for a drinking problem. What is one of the four questions included on this test? ."How will you manage the next time your problems start piling up?" - ANSWERS-A nurse moves into the working phase of a therapeutic relationship with a depressed client who has a history of suicide attempts. What question should the nurse ask the client when exploring alternative coping strategies? ."I didn't hear anyone talking; come with me to your room." - ANSWERS-The nurse finds a client with schizophrenia lying under a bench in the hall. The client says, "God told me to lie here." What is the best response by the nurse? ."I don't hear anyone else talking, but I can see that you're upset." - ANSWERS-A nurse enters a client's room and notes that the client appears preoccupied. Turning to the nurse, the client says, "They're saying terrible things about me. Can't you hear them?" What is the most therapeutic response by the nurse? ."I don't like hearing your threats, but tell me more about your feelings." - ANSWERS-A client has been on the psychiatric unit for several days. The client arouses anxiety and frustration in the staff and manipulates them so well that staff members are afraid to approach the client. One morning the client shouts at the nurse, "You've worked it so I can't go for a walk with the group today. You're as cunning as a fox. I hate you! Get out, or I'll hit you!" What is the best response by the nurse? ."I know there's no reason to do these things, but I can't help myself." - ANSWERS-A client is admitted to the hospital because of incapacitating obsessive-compulsive behavior. The statement that best describes how clients with obsessive-compulsive behavior view this disorder is: ."I know you don't feel like getting up, but you might feel better if you did. Let me help you get started." - ANSWERS-A nurse has been assigned to work with a depressed client on a one-on-one basis. The next morning the client refuses to get out of bed, saying, "I'm too sick to be helped, and I don't want to be bothered." What is the best response by the nurse? ."I understand that these voices are real to you, but I want you to know that I don't hear them." - ANSWERS-A client tells the nurse, "The voices say I'll be safe only if I stay in this room, wear these clothes, and avoid stepping on the cracks between the floor tiles." What is the best initial response by the nurse? ."I'll help you take your shower now." - ANSWERS-A client with schizophrenia is admitted to a psychiatric unit. The client is talking while walking in the hall, is unkempt, and obviously has not washed in several days. What should the nurse say when trying to help this client shower? ."I'm going to do my best to fight this awful disease." "Now I can't go to the prom because I have this stupid disease." "This illness is serious, but with treatment I think I have a chance to get better." - ANSWERS-A 17-year-old teenager is found to have leukemia. Which statements by the teenager reflect Piaget's cognitive processes associated with adolescence? (Select all that apply.) ."It can be frightening to feel that way." - ANSWERS-A confused hallucinating client says, "My arms are turning to stone." What is the most therapeutic response by the nurse? ."It must be frustrating to deal with your child's behavior." - ANSWERS-The parent of a child with a tentative diagnosis of attention deficit-hyperactivity disorder (ADHD) arrives at the pediatric clinic insisting on getting a prescription for medication that will control the child's behavior. What is best response by the nurse? ."It's time for you to go for a walk now." - ANSWERS-A client with schizophrenia plans an activity schedule with the help of the treatment team. A written copy is posted in the client's room. What should the nurse say when it is time for the client to go for a walk? ."Let's discuss this concern a little more." - ANSWERS-During a routine yearly physical an older adult says to a nurse, "I haven't had sex lately because I can't get an erection anymore!" What should the nurse's initial response be? ."My stomach has disintegrated." A somatic delusion is a false belief that one has a disease or a physical defect. A delusion about being a person of importance is a grandiose delusion. A delusion about death is a nihilistic delusion. A delusion that others are out to cause personal harm is a paranoid delusion. - ANSWERS-The nurse notes that a client has been experiencing a somatic delusion. Which statement led to this conclusion? ."No, I don't see any bugs." - ANSWERS-A client with alcohol dependence problem asks whether the nurse can see the bugs