WCU - MH Final Review
A family brings in a non-responsive client. The family reports the client is catatonic due
to schizophrenia, has a history of diabetes, seizures & COPD. What is the nurse's initial
action? - ✔️✔️check the client's blood sugar
What is a good activity for a client diagnosed w/ schizophrenia who is paranoid? -
✔️✔️allow the client to initiate the activity
A client asks the nurse if he hears the devil talking. What is the nurse's best response? -
✔️✔️even though the voice seems real to you, I do not hear the voice speaking
- Ask the Pt what they're experiencing
Transference - ✔️✔️tendency to assign feelings & attitudes from their childhood onto
someone in their present environment.
Countertransference - ✔️✔️redirecting psychotherapist's feelings towards a client;
therapist's emotional entanglement with a client.
Which if the below symptoms are positive signs of schizophrenia? Select all that apply. -
✔️✔️- visual hallucinations
- making up words
- agitation
- introducing unrelated topics
A schizophrenia client begins to masturbate in the day room. What is the nurse's initial
action? - ✔️✔️ask the client if he needs privacy & escort him to his room
In the development of a therapeutic relationship w/ a new admission w/ the Dx of post
self-inflicted GSW to the head. Which of the following is a priority for the nurse? -
✔️✔️assess the feelings towards this client
- Therapeutic relationships includes feelings only of the Pt
A 16 y/o Asian client requests an outside provider give her a coining treatment. What is
the RN's best response? - ✔️✔️respect cultural beliefs, but do not allow the treatment
in the hospital
A terminal CA client states to the nurse, "I wish my family would stop hoping for a cure. I
know I am going to die and I wish they would stop." The nurse's best response is: -
✔️✔️it sounds as though you are feeling ...
A client on the psychiatric unit states "I feel like a bird." The best response for the nurse
to make is: - ✔️✔️that must be distressing for you, you don't look different to me
,- Don't argue w/ the Pt
The nurse is deciding if she can restrain an angry, acting out client. The client tells her,
"I will sue you if you tie me down." Her best response would be: - ✔️✔️if you cannot be
kept from hurting yourself or others except by physical restraint, I will do it
A male client is coming down from a manic period. He states, "I feel bad about cheating
on my wife." What is the nurse's best response? - ✔️✔️Hyper-sexuality is a part of your
illness. Let's discuss early signs of a manic episode
- Educate Pt on his condition & that hyper-sexuality is a part of Mania
The Rn must inform a family member his mother has just died. When informed of this
news, the 35 y/o son smiles & states he is going to the vending area to buy some
candy. What is the most appropriate intervention for the nurse to make at this time? -
✔️✔️Repeat, "I just told you your mother died, how do you feel about this?"
- important to repeat what has happened b/c some people will go into a form of Shock &
will deny the truth
A client is diagnosed w/ Major Depression. What is the most important part of the
mental status exam to assess? - ✔️✔️mood
- "How are you feeling?"
A client is scheduled for ECT what family teaching should the RN focus on? -
✔️✔️education on the client's memory loss
A nurse has observed that the client is still crying often & expresses anger at her
deceased husband after 9 months & has stopped seeing friends and family. She is
complaining that she is feeling helpless to change anything to improve her future. The
priority assessment would be: - ✔️✔️symptoms of complicated grief, dysfunctional
mourning & social isolation
Which client is most at risk for committing suicide? - ✔️✔️elderly, single male w/
cancer
Which statement shows a nurse has empathy for a patient who made a suicide
attempt? - ✔️✔️you must have been very upset when you tried to hurt yourself
In a sad voice, an elderly Pt tells the nurse of the recent deaths of a spouse & daughter
in an automobile accident. As the person sadly relates that she has no other family, only
a few acquaintances in the community, she says there is no hope. The nurse's priority is
to gather additional assessment data to determine which nursing diagnosis best directs
care for this Pt? - ✔️✔️risk for suicide related to hopelessness after recent deaths of
significant others
, The ED calls the nurse & states a suicidal client needs a bed on her unit. Hospital policy
states suicidal clients must have a room w/ locked windows. The only room w/ locked
windows is occupied by a post-op client who has been in pain all day & is a now finally
sleeping. What is the nurse's best action? - ✔️✔️move the post-op Pt & put the suicidal
client in the room w/ locked windows
Randall is a 36 y/o male admitted to the hospital for symptoms of depression & passive
suicidal thoughts. He tells the nurse upon admission "I know I need to be here, and I'm
so happy you are going to be my nurse while I'm here. You are such a good listener!"
