Mental Health Midterm Study Guide Questions With
Complete Solutions
A 15-year-old was placed in a residential program after truancy,
running away, and an arrest for theft. At the program, the
adolescent refused to join in planned activities and pushed a
staff member, causing a fall. Which approach by nursing staff
will be most therapeutic?
a. Planned ignoring
b. Establish firm limits
c. Neutrally permit refusals
d. Coaxing to gain compliance
Rationale: Firm limits are necessary to ensure physical safety
and emotional security. Limit setting will also protect other
patients from the teen's thoughtless or aggressive behavior.
Permitting refusals to participate in the treatment plan, ignoring,
coaxing, and bargaining are strategies that do not help the
patient learn to abide by rules or structure. Correct Answer B
A 16-year-old wants to drive, but the parents will not allow it. A
14-year-old sibling was invited to several sleepovers, but the
parents found reasons to deny permission. Both teens are
annoyed because the parents buy clothes for them that are more
suitable for younger children. The parents say, "We don't want
our kids to grow up too fast." Which term best describes this
family's boundaries?
a. Rigid
b. Clear
,c. Enmeshed
d. Differentiated
Rationale: Rigid boundaries are those that do not change or flex
with changing circumstances, as indicated here by parents who
are reluctant to revise their roles and expectations about their
children as the children mature. Enmeshed boundaries are those
that have failed to differentiate or develop individually; the
family shares roles and thoughts to an excessive degree, without
a healthy degree of individuality. Correct Answer A
A client diagnosed with Schizophrenia, exhibits little
spontaneous movement and demonstrates waxy flexibility. The
nurses highest priority intervention will address what problem?
A. Muscle atrophy
B. Decubitus ulcers
C. Nutrition
D. Dysphasia
Rationale: Physiological needs must be met to preserve life. A
patient with waxy flexibility must be fed by hand or gastric tube.
Although the other symptoms are a concern, nutrition would be
the priority. Correct Answer C
A client taking Lithium citrate 600mg PO 3 times a day. The
client calls the metal health nurse complaining of nausea. What
will the client nurse teach the client?
a. Take it with antacid
b. Take it with an antiemetic
,c. Take it with a large glass of orange juice
d. Take it with meals Correct Answer D
A client with acute mania has been verbally abusive to staff
since admission 3 hours ago. The client tells the nurse, "You
would make a better call girl than a nurse and you can't work
with me you should be fired." What response by the nurse would
be the most therapeutic?
a. Tell the client this type of behavior is unacceptable and
request an apology
b. Tell the client inappropriate statements and behavior will be
documented in the chart
c. Calmly tell the client a degree in nursing is required to work
in this hospital
d. Tell the client, "I will return in a few minutes to continue the
assessment interview." Correct Answer D
A client with schizophrenia begins to talk about volmers hiding
in the warehouse where he works and undoing his work each
night. What will the nurse document in the clients' chart?
A. The client uses neologisms when speaking.
B. The client displays concrete thinking.
C. The client is experiencing thought insertion.
D. The client frequently engages in expressing ideas of
reference.
Rationale: Correct answer: A neologism is a newly coined word
having special meaning to the client. Volmer is not a known
word. The other options are incorrect because: Concrete
, thinking refers to the inability to think abstractly. Thought
insertion refers to the idea that the thoughts of others are being
planted in ones mind. Ideas of reference are a type of delusion in
which trivial events are given personal significance Correct
Answer A
A client with schizophrenia is demonstrating waxy flexibility.
Which intervention is the best way to manage the possible
outcome of this behavior?
A. Providing thickened liquids to minimize the risk of aspiration
B. Documenting intake and output each shift to monitor
hydration
C. Reinforcing appropriate social boundaries through staff role
modeling
D. Performing passive range-of-motion exercises three times a
day for effective joint health Correct Answer D
A drug blocks the attachment of norepinephrine to α1 receptors.
The patient may experience
a. hypertensive crisis.
b. orthostatic hypotension.
c. severe appetite disturbance.
d. an increase in psychotic symptoms.
Rationale: Sympathetic-mediated vasoconstriction is essential
for maintaining normal blood pressure in the upright position.
