Evolve psychiatric exam

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  • my assistant was looking for CA Notice of Client\'s Right - State Bar a few weeks ago and discovered an online service with lots of sample forms . If others require CA Notice of Client\'s Right - State Bar also , here's a client arbitration
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Evolve psychiatric exam

  1. 1. 1.A schizophrenic client says, “I’m away for the day ... but don’t think we should play … or dowe have feet of clay?” Which alteration in the client’s speech does the nurse document?A) NeologismB) Word saladC) Clang associationD) Associative loosenessFeedback: INCORRECTRationale: Clang association is the meaningless rhyming of words in which the rhyming ismore important than the context of the words. A neologism is a made-up word that hasmeaning only to the client. Word salad is the term for a mixture of meaningless phrases,either to the client or to the listener. Associative looseness is a term used to describeschizophrenic speech in which connections and threads are interrupted or missing.Test-Taking Strategy: Knowledge of the speech patterns exhibited by the client withschizophrenia is needed to answer this question. Focus on the data in the question and notethe meaningless rhyming of words. Review these speech patterns if you had difficulty withthis question.Reference: Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing:A communication approach to evidence-based care (p. 281). St. Louis: Saunders.Cognitive Ability: ApplyingClient Needs: Psychosocial IntegrityIntegrated Process: Communication and DocumentationContent Area: Mental HealthPoints Earned: 0.0/1.02.A client with schizophrenia and his parents are meeting with the nurse. One of the youngman’s parents says to the nurse, “We were stunned when we learned that our son hadschizophrenia. He was no different than from his older brother when they were growing up.Now he’s had another relapse, and we can’t understand why he stopped his medication.”Which response by the nurse is appropriate?A) Telling the parents, “Medication noncompliance is the most frequent reason that peoplewith this diagnosis relapse.”B) Telling the parents, “Well, it’s his decision to take his medicine, but it’s yours to have himlive with you if he stops the medication.”C) Asking the client, “How can we help you to take your medicine or to tell us when you’rehaving problems so that your medication can be adjusted?”
  2. 2. D) Saying to the parents, “Your concerns are appropriate, but I wonder whether your sonwas having trouble telling someone that he had concerns about his medication.”Feedback: INCORRECTRationale: The therapeutic response is the one in which the nurse models speaking directlyto the client. This facilitates further assessment of the situation and helps elicit the causesof and motivations for the client’s behavior for both the nurse and the family. In the correctoption, the nurse also seeks clarification of the degree of openness and mutuality felt by theclient and his family toward each other. The nurse provides information to the family whenstating that noncompliance is the most frequent reason for relapse in people with thisdiagnosis. However, the statement is nontherapeutic at this time because it does notfacilitate the expression of feelings. The nurse uses a superego style of communicationwhen stating, “Well, it’s his decision to take his medicine, but it’s yours to have him live withyou if he stops the medication.” The content of this statement may be true, but it isnontherapeutic in that it carries a threatening message and may prevent the family fromtrusting the nurse. By stating, “Your concerns are appropriate, but I wonder whether yourson was having trouble telling someone that he had concerns about his medication,” thenurse gives approval and prematurely analyzes the client’s motivation without sufficientassessment.Test-Taking Strategy: Use your knowledge of therapeutic communication techniques andremember to focus on the client’s feelings. Also note that the correct option is the onlyoption in which the nurse directly addresses the client. Review therapeutic communicationtechniques if you had difficulty with this question.Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31).St. Louis: Mosby.Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing: Acommunication approach to evidence-based care (p. 297). St. Louis: Saunders.Cognitive Ability: ApplyingClient Needs: Psychosocial IntegrityIntegrated Process: Communication and DocumentationContent Area: Mental HealthPoints Earned: 0.0/1.03.An acutely ill schizophrenic client says to the nurse, “He keeps saying that he likes you, andI keep telling him you’re married, but he won’t listen, and I think he’s going to get freshwith you.” Once the nurse has determined that the client is hallucinating, which response tothe client would be most appropriate statement?A) “Try not to listen to the voices right now so that I can talk with you.”B) “I think that you can help him stop his behavior if you concentrate.”C) “Tell him I said to mind his p’s and q’s or I’ll call the police on him.”
