Pollard / Jakubec, Varcarolis's Canadian Psychiatric
Mental Health Nursing 3rd Edition TEST BANK
A parent of a 17-year-old girl who has been hospitalized for extremely disturbed
acting-out behavior leaves a gift for the daughter but says, "I'm too busy to visit
today." The daughter becomes upset and tearful after being given the message and
opening the package. What does the nurse conclude that the parent's actions
represent? - ANSWER: Double-bind message
What treatment should a nurse anticipate will be prescribed for a client with severe,
persistent, intractable depression and suicidal ideation? - ANSWER:
Electroconvulsive therapy
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: - ANSWER: "Don't be afraid. I'm
your nurse, and everyone here in the hospital is here to help you."
An older depressed person at an independent living facility constantly complains
about her health problems to anyone who will listen. One day the client says, "I'm
not going to any more activities. All these old crabby people do is talk about their
problems." What defense mechanism does the nurse conclude that the client is
using? - ANSWER: Projection
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? - ANSWER: "No, I don't
see any bugs."
A client is responding within an hour of receiving naloxone to combat respiratory
depression from an overdose of heroin. Why should a nurse continue to closely
monitor this client's status? - ANSWER: Symptoms of the heroin overdose may
return after the naloxone is metabolized.
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? - ANSWER: "I understand that these voices are
real to you, but I want you to know that I don't hear them."
A client in the mental health clinic has a phobia about closed spaces. Which
desensitization method should the nurse expect to be used successfully with this
client? - ANSWER: Imagery
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? - ANSWER: "I'll help you
take your shower now."
When a client is expressing severe anxiety by sobbing in the fetal position on her
bed, the nurse's priority is: - ANSWER: Ensuring a safe therapeutic milieu
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: - ANSWER: Are dependent on it
A nurse is caring for a client with the diagnosis of alcohol withdrawal delirium. Which
action is most appropriate for the nurse to implement? - ANSWER: Assuring the
client that the symptoms are part of the withdrawal syndrome
A 30-year-old woman reports to the mental health clinic on the recommendation of
her primary health care provider. She has been unable to carry out everyday
activities because of increased pain in her lower back and legs. Numerous
neurological and orthopedic workups indicate that her symptoms seem excessive
when compared with the physical problems shown on physical examination and
repeated MRIs and x-rays. She says that no one understands how difficult it has been
to care for her 32-year-old husband, who has an inoperable brain tumor and is
undergoing chemotherapy. In light of the history and symptoms, what disorder
should the nurse suspect? - ANSWER: Conversion
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: - ANSWER: "I know there's no reason to do these
things, but I can't help myself."
A client with schizophrenia is demonstrating waxy flexibility. Which intervention is
the best way to manage the possible outcome of this behavior? - ANSWER: Passive
range-of-motion exercises three times a day for effective joint health
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? -
ANSWER: "I don't like hearing your threats, but tell me more about your feelings."
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? - ANSWER: Asking the client, "Have you ever acted on these thoughts?"
In her eighth month of pregnancy, a 24-year-old client is brought to the hospital by
the police, who were called when she barricaded herself in a ladies' restroom of a
restaurant. During admission the client shouts, "Don't come near me! My stomach is
, filled with bombs, and I'll blow up this place if anyone comes near me." The nurse
concludes that the client is exhibiting: - ANSWER: Delusional thinking
A client who is on the third day of detoxification therapy becomes agitated and
restless. What are the signs and symptoms that indicate impending alcohol
withdrawal delirium? (Select all that apply.) - ANSWER: Diaphoresis
Tachycardia
Hypertension
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? - ANSWER: "The medication will increase your
appetite and make you feel better."
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? - ANSWER:
"What were you doing yesterday when you first noticed the feeling?"
A client believes that doorknobs are contaminated and refuses to touch them except
with a paper tissue. What nursing intervention will be most therapeutic for this
client? - ANSWER: Supplying the client with tissues to maintain function until the
anxiety eases
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? - ANSWER: Command hallucination
A nurse recalls that language development in the autistic child resembles: - ANSWER:
Echolalia
What is a therapeutic nursing action in the care of a depressed client? - ANSWER:
Sitting down next to the client at frequent intervals
A nurse is caring for a client who uses ritualistic behavior. What common
antiobsessional medication does the nurse anticipate will be prescribed? - ANSWER:
Fluvoxamine (Luvox)
A client is found to have a borderline personality disorder. What behavior does the
nurse consider is most typical of these clients? - ANSWER: Impulsive
An older adult with a diagnosis of delirium on the mental health unit begins acting
out while in the dayroom. What is the initial nursing intervention? - ANSWER: Giving
the client one simple direction at a time in a firm low-pitched voice
Mental Health Nursing 3rd Edition TEST BANK
A parent of a 17-year-old girl who has been hospitalized for extremely disturbed
acting-out behavior leaves a gift for the daughter but says, "I'm too busy to visit
today." The daughter becomes upset and tearful after being given the message and
opening the package. What does the nurse conclude that the parent's actions
represent? - ANSWER: Double-bind message
What treatment should a nurse anticipate will be prescribed for a client with severe,
persistent, intractable depression and suicidal ideation? - ANSWER:
Electroconvulsive therapy
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: - ANSWER: "Don't be afraid. I'm
your nurse, and everyone here in the hospital is here to help you."
