FOCUS ON MENTAL HEALTH EXAM
1. A nurse overhears a hospitalized client with mania telling another client,
"I'm actually a journalist writing an article for a magazine — I'm just posing as
a person with mental illness." How should the nurse respond?: Presenting the
client with the actual situation
Rationale: When dealing with a delusional client, it is important for the nurse to state
clearly that the nurse does not share the client's perceptions. All three of the other
options — ignoring the delusion, taking the client to a quiet room, and supporting
the client's denial of illness — do not focus on reality, and they ignore the issue.
Presenting the client with the actual situation helps orient the client to reality.
2. A client who is hallucinating fearfully says to the nurse, "Please tell that
demon to get out." How should the nurse respond to the client?: "I know you
must be very upset by this, but I don't see a demon."
Rationale: If the client hallucinates, it is best to provide reality-based perceptions
and not negate the client's experience, because this may lead to a regressive
struggle with the client. Giving advice or false reassurance is incorrect because such
techniques indicate that demons actually are present, which feeds into the client's
hallucination and reinforces the client's behavior.
3. The mother of a 3-year-old says, "My child hit his teddy bear after being
scolded for picking the neighbors' flowers." Which defense mechanism was
the child using?: Displacement
Rationale: The defense mechanism of displacement involves the discharge of in-
tense feelings for one person onto a less threatening substitute person or object to
satisfy an impulse. Projection involves attributing an attitude, behavior, or impulse to
someone else, such as that which occurs in blaming or scapegoating. Sublimation
is rechanneling an impulse into a more socially acceptable object. Identification
involves modeling behavior after someone else's.
4. A client says to the nurse, "Even though my husband and I keep telling them
we don't want to have children, our parents are pressuring us to 'start a family.'
What should we say to them?" Which of the following responses by the nurse
is therapeutic?: "This must be very difficult for both of you."
,Rationale: Childless families may elect not to have children or to postpone having
them until they have established themselves occupationally or financially. Telling the
client to tell the parents that the couple can't have children is incorrect because
the client is being encouraged to lie about life decisions rather than helping the
parents understand the couple's choices. Asking how they usually cope with such
,interference is incorrect because it indicates that the nurse is judgmental and has
decided that the parents are interfering with the client and spouse. Saying, "Tell them
to have more children if they want them so badly," is incorrect because it is sarcastic
and ridicules the situation over which the client has expressed concerns.
5. A young adult client says, "I just can't seem to stop snapping at my parents.
I know they work hard to support me, but what do I do when they're so
overbearing?" Which responses by the nurse is therapeutic?: "Have you talked
to your parents about your frustrations?"
Rationale: The correct response is focused on the client's concerns and encourages
the therapeutic technique of formulating a plan of action. "It's important not to be
rude to your parents" and "You need to be more patient with your parents" are
both nontherapeutic, judgmental responses that do not encourage the client to
further explore her feelings and problem-solve. "Snapping at your parents is childish.
How could you?" is incorrect because it is sarcastic and condescending, which is
nontherapeutic.
6. A client says, "I have so much trouble caring for my husband's child from
his first marriage. I resent the money we have to pay for child support because
we have to deprive my own child of things. How can I stop feeling this way?"
Which response by the nurse is therapeutic?: "Have you shared your feelings
with your husband?"
Rationale: Remarried individuals often encounter problems as a result of the stres-
sors they bring into a marriage without prior discussion with the new partner. Bonding
sometimes does always occur when a child is not one's biological offspring. The
correct answer is focused on the client's feelings. "Your child benefits from having a
sibling" is not facilitative. "I wonder why you married him, knowing that he wouldn't
desert his biological child" is incorrect because it prejudges the client. "You need to
take a second job to give your child what you think she deserves" is not open ended,
does not facilitate feelings, and gives advice.
7. A client says to the nurse, "My wife retired last year from a lucrative law
practice, and I'm really discouraged. I'll be working until I die, even though I
helped pay for her education." Which response by the nurse is supportive?: -
"You sound very troubled by this."
Rationale: Saying that the situation is unfair is judgmental and does not encourage
the client to express his feelings; nor does "That's such a tough break for you."
