Psychiatric/Mental Health Practice

An adult male client who was admitted to the mental health unit yesterday tells the nurse that microchips were planted in his head for military surveillance of his every move. Which response is best for the nurse to provide?
A. You are in the hospital, and I am the nurse caring for you.
B. It must be difficult for you to control your anxious feelings.
C. Go to occupational therapy and start a project. Correct
D. You are not in a war area now; this is the United States.
C. Go to occupational therapy and start a project.

Delusions often generate fear and isolation, so the nurse should help the client participate in activities that avoid focusing on the false belief and encourage interaction with others (C). Delusions are often well-fixed, and though (A) reinforces reality, it is argumentative and dismisses the client’s fears. It is often difficult for the client to recognize the relationship between delusions and anxiety (B), and the nurse should reassure the client that he is in a safe place. Dismissing delusional thinking (D) is unrealistic because neurochemical imbalances that cause positive symptoms of schizophrenia require antipsychotic drug therapy.

The nurse should hold the next scheduled dose of a client’s haloperidol (Haldol) based on which assessment finding(s)?
a. Dizziness when standing.
b. Shuffling gait and hand tremors.
c. Urinary retention.
d. Fever of 102° F.
d. Fever of 102° F.

A fever (D) may indicate neuroleptic malignant syndrome (NMS), a potentially fatal complication of antipsychotics. The healthcare provider should be contacted before administering the next dose of Haldol. (A, B, and C) are all adverse effects of Haldol which can be managed.

A client is receiving substitution therapy during withdrawal from benzodiazepines. Which expected outcome statement has the highest priority when planning nursing care?
a. Client will not demonstrate cross-addiction.
b. Co-dependent behaviors will be decreased.
c. Excessive CNS stimulation will be reduced.
d. Client’s level of consciousness will increase.
c. Excessive CNS stimulation will be reduced. Correct

Substitution therapy with another CNS depressant is intended to decrease the excessive CNS stimulation that can occur during benzodiazepine withdrawal (C). (A, B, and D) are all appropriate outcome statements for the client described, but do not have the priority of (C).

A client is admitted with a diagnosis of depression. The nurse knows that which characteristic is most indicative of depression?
a. Grandiose ideation.
b. Self-destructive thoughts.
c. Suspiciousness of others.
d. A negative view of self and the future.
d. A negative view of self and the future.

Negative self-image and feelings of hopelessness about the future (D) are specific indicators for depression. (A and/or C) occurs with paranoia or paranoid ideation. (B) may be seen in depressed clients, but are not always present, so (D) is a better answer than (B).

A male client is admitted to the mental health unit because he was feeling depressed about the loss of his wife and job. The client has a history of alcohol dependency and admits that he was drinking alcohol 12 hours ago. Vital signs are: temperature, 100° F, pulse 100, and BP 142/100. The nurse plans to give the client lorazepam (Ativan) based on which priority nursing diagnosis?
a. Risk for injury related to suicidal ideation.
b. Risk for injury related to alcohol detoxification.
c. Knowledge deficit related to ineffective coping.
d. Health seeking behaviors related to personal crisis.
b. Risk for injury related to alcohol detoxification.

The most important nursing diagnosis is related to alcohol detoxification (B) because the client has elevated vital signs, a sign of alcohol detoxification. Maintaining client safety related to (A) should be addressed after giving the client Ativan for elevated vital signs secondary to alcohol withdrawal. (C and D) can be addressed when immediate needs for safety are met.

A nurse working in the emergency room of a children’s hospital admits a child whose injuries could have resulted from abuse. Which statement most accurately describes the nurse’s responsibility in cases of suspected child abuse?
a. The nurse should obtain objective data such as x-rays before reporting suspicions to the authorities.
b. The nurse should confirm any suspicions of child abuse with the healthcare provider before reporting to the authorities.
c. The nurse should report any case of suspected child abuse to the nurse in charge.
d. The nurse should note in the client’s record any suspicions of child abuse so that a history of such suspicions can be tracked.
c. The nurse should report any case of suspected child abuse to the nurse in charge. Correct

It is the nurse’s legal responsibility to report all suspected cases of child abuse. Notifying the charge nurse starts the legal reporting process (C).

A male client with schizophrenia tells the nurse that the voices he hears are saying, “You must kill yourself.” To assist the client in coping with these thoughts, which response is best for the nurse to provide?
a. Tell yourself that the voices are unreasonable.
b. Exercise when you hear the voices.
c. Talk to someone when you hear the voices.
d. The voices aren’t real, so ignore them.
a. Tell yourself that the voices are unreasonable. Correct

The nurse should teach the client to use self-talk to disprove the voices (A). Although (B) may be helpful, the client’s concrete thinking may make it difficult to understand this suggestion. Clients with schizophrenia have difficulty initiating interaction with others (C). Auditory hallucinations are often relentless, so it is difficult to ignore them (D).

