Mental Health Nursing Exam Questions – Depression, MAOI
Diets, ICU Psychosis, and Schizophrenia Care |Complete Exam
Questions with Verified A+Graded Answers
The nurse should include which interventions in the plan of care for a severely depressed
client with neurovegetative symptoms? (Select all that apply.)
o Permit rest periods as needed.
o Speaking slowly and simply.
o Place the client on suicide precautions.
o Observe and encourage food and fluid intake.
o Encourage vigorous exercise and long walks on the unit.
o Permit rest periods as needed.
o Speaking slowly and simply.
o Place the client on suicide precautions.
o Observe and encourage food and fluid intake.
· Neurovegetative symptoms that accompany the mood disorder of depression include
physiological disruptions, such as anorexia, constipation, sleep disturbance, and psychomotor
retardation. The client's plan of care should include measures that promote the client's
comfort and well-being, such as rest, nutrition, suicide precautions, and simple
communications. Vigorous exercise and long walks are not indicated for clients in a
neurovegetative state.
Which diet selection by a client who is depressed and taking the MAO inhibitor
tranylcypromine sulfate (Parnate) indicates to the nurse that the client understands the
dietary restrictions imposed by this medication regimen?
o Hamburger, French fries, and chocolate milkshake.
o Liver and onions, broccoli, and decaffeinated coffee.
o Pepperoni and cheese pizza, tossed salad, and a soft drink.
o Roast beef, baked potato with butter, and iced tea.
o Roast beef, baked potato with butter, and iced tea.
,· Foods with tyramine interact with MAOI antidepressant, such as Parnate, and can cause a
hypertensive crisis that is life-threatening. Roast beef, potatoes, butter, and tea do not
contain tyramine. The other selections contain tyramine and should be avoided by the client
who is taking Parnate.
An older male client in the intensive care unit who has been oriented suddenly becomes
disoriented and fearful. Assessment of vital signs and other physical parameters reveal no
significant change and the nurse formulates the client's problem as confusion related to ICU
psychosis. Which intervention is most important for the nurse implement?
o Move all machines away from the client's immediate area.
o Attempt to allay the client's fears by explaining the etiology of confusion.
o Cluster care so brief periods of rest can be scheduled during the day.
o Extend visitation times for family and friends.
o Cluster care so brief periods of rest can be scheduled during the day.
· The critical care environment confronts clients with an environment which is stressful and
heightened by treatment modalities that may prove to be lifesaving. These stressors can
result in isolation or sensory overload that leads to confusion. The best intervention is to
cluster care to provide the client with uninterrupted rest periods. The other actions may not
be possible.
A male client is admitted to the psychiatric unit with a medical diagnosis of paranoid
schizophrenia. During the admission procedure, the client looks up and states, "No, it's not
MY fault. You can't blame me. I didn't kill him, you did." What action is best for the nurse to
take?
o Reassure the client by telling him that his fear of the admission procedure is to be expected.
o Tell the client that no one is accusing him of murder and remind him that the hospital is a
safe place.
o Assess the content of the hallucinations by asking the client what he is hearing.
o Ignore the behavior and make no response at all to his delusional statements.
o Assess the content of the hallucinations by asking the client what he is hearing.
· Further assessment is indicated and the nurse should obtain information about what the
client believes the voices are telling him--they may be telling him to kill himself or the nurse.
The other actions are not indicated.
,The nurse is assessing a client's intelligence. Which factor should the nurse remember during
this part of the mental status exam?
o Acute psychiatric illnesses impair intelligence.
o Intelligence is influenced by social and cultural beliefs.
o Poor concentration skills suggests limited intelligence.
o The inability to think abstractly indicates limited intelligence.
o Intelligence is influenced by social and cultural beliefs.
· Social and cultural beliefs have significant impact on intelligence. The other factors do not
necessarily suggest limited intelligence.
A young adult male client, diagnosed with paranoid schizophrenia, believes that world is
trying to poison him. What intervention should the nurse include in this client's plan of care?
o Remind the client that his suspicions are not true.
o Ask one nurse to spend time with the client daily.
o Encourage the client to participate in group activities.
o Assign the client to a room closest to the activity room.
o Ask one nurse to spend time with the client daily.