that are crawling on the bed. What is the nurse's initial reply? ."Set clear limits, explain the consequences if she disregards them, and firmly and consistently apply them." - ANSWERS-An adolescent female with an antisocial personality disorder plans to live with her parents after discharge. The parents request advice on how to respond to their daughter's unruly behavior. What is the most therapeutic response by the nurse? ."Tell me again how your child fell down the stairs." - ANSWERS-A nurse determines that the information about falling down the stairs given by a parent suspected of child abuse contradicts the information given by the child. What should the nurse say to the parent? ."Tell me how you feel about it." - ANSWERS-A client is admitted to the surgical unit with superficial wounds of both wrists, the result of a suicide attempt. When the nurse enters the room, the client says, "I suppose you're going to ask me about my suicide attempt." What is the best response by the nurse? ."That hurts a lot when you want to be liked." - ANSWERS-The parents of an overweight 12-year-old bring their child to the mental health clinic. One parent says, "You've got to do something to help us—just look how huge he is." The child tells the nurse, "I hate school. The other kids tease me about my weight. I'm always last when they pick teams in gym." What is the most therapeutic response by the nurse? ."The medication will increase your appetite and make you feel better." - ANSWERS-A client is lonely and extremely depressed, and the health care provider prescribes a tricyclic antidepressant. The client asks the nurse what the medication will do. What is the best response by the nurse? ."Was reasonable care provided?" "Was there a breach of nursing duty?" "Was there an act of omission that resulted in harm? "Except for the nurse's action, would the injury have occurred?" - ANSWERS-Certain questions are applicable in determining nursing negligence. (Select all that apply.) ."What emotion were you feeling before you felt the weakness?" - ANSWERS-A client who has a history of a conversion reaction that involves weakness in the right arm that periodically progresses to paralysis is hospitalized on the mental health unit of the local community hospital. While listening to instructions for a group project, the client experiences a feeling of weakness and is unable to move the right arm. After evaluating the client, what should the nurse ask? ."What were you doing yesterday when you first noticed the feeling?" - ANSWERS-A client with a diagnosis of panic disorder who had a panic attack on the previous day says to the nurse, "That was a terrible feeling I had yesterday. I'm so afraid to talk about it." What is the most therapeutic response by the nurse? ."When I look at you I see a person, not a devil." - ANSWERS-One day the nurse and a young adult client sit together and draw. The client draws a face with horns and says, "This is me. I'm a devil." What is the best response by the nurse? ."You feel worried that someone wants to poison you?" - ANSWERS-A delusional client has refused to eat for the past 24 hours because, he says, "the food is poisoned." How should the nurse respond? ."You really seem to be upset about this." - ANSWERS-One morning a client with the diagnosis of acute depression says to the nurse, "God is punishing me for my past sins." What is the best response by the nurse? ."You seem upset. Let's talk about what's bothering you." - ANSWERS-An older widower who is sitting by himself in a lounge in the nursing home, says, "I'm all alone; no one has any use for me." Which response by the nurse is most therapeutic? ."You sound upset about not being able to have an erection." - ANSWERS-A 67-year-old man with type 2 diabetes sadly confides in the nurse that he has been unable to have an erection for several years. What is the best response by the nurse? ."You sound upset; let's talk about it." - ANSWERS-An adult client charged with molesting a child is admitted for psychiatric evaluation. When a nurse invites the client to come to dinner, the client refuses and says, "I don't want anyone to see me. Leave me alone." What is the best response by the nurse? ."You would rather not live." - ANSWERS-A depressed client tells a nurse, "I want to die." What is the most therapeutic response by the nurse? ."You're frightened. Come with me to your room, and we can talk about it." - ANSWERS-One evening a nurse finds a client who has been experiencing persecutory delusions trying to get out the door. The client begs, "Please let me go. I trust you. The Mafia is going