Blockage of α1 receptors leads to vasodilation and orthostatic
hypotension. Orthostatic hypotension may cause fainting and
Complete Solutions
A 15-year-old was placed in a residential program after truancy,
running away, and an arrest for theft. At the program, the
adolescent refused to join in planned activities and pushed a
staff member, causing a fall. Which approach by nursing staff
will be most therapeutic?
a. Planned ignoring
b. Establish firm limits
c. Neutrally permit refusals
d. Coaxing to gain compliance
Rationale: Firm limits are necessary to ensure physical safety
and emotional security. Limit setting will also protect other
patients from the teen's thoughtless or aggressive behavior.
Permitting refusals to participate in the treatment plan, ignoring,
coaxing, and bargaining are strategies that do not help the
patient learn to abide by rules or structure. Correct Answer B
A 16-year-old wants to drive, but the parents will not allow it. A
14-year-old sibling was invited to several sleepovers, but the
parents found reasons to deny permission. Both teens are
annoyed because the parents buy clothes for them that are more
suitable for younger children. The parents say, "We don't want
our kids to grow up too fast." Which term best describes this
family's boundaries?
a. Rigid
b. Clear
,c. Enmeshed
d. Differentiated
Rationale: Rigid boundaries are those that do not change or flex
with changing circumstances, as indicated here by parents who
are reluctant to revise their roles and expectations about their
children as the children mature. Enmeshed boundaries are those
that have failed to differentiate or develop individually; the
family shares roles and thoughts to an excessive degree, without
a healthy degree of individuality. Correct Answer A
A client diagnosed with Schizophrenia, exhibits little
spontaneous movement and demonstrates waxy flexibility. The
nurses highest priority intervention will address what problem?
A. Muscle atrophy
B. Decubitus ulcers
C. Nutrition
D. Dysphasia
Rationale: Physiological needs must be met to preserve life. A
patient with waxy flexibility must be fed by hand or gastric tube.
Although the other symptoms are a concern, nutrition would be
the priority. Correct Answer C
A client taking Lithium citrate 600mg PO 3 times a day. The
client calls the metal health nurse complaining of nausea. What
will the client nurse teach the client?
a. Take it with antacid
b. Take it with an antiemetic
,c. Take it with a large glass of orange juice
d. Take it with meals Correct Answer D
A client with acute mania has been verbally abusive to staff
since admission 3 hours ago. The client tells the nurse, "You
would make a better call girl than a nurse and you can't work
with me you should be fired." What response by the nurse would
be the most therapeutic?
a. Tell the client this type of behavior is unacceptable and
request an apology
b. Tell the client inappropriate statements and behavior will be
documented in the chart
c. Calmly tell the client a degree in nursing is required to work
in this hospital
d. Tell the client, "I will return in a few minutes to continue the
assessment interview." Correct Answer D
A client with schizophrenia begins to talk about volmers hiding
in the warehouse where he works and undoing his work each
night. What will the nurse document in the clients' chart?
A. The client uses neologisms when speaking.
B. The client displays concrete thinking.
C. The client is experiencing thought insertion.
D. The client frequently engages in expressing ideas of
reference.
Rationale: Correct answer: A neologism is a newly coined word
having special meaning to the client. Volmer is not a known
word. The other options are incorrect because: Concrete
, thinking refers to the inability to think abstractly. Thought
insertion refers to the idea that the thoughts of others are being
planted in ones mind. Ideas of reference are a type of delusion in
which trivial events are given personal significance Correct
Answer A
A client with schizophrenia is demonstrating waxy flexibility.
Which intervention is the best way to manage the possible
outcome of this behavior?
A. Providing thickened liquids to minimize the risk of aspiration
B. Documenting intake and output each shift to monitor
hydration
C. Reinforcing appropriate social boundaries through staff role
modeling
D. Performing passive range-of-motion exercises three times a
day for effective joint health Correct Answer D
A drug blocks the attachment of norepinephrine to α1 receptors.
The patient may experience
a. hypertensive crisis.
b. orthostatic hypotension.
c. severe appetite disturbance.
d. an increase in psychotic symptoms.
Rationale: Sympathetic-mediated vasoconstriction is essential
for maintaining normal blood pressure in the upright position.
Blockage of α1 receptors leads to vasodilation and orthostatic
hypotension. Orthostatic hypotension may cause fainting and
