UNIT VI MENTAL HEALTH TEST BANK
(ALL ANSWERS) WITH COMPLETE
SOLUTIONS
A nurse is caring for four clients taking various medications, including imipramine
(Tofranil), doxepine (Sinequan), ziprasidone (Geodon), and tranylcypromine
(Parnate). The nurse orders a special diet for the client receiving which medication?
A. Tofranil
B. Senequan
C. Geodon
D. Parnate - Answer-ANSWER: D
RATIONALE: Hypertensive crisis occurs in clients receiving a monoamine oxidase
inhibitor (MAOI) who consume foods or drugs with a high tyramine content.
A client admitted to the psychiatric unit following a suicide attempt is diagnosed with
major depressive disorder. Which behavioral symptoms should the nurse expect to
assess?
A. Anxiety and unconscious anger
B. Lack of attention to grooming and hygiene
C. Guilt and indecisiveness
D. Low self-esteem - Answer-ANSWER: B
RATIONALE: Lack of attention to grooming and hygiene is the only behavioral
symptom presented. Lack of energy, low self-esteem, and feelings of helplessness
and hopelessness (all common symptoms of depression) contribute to lack of
attention to activities of daily living, including grooming and hygiene.
A newly admitted client diagnosed with major depressive disorder states, I have
never considered suicide. Later the client confides to the nurse about plans to end it
all by medication overdose. What is the most helpful nursing reply?
A. There is nothing to worry about. We will handle it together.
B. Bringing this up is a very positive action on your part.
C. We need to talk about the things you have to live for.
D. I think you should consider all your options prior to taking this action. - Answer-
ANSWER: B
RATIONALE: By admitting to the staff a suicide plan, this client has taken
responsibility for possible personal actions and expresses trust in the nurse.
Therefore, the client may be receptive to continuing a safety plan. Recognition of this
achievement reinforces this adaptive behavior.
A newly admitted client is diagnosed with major depressive disorder with suicidal
ideations. Which would be the priority nursing intervention for this client?
A. Teach about the effect of suicide on family dynamics.
,B. Carefully and unobtrusively observe on the basis of assessed data, at varied
intervals around the clock.
C. Encourage the client to spend a portion of each day interacting within the milieu.
D. Set realistic achievable goals to increase self-esteem. - Answer-ANSWER: B
RATIONALE: The most effective way to interrupt a suicide attempt is to carefully,
unobtrusively observe on the basis of assessed data at varied intervals around the
clock. If a nurse observes behavior that indicates self-harm, the nurse can intervene
to stop the behavior and keep the client safe.
The nurse is providing counseling to clients diagnosed with major depressive
disorder. The nurse chooses to help the clients alter their mood by learning how to
change the way they think. The nurse is functioning under which theoretical
framework?
A. Psychoanalytic theory
B. Interpersonal theory
C. Cognitive theory
D. Behavioral theory - Answer-ANSWER: C
RATIONALE: Cognitive theory suggests that depression is a product of negative
thinking. Helping the individual change the way they think is believed to have a
positive impact on mood and self-esteem.
Which client statement expresses a typical underlying feeling of clients diagnosed
with major depressive disorder?
A. Its just a matter of time and I will be well.
B. If I ignore these feelings, they will go away.
C. I can fight these feelings and overcome this disorder.
D. Nothing will help me feel better. - Answer-ANSWER: D
RATIONALE: Hopelessness and helplessness are typical symptoms of clients
diagnosed with major depressive disorder.
A 75-year-old client with a long history of depression is currently on doxepin
(Sinequan), 100 mg daily. The client takes a daily diuretic for hypertension and is
recovering from the flu. Which nursing diagnosis should the nurse assign highest
priority?
A. Risk for ineffective thermoregulation R/T anhidrosis
B. Risk for constipation R/T excessive fluid loss
C. Risk for injury R/T orthostatic hypotension
D. Risk for infection R/T suppressed white blood cell count - Answer-ANSWER: C
RATIONALE: A side effect of Sinequan is orthostatic hypotension. Dehydration due
to fluid loss from a combination of diuretic medication and flu symptoms can also
contribute to this problem, putting this client at risk for injury R/T orthostatic
hypotension.
, A client is admitted with a diagnosis of persistent depressive disorder. Which client
statement would describe a symptom consistent with this diagnosis?