  3. 3. D) “I think that you’re trying to share your own feelings toward me, but you’re shy.”Feedback: INCORRECTRationale: The appropriate statement by the nurse is the one that does not acknowledge theclient’s hallucinations. By responding, “I think that you can help him stop his behavior if youconcentrate” or “Tell him I said to mind his p’s and q’s or I’ll call the police on him,” thenurse acknowledges the hallucinations. The nurse attempts to interpret the client’s thinkingwith a statement such as “I think that you’re trying to share your own feelings toward me,but you’re shy.”Test-Taking Strategy: Use your knowledge of therapeutic communication techniques andremember that the nurse should not acknowledge the client’s hallucinations. Also note thatthe correct option is the only one that encourages realistic verbalization from the client.Review therapeutic communication techniques with a client who is hallucinating if you haddifficulty with this question.References: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31). St. Louis: Mosby.Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing: Acommunication approach to evidence-based care (pp. 287, 288). St. Louis: Saunders.Cognitive Ability: ApplyingClient Needs: Psychosocial IntegrityIntegrated Process: Communication and DocumentationContent Area: Mental HealthPoints Earned: 0.0/1.04.A client says to the nurse, “It’s over for me — the whole thing is over.” Which response bythe nurse would be therapeutic?A) “What do you mean, ‘The whole thing is over’?”B) “Over? Well, that sounds pretty drastic to me. Let’s discuss this in the strictestconfidence.”C) “Can you tell me more about why it’s over for you? I’ll keep your thoughts strictlyconfidential.”D) “Let’s talk more about your feeling that the whole thing is over for you. This is important,and I may need to share your feelings with other staff members.”Feedback: INCORRECTRationale: The therapeutic response seeks clarification, employs paraphrasing, and informsthe client that the nurse needs to share any information that requires crisis interventionwith other staff members. Asking, “What do you mean, ‘The whole thing is over’?” employsparaphrasing, but the message is blunt and closed-ended. In stating, “Over? Well, thatsounds pretty drastic to me. Let’s discuss this in the strictest confidence,” the nurse uses
  4. 4. hysterical exaggeration (at an inappropriate time) and gives incorrect information regardingconfidentiality. In stating, “Can you tell me more about why it’s over for you? I’ll keep yourthoughts strictly confidential,” the nurse uses the therapeutic technique of seekingclarification but does not clarify with the client that the information might need to beshared.Test-Taking Strategy: Use the process of elimination. Eliminate the options that arecomparable or alike and indicate that shared information will be maintained as confidential.To select from the remaining options, focus on the statement that addresses the client’sfeelings. Review therapeutic communication techniques if you had difficulty with thisquestion.Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31).St. Louis: Mosby.Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Communication and DocumentationContent Area: Mental HealthPoints Earned: 0.0/1.05.A nurse performing a lethality assessment asks the client whether he is thinking of suicide.Which statement by the client would be of most concern to the nurse?A) “No, I wasn’t, but I am now, thanks to you.”B) “I hadn’t thought of that, but I can see that you are.”C) “Of course not, but there are days when I think that I should be.”D) “What is suicide going to do for me except get me excommunicated from the church?”Feedback: CORRECTRationale: The client’s response that he is now thinking about suicide is of the greatestconcern to the nurse. In making the statement “I hadn’t thought of that, but I can see thatyou are” the client projects his own thoughts of suicide onto the nurse. In stating, “Ofcourse not, but there are days when I think that I should be,” the client is being sarcasticbut is not specifically talking about suicide. In stating, “What is suicide going to do for meexcept get me excommunicated from the church?” the client indicates that suicide is not anoption because of his religious beliefs.Test-Taking Strategy: Use the process of elimination and note the strategic words “of mostconcern to the nurse.” Note the words “but I am now” in the correct option. This is the onlyoption that identifies definite suicidal thoughts. Review lethality assessment in the suicidalclient if you had difficulty with this question.