An older depressed person at an independent living facility constantly complains
about her health problems to anyone who will listen. One day the client says, "I'm
not going to any more activities. All these old crabby people do is talk about their
problems." What defense mechanism does the nurse conclude that the client is
using? - ANSWER: Projection
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? - ANSWER: "No, I don't
see any bugs."
A client is responding within an hour of receiving naloxone to combat respiratory
depression from an overdose of heroin. Why should a nurse continue to closely
monitor this client's status? - ANSWER: Symptoms of the heroin overdose may
return after the naloxone is metabolized.
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? - ANSWER: "I understand that these voices are
real to you, but I want you to know that I don't hear them."
A client in the mental health clinic has a phobia about closed spaces. Which
desensitization method should the nurse expect to be used successfully with this
client? - ANSWER: Imagery
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? - ANSWER: "I'll help you
take your shower now."
When a client is expressing severe anxiety by sobbing in the fetal position on her
bed, the nurse's priority is: - ANSWER: Ensuring a safe therapeutic milieu
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: - ANSWER: Are dependent on it
A nurse is caring for a client with the diagnosis of alcohol withdrawal delirium. Which
action is most appropriate for the nurse to implement? - ANSWER: Assuring the
client that the symptoms are part of the withdrawal syndrome
A 30-year-old woman reports to the mental health clinic on the recommendation of
her primary health care provider. She has been unable to carry out everyday
activities because of increased pain in her lower back and legs. Numerous
neurological and orthopedic workups indicate that her symptoms seem excessive
when compared with the physical problems shown on physical examination and
repeated MRIs and x-rays. She says that no one understands how difficult it has been
to care for her 32-year-old husband, who has an inoperable brain tumor and is
undergoing chemotherapy. In light of the history and symptoms, what disorder
should the nurse suspect? - ANSWER: Conversion
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: - ANSWER: "I know there's no reason to do these
things, but I can't help myself."
A client with schizophrenia is demonstrating waxy flexibility. Which intervention is
the best way to manage the possible outcome of this behavior? - ANSWER: Passive
range-of-motion exercises three times a day for effective joint health
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? -
ANSWER: "I don't like hearing your threats, but tell me more about your feelings."
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? - ANSWER: Asking the client, "Have you ever acted on these thoughts?"
In her eighth month of pregnancy, a 24-year-old client is brought to the hospital by
the police, who were called when she barricaded herself in a ladies' restroom of a
restaurant. During admission the client shouts, "Don't come near me! My stomach is
, filled with bombs, and I'll blow up this place if anyone comes near me." The nurse
concludes that the client is exhibiting: - ANSWER: Delusional thinking
A client who is on the third day of detoxification therapy becomes agitated and
restless. What are the signs and symptoms that indicate impending alcohol
withdrawal delirium? (Select all that apply.) - ANSWER: Diaphoresis
Tachycardia
Hypertension
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? - ANSWER: "The medication will increase your
appetite and make you feel better."
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? - ANSWER:
"What were you doing yesterday when you first noticed the feeling?"
A client believes that doorknobs are contaminated and refuses to touch them except
with a paper tissue. What nursing intervention will be most therapeutic for this
client? - ANSWER: Supplying the client with tissues to maintain function until the
anxiety eases
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? - ANSWER: Command hallucination
A nurse recalls that language development in the autistic child resembles: - ANSWER:
Echolalia
What is a therapeutic nursing action in the care of a depressed client? - ANSWER:
Sitting down next to the client at frequent intervals
A nurse is caring for a client who uses ritualistic behavior. What common
antiobsessional medication does the nurse anticipate will be prescribed? - ANSWER:
Fluvoxamine (Luvox)
A client is found to have a borderline personality disorder. What behavior does the
nurse consider is most typical of these clients? - ANSWER: Impulsive
An older adult with a diagnosis of delirium on the mental health unit begins acting
out while in the dayroom. What is the initial nursing intervention? - ANSWER: Giving
the client one simple direction at a time in a firm low-pitched voice