to kill me tonight." Which response is most therapeutic? ."You're going to kill yourself?" - ANSWERS-One day while shaving, a male client with the diagnosis of bipolar disorder tells the nurse, "I've hidden a razor blade, and tonight I'm going to kill myself." What is the best reply by the nurse? .2 years - ANSWERS-A nurse is evaluating a child with suspected autism. At what age does the nurse determine that the signs of autism initially may be evident? .A group can offer increased support. - ANSWERS-A nurse in a community therapeutic recreation program is working with a client with dysthymia. The treatment plan suggests group activities when possible for this client. What is the priority rationale for this intervention? .Accepting that the client is unable to control this behavior and setting appropriate limits - ANSWERS-A psychologist has been a client on a mental health unit for 3 days. The client has questioned the authority of the treatment team, advised other clients that their treatment plans are wrong, and been disruptive in group therapy. What is the most appropriate nursing intervention? .Accepting the client's statements as the client's beliefs - ANSWERS-What is the best initial nursing approach to take with a self-accusatory, guilt-ridden client? .Active membership in Alcoholics Anonymous - ANSWERS-A nurse is discussing plans with a client who has decided to withdraw from alcohol. What should the nurse recommend as one of the most effective treatments for alcoholism? .Administering chlordiazepoxide as indicated by the client's CIWA score - ANSWERS-Oral chlordiazepoxide (Librium) 100 mg/ hr is prescribed for a client with a Clinical Institute Withdrawal Assessment (CIWA) score of 25. The client has had 300 mg in 3 hours but is still displaying acute alcohol withdrawal symptoms. What is the next nursing action? .Aged cheese Ripe avocados Delicatessen meats - ANSWERS-A client is prescribed a monoamine oxidase inhibitor. The nurse teaches the client about what foods to avoid when taking this medication. (Select all that apply.) .Aged cheeses - ANSWERS-A monoamine oxidase inhibitor (MAOI) is prescribed. What should the nurse instruct the client to avoid while taking this drug? .Alcoholism involves the entire family. - ANSWERS-What is the primary reason that the nurse encourages the family of an alcoholic to become involved in the treatment program? .Allow the client to undress when ready to help maintain identity - ANSWERS-A client with schizophrenia who is being admitted to a psychiatric hospital for evaluation refuses to remove dirty clothing. What should the nurse do to best meet the client's needs? .Ambivalence - ANSWERS-A nurse is monitoring a client with the diagnosis of schizophrenia who is experiencing opposing emotions simultaneously. When providing a change-of-shift report, how should the nurse refer to this emotional experience of the client? .An uncomplicated daily schedule - ANSWERS-A nurse is caring for a group of depressed clients. What should the nurse attempt to provide? .Angry - ANSWERS-A client with bipolar disorder, manic episode, has a superior, authoritative manner and constantly instructs other clients in how to dress, what to eat, and where to sit. The nurse should intervene because these behaviors eventually will cause the other clients to feel: .Antisocial personality - ANSWERS-A nurse works with school-age children who have conduct disorder, childhood-onset type. The nurse knows that these children are at risk for progression to another disorder during adolescence. For signs of which disorder should the nurse evaluate their current behavior? .Anxious over the arrival of new staff members - ANSWERS-During the orientation tour for three new staff members, a young, hyperactive manic client greets them by saying, "Welcome to the funny farm. I'm Jo-Jo, the head yo-yo." Which meaning can the nurse assign to the client's statement? .Are dependent on it - ANSWERS-A nurse is caring for several clients who are going through withdrawal from alcohol. The primary reason for the ingestion of alcohol by clients with a history of alcohol abuse is that they: .Asking the client, "Have you ever acted on these thoughts?" - ANSWERS-An adult client confides to a clinic nurse, "I fantasize about having sex with children, and I get the urge to do it, too." What is the most appropriate response by the nurse? .Assuring the client that the symptoms are part of the withdrawal syndrome - ANSWERS-A nurse is caring for a client with the diagnosis of alcohol withdrawal delirium. Which action is most appropriate for the nurse to