A 38-year-old female client is admitted with a diagnosis of paranoid schizophrenia. When her tray is brought to her, she refuses to eat and tells the nurse, “I know you are trying to poison me with that food.” Which response is most appropriate for the nurse to make?
a. I’ll leave your tray here. I am available if you need anything else.
b. You’re not being poisoned. Why do you think someone is trying to poison you?
c. No one on this unit has ever died from poisoning. You’re safe here.
d. I will talk to your healthcare provider about the possibility of changing your diet.
a. I’ll leave your tray here. I am available if you need anything else.

(A) is the best choice cited. The nurse does not argue with the client nor demand that she eat, but offers support by agreeing to “be there if needed”, e.g., to warm the food. (B and C) are arguing with the client’s delusions, and (B) asks “why” which is usually not a good question for a psychotic client. (D) has nothing to do with the actual problem; i.e., the problem is not the diet (she thinks any food given to her is poisoned.)

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?
a. Reassure the client by telling him that his fear of the admission procedure is to be expected.
b. Tell the client that no one is accusing him of murder and remind him that the hospital is a safe place.
c. Assess the content of the hallucinations by asking the client what he is hearing.
d. Ignore the behavior and make no response at all to his delusional statements.
c. Assess the content of the hallucinations by asking the client what he is hearing.

Further assessment is indicated (C). The nurse should obtain information about what the client believes the voices are telling him–they may be telling him to kill the nurse! (A) is telling the client how he feels (fearful). The nurse should leave communications open and seek more information. (B) is arguing with the client’s delusion, and the nurse should never argue with a client’s hallucinations or delusions, also (B) is possibly offering false reassurance. (D) is avoiding the situation and the client’s needs.

A female client with obsessive-compulsive disorder (OCD) is describing her obsessions and compulsions and asks the nurse why these make her feel safer. What information should the nurse include in this client’s teaching plan? (Select all that apply.)
a. Compulsions relieve anxiety.
b. Anxiety is the key reason for OCD.
c. Obsessions cause compulsions.
d. Obsessive thoughts are linked to levels of neurochemicals.
e. Antidepressant medications increase serotonin levels.
a. Compulsions relieve anxiety. Correct
b. Anxiety is the key reason for OCD. Correct
d. Obsessive thoughts are linked to levels of neurochemicals. Correct
e. Antidepressant medications increase serotonin levels. Correct

Correct choices are (A, B, D, and E). To promote client understanding and compliance, the teaching plan should include explanations about the origin and treatment options of OCD symptomology. Compulsions are behaviors that help relieve anxiety (A), which is a vague feeling related to unknown fears, that motivate behavior (B) to help the client cope and feel secure. All obsessions (C) do not result in compulsive behavior. OCD is supported by the neurophysiology theory, which attributes a diminished level of neurochemicals (D), particularly serotonin, and responds to selective serotonin reuptake inhibitors (SSRI).

On admission to a residential care facility, an elderly female client tells the nurse that she enjoys cooking, quilting, and watching television. Twenty-fours after admission, the nurse notes that the client is withdrawn and isolated. It is best for the nurse to encourage this client to become involved in which activity?
a. Clean the unit kitchen cabinets.
b. Participate in a group quilting project.
c. Watch television in the activity room.
d. Bake a cake for a resident’s birthday.
b. Participate in a group quilting project.

Peer interaction in a group activity (B) will help to prevent social isolation and withdrawal. (A, C, and D) are activities that can be accomplished alone, without peer interaction.

An elderly female client with advanced dementia is admitted to the hospital with a fractured hip. The client repeatedly tells the staff, “Take me home. I want my Mommy.” Which response is best for the nurse to provide?
a. Orient the client to the time, place, and person.
b. Tell the client that the nurse is there and will help her.
c. Remind the client that her mother is no longer living.
d. Explain the seriousness of her injury and need for hospitalization.
b. Tell the client that the nurse is there and will help her.

Those with dementia often refer to home or parents when seeking security and comfort. The nurse should use the techniques of “offering self” and “talking to the feelings” to provide reassurance (B). Clients with advanced dementia have permanent physiological changes in the brain (plaques and tangles) that prevent them from comprehending and retaining new information, so (A, C, and D) are likely to be of little use to this client and do not help the client’s emotional needs.

A client who has been admitted to the psychiatric unit tells the nurse, “My problems are so bad that no one can help me.” Which response is best for the nurse to make?
a. How can I help?
b. Things probably aren’t as bad as they seem right now.
c. Let’s talk about what is right with your life.
d. I hear how miserable you are, but things will get better soon.
a. How can I help?

Offering self shows empathy and caring (A), and is the best of the choices provided. Combining the first part of (D) with (A) would be the best response, but this is not a fill-in-the-blank or an essay test! Choose the best of those choices provided and move on. (B) dismisses the client, things are bad as far as this client is concerned. (C) avoids the client’s problems and promotes denial. “I hear how miserable you are” is an example of reflective dialogue and would be the best choice if it were not for the rest of the sentence–“but things will get better” which is offering false reassurance.

Physical examination of a 6-year-old reveals several bite marks in various locations on his body. X-ray examination reveals healed fractures of the ribs. The mother tells the nurse that her child is always having accidents. Which initial response by the nurse would be most appropriate?
a. I need to inform the healthcare provider about your child’s tendency to be accident prone.
b. Tell me more specifically about your child’s accidents.
c. I must report these injuries to the authorities because they do not seem accidental.
d. Boys this age always seem to require more supervision and can be quite accident prone.
b. Tell me more specifically about your child’s accidents.

(B) seeks more information using an open ended, non-threatening statement. (A) could be appropriate, but it is not the best answer because the nurse is being somewhat sarcastic and is also avoiding the situation by referring it to the healthcare provider for resolution. Although it is true that suspected cases of child abuse must be reported, (C) is virtually an attack and is jumping to conclusions before conclusive data has been obtained. (D) is a cliché and dismisses the seriousness of the situation.

A 30-year-old sales manager tells the nurse, “I am thinking about a job change. I don’t feel like I am living up to my potential.” Which of Maslow’s developmental stages is the sales manager attempting to achieve?
a. Self-Actualization.
b. Loving and Belonging.
c. Basic Needs.
d. Safety and Security.
a. Self-Actualization.

Self-actualization is the highest level of Maslow’s development stages, which is an attempt to fulfill one’s full potential (A). (B) is identifying support systems. (C) is the first level of Maslow’s developmental stages and is the foundation upon which higher needs rest. Individuals who feel safe and secure (D) in their environment perceive themselves as having physical safety and lack fear of harm.

The charge nurse is collaborating with the nursing staff about the plan of care for a client who is very depressed. What is the most important intervention to implement during the first 48 hours after the client’s admission to the unit?
a. Monitor appetite and observe intake at meals.
b. Maintain safety in the client’s milieu.
c. Provide ongoing, supportive contact.
d. Encourage participation in activities.
b. Maintain safety in the client’s milieu.

The most important reason for closely observing a depressed client immediately after admission is to maintain safety (B), since suicide is a risk with depression. (A, C, and D) are all important interventions, but safety is the priority.

Based on non-compliance with the medication regimen, an adult client with a medical diagnosis of substance abuse and schizophrenia was recently switched from oral fluphenazine HCl (Prolixin) to IM fluphenazine decanoate (Prolixin Decanoate). What is most important to teach the client and family about this change in medication regimen?
a. Signs and symptoms of extrapyramidal effects (EPS).
b. Information about substance abuse and schizophrenia.
c. The effects of alcohol and drug interaction.
d. The availability of support groups for those with dual diagnoses.
c. The effects of alcohol and drug interaction.

Alcohol enhances the EPS side effects of Prolixin. The half-life of Prolixin PO is 8 hours, whereas the half-life of the Prolixin Decanoate IM is 2 to 4 weeks. That means the side effects of drinking alcohol are far more severe when the client drinks alcohol after taking the long-acting Prolixin Decanoate IM. (A, B, and D) provide valuable information and should be included in the client/family teaching, but they do not have the priority of (C).

A client, who is on a 30-day commitment to a drug rehabilitation unit, asks the nurse if he can go for a walk on the grounds of the treatment center. When he is told that his privileges do not include walking on the grounds, the client becomes verbally abusive. Which approach should the nurse use?
a. Call a staff member to escort the client to his room.
b. Tell the client to talk to his healthcare provider about his privileges.
c. Remind the client of the unit rules.
d. Ignore the client’s inappropriate behavior.
d. Ignore the client’s inappropriate behavior.

The client is trying to engage the nurse in a dispute. Ignoring the behavior (D) provides no reinforcement for the inappropriate behavior. (A) is not necessary unless the client becomes a physical threat to the nurse. (B) would be inappropriate, because it is referring the situation to the healthcare provider and is not in keeping with good health team management. Consistent limits must be established and enforced. (C) would subject the nurse to more verbal abuse because the client could use any response as an excuse to attack the nurse once again.

Within several days of hospitalization, a client is repeatedly washing the top of the same table. Which initial intervention is best for the nurse to implement to help the client cope with anxiety related to this behavior?
a. Administer a prescribed PRN antianxiety medication.
b. Assist the client to identify stimuli that precipitates the ritualistic activity.
c. Allow time for the ritualistic behavior, then redirect the client to other activities.
d. Teach the client relaxation and thought stopping techniques.
c. Allow time for the ritualistic behavior, then redirect the client to other activities.

