Focus on Mental Health Exam
A client admitted to the mental health unit with depression is unclean, has body odor, and is
inappropriately dressed. An accompanying family member is embarrassed about the client's
appearance. When planning care, it is most important for the client and family member to
understand that: - ANS-The nurse will help the client meet hygiene needs until the client is
able to do so
Rationale: Both the client and family need to know that the nurse will assist the client until is
able to resume self-care activities. A client with depression has decreased energy and is
subject to psychomotor retardation, so, assistance is necessary. Indicating that self-esteem
needs to take priority over appearance, that hygiene is not important, and that peer pressure
will soon have the client attending to hygiene needs are all incorrect conclusions.
A client compulsively makes and remakes the bed numerous times and often misses
breakfast and some morning activities because of this ritual. Which nursing action is
appropriate? - ANS-Offering reflective feedback such as "I see you made your bed several
times. That takes a lot of energy."
Rationale: Reflective feedback lets the client know that the nurse acknowledges the behavior
and understands that it can be very tiring. Verbalizing even tactful disapproval would
increase the client's anxiety and reinforce the need to perform the ritual. Helping with the
ritual is nontherapeutic and reinforces the behavior. Teaching the client about the role of
neurotransmitters in compulsive behavior does not focus on the client's feelings.
A client diagnosed with schizophrenia tells the nurse. "There are voices outside the window
telling me what to do all the time. Can you hear them? What should I tell them?" How should
the nurse respond initially? - ANS-"What are the voices telling you?"
Rationale: The nurse should first assess the situation. When a client is experiencing an
auditory hallucination, it is important initially to determine what the voices are saying or
telling the client to do. Suicidal or homicidal messages, if heard by the client, necessitate the
implementation of safety measures as a priority. The incorrect options are inappropriate and
do not reinforce reality or provide important information to the nurse.
A client experienced the sudden onset of blindness, but extensive testing revealed no
organic reason that the client could not see. The nurse later learned that the blindness
developed after the client witnessed a fire at a neighboring house in which the family of three
died. Which problem should the nurse suspect? - ANS-Conversion disorde
Rationale: A conversion disorder is an alteration or loss of a physical function that cannot be
explained by any known pathophysiological mechanism. It is often an expression of a
psychological need or conflict. Psychosis is a state in which a person's mental capacity to
recognize reality, communicate, and relate to others is impaired, thus interfering with the
person's capacity to deal with life demands. Repression is a coping mechanism in which
unacceptable feelings are kept out of awareness. A dissociative disorder is a disturbance or
alteration in the normally integrative functions of identity, memory, or consciousness.
,A client has a diagnosis of dependent personality disorder. Which goal is most appropriate
for this client? - ANS-Using the problem-solving process effectively
Rationale: The client with dependent personality disorder exhibits an unusually strong need
to be cared for and has difficulty making personal choices and every day decisions in fear of
making the wrong decision. An appropriate goal would be for the client to use the
problem-solving process effectively in everyday situations. The client described in the
question does not exhibit any suicidal traits, nor does he suffer from an
obsessive-compulsive personality disorder or an anxiety disorder.
A client hospitalized in a mental health unit is restrained after becoming extremely violent.
Which finding indicates to the nurse that the client can be removed from the restraints? -
ANS-The client initiates no aggressive acts for 30 minutes after the release of two leg
restraints
Rationale: The best indicator that the client's behavior is under control is when the client
refrains from aggression after partial release from the restraints. Generally a structured
reintegration, begun by reducing a client's four-point restraints to two-point restraints, is
initiated. If the client continues to exhibit nonaggressive behavior, the remaining restraints
are removed. The incorrect options are not indicators that the client's behavior is under
control.
A client hospitalized with schizophrenia says to the nurse, "Get your goat. Go out and vote.
Don't be a cut throat. Row your boat." How should the nurse document the client's behavior?
- ANS-Clang associations
Rationale: Repetition of words or phrases that are similar in sound but in no other way,
known as clang association, is an assessment finding in some clients with schizophrenia.
Clang associations often take the form of rhyme. Echolalia, the pathological repeating of
another's word, is often seen in people with catatonia. Word salad is a mixture of phrases
that is meaningless to the listener and perhaps to the speaker as well. Thought broadcasting
is the belief that others can know one's thoughts.
A client hospitalized with severe depression is withdrawn and exhibits poor motivation and
concentration. Which activity should the nurse plan for this client? - ANS-Drawing
Rationale: When a client is severely depressed, the client should be involved in activities that
require little concentration and have no elements of being "right" or "wrong." As the client's
condition improves, the client may become involved in activities with small groups, such as
cooking class, dance therapy, and small group discussions.
A client in the mental health unit points to another client and says to the nurse, "He's been
working with the Taliban, pouring anthrax into our water supply." How should the nurse
respond to the client? - ANS-"Are you saying that you don't feel safe about drinking our
water?"