For the remainder of the shift, Randall... - ✔️✔️set limits on interactions w/ this Pt &
discuss his case w/ fellow nurses & supervisors
A 20 y/o economics major became severely depressed after failing 2 exams in
economics. She cried for 2 hours, then called her parents who live in the neighboring
state, planning to ask if she could return home. However, her parents were in Europe.
When her roommates went home for the weekend, the Pt gave... - ✔️✔️giving away
her favorite possessions
A Pt w/ a somatic symptom disorder has been started on relaxation & has identified how
negative assumptions make his symptoms worse. Currently, he believes his palpitations
in his chest are due to a heart attack. He has a high pulse rate. The nurse is teaching
him cognitive reframing. Which statement best shows the Pt understandings? - ✔️✔️a
good explanation of how I'm feeling might be the extra coffee & the stress I am under at
work.
A 22y/o woman is seen in the outpatient mental health clinic complaining of frequent
nightmares, feelings of guilt, & poor concentration. During the intake assessment, the
nurse learns that the Pt was physically abused as a child. This Hx & symptoms are most
related to: - ✔️✔️PTSD
Which client is most at risk for development of PTSD? - ✔️✔️rescued client trapped
under a collapsed roof of a building
- the client actually experienced near death
The parent of an adolescent diagnosed w/ depression asks the nurse, "Why do you
want to do a family assessment? My teenager is the patient, not the rest of us." Select
the nurse's best response. - ✔️✔️every family member's perception of events is
different and helps in planning how to improve functioning of the family
Which statement about crisis theory will provide a basis of nursing interventions? -
✔️✔️a crisis is an acute, time limited phenomenon experiences as an overwhelming
emotional reaction to a problem perceived as unsolvable
A family brings in a non-responsive client. The family reports the client is catatonic due
to schizophrenia, has a history of diabetes, seizures & COPD. What is the nurse's initial
action? - ✔️✔️check the client's blood sugar
What is a good activity for a client diagnosed w/ schizophrenia who is paranoid? -
✔️✔️allow the client to initiate the activity
A client asks the nurse if he hears the devil talking. What is the nurse's best response? -
✔️✔️even though the voice seems real to you, I do not hear the voice speaking
- Ask the Pt what they're experiencing
Transference - ✔️✔️tendency to assign feelings & attitudes from their childhood onto
someone in their present environment.
Countertransference - ✔️✔️redirecting psychotherapist's feelings towards a client;
therapist's emotional entanglement with a client.
Which if the below symptoms are positive signs of schizophrenia? Select all that apply. -
✔️✔️- visual hallucinations
- making up words
- agitation
- introducing unrelated topics
A schizophrenia client begins to masturbate in the day room. What is the nurse's initial
action? - ✔️✔️ask the client if he needs privacy & escort him to his room
In the development of a therapeutic relationship w/ a new admission w/ the Dx of post
self-inflicted GSW to the head. Which of the following is a priority for the nurse? -
✔️✔️assess the feelings towards this client
- Therapeutic relationships includes feelings only of the Pt
A 16 y/o Asian client requests an outside provider give her a coining treatment. What is
the RN's best response? - ✔️✔️respect cultural beliefs, but do not allow the treatment
in the hospital
A terminal CA client states to the nurse, "I wish my family would stop hoping for a cure. I
know I am going to die and I wish they would stop." The nurse's best response is: -
✔️✔️it sounds as though you are feeling ...