A. I am sad most of the time and Ive felt this way for the last several years.
B. I find myself preoccupied with death.
C. Sometimes I hear voices telling me to kill myself.
D. Im afraid to leave the house. - Answer-ANSWER: A
RATIONALE: Persistent depressive disorder is characterized by depressed mood for
most of day, for more days than not, for at least 2 years. Thoughts of death would be
more consistent with major depressive disorder; hearing voices is more consistent
with a psychotic disorder; and fear of leaving the house is more consistent with a
phobia.
A client diagnosed with major depressive disorder was raised in a strongly religious
family where bad behavior was equated with sins against God. Which nursing
intervention would be most appropriate to help the client address spirituality as it
relates to his illness?
A. Encourage the client to bring into awareness underlying sources of guilt.
B. Teach the client that religious beliefs should be put into perspective throughout
the life span.
C. Confront the client with the irrational nature of the belief system.
D. Assist the client to modify his or her belief system in order to improve coping
skills. - Answer-ANSWER: A
RATIONALE: A client raised in an environment that reinforces ones inadequacy may
be at risk for experiencing guilt, shame, low self-esteem, and hopelessness, which
can contribute to depression. Assisting the client to bring these feelings into
awareness allows the client to realistically appraise distorted responsibility and
dysfunctional guilt.
An isolative client was admitted 4 days ago with a diagnosis of major depressive
disorder. Which nursing statement would best motivate this client to attend a
therapeutic group being held in the milieu?
A. We'll go to the day room when you are ready for group.
B. I'll walk with you to the day room. Group is about to start.
C. It must be difficult for you to attend group when you feel so bad.
D. Let me tell you about the benefits of attending this group. - Answer-ANSWER: B
RATIONALE: A client diagnosed with major depressive disorder exhibits little to no
motivation and must be actively directed by staff to participate in therapy. It is difficult
for a severely depressed client to make decisions, and this function must be
temporarily assumed by the staff.
A client who is diagnosed with major depressive disorder asks the nurse what
causes depression. Which of these is the most accurate response?
A. Depression is caused by a deficiency in neurotransmitters, including serotonin
and norepinephrine.
B. The exact cause of depressive disorders is unknown. A number of things,
including genetic, biochemical, and environmental influences, likely play a role.
(ALL ANSWERS) WITH COMPLETE
SOLUTIONS
A nurse is caring for four clients taking various medications, including imipramine
(Tofranil), doxepine (Sinequan), ziprasidone (Geodon), and tranylcypromine
(Parnate). The nurse orders a special diet for the client receiving which medication?
A. Tofranil
B. Senequan
C. Geodon
D. Parnate - Answer-ANSWER: D
RATIONALE: Hypertensive crisis occurs in clients receiving a monoamine oxidase
inhibitor (MAOI) who consume foods or drugs with a high tyramine content.
A client admitted to the psychiatric unit following a suicide attempt is diagnosed with
major depressive disorder. Which behavioral symptoms should the nurse expect to
assess?
A. Anxiety and unconscious anger
B. Lack of attention to grooming and hygiene
C. Guilt and indecisiveness
D. Low self-esteem - Answer-ANSWER: B
RATIONALE: Lack of attention to grooming and hygiene is the only behavioral
symptom presented. Lack of energy, low self-esteem, and feelings of helplessness
and hopelessness (all common symptoms of depression) contribute to lack of
attention to activities of daily living, including grooming and hygiene.
A newly admitted client diagnosed with major depressive disorder states, I have
never considered suicide. Later the client confides to the nurse about plans to end it
all by medication overdose. What is the most helpful nursing reply?
A. There is nothing to worry about. We will handle it together.
B. Bringing this up is a very positive action on your part.
C. We need to talk about the things you have to live for.
D. I think you should consider all your options prior to taking this action. - Answer-
ANSWER: B
RATIONALE: By admitting to the staff a suicide plan, this client has taken
responsibility for possible personal actions and expresses trust in the nurse.
Therefore, the client may be receptive to continuing a safety plan. Recognition of this
achievement reinforces this adaptive behavior.
A newly admitted client is diagnosed with major depressive disorder with suicidal
ideations. Which would be the priority nursing intervention for this client?
A. Teach about the effect of suicide on family dynamics.
,B. Carefully and unobtrusively observe on the basis of assessed data, at varied
intervals around the clock.