Rationale: The nurse appropriately responds by addressing the client's feelings associated
with the delusional thinking. The correct response involves reflection, a therapeutic
communication technique. After responding to the client's feelings, the nurse should address
the client in an open, honest, and matter-of-fact way to ease the client's suspiciousness. The
incorrect responses do not deal directly with the client's concerns, which may result in a
regressive struggle with the client.
, A client is hospitalized after falling asleep at the wheel of the) car, hitting and killing a
pedestrian crossing the street. The nurse caring for the client notes that the client is crying
and upset. What is the appropriate reaction by the nurse? - ANS-Saying to the client, "I see
that you're crying. I'm here to talk to you."
Rationale: Making a neutral observation and offering self are therapeutic communication
techniques. In the interest of safety, the client needs supervision. The nurse should assess
the client and provide comfort measures before administering a sedative or contacting the
healthcare provider. Additionally, a prescription must be obtained before administering a
sedative. Telling the client that the pedestrian's death was a result of his falling asleep at the
wheel is inappropriate and a block to communication.
A client is unwilling to leave the house for fear of doing "something bizarre in public." As a
result, the client remains homebound except when accompanied by her husband. The nurse
analyzes this data and determines that the client is experiencing: - ANS-Agoraphobia
Rationale: Agoraphobia is a fear of open spaces and the fear of being trapped in a situation
from which there may not be an escape. Agoraphobia includes the possibility of experiencing
a sense of helplessness or embarrassment if a phobic attack occurs. Avoidance of such
situations usually results in a reduction in social and professional interactions. Social phobia
is focused more on a specific situation, such as the fear of speaking, performing, or eating in
public. Clients with hypochondriacal symptoms focus their anxiety on physical complaints
and are preoccupied with their health. Claustrophobia is a fear of closed-in places.
A client on the mental health unit says to the evening nurse, "The staff on the day shift let me
smoke two cigarettes. You only let me smoke one." Which response by the nurse is
therapeutic? - ANS-"The policy is one cigarette. We'll follow the policy."
Rationale: The correct option is therapeutic because it provides the client with a clear and
direct response regarding the policy on the unit. In the incorrect options, the nurse criticizes
the day shift staff.
A client prepares to attend an Alcoholics Anonymous meeting for the first time. Which step,
the first in the 12-step program, should the nurse discuss with the client? - ANS-Admitting to
having a problem
Rationale: The first step in the 12-step program is admitting that a problem exists. Stating
that drinking will stop and discontinuing relationships with friends who drink are unrealistic as
first steps in the process to recovery. Although identifying healthy alternatives to drinking
may be a useful strategy, it is not the first step.
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? - ANS-"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
A client admitted to the mental health unit with depression is unclean, has body odor, and is
inappropriately dressed. An accompanying family member is embarrassed about the client's
appearance. When planning care, it is most important for the client and family member to
understand that: - ANS-The nurse will help the client meet hygiene needs until the client is
able to do so
Rationale: Both the client and family need to know that the nurse will assist the client until is
able to resume self-care activities. A client with depression has decreased energy and is
subject to psychomotor retardation, so, assistance is necessary. Indicating that self-esteem
needs to take priority over appearance, that hygiene is not important, and that peer pressure
will soon have the client attending to hygiene needs are all incorrect conclusions.
A client compulsively makes and remakes the bed numerous times and often misses
breakfast and some morning activities because of this ritual. Which nursing action is
appropriate? - ANS-Offering reflective feedback such as "I see you made your bed several
times. That takes a lot of energy."
Rationale: Reflective feedback lets the client know that the nurse acknowledges the behavior
and understands that it can be very tiring. Verbalizing even tactful disapproval would
increase the client's anxiety and reinforce the need to perform the ritual. Helping with the
ritual is nontherapeutic and reinforces the behavior. Teaching the client about the role of
neurotransmitters in compulsive behavior does not focus on the client's feelings.
A client diagnosed with schizophrenia tells the nurse. "There are voices outside the window
telling me what to do all the time. Can you hear them? What should I tell them?" How should
the nurse respond initially? - ANS-"What are the voices telling you?"
Rationale: The nurse should first assess the situation. When a client is experiencing an
auditory hallucination, it is important initially to determine what the voices are saying or
telling the client to do. Suicidal or homicidal messages, if heard by the client, necessitate the
implementation of safety measures as a priority. The incorrect options are inappropriate and
do not reinforce reality or provide important information to the nurse.
A client experienced the sudden onset of blindness, but extensive testing revealed no
organic reason that the client could not see. The nurse later learned that the blindness
developed after the client witnessed a fire at a neighboring house in which the family of three
died. Which problem should the nurse suspect? - ANS-Conversion disorde
Rationale: A conversion disorder is an alteration or loss of a physical function that cannot be
explained by any known pathophysiological mechanism. It is often an expression of a
psychological need or conflict. Psychosis is a state in which a person's mental capacity to
recognize reality, communicate, and relate to others is impaired, thus interfering with the
person's capacity to deal with life demands. Repression is a coping mechanism in which
unacceptable feelings are kept out of awareness. A dissociative disorder is a disturbance or
alteration in the normally integrative functions of identity, memory, or consciousness.
