Nursing 4530 - Mental Health - Exam 1 Questions With
Complete Solutions
A 75 yr old client with a long history of depression is currently
on doxepin 100 mg daily. The client takes a daily diuretic for
hypertension and is recovering from the flu. Which nursing
diagnosis should the nurse assign the highest priority?
A. risk for constipation R/T excessive fluid loss
B. risk for infection R/T suppressed WBC count
C. risk for ineffective thermoregulation R/T anhidrosis
D. risk for injury R/T orthostatic hypotension Correct Answer
D. risk for injury R/T orthostatic hypotension
A client cheats on their spouse and then brings the spouse of a
dozen roses. Which ego defense mechanism does this represent?
A. undoing
B. repression
C. denial
D. suppression Correct Answer A. undoing
A client comes to day treatment intoxicated but says he is not.
The nurse identifies that the client is exhibiting symptoms of
A. reaction formation
B. denial
C. projection
D. transference Correct Answer denial
A client diagnosed with bipolar I disorder is distraught over
insomnia over the last 3 nights and a 12 pound weight loss over
the past 2 weeks. Which should be the client's priority nursing
diagnosis?
,A. knowledge deficit R/T bipolar disorder AEB concern about
symptoms
B. altered nutrition less than body requirements R/T
hyperactivity AEB weight loss
C. risk for suicide R/T powerlessness AEB insomnia and
anorexia
D. altered sleep patterns R/T mania AEB insomnia for past 3
nights Correct Answer D. altered nutrition: less than body
requirements R/T hyperactivity AEB weight loss
A client diagnosed with panic disorder states, "When an attack
happens, I feel like I am going to die." Which is the most
appropriate nursing reply?
A. "Most people who experience panic attacks have feeling of
impending doom"
B. "Tell me why you think you are going to die every time you
have a panic attack"
C. "Death from a panic attack happens so infrequently that there
is no need to worry"
D. "I know it's frightening, so I will stay with you" Correct
Answer D. "I know it's frightening, so I will stay with you."
A client has been depressed and suicidal. The client started
taking a tricyclic antidepressant 2 weeks ago. The nurse is
preparing the client for discharge. Which is the concern of the
nurse at discharge?
A. the nurse will evaluate for risk of suicide by overdose of the
tricyclic antidepressant
B. the client will need regular laboratory work to monitor
therapeutic drug levels
, C. the client may need a prescription for diphenhydramine
(Benadryl) to use for side effects
D. The nurse will need to teach the client about signs and
symptoms of neuroleptic malignant syndrome Correct Answer
The nurse will evaluate risk for suicide by overdose of the
antidepressant
A client is admitted to the psychiatric unit with a diagnosis of
major depressive disorder. The client is unable to concentrate,
has no appetitive, and is experiencing insomnia. Which should
be included in this client's plan of care?
A. a schedule that includes mandatory activities to decreased
social isolation
B. a flexible schedule that allows the client opportunities for
decision making
C. a daily schedule filled with activities to promote socialization
D. a simple, structured daily schedule with limited choices of
activities Correct Answer A single, structured daily schedule
with limited choices of activities
A client is admitted with ETOH and Major Depression. During
the admission process, the nurse notices the client's speech is
slurred and asks if they've been drinking. The client states they
drink daily and lost their job lately. Which interventions will be
important? Correct Answer encourage the client to identify
behaviors that have causes problems in their life
ask the client when they last had an alcoholic drink
validate the client's frustration or anger in dealing with dual
problems
Complete Solutions
A 75 yr old client with a long history of depression is currently
on doxepin 100 mg daily. The client takes a daily diuretic for
hypertension and is recovering from the flu. Which nursing
diagnosis should the nurse assign the highest priority?
A. risk for constipation R/T excessive fluid loss
B. risk for infection R/T suppressed WBC count
C. risk for ineffective thermoregulation R/T anhidrosis
D. risk for injury R/T orthostatic hypotension Correct Answer
D. risk for injury R/T orthostatic hypotension
A client cheats on their spouse and then brings the spouse of a
dozen roses. Which ego defense mechanism does this represent?
A. undoing
B. repression
C. denial
D. suppression Correct Answer A. undoing
A client comes to day treatment intoxicated but says he is not.
The nurse identifies that the client is exhibiting symptoms of
A. reaction formation
B. denial
C. projection
D. transference Correct Answer denial
A client diagnosed with bipolar I disorder is distraught over
insomnia over the last 3 nights and a 12 pound weight loss over
the past 2 weeks. Which should be the client's priority nursing
diagnosis?
,A. knowledge deficit R/T bipolar disorder AEB concern about
symptoms
B. altered nutrition less than body requirements R/T
hyperactivity AEB weight loss
C. risk for suicide R/T powerlessness AEB insomnia and
anorexia
D. altered sleep patterns R/T mania AEB insomnia for past 3
nights Correct Answer D. altered nutrition: less than body
requirements R/T hyperactivity AEB weight loss
A client diagnosed with panic disorder states, "When an attack
happens, I feel like I am going to die." Which is the most
appropriate nursing reply?
A. "Most people who experience panic attacks have feeling of
impending doom"
B. "Tell me why you think you are going to die every time you
have a panic attack"
C. "Death from a panic attack happens so infrequently that there
is no need to worry"
D. "I know it's frightening, so I will stay with you" Correct
Answer D. "I know it's frightening, so I will stay with you."
A client has been depressed and suicidal. The client started
taking a tricyclic antidepressant 2 weeks ago. The nurse is
preparing the client for discharge. Which is the concern of the
nurse at discharge?
A. the nurse will evaluate for risk of suicide by overdose of the
tricyclic antidepressant
B. the client will need regular laboratory work to monitor
therapeutic drug levels
, C. the client may need a prescription for diphenhydramine
(Benadryl) to use for side effects
D. The nurse will need to teach the client about signs and
symptoms of neuroleptic malignant syndrome Correct Answer
The nurse will evaluate risk for suicide by overdose of the
antidepressant
A client is admitted to the psychiatric unit with a diagnosis of
major depressive disorder. The client is unable to concentrate,
has no appetitive, and is experiencing insomnia. Which should
be included in this client's plan of care?
A. a schedule that includes mandatory activities to decreased
social isolation
B. a flexible schedule that allows the client opportunities for
decision making
C. a daily schedule filled with activities to promote socialization
D. a simple, structured daily schedule with limited choices of
activities Correct Answer A single, structured daily schedule
with limited choices of activities
A client is admitted with ETOH and Major Depression. During
the admission process, the nurse notices the client's speech is
slurred and asks if they've been drinking. The client states they
drink daily and lost their job lately. Which interventions will be
important? Correct Answer encourage the client to identify
behaviors that have causes problems in their life
ask the client when they last had an alcoholic drink
validate the client's frustration or anger in dealing with dual
problems