Suggesting that the husband approach the spouse for help is incorrect because it
, prematurely gives advice, a nontherapeutic communication technique. The correct
option is focused on the client's feelings.
8. A gay man is brought to the emergency department by the police. The
client tells the nurse, "I was beaten up. I guess I just have to expect this
kind of treatment for the rest of my life." Which statement by the nurse is
therapeutic?: "You feel that being beaten up goes along with being gay?"
Rationale: Many lesbians and gays encounter harassment or violence in the course
of their lives. "I think you should take some self-defense classes" is incorrect because
it advises the client, and giving advice is not therapeutic. "Maybe you should be
more discreet when you're in public" also gives advice and presumes that the client
has been indiscreet. "Why not try counseling to change your sexual orientation?" is
incorrect because it assumes that sexual orientation can or should be changed. The
correct option indicates reflection and is focused on the client's feelings.
9. A client whose spouse recently died is experiencing dysfunctional grieving.
Which intervention has priority in the plan of care?: Assessing the client's risk
for violence toward self and others
Rationale: The priority intervention for a client with dysfunctional grieving is assess-
ment of the client's risk for violence toward self and others. Although the nurse will
assist the client in resolving the grief and monitor the client's sleep pattern, these
are not the priority interventions of the options given. Obtaining a prescription for an
antidepressant is not a priority.
10. A nurse develops a plan of care for a client in whom AIDS was recently
diagnosed. The client is experiencing difficulty adjusting to the illness. Which
interventions are appropriate for this client? Select all that apply.: Assisting the
client in verbalizing fears
Helping the client identify sources of hope
Monitoring the client for signs of self-harm
Assisting the client with problem-solving and decision-making
Rationale: Assisting the client with problem-solving and decision-making, helping
the client verbalize fears, helping the client identify sources of hope, and monitoring
the client for signs of self-harm are all appropriate interventions. In planning care for
a client having difficulty adjusting to an illness, the nurse develops interventions to
promote social networking that will provide needed support and information to the
client.
11. An emergency department nurse is caring for an older client who is a victim
of physical abuse. List in order of priority the following nursing actions, with
1. A nurse overhears a hospitalized client with mania telling another client,
"I'm actually a journalist writing an article for a magazine — I'm just posing as
a person with mental illness." How should the nurse respond?: Presenting the
client with the actual situation
Rationale: When dealing with a delusional client, it is important for the nurse to state
clearly that the nurse does not share the client's perceptions. All three of the other
options — ignoring the delusion, taking the client to a quiet room, and supporting
the client's denial of illness — do not focus on reality, and they ignore the issue.
Presenting the client with the actual situation helps orient the client to reality.
2. A client who is hallucinating fearfully says to the nurse, "Please tell that
demon to get out." How should the nurse respond to the client?: "I know you
must be very upset by this, but I don't see a demon."
Rationale: If the client hallucinates, it is best to provide reality-based perceptions
and not negate the client's experience, because this may lead to a regressive
struggle with the client. Giving advice or false reassurance is incorrect because such
techniques indicate that demons actually are present, which feeds into the client's
hallucination and reinforces the client's behavior.
3. The mother of a 3-year-old says, "My child hit his teddy bear after being
scolded for picking the neighbors' flowers." Which defense mechanism was
the child using?: Displacement
Rationale: The defense mechanism of displacement involves the discharge of in-
tense feelings for one person onto a less threatening substitute person or object to
satisfy an impulse. Projection involves attributing an attitude, behavior, or impulse to
someone else, such as that which occurs in blaming or scapegoating. Sublimation
is rechanneling an impulse into a more socially acceptable object. Identification
involves modeling behavior after someone else's.
4. A client says to the nurse, "Even though my husband and I keep telling them
we don't want to have children, our parents are pressuring us to 'start a family.'
What should we say to them?" Which of the following responses by the nurse
is therapeutic?: "This must be very difficult for both of you."