,A client has a diagnosis of dependent personality disorder. Which goal is most appropriate
for this client? - ANS-Using the problem-solving process effectively
Rationale: The client with dependent personality disorder exhibits an unusually strong need
to be cared for and has difficulty making personal choices and every day decisions in fear of
making the wrong decision. An appropriate goal would be for the client to use the
problem-solving process effectively in everyday situations. The client described in the
question does not exhibit any suicidal traits, nor does he suffer from an
obsessive-compulsive personality disorder or an anxiety disorder.
A client hospitalized in a mental health unit is restrained after becoming extremely violent.
Which finding indicates to the nurse that the client can be removed from the restraints? -
ANS-The client initiates no aggressive acts for 30 minutes after the release of two leg
restraints
Rationale: The best indicator that the client's behavior is under control is when the client
refrains from aggression after partial release from the restraints. Generally a structured
reintegration, begun by reducing a client's four-point restraints to two-point restraints, is
initiated. If the client continues to exhibit nonaggressive behavior, the remaining restraints
are removed. The incorrect options are not indicators that the client's behavior is under
control.
A client hospitalized with schizophrenia says to the nurse, "Get your goat. Go out and vote.
Don't be a cut throat. Row your boat." How should the nurse document the client's behavior?
- ANS-Clang associations
Rationale: Repetition of words or phrases that are similar in sound but in no other way,
known as clang association, is an assessment finding in some clients with schizophrenia.
Clang associations often take the form of rhyme. Echolalia, the pathological repeating of
another's word, is often seen in people with catatonia. Word salad is a mixture of phrases
that is meaningless to the listener and perhaps to the speaker as well. Thought broadcasting
is the belief that others can know one's thoughts.
A client hospitalized with severe depression is withdrawn and exhibits poor motivation and
concentration. Which activity should the nurse plan for this client? - ANS-Drawing
Rationale: When a client is severely depressed, the client should be involved in activities that
require little concentration and have no elements of being "right" or "wrong." As the client's
condition improves, the client may become involved in activities with small groups, such as
cooking class, dance therapy, and small group discussions.
A client in the mental health unit points to another client and says to the nurse, "He's been
working with the Taliban, pouring anthrax into our water supply." How should the nurse
respond to the client? - ANS-"Are you saying that you don't feel safe about drinking our
water?"
Rationale: The nurse appropriately responds by addressing the client's feelings associated
with the delusional thinking. The correct response involves reflection, a therapeutic
communication technique. After responding to the client's feelings, the nurse should address
the client in an open, honest, and matter-of-fact way to ease the client's suspiciousness. The
incorrect responses do not deal directly with the client's concerns, which may result in a
regressive struggle with the client.
, A client is hospitalized after falling asleep at the wheel of the) car, hitting and killing a
pedestrian crossing the street. The nurse caring for the client notes that the client is crying
and upset. What is the appropriate reaction by the nurse? - ANS-Saying to the client, "I see
that you're crying. I'm here to talk to you."
Rationale: Making a neutral observation and offering self are therapeutic communication
techniques. In the interest of safety, the client needs supervision. The nurse should assess
the client and provide comfort measures before administering a sedative or contacting the
healthcare provider. Additionally, a prescription must be obtained before administering a
sedative. Telling the client that the pedestrian's death was a result of his falling asleep at the
wheel is inappropriate and a block to communication.
A client is unwilling to leave the house for fear of doing "something bizarre in public." As a
result, the client remains homebound except when accompanied by her husband. The nurse
analyzes this data and determines that the client is experiencing: - ANS-Agoraphobia
Rationale: Agoraphobia is a fear of open spaces and the fear of being trapped in a situation
from which there may not be an escape. Agoraphobia includes the possibility of experiencing
a sense of helplessness or embarrassment if a phobic attack occurs. Avoidance of such
situations usually results in a reduction in social and professional interactions. Social phobia
is focused more on a specific situation, such as the fear of speaking, performing, or eating in
public. Clients with hypochondriacal symptoms focus their anxiety on physical complaints
and are preoccupied with their health. Claustrophobia is a fear of closed-in places.
A client on the mental health unit says to the evening nurse, "The staff on the day shift let me
smoke two cigarettes. You only let me smoke one." Which response by the nurse is
therapeutic? - ANS-"The policy is one cigarette. We'll follow the policy."
Rationale: The correct option is therapeutic because it provides the client with a clear and
direct response regarding the policy on the unit. In the incorrect options, the nurse criticizes
the day shift staff.
A client prepares to attend an Alcoholics Anonymous meeting for the first time. Which step,
the first in the 12-step program, should the nurse discuss with the client? - ANS-Admitting to
having a problem
Rationale: The first step in the 12-step program is admitting that a problem exists. Stating
that drinking will stop and discontinuing relationships with friends who drink are unrealistic as
first steps in the process to recovery. Although identifying healthy alternatives to drinking
may be a useful strategy, it is not the first step.
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? - ANS-"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