  5. 5. References: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31). St. Louis: Mosby.Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing: Acommunication approach to evidence-based care (p. 412). St. Louis: Saunders.Cognitive Ability: AnalyzingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/AssessmentContent Area: Mental HealthPoints Earned: 1.0/1.06.A client who has expressed suicidal ideation in the past says to the nurse, while shufflingseveral documents in an effort to organize them, “Well, I’m feeling so much better nowsince I got organized. My lawyer wrote my will and durable power of attorney.” Whichresponse by the nurse is appropriate?A) “Good grief! You don’t look organized to me.”B) “Okay, what are you up to today? Your behavior is not appropriate.”C) “You talk about getting organized. Are you thinking of killing yourself?”D) “If you keep behaving like this, you know that I’ll have to tell the doctor, and we’ll haveto seclude you.”Feedback: CORRECTRationale: The client is exhibiting behaviors that indicate plans for suicide. Talking ofsuddenly “feeling so much better” and putting affairs in order are key verbal and behavioralclues that the client is planning to commit suicide. In exclaiming, “Good grief! You don’t lookorganized to me,” the nurse nontherapeutically uses hysterical exaggeration, whichminimizes the client’s feelings. In asking, “Okay, what are you up to today? Your behavior isnot appropriate,” the nurse uses teasing to determine the client’s behaviors, whichminimizes them. Additionally, the nurse is employing a nontherapeutic technique of judging.In stating, “If you keep behaving like this, you know that I’ll have to tell the doctor and we’llhave to seclude you,” the nurse uses a threat.Test-Taking Strategy: Use the process of elimination. Focus on the information in thequestion and note the relationship between the words “expressed suicidal ideation” in thequestion and “thinking of killing yourself” in the correct option. Review the clues thatindicate the potential for suicide if you had difficulty with this question.Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31,316). St. Louis: Mosby.Cognitive Ability: ApplyingClient Needs: Safe and Effective Care Environment
  6. 6. Integrated Process: Communication and DocumentationContent Area: Mental HealthPoints Earned: 1.0/1.07.An adolescent client says, “I’m just a burden to my folks. They wish I’d never been born. Mydad told me he had to marry Mom because she got pregnant.” Which response by the nursewould be therapeutic?A) “You’re feeling that your folks didn’t want you, but they chose to marry and have you.”B) “You feel that you were a burden and not wanted? Let’s talk with your parents to seewhether you’re right.”C) “Let’s speak with your parents about what you’ve just told me. Let’s ask whether youwere truly unwanted.”D) “Sounds like your father was very inappropriate, but I’m certain that he didn’t mean thatyou were a burden to him.”Feedback: INCORRECTRationale: In the correct option, the nurse uses reflection to explore the client’s lethality riskand then uses reframing to determine whether the client is able to view what happened in adifferent way. In suggesting, “You feel that you were a burden and not wanted? Let’s talkwith your parents to see whether you’re right,” the nurse uses paraphrasing but is thennontherapeutic in trying to persuade the client to talk to the parents. In suggesting, “Let’sspeak with your parents about what you’ve just told me. Let’s ask whether you were trulyunwanted,” the nurse uses a parental approach, which may be threatening to the client, whoseems to have been unable to talk with the parents before now. In stating, “Sounds likeyour father was very inappropriate, but I’m certain that he didn’t mean that you were aburden to him,” the nurse offers an opinion about the client’s father and then provides falsereassurance.Test-Taking Strategy: Use the process of elimination. Eliminate the options that arecomparable or alike and address discussing the client’s feelings with the parents. Inselecting from the remaining options, remember to focus on the client’s feelings. This willdirect you to the correct option. Review therapeutic communication techniques if you haddifficulty with this question.Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31,683). St. Louis: Mosby.Cognitive Ability: ApplyingClient Needs: Psychosocial IntegrityIntegrated Process: Communication and DocumentationContent Area: Mental Health