implement? .Attempting to establish a meaningful relationship with the client - ANSWERS-A nurse is assigned to care for a college student who has been talking to unseen people and refusing to get out of bed, go to class, or participate in daily grooming activities. What is the nurse's initial effort toward helping this client? .Avoidance - ANSWERS-The nurse recalls that the major defense mechanism used by an individual with a phobic disorder is: .Avoiding focusing on the client's physical symptoms - ANSWERS-A nurse is caring for a client with a diagnosis of conversion disorder manifesting as paralysis of the legs. Which is the most therapeutic nursing intervention? .Based on realistic limits - ANSWERS-What characteristic of the environment is most therapeutic for clients with the diagnosis of bulimia nervosa? .Bipolar disorder, manic phase - ANSWERS-A client is admitted to a psychiatric hospital after a month of unusual behavior that has included eating and sleeping very little, talking and singing constantly, and going on frequent shopping sprees. In the hospital, the client is demanding, bossy, and sarcastic. Which disorder does the nurse associate with these behaviors? .Blurred vision Suicidal ideation Difficult urination - ANSWERS-An adolescent with a major depressive disorder is prescribed venlafaxine (Effexor). What signs or symptoms related to the medication should the nurse communicate immediately to the prescribing provider? (Select all that apply.) .Blurs reality - ANSWERS-A nurse is working in a clinic that provides services to clients who abuse drugs. What effect of cocaine should the nurse consider as the reason that it easily causes dependence? .By allowing the behavior for the time being - ANSWERS-A client with the diagnosis of obsessive-compulsive disorder uses paper towels to open doors to avoid touching dirty doorknobs. How should the nurse respond initially to this behavior? .By limiting unnecessary interactions with the client - ANSWERS-How can a nurse minimize agitation in a disturbed client? .By reminding the nurse that once the content is known, there is no need to focus on the hallucinations because doing so reinforces them - ANSWERS-A client newly admitted to the psychiatric unit because of an acute psychotic episode is actively hallucinating. The admitting nurse has documented the content of the auditory hallucinations, which center on the theme of powerlessness. Later the primary nurse approaches the client, who appears to be listening to voices, and comments, "You seem to be listening to something. Tell me what you hear." The primary nurse requests feedback from the psychiatric clinical specialist regarding this nursing intervention. How should the clinical specialist respond? .By visiting frequently for short periods with the client each day - ANSWERS-A nurse identifies the establishment of trust as a major nursing goal for a depressed client. How can this goal best be accomplished? .Calm Matter-of-fact (In their head) - ANSWERS-A nurse is caring for a client with the diagnosis of somatoform disorder, conversion type. What type of affect does the nurse expect this client to exhibit? (Select all that apply.) .Chlorpromazine - ANSWERS-A nurse is teaching a client about side effects of medications. Which drug will cause a heightened skin reaction to sunlight? .Clients do not want to repeat their rituals but feel compelled to do so. - ANSWERS-What should a nurse consider when planning care for a client who is using ritualistic behavior? .Clinical depression - ANSWERS-Electroconvulsive therapy (ECT) is a mode of treatment that is used primarily to treat: .Command hallucination - ANSWERS-A man is admitted to the psychiatric unit after attempting suicide. The client's history reveals that his first child died of sudden infant death syndrome 2 years ago, that he has been unable to work since the death of the child, and that he has attempted suicide before. When talking with the nurse he says, "I hear my son telling me to come over to the other side." What should the nurse conclude that the client is experiencing? .Community-based self-help group - ANSWERS-A client with a long history of alcohol dependence spends 28 days in an alcohol-rehabilitation unit. What type of referral does the nurse anticipate will be included in the discharge plan? .Confined when the nurse walked into the room - ANSWERS-As a nurse enters a room and approaches a client who has schizophrenia, the client shouts, "Get out of here before I hit you! Go away!" The nurse concludes that this aggressive behavior is probably related to the fact that the client felt: