Foundations of Psychiatric Mental Health Nursing

MULTIPLE CHOICE 1. A nurse sits with a client diagnosed with schizophrenia. The client starts to laugh uncontrollably, although the nurse has not said anything funny. What is the nurse’s most therapeutic response? a. “Why are you laughing?” b. “Please share the joke with me.” c. “I don’t think I said anything funny.” d. “You’re laughing. Tell me what’s happening.” ANS: D The client is likely laughing in response to inner stimuli, such as hallucinations or fan...

MULTIPLE CHOICE 1. A nurse assesses a 3-year-old diagnosed with an autism spectrum disorder. Which finding is most associated with the child’s disorder? a. has occasional toileting accidents. b. interrupts or intrudes on others. c. cries when separated from a parent. d. continuously rocks in place for 30 minutes. ANS: D Autism spectrum disorder involves distortions in development of social skills and language that include perception, motor movement, attention, and reality testing....

MULTIPLE CHOICE 1. Major depressive disorder resulted after a client’s employment was terminated. The client now says to the nurse, “I’m not worth the time you spend with me. I am the most useless person in the world.” Which nursing diagnosis applies? a. Powerlessness b. Defensive coping c. Situational low self-esteem d. Disturbed personal identity ANS: C The client’s statements express feelings of worthlessness and most clearly relate to the nursing diagnosis of situation...

MULTIPLE CHOICE 1. A client waves a newspaper and says, “I must have my credit card and use the computer right now. A store is having a big sale, and I need to order 10 dresses and four pairs of shoes.” What is the nurse’s appropriate intervention? a. suggesting the client have a friend do the shopping and bring purchases to the unit. b. inviting the client to sit together and look at new fashion magazines. c. telling the client computer use is not allowed until self-control improves...

MULTIPLE CHOICE 1. A nurse assesses an older adult client brought to the emergency department (ED) by a family member. The client was wandering outside saying, “I can’t find my way home.” The client is confused and unable to answer questions. Select the nurse’s best action. a. Record the client’s answers to questions on the nursing assessment form. b. Ask an advanced practice nurse to perform the assessment interview. c. Call for a mental health advocate to maintain the client’...

MULTIPLE CHOICE 1. When private insurance will not pay for continued private hospitalization of a mentally ill client, he family considers transferring the client to a public hospital but expresses concern that the client will not get any treatment if transferred. What is the nurse’s most helpful reply? a. “By law, treatment must be provided. Hospitalization without treatment violates clients’ rights.” b. “All clients in public hospitals have the right to choose both a primary the...

MULTIPLE CHOICE 1. During a one-on-one interaction with the nurse, a client frequently looks nervously at the door. What is the best comment by the nurse regarding this nonverbal communication? a. “I notice you keep looking toward the door.” b. “This is our time together. No one is going to interrupt us.” c. “It looks as if you are eager to end our discussion for today.” d. “If you are uncomfortable in this room, we can move someplace else.” ANS: A Making observation...

MULTIPLE CHOICE 1. What action should a nurse take to demonstrate genuineness with a patient diagnosed with schizophrenia? a. Restate what the patient says. b. Use congruent communication strategies. c. Use self-revelation in patient interactions. d. Consistently interpret the patient’s behaviors. ANS: B Genuineness is a desirable characteristic involving awareness of one’s own feelings as they arise and the ability to communicate them when appropriate. The incorrect options are...

MULTIPLE CHOICE 1. Operant conditioning is part of the treatment plan to encourage speech in a child who is nearly mute. Which technique applies? a. Encourage the child to observe others talking. b. Include the child in small group activities. c. Give the child a small treat for speaking. d. Teach the child relaxation techniques. ANS: C Operant conditioning involves giving positive reinforcement for a desired behavior. Treats are rewards and reinforce speech through positive reinfor...

MULTIPLE CHOICE 1. An adult says, “Most of the time I’m happy and feel good about myself. I have learned that what I get out of something is proportional to the effort I put into it.” Which number on this mental health continuum should the nurse select? Mental Illness Mental Health 1 2 3 4 5 a. 1 b. 2 c. 3 d. 4 e. 5 ANS: E The adult is generally happy and has an adequate self-concept. The statement indicates the adult is reality-oriented, works effectively, and has contro...