,Rationale: Childless families may elect not to have children or to postpone having
them until they have established themselves occupationally or financially. Telling the
client to tell the parents that the couple can't have children is incorrect because
the client is being encouraged to lie about life decisions rather than helping the
parents understand the couple's choices. Asking how they usually cope with such
,interference is incorrect because it indicates that the nurse is judgmental and has
decided that the parents are interfering with the client and spouse. Saying, "Tell them
to have more children if they want them so badly," is incorrect because it is sarcastic
and ridicules the situation over which the client has expressed concerns.
5. A young adult client says, "I just can't seem to stop snapping at my parents.
I know they work hard to support me, but what do I do when they're so
overbearing?" Which responses by the nurse is therapeutic?: "Have you talked
to your parents about your frustrations?"
Rationale: The correct response is focused on the client's concerns and encourages
the therapeutic technique of formulating a plan of action. "It's important not to be
rude to your parents" and "You need to be more patient with your parents" are
both nontherapeutic, judgmental responses that do not encourage the client to
further explore her feelings and problem-solve. "Snapping at your parents is childish.
How could you?" is incorrect because it is sarcastic and condescending, which is
nontherapeutic.
6. A client says, "I have so much trouble caring for my husband's child from
his first marriage. I resent the money we have to pay for child support because
we have to deprive my own child of things. How can I stop feeling this way?"
Which response by the nurse is therapeutic?: "Have you shared your feelings
with your husband?"
Rationale: Remarried individuals often encounter problems as a result of the stres-
sors they bring into a marriage without prior discussion with the new partner. Bonding
sometimes does always occur when a child is not one's biological offspring. The
correct answer is focused on the client's feelings. "Your child benefits from having a
sibling" is not facilitative. "I wonder why you married him, knowing that he wouldn't
desert his biological child" is incorrect because it prejudges the client. "You need to
take a second job to give your child what you think she deserves" is not open ended,
does not facilitate feelings, and gives advice.
7. A client says to the nurse, "My wife retired last year from a lucrative law
practice, and I'm really discouraged. I'll be working until I die, even though I
helped pay for her education." Which response by the nurse is supportive?: -
"You sound very troubled by this."
Rationale: Saying that the situation is unfair is judgmental and does not encourage
the client to express his feelings; nor does "That's such a tough break for you."
Suggesting that the husband approach the spouse for help is incorrect because it
, prematurely gives advice, a nontherapeutic communication technique. The correct
option is focused on the client's feelings.
8. A gay man is brought to the emergency department by the police. The
client tells the nurse, "I was beaten up. I guess I just have to expect this
kind of treatment for the rest of my life." Which statement by the nurse is
therapeutic?: "You feel that being beaten up goes along with being gay?"
Rationale: Many lesbians and gays encounter harassment or violence in the course
of their lives. "I think you should take some self-defense classes" is incorrect because
it advises the client, and giving advice is not therapeutic. "Maybe you should be
more discreet when you're in public" also gives advice and presumes that the client
has been indiscreet. "Why not try counseling to change your sexual orientation?" is
incorrect because it assumes that sexual orientation can or should be changed. The
correct option indicates reflection and is focused on the client's feelings.
9. A client whose spouse recently died is experiencing dysfunctional grieving.
Which intervention has priority in the plan of care?: Assessing the client's risk
for violence toward self and others
Rationale: The priority intervention for a client with dysfunctional grieving is assess-
ment of the client's risk for violence toward self and others. Although the nurse will
assist the client in resolving the grief and monitor the client's sleep pattern, these
are not the priority interventions of the options given. Obtaining a prescription for an
antidepressant is not a priority.
10. A nurse develops a plan of care for a client in whom AIDS was recently
diagnosed. The client is experiencing difficulty adjusting to the illness. Which
interventions are appropriate for this client? Select all that apply.: Assisting the
client in verbalizing fears
Helping the client identify sources of hope
Monitoring the client for signs of self-harm
Assisting the client with problem-solving and decision-making
Rationale: Assisting the client with problem-solving and decision-making, helping
the client verbalize fears, helping the client identify sources of hope, and monitoring
the client for signs of self-harm are all appropriate interventions. In planning care for
a client having difficulty adjusting to an illness, the nurse develops interventions to
promote social networking that will provide needed support and information to the
client.
11. An emergency department nurse is caring for an older client who is a victim
of physical abuse. List in order of priority the following nursing actions, with
