Psych Nursing Final Exam Review with
solutions
A client hates her mother because of childhood neglect. The nurse determines which client
statement represents the use of the defense mechanism of reaction formation?
A. "I don't like to talk about my relationship with my mother."
B. "My mother hates me."
C. "I have a very wonderful mother whom I love very much."
D. "She always loved my sister more than she loved me." - VERIFIED ANSWERS **✔C. "I
have a very wonderful mother whom I love very much."
A widow of 23 years has not removed any of her husband's possessions, including the
slippers by their bed. Which pathological grief response is exhibited by this client?
A. Inhibited grief response
B. Prolonged grief response
C. Delayed grief response
D. Distorted grief response - VERIFIED ANSWERS **✔B. Prolonged grief response
Assessing a client with occasional feelings of sadness because of the recent death of a pet,
appetite sleep pattern & daily routine has not changed... - VERIFIED ANSWERS **✔No
functional impairment
At what point should the nurse determine the client is at risk for developing mental illness?
- VERIFIED ANSWERS **✔When maladaptive responses to stress are coupled with
interference in daily functioning.
During an intake assessment, the nurses asks physiological and psychosocial questions.
Client angrily responds, "I'm here for my heart, not my head problems." What is the nurse's
,best response? - VERIFIED ANSWERS **✔Psychological factors such as excessive stress
have been found to affect medical conditions.
When under stress, client routinely uses alcohol to destress. Which statement exhibits
denial? - VERIFIED ANSWERS **✔Client says to husband, "I don't drink too much."
A depressed client states, "I have a chemical imbalance in my brain I have no control over
my actions. Medications are my only hope." What is the nurse's best response? - VERIFIED
ANSWERS **✔Medications only address biological factors, environment and interpersonal
factors must be addressed too.
An instructor is teaching nursing student about neurotransmitters. Which term best
explains the process of how neurotransmitters released in the synaptic cleft may return to
the presynaptic neuron? - VERIFIED ANSWERS **✔Reuptake
Restless, agitated client is manifesting fight-or-flight, associated with which
neurotransmitter? - VERIFIED ANSWERS **✔Norepinephrine
Client diagnosed with MDD asks, "what part of my brain controls my emotions?" What is
the nurse's best response? - VERIFIED ANSWERS **✔The limbic system is responsible for
one's emotional state.
Increased dopamine activity may play a significant role in developing which mental
disorder? - VERIFIED ANSWERS **✔Schizophrenia--too much dopamine
Antipsychotics: block dopamine receptor sites
Parkinson's--not enough dopamine, if you give too many antipsychotics to pt with
schizophrenia: parkinsonian's syndrome
Client admitted with catatonic schizophrenia. Which neurotransmitter should the nurse
expect to be elevated? - VERIFIED ANSWERS **✔Dopamine
,Symptoms associated with development of increased levels of TSH... - VERIFIED
ANSWERS **✔Depression, hypothyroidism
Decreased TSH: anxiety, hyperthyroidism.
Without authorization, nurse administers extra dose of narcotic tranquilizer to agitated
patient, coworker sees but takes no action... - VERIFIED ANSWERS **✔Taking no action is
still considered an unethical action by the coworker.
Group therapy is strongly encouraged but not mandatory in inpatient psych unit. Unit
manager's policy preserves what ethical principle? - VERIFIED ANSWERS **✔Autonomy
Which potential client should the nurse identify as a candidate for involuntary
commitment? - VERIFIED ANSWERS **✔Client threatening to commit suicide
(takes 2 physicians for involuntary commitment; only condition for involuntary
commitment is danger to self or others)
Client is dx with schizophrenia & refuses to take medications, citing right of autonomy.
When can nurse give the patient medications involuntarily? - VERIFIED ANSWERS
**✔Client physically attacks another client (danger to others)
Psych nurse working on inpatient unit receives a call asking if a person has been a patient in
the facility. What is the appropriate nursing response? - VERIFIED ANSWERS **✔Nurse
refuses to give information to the caller, citing confidentiality.
Client requests info on medications, nurse should provide info to facilitate which ethical
principle? - VERIFIED ANSWERS **✔Autonomy (the person's right to information)
Diagnosed with schizophrenia receives Fluphenazine deaconate (Prolix-traditional
antipsychotic, injectable: good for a month) from a community home health nurse. The
, client refused meds on a regular home visit. What is the nurse's appropriate response? -
VERIFIED ANSWERS **✔Allow client to refuse the medication and document it.
Geriatric client confused & wandering. What is the least restrictive alternative? - VERIFIED
ANSWERS **✔Monitored by ankle bracelet.
Disturbing peace, aggressive, disoriented, unkempt homeless individual escorted to ER.
Threatens suicide--involuntary admission... - VERIFIED ANSWERS **✔Danger to self and
others & unable to meet based needs
(When individuals say "suicide" they have to be kept)
When working with clients of a particular culture, which action should the nurse avoid? -
VERIFIED ANSWERS **✔Assuming that all people who share a culture or ethnic group are
similar.
What is the most essential task for the nurse to accomplish PRIOR to forming therapeutic
relationship with client?... - VERIFIED ANSWERS **✔Clarify personal attitudes, values,
beliefs
Client demonstrates transference (feelings toward) with a nurse, how should the nurse
respond? - VERIFIED ANSWERS **✔Help clarify the meaning of their relationship based
on present situation
Priority nursing actions during orientation or introduction phase of nurse-client
relationship?... - VERIFIED ANSWERS **✔Establish rapport and develop treatment goals.
Which client action should nurse expect during working phase of nurse-client
relationship?... - VERIFIED ANSWERS **✔Client explores personal strengths & weaknesses
that impact behavioral choices.
solutions
A client hates her mother because of childhood neglect. The nurse determines which client
statement represents the use of the defense mechanism of reaction formation?