A client on the psychiatric unit states "I feel like a bird." The best response for the nurse
to make is: - ✔️✔️that must be distressing for you, you don't look different to me
,- Don't argue w/ the Pt
The nurse is deciding if she can restrain an angry, acting out client. The client tells her,
"I will sue you if you tie me down." Her best response would be: - ✔️✔️if you cannot be
kept from hurting yourself or others except by physical restraint, I will do it
A male client is coming down from a manic period. He states, "I feel bad about cheating
on my wife." What is the nurse's best response? - ✔️✔️Hyper-sexuality is a part of your
illness. Let's discuss early signs of a manic episode
- Educate Pt on his condition & that hyper-sexuality is a part of Mania
The Rn must inform a family member his mother has just died. When informed of this
news, the 35 y/o son smiles & states he is going to the vending area to buy some
candy. What is the most appropriate intervention for the nurse to make at this time? -
✔️✔️Repeat, "I just told you your mother died, how do you feel about this?"
- important to repeat what has happened b/c some people will go into a form of Shock &
will deny the truth
A client is diagnosed w/ Major Depression. What is the most important part of the
mental status exam to assess? - ✔️✔️mood
- "How are you feeling?"
A client is scheduled for ECT what family teaching should the RN focus on? -
✔️✔️education on the client's memory loss
A nurse has observed that the client is still crying often & expresses anger at her
deceased husband after 9 months & has stopped seeing friends and family. She is
complaining that she is feeling helpless to change anything to improve her future. The
priority assessment would be: - ✔️✔️symptoms of complicated grief, dysfunctional
mourning & social isolation
Which client is most at risk for committing suicide? - ✔️✔️elderly, single male w/
cancer
Which statement shows a nurse has empathy for a patient who made a suicide
attempt? - ✔️✔️you must have been very upset when you tried to hurt yourself
In a sad voice, an elderly Pt tells the nurse of the recent deaths of a spouse & daughter
in an automobile accident. As the person sadly relates that she has no other family, only
a few acquaintances in the community, she says there is no hope. The nurse's priority is
to gather additional assessment data to determine which nursing diagnosis best directs
care for this Pt? - ✔️✔️risk for suicide related to hopelessness after recent deaths of
significant others
, The ED calls the nurse & states a suicidal client needs a bed on her unit. Hospital policy
states suicidal clients must have a room w/ locked windows. The only room w/ locked
windows is occupied by a post-op client who has been in pain all day & is a now finally
sleeping. What is the nurse's best action? - ✔️✔️move the post-op Pt & put the suicidal
client in the room w/ locked windows
Randall is a 36 y/o male admitted to the hospital for symptoms of depression & passive
suicidal thoughts. He tells the nurse upon admission "I know I need to be here, and I'm
so happy you are going to be my nurse while I'm here. You are such a good listener!"
For the remainder of the shift, Randall... - ✔️✔️set limits on interactions w/ this Pt &
discuss his case w/ fellow nurses & supervisors
A 20 y/o economics major became severely depressed after failing 2 exams in
economics. She cried for 2 hours, then called her parents who live in the neighboring
state, planning to ask if she could return home. However, her parents were in Europe.
When her roommates went home for the weekend, the Pt gave... - ✔️✔️giving away
her favorite possessions
A Pt w/ a somatic symptom disorder has been started on relaxation & has identified how
negative assumptions make his symptoms worse. Currently, he believes his palpitations
in his chest are due to a heart attack. He has a high pulse rate. The nurse is teaching
him cognitive reframing. Which statement best shows the Pt understandings? - ✔️✔️a
good explanation of how I'm feeling might be the extra coffee & the stress I am under at
work.
A 22y/o woman is seen in the outpatient mental health clinic complaining of frequent
nightmares, feelings of guilt, & poor concentration. During the intake assessment, the
nurse learns that the Pt was physically abused as a child. This Hx & symptoms are most
related to: - ✔️✔️PTSD
Which client is most at risk for development of PTSD? - ✔️✔️rescued client trapped
under a collapsed roof of a building
- the client actually experienced near death
The parent of an adolescent diagnosed w/ depression asks the nurse, "Why do you
want to do a family assessment? My teenager is the patient, not the rest of us." Select
the nurse's best response. - ✔️✔️every family member's perception of events is
different and helps in planning how to improve functioning of the family
Which statement about crisis theory will provide a basis of nursing interventions? -
✔️✔️a crisis is an acute, time limited phenomenon experiences as an overwhelming
emotional reaction to a problem perceived as unsolvable