C. Encourage the client to spend a portion of each day interacting within the milieu.
D. Set realistic achievable goals to increase self-esteem. - Answer-ANSWER: B
RATIONALE: The most effective way to interrupt a suicide attempt is to carefully,
unobtrusively observe on the basis of assessed data at varied intervals around the
clock. If a nurse observes behavior that indicates self-harm, the nurse can intervene
to stop the behavior and keep the client safe.
The nurse is providing counseling to clients diagnosed with major depressive
disorder. The nurse chooses to help the clients alter their mood by learning how to
change the way they think. The nurse is functioning under which theoretical
framework?
A. Psychoanalytic theory
B. Interpersonal theory
C. Cognitive theory
D. Behavioral theory - Answer-ANSWER: C
RATIONALE: Cognitive theory suggests that depression is a product of negative
thinking. Helping the individual change the way they think is believed to have a
positive impact on mood and self-esteem.
Which client statement expresses a typical underlying feeling of clients diagnosed
with major depressive disorder?
A. Its just a matter of time and I will be well.
B. If I ignore these feelings, they will go away.
C. I can fight these feelings and overcome this disorder.
D. Nothing will help me feel better. - Answer-ANSWER: D
RATIONALE: Hopelessness and helplessness are typical symptoms of clients
diagnosed with major depressive disorder.
A 75-year-old client with a long history of depression is currently on doxepin
(Sinequan), 100 mg daily. The client takes a daily diuretic for hypertension and is
recovering from the flu. Which nursing diagnosis should the nurse assign highest
priority?
A. Risk for ineffective thermoregulation R/T anhidrosis
B. Risk for constipation R/T excessive fluid loss
C. Risk for injury R/T orthostatic hypotension
D. Risk for infection R/T suppressed white blood cell count - Answer-ANSWER: C
RATIONALE: A side effect of Sinequan is orthostatic hypotension. Dehydration due
to fluid loss from a combination of diuretic medication and flu symptoms can also
contribute to this problem, putting this client at risk for injury R/T orthostatic
hypotension.
, A client is admitted with a diagnosis of persistent depressive disorder. Which client
statement would describe a symptom consistent with this diagnosis?
A. I am sad most of the time and Ive felt this way for the last several years.
B. I find myself preoccupied with death.
C. Sometimes I hear voices telling me to kill myself.
D. Im afraid to leave the house. - Answer-ANSWER: A
RATIONALE: Persistent depressive disorder is characterized by depressed mood for
most of day, for more days than not, for at least 2 years. Thoughts of death would be
more consistent with major depressive disorder; hearing voices is more consistent
with a psychotic disorder; and fear of leaving the house is more consistent with a
phobia.
A client diagnosed with major depressive disorder was raised in a strongly religious
family where bad behavior was equated with sins against God. Which nursing
intervention would be most appropriate to help the client address spirituality as it
relates to his illness?
A. Encourage the client to bring into awareness underlying sources of guilt.
B. Teach the client that religious beliefs should be put into perspective throughout
the life span.
C. Confront the client with the irrational nature of the belief system.
D. Assist the client to modify his or her belief system in order to improve coping
skills. - Answer-ANSWER: A
RATIONALE: A client raised in an environment that reinforces ones inadequacy may
be at risk for experiencing guilt, shame, low self-esteem, and hopelessness, which
can contribute to depression. Assisting the client to bring these feelings into
awareness allows the client to realistically appraise distorted responsibility and
dysfunctional guilt.
An isolative client was admitted 4 days ago with a diagnosis of major depressive
disorder. Which nursing statement would best motivate this client to attend a
therapeutic group being held in the milieu?
A. We'll go to the day room when you are ready for group.
B. I'll walk with you to the day room. Group is about to start.
C. It must be difficult for you to attend group when you feel so bad.
D. Let me tell you about the benefits of attending this group. - Answer-ANSWER: B
RATIONALE: A client diagnosed with major depressive disorder exhibits little to no
motivation and must be actively directed by staff to participate in therapy. It is difficult
for a severely depressed client to make decisions, and this function must be
temporarily assumed by the staff.
A client who is diagnosed with major depressive disorder asks the nurse what
causes depression. Which of these is the most accurate response?
A. Depression is caused by a deficiency in neurotransmitters, including serotonin
and norepinephrine.
B. The exact cause of depressive disorders is unknown. A number of things,
including genetic, biochemical, and environmental influences, likely play a role.