· A client with paranoid schizophrenia has difficulty with trust and developing a trusting
relationships, the plan of care should include providing one nurse to spend time with the
client daily, which is likely to be therapeutic for this client. The other actions are too stressful
for the client and not indicated.
The nurse is assessing a client who is admitted with a diagnosis of depression. Which findings
is characteristic of depression?
o Grandiose ideation.
o Self-destructive thoughts.
o Suspiciousness of others.
o A negative view of self and the future.
o A negative view of self and the future.
· Negative self-image and feelings of hopelessness about the future are specific findings in
depression. The other findings are not the underlying manifestations in depression.
, The nurse is taking a history for a female client who is requesting a routine female exam.
Which assessment finding requires follow-up?
o Menstruation onset at age 9.
o Contraceptive method includes condoms only.
o Menstrual cycle occurs every 35 days.
o "Black-out" after one drink last night on a date.
o "Black-out" after one drink last night on a date.
· A "black-out" typically occurs after ingestion of alcohol beverages that the client has no
recall of experiences or one's behavior and is indicative of high blood alcohol levels. The
client's experience of a "black-out" after one drink is suspicious of the client receiving a "date
rape" drug, such as flunitrazepam ("Rohypnol"), and needs additional follow-up. The other
findings do not need follow-up at this time.
The nurse is preparing to administer phenelzine sulfate (Nardil) to a client on the psychiatric
unit. Which side effect reported by the client is related to administration of this drug?
o My mouth feels like cotton.
o That stuff gives me indigestion.
o This pill gives me diarrhea.
o My urine looks pink.
o My mouth feels like cotton.
· A dry mouth is an anticholinergic response that is an expected side effect of MAO inhibitors,
such as phenelzine sulfate (Nardil). The other subjective reports are not related to this
medication.
An adult female client is admitted to the psychiatric hospital with a diagnosis of bipolar
disorder, manic phase. She is demanding and active. Which intervention should the nurse
include in this client's plan of care?
o Schedule her to attend various group activities.
o Reinforce her ability to make her own decisions.
o Encourage her to identify feelings of anger.
o Provide a structured environment with little stimuli.
Diets, ICU Psychosis, and Schizophrenia Care |Complete Exam
Questions with Verified A+Graded Answers
The nurse should include which interventions in the plan of care for a severely depressed
client with neurovegetative symptoms? (Select all that apply.)
o Permit rest periods as needed.
o Speaking slowly and simply.
o Place the client on suicide precautions.
o Observe and encourage food and fluid intake.
o Encourage vigorous exercise and long walks on the unit.
o Permit rest periods as needed.
o Speaking slowly and simply.
o Place the client on suicide precautions.
o Observe and encourage food and fluid intake.
· Neurovegetative symptoms that accompany the mood disorder of depression include
physiological disruptions, such as anorexia, constipation, sleep disturbance, and psychomotor
retardation. The client's plan of care should include measures that promote the client's
comfort and well-being, such as rest, nutrition, suicide precautions, and simple
communications. Vigorous exercise and long walks are not indicated for clients in a
neurovegetative state.
Which diet selection by a client who is depressed and taking the MAO inhibitor
tranylcypromine sulfate (Parnate) indicates to the nurse that the client understands the
dietary restrictions imposed by this medication regimen?
o Hamburger, French fries, and chocolate milkshake.
o Liver and onions, broccoli, and decaffeinated coffee.
o Pepperoni and cheese pizza, tossed salad, and a soft drink.
o Roast beef, baked potato with butter, and iced tea.
o Roast beef, baked potato with butter, and iced tea.
,· Foods with tyramine interact with MAOI antidepressant, such as Parnate, and can cause a
hypertensive crisis that is life-threatening. Roast beef, potatoes, butter, and tea do not
contain tyramine. The other selections contain tyramine and should be avoided by the client
who is taking Parnate.
An older male client in the intensive care unit who has been oriented suddenly becomes
disoriented and fearful. Assessment of vital signs and other physical parameters reveal no
significant change and the nurse formulates the client's problem as confusion related to ICU
psychosis. Which intervention is most important for the nurse implement?
o Move all machines away from the client's immediate area.
o Attempt to allay the client's fears by explaining the etiology of confusion.
o Cluster care so brief periods of rest can be scheduled during the day.
o Extend visitation times for family and friends.
o Cluster care so brief periods of rest can be scheduled during the day.