Initially, the nurse should allow time for the ritual (C) to prevent anxiety. (A) may help reduce the client’s anxiety, but will not prevent ritualistic behavior resulting from the client’s ineffective coping ability. (B) is a long-term goal of individual therapy, but is not directly related to controlling the behavior at this time. (D) lists techniques that can be used to assist the client in learning new ways of interrupting obsessive thoughts and resulting ritualistic behavior as treatment progresses.

On admission, a highly anxious client is described as delusional. The nurse understands that delusions are most likely to occur with which class of disorder?
a. Neurotic.
b. Personality.
c. Anxiety.
d. Psychotic.
d. Psychotic.

Delusions are false beliefs associated with psychotic behavior, and psychotic persons are not in touch with reality (D). (A, B, and C) are mental health disorders which are not associated with a break in reality, nor with hallucinations (false sensations such as hearing, or seeing) or delusions (false beliefs).

The nurse observes a client who is admitted to the mental health unit and identifies that the client is talking continuously, using words that rhyme but that have no context or relationship with one topic to the next in the conversation. This client’s behavior and thought processes are consistent with which syndrome?
Dementia.
Depression.
Schizophrenia.
Chronic brain syndrome.
A homeless person who is in the manic phase of bipolar disorder is admitted to the mental health unit. Which laboratory finding obtained on admission is most important for the nurse to report to the healthcare provider?
Decreased thyroid stimulating hormone level.
Elevated liver function profile.
Increased white blood cell count.
Decreased hematocrit and hemoglobin levels.
The nurse is assessing a client’s intelligence. Which factor should the nurse remember during this part of the mental status exam?
Acute psychiatric illnesses impair intelligence.
Intelligence is influenced by social and cultural beliefs.
Poor concentration skills suggests limited intelligence.
The inability to think abstractly indicates limited intelligence.
At a support meeting of parents of a teenager with polysubstance dependency, a parent states, “Each time my son tries to quit taking drugs, he gets so depressed that I’m afraid he will commit suicide.” The nurse’s response should be based on which information?
Addiction is a chronic, incurable disease.
Tolerance to the effects of drugs causes feelings of depression.
Feelings of depression frequently lead to drug abuse and addiction.
Careful monitoring should be provided during withdrawal from the drugs.
The wife of a male client recently diagnosed with schizophrenia asks the nurse, “What exactly is schizophrenia? Is my husband all right?” Which response is best for the nurse to provide to this family member?
It sounds like you’re worried about your husband. Let’s sit down and talk.
It is a chemical imbalance in the brain that causes disorganized thinking.
Your husband will be just fine if he takes his medications regularly.
I think you should talk to your husband’s psychologist about this question.
A young adult male client, diagnosed with paranoid schizophrenia, believes that world is trying poison him. What intervention should the nurse include in this client’s plan of care?
Remind the client that his suspicions are not true.
Ask one nurse to spend time with the client daily.
Encourage the client to participate in group activities.
Assign the client to a room closest to the activity room.
The community health nurse talks to a male client who has bipolar disorder. The client explains that he sleeps 4 to 5 hours a night and is working with his partner to start two new businesses and build an empire. The client stopped taking his medications several days ago. What nursing problem has the highest priority?
Excessive work activity.
Decreased need for sleep.
Medication management.
Inflated self-esteem.
A female client with obsessive-compulsive disorder (OCD) is describing her obsessions and compulsions and asks the nurse why these make her feel safer. What information should the nurse include in this client’s teaching plan? (Select all that apply.)
Compulsions relieve anxiety.
Anxiety is the key reason for OCD.
Obsessions cause compulsions.
Obsessive thoughts are linked to levels of neurochemicals.
Antidepressant medications increase serotonin levels.
The nurse observes a female client with schizophrenia watching the news on TV. She begins to laugh softly and says, “Yes, my love, I’ll do it.” When the nurse questions the client about her comment she states, “The news commentator is my lover and he speaks to me each evening. Only I can understand what he says.” What is the best response for the nurse to make?
What do you believe the news commentator said to you?
Let’s watch news on a different television channel.
Does the news commentator have plans to harm you or others?
The news commentator is not talking to you.
A 40-year-old male client diagnosed with schizophrenia and alcohol dependence has not had any visitors or phone calls since admission. He reports he has no family that cares about him and was living on the streets prior to this admission. According to Erikson’s theory of psychosocial development, which stage is the client in at this time?
Isolation.
Stagnation.
Despair.
Role confusion.
The parents of a 14-year-old boy bring their son to the hospital. He is lethargic, but responsive. The mother states, “I think he took some of my pain pills.” During initial assessment of the teenager, what information is most important for the nurse to obtain from the parents?
If he has seemed depressed recently.
If a drug overdose has ever occurred before.
If he might have taken any other drugs.
If he has a desire to quit taking drugs.

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