  7. 7. Points Earned: 0.0/1.08.A client says to the nurse, “I’ve ruined my life. I left college with only a few credits to go. Ikeep telling myself that I’m going to make it as a writer, but I’ll be a loser and a nothing forthe rest of my life.” Which response by the nurse is therapeutic?A) “What are you saying? Sounds like you need to pull yourself together and go back toschool.”B) “Having faith in yourself is one thing, but looking at your alternatives realistically isanother.”C) “You seem to be saying that your choices are final and that you’ve lost any otheropportunities.”D) “Sounds like you feel that things should come easy for you, unlike the rest of us, whowork for what we get.”Feedback: INCORRECTRationale: The client in this question is engaging in catastrophizing rather than reframingand viewing other alternatives. The task for the nurse is to assess the lethality of the client’ssituation and to help the client feel empowered to take another course of action and find theperseverance and confidence to do so. The therapeutic response here is the one that isnonjudgmental. In responding, “What are you saying? Sounds like you need to pull yourselftogether and go back to school,” or “Sounds like you feel that things should come easy foryou, unlike the rest of us, who work for what we get,” the nurse communicates with theclient as a parent, using a judging style. In stating, “Having faith in yourself is one thing,but looking at your options realistically is another,” the nurse communicates prematurelyand gives advice.Test-Taking Strategy: Use the process of elimination and your knowledge of therapeuticcommunication techniques. Eliminate the options that are comparable or alike in that thenurse uses a judging style to deal with the client. To select from the remaining options,eliminate the option that is nontherapeutic in that the nurse gives advice. Reviewtherapeutic communication techniques if you had difficulty with this question.Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31,94). St. Louis: Mosby.Cognitive Ability: ApplyingClient Needs: Psychosocial IntegrityIntegrated Process: Communication and DocumentationContent Area: Mental HealthPoints Earned: 0.0/1.0
  8. 8. 9.A client who has twice attempted suicide says, “If people would just leave me alone and letme do what I want with my life, I could get on with what I want to do.” Which responseshould the nurse should give to the client?A) “Of course you can’t be left alone to get on with what you want to do.”B) “Okay, go ahead and do whatever you want to do. Human beings have free will.”C) “You’ve tried to end your life twice, yet you feel that everyone should let you do what youwant to do?”D) “Sounds like you’re angry with people for caring enough about you to try to keep youfrom hurting yourself.”Feedback: CORRECTRationale: The therapeutic response is the one that offers reflection, which permits the clientto observe the content of what she is saying. In stating, “Of course, you can’t be left aloneto get on with what you want to do,” the nurse makes a response that is social and belittlesthe client’s feelings. In stating, “Okay, go ahead and do whatever you want to do. Humanbeings have free will,” the nurse makes a response that seems sarcastic and angry; it is alsojudgmental and biased. In stating, “Sounds like you’re angry with people for caring enoughabout you to try to keep you from hurting yourself,” the nurse makes a prematurejudgment.Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. Thecorrect option is the only response that is therapeutic in that it uses reflection. Reviewtherapeutic communication techniques if you had difficulty with this question.References: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31). St. Louis: Mosby.Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing: Acommunication approach to evidence-based care (pp. 413, 415, 416). St. Louis: Saunders.Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Communication and DocumentationContent Area: Mental HealthPoints Earned: 1.0/1.010.A homeless client with an antisocial disorder is brought to the emergency department by thepolice after disturbing customers in a department store. The client says to the nurse, “Ineed to be hospitalized. It’s getting cold out, and I need a warm bed. If you don’t get meinto a hospital, I’ll jump off a bridge.” Which nursing intervention would be therapeutic?