A. "I don't like to talk about my relationship with my mother."
B. "My mother hates me."
C. "I have a very wonderful mother whom I love very much."
D. "She always loved my sister more than she loved me." - VERIFIED ANSWERS **✔C. "I
have a very wonderful mother whom I love very much."
A widow of 23 years has not removed any of her husband's possessions, including the
slippers by their bed. Which pathological grief response is exhibited by this client?
A. Inhibited grief response
B. Prolonged grief response
C. Delayed grief response
D. Distorted grief response - VERIFIED ANSWERS **✔B. Prolonged grief response
Assessing a client with occasional feelings of sadness because of the recent death of a pet,
appetite sleep pattern & daily routine has not changed... - VERIFIED ANSWERS **✔No
functional impairment
At what point should the nurse determine the client is at risk for developing mental illness?
- VERIFIED ANSWERS **✔When maladaptive responses to stress are coupled with
interference in daily functioning.
During an intake assessment, the nurses asks physiological and psychosocial questions.
Client angrily responds, "I'm here for my heart, not my head problems." What is the nurse's
,best response? - VERIFIED ANSWERS **✔Psychological factors such as excessive stress
have been found to affect medical conditions.
When under stress, client routinely uses alcohol to destress. Which statement exhibits
denial? - VERIFIED ANSWERS **✔Client says to husband, "I don't drink too much."
A depressed client states, "I have a chemical imbalance in my brain I have no control over
my actions. Medications are my only hope." What is the nurse's best response? - VERIFIED
ANSWERS **✔Medications only address biological factors, environment and interpersonal
factors must be addressed too.
An instructor is teaching nursing student about neurotransmitters. Which term best
explains the process of how neurotransmitters released in the synaptic cleft may return to
the presynaptic neuron? - VERIFIED ANSWERS **✔Reuptake
Restless, agitated client is manifesting fight-or-flight, associated with which
neurotransmitter? - VERIFIED ANSWERS **✔Norepinephrine
Client diagnosed with MDD asks, "what part of my brain controls my emotions?" What is
the nurse's best response? - VERIFIED ANSWERS **✔The limbic system is responsible for
one's emotional state.
Increased dopamine activity may play a significant role in developing which mental
disorder? - VERIFIED ANSWERS **✔Schizophrenia--too much dopamine
Antipsychotics: block dopamine receptor sites
Parkinson's--not enough dopamine, if you give too many antipsychotics to pt with
schizophrenia: parkinsonian's syndrome
Client admitted with catatonic schizophrenia. Which neurotransmitter should the nurse
expect to be elevated? - VERIFIED ANSWERS **✔Dopamine
,Symptoms associated with development of increased levels of TSH... - VERIFIED
ANSWERS **✔Depression, hypothyroidism
Decreased TSH: anxiety, hyperthyroidism.
Without authorization, nurse administers extra dose of narcotic tranquilizer to agitated
patient, coworker sees but takes no action... - VERIFIED ANSWERS **✔Taking no action is
still considered an unethical action by the coworker.
Group therapy is strongly encouraged but not mandatory in inpatient psych unit. Unit
manager's policy preserves what ethical principle? - VERIFIED ANSWERS **✔Autonomy
Which potential client should the nurse identify as a candidate for involuntary
commitment? - VERIFIED ANSWERS **✔Client threatening to commit suicide
(takes 2 physicians for involuntary commitment; only condition for involuntary
commitment is danger to self or others)
Client is dx with schizophrenia & refuses to take medications, citing right of autonomy.
When can nurse give the patient medications involuntarily? - VERIFIED ANSWERS
**✔Client physically attacks another client (danger to others)
Psych nurse working on inpatient unit receives a call asking if a person has been a patient in
the facility. What is the appropriate nursing response? - VERIFIED ANSWERS **✔Nurse
refuses to give information to the caller, citing confidentiality.
Client requests info on medications, nurse should provide info to facilitate which ethical
principle? - VERIFIED ANSWERS **✔Autonomy (the person's right to information)
Diagnosed with schizophrenia receives Fluphenazine deaconate (Prolix-traditional
antipsychotic, injectable: good for a month) from a community home health nurse. The
, client refused meds on a regular home visit. What is the nurse's appropriate response? -
VERIFIED ANSWERS **✔Allow client to refuse the medication and document it.
Geriatric client confused & wandering. What is the least restrictive alternative? - VERIFIED
ANSWERS **✔Monitored by ankle bracelet.
Disturbing peace, aggressive, disoriented, unkempt homeless individual escorted to ER.
Threatens suicide--involuntary admission... - VERIFIED ANSWERS **✔Danger to self and
others & unable to meet based needs
(When individuals say "suicide" they have to be kept)
When working with clients of a particular culture, which action should the nurse avoid? -
VERIFIED ANSWERS **✔Assuming that all people who share a culture or ethnic group are
similar.
What is the most essential task for the nurse to accomplish PRIOR to forming therapeutic
relationship with client?... - VERIFIED ANSWERS **✔Clarify personal attitudes, values,
beliefs
Client demonstrates transference (feelings toward) with a nurse, how should the nurse
respond? - VERIFIED ANSWERS **✔Help clarify the meaning of their relationship based
on present situation
Priority nursing actions during orientation or introduction phase of nurse-client
relationship?... - VERIFIED ANSWERS **✔Establish rapport and develop treatment goals.
Which client action should nurse expect during working phase of nurse-client
relationship?... - VERIFIED ANSWERS **✔Client explores personal strengths & weaknesses
that impact behavioral choices.