· The critical care environment confronts clients with an environment which is stressful and
heightened by treatment modalities that may prove to be lifesaving. These stressors can
result in isolation or sensory overload that leads to confusion. The best intervention is to
cluster care to provide the client with uninterrupted rest periods. The other actions may not
be possible.
A male client is admitted to the psychiatric unit with a medical diagnosis of paranoid
schizophrenia. During the admission procedure, the client looks up and states, "No, it's not
MY fault. You can't blame me. I didn't kill him, you did." What action is best for the nurse to
take?
o Reassure the client by telling him that his fear of the admission procedure is to be expected.
o Tell the client that no one is accusing him of murder and remind him that the hospital is a
safe place.
o Assess the content of the hallucinations by asking the client what he is hearing.
o Ignore the behavior and make no response at all to his delusional statements.
o Assess the content of the hallucinations by asking the client what he is hearing.
· Further assessment is indicated and the nurse should obtain information about what the
client believes the voices are telling him--they may be telling him to kill himself or the nurse.
The other actions are not indicated.
,The nurse is assessing a client's intelligence. Which factor should the nurse remember during
this part of the mental status exam?
o Acute psychiatric illnesses impair intelligence.
o Intelligence is influenced by social and cultural beliefs.
o Poor concentration skills suggests limited intelligence.
o The inability to think abstractly indicates limited intelligence.
o Intelligence is influenced by social and cultural beliefs.
· Social and cultural beliefs have significant impact on intelligence. The other factors do not
necessarily suggest limited intelligence.
A young adult male client, diagnosed with paranoid schizophrenia, believes that world is
trying to poison him. What intervention should the nurse include in this client's plan of care?
o Remind the client that his suspicions are not true.
o Ask one nurse to spend time with the client daily.
o Encourage the client to participate in group activities.
o Assign the client to a room closest to the activity room.
o Ask one nurse to spend time with the client daily.
· A client with paranoid schizophrenia has difficulty with trust and developing a trusting
relationships, the plan of care should include providing one nurse to spend time with the
client daily, which is likely to be therapeutic for this client. The other actions are too stressful
for the client and not indicated.
The nurse is assessing a client who is admitted with a diagnosis of depression. Which findings
is characteristic of depression?
o Grandiose ideation.
o Self-destructive thoughts.
o Suspiciousness of others.
o A negative view of self and the future.
o A negative view of self and the future.
· Negative self-image and feelings of hopelessness about the future are specific findings in
depression. The other findings are not the underlying manifestations in depression.
, The nurse is taking a history for a female client who is requesting a routine female exam.
Which assessment finding requires follow-up?
o Menstruation onset at age 9.
o Contraceptive method includes condoms only.
o Menstrual cycle occurs every 35 days.
o "Black-out" after one drink last night on a date.
o "Black-out" after one drink last night on a date.
· A "black-out" typically occurs after ingestion of alcohol beverages that the client has no
recall of experiences or one's behavior and is indicative of high blood alcohol levels. The
client's experience of a "black-out" after one drink is suspicious of the client receiving a "date
rape" drug, such as flunitrazepam ("Rohypnol"), and needs additional follow-up. The other
findings do not need follow-up at this time.
The nurse is preparing to administer phenelzine sulfate (Nardil) to a client on the psychiatric
unit. Which side effect reported by the client is related to administration of this drug?
o My mouth feels like cotton.
o That stuff gives me indigestion.
o This pill gives me diarrhea.
o My urine looks pink.
o My mouth feels like cotton.
· A dry mouth is an anticholinergic response that is an expected side effect of MAO inhibitors,
such as phenelzine sulfate (Nardil). The other subjective reports are not related to this
medication.
An adult female client is admitted to the psychiatric hospital with a diagnosis of bipolar
disorder, manic phase. She is demanding and active. Which intervention should the nurse
include in this client's plan of care?
o Schedule her to attend various group activities.
o Reinforce her ability to make her own decisions.
o Encourage her to identify feelings of anger.
o Provide a structured environment with little stimuli.