  9. 9. A) Sending the client to the psychiatric hospital intake center immediately for evaluationB) Asking the police to pick the client up and arrest him for vagrancy, as they should havedone immediatelyC) Discharging the client with a follow-up appointment for the next day and guaranteeinghim a hospital bed if he shows upD) Sending the client to a shelter that will provide temporary housing if he signs a contractagreeing not to attempt suicideFeedback: CORRECTRationale: The client is clearly using suicide as a threat so that he will be hospitalized. Aslong as self-harm is not an issue, providing the client with shelter will meet his needs.Sending the client to the psychiatric hospital intake center immediately for evaluation is anintervention that should be used if the client refuses to sign a contract for “no suicide.”Guaranteeing the client a hospital bed if he shows up for a follow-up appointment ismanipulation, which is a nontherapeutic intervention. The nurse would not order the policeto arrest a client.Test-Taking Strategy: Use the process of elimination. Eliminate the option that indicatesarresting the client, because it is not the nurse’s role to determine who requires arrest bythe police. Next eliminate the option that involves manipulation. From the remainingoptions, select the option that provides the client shelter and addresses the risk of self-harm. Review self-harm issues and the appropriate nursing interventions if you had difficultywith this question.References: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., p. 633).St. Louis: Mosby.Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing: Acommunication approach to evidence-based care (p. 181). St. Louis: Saunders.Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Mental HealthPoints Earned: 1.0/1.011.A client is admitted to the medical-surgical unit of a hospital, and suicide precautions aretaken until the client can be admitted to the psychiatric unit. Which nursing interventiondoes the nurse implement?A) Placing the client in a private room and locking the client’s closets and bathroomB) Placing the client in a private room and removing all knives and glass from the client’smeal trayC) Allowing the client to go out on pass as long as the client is accompanied by aresponsible adult
  10. 10. D) Placing the client in a semiprivate room, providing plastic utensils for eating, and keepingan arm’s distance from the client at all timesFeedback: INCORRECTRationale: When a client is suicidal, someone must be at arm’s length at all times, observingthe client, and the client must be in view at all times, even while toileting and showering.Plastic utensils are used for eating. A semiprivate room is better than isolation in a privateroom. Searching the client and the client’s room for harmful objects is done openly andrandomly. Glass mirrors are removed and the bathroom is harmproofed by replacing themetal shower curtain rod with a plastic rod that falls when 50 pounds of pressure is placedon it. Off-unit passes are not issued when a client is suicidal.Test-Taking Strategy: Use the process of elimination and focus on the subject, suicideprecautions. Eliminate the options that are comparable or alike and involve the provision ofa private room, because this environment further isolates the client. Next recall that asuicidal client would not be allowed off the nursing unit. Review suicide precautions if youhad difficulty with this question.References: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., p. 327).St. Louis: Mosby.Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing: Acommunication approach to evidence-based care (p. 417). St. Louis: Saunders.Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Mental HealthPoints Earned: 0.0/1.012.A client is admitted to the psychiatric inpatient unit and suicide precautions are instituted.Which of the following interventions does the nurse implement?A) Restricting visitorsB) Placing the client in a private room and locking the bathroom doorC) Removing perfume, shampoo, and other toiletries from the client’s roomD) Placing flowers brought to the client in a small glass vase and putting them in the client’sroomFeedback: CORRECTRationale: When suicide precautions are instituted, all of the client’s belongings that arepotentially harmful are removed and placed in a locked area from which the nursing staffcan retrieve them as the client needs to use them. Visitors are not restricted. However, anyitems that a visitor brings to the client must be checked by the nurse. Glass items are notplaced in the suicidal client’s room.
  11. 11. Test-Taking Strategy: Use the process of elimination and focus on the subject, suicideprecautions. Eliminate the option that is a violation of client rights; the client is allowed tohave visitors. Next eliminate the options that contain the words “private room” and “glass.”Review suicide precautions if you had difficulty with this question.Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 326,327). St. Louis: Mosby.Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Mental HealthPoints Earned: 1.0/1.013.A client who is undergoing psychiatric counseling calls a nurse on a hotline, crying, andstates, “My priest assaulted me when I was an altar boy, and my dad just found out. He’sgot a gun, and he’s driving over to the church rectory. I don’t know what to do.” Whichresponse by the nurse is most appropriate initially?A) “How did your dad learn of your abuse by clergy?”B) “Call the police immediately and then call the priest to warn him that your dad has agun.”C) “Call the priest immediately and tell him to lock the doors until the police arrive. I’ll callthe police.”D) “You will want to come in to see our psychiatrist with your father, but, for now, call thepolice and tell them what happened.”Feedback: INCORRECTRationale: Usually the volunteers on hotlines are trained to keep the client on the line, but inthis case, the duty to warn the priest of the danger he is facing is paramount. Whenviolence erupts, the nurse must think and act quickly and with clarity. “How did your dadlearn of your abuse by clergy?” is off focus and inappropriate to the situation. Telling theclient, “Call the police immediately and then call the priest to warn him that your dad has agun,” is incorrect, because the priest should be warned first. In stating, “You will want tocome in to see our psychiatrist with your father, but, for now, call the police and tell themwhat happened,” the nurse does not focus on the imminent violence described in thequestion.Test-Taking Strategy: Note the strategic words “initially.” Eliminate the options that arecomparable or alike and direct the client to call the police first. To select from the remainingoptions, consider the seriousness of the situation. This will direct you to the correct option.The priest needs to be warned of the danger. Review nursing responsibilities in violentsituations if you had difficulty with this question.
  12. 12. Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 130,131). St. Louis: Mosby.Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Mental HealthPoints Earned: 0.0/1.014.A nurse determines that a client whose son died in a car accident is at risk for self-harm.Which intervention is most appropriate initially?A) Making a “no suicide” contract with the clientB) Telling the client that anger should be suppressedC) Providing a peaceful place for the client to meditateD) Helping the client control expression of his feelingsFeedback: CORRECTRationale: The nurse would first plan to implement a “no suicide” contract when a client is atrisk for self-harm. The safety of the client is the priority. The nurse would encourage theclient to express angry, hostile feelings, not suppress them. Providing a peaceful place forthe client to meditate is incorrect because the nurse would not want the client to isolatehimself. Rather, the nurse would promote social interaction for the client. The nurse wouldhelp the client express (not control expression of) feelings that are painful.Test-Taking Strategy: Use the process of elimination and note the strategic word “initially.”Note the relationship between the words “at risk for self-harm” in the question and “‘nosuicide’ contract” in the correct option. Review initial interventions for the client at risk forsuicide if you had difficulty with this question.Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., p. 327). St.Louis: Mosby.Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Mental Health
  13. 13. Points Earned: 1.0/1.015.A client says to the nurse, “I’m worried about my husband. He’s talking about ending it allsince his law practice dropped off and his son by his late first wife died of a drug overdose —but he’s too intelligent to hurt himself, isn’t he?” Which response by the nurse isappropriate?A) “Yes, he’s too intelligent to end it all.”B) “I’m not sure. I don’t know him that well.”C) “Most people who talk about ending it all are just looking for attention.”D) “Your husband is displaying behaviors that indicate a risk for self-harm.”Feedback: CORRECTRationale: Risk factors for suicide include male gender, professional status (physician,attorney, dentist, military personnel), loss to death, financial problems, and physical illness.Other risk indicators include a suicide plan, depressed mood, and prior attempts at suicide.In stating, “Yes, he’s too intelligent to end it all,” the nurse provides false reassurance. Inresponding, “I’m not sure. I don’t know him that well,” the nurse may be accurate, but theanswer avoids the client’s concern. The statement “Most people who talk about ending it allare just looking for attention.” is inaccurate. Any implication of suicide should be takenseriously.Test-Taking Strategy: Use the process of elimination and focus on the data in the question.Recalling the risk factors associated with suicide will direct you to the correct option. Reviewthese risk factors if you had difficulty with this question.Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., p. 322). St.Louis: Mosby.Cognitive Ability: ApplyingClient Needs: Psychosocial IntegrityIntegrated Process: Communication and DocumentationContent Area: Mental HealthPoints Earned: 1.0/1.016.A client says to the nurse, “I came in to see you because I’ve been off my medication for 4years but I feel as though I may be getting depressed again. I’ve been despondent againand thinking I should have ended it. That’s why I’m here to get help.” Which response bythe nurse would be therapeutic?
  14. 14. A) “Well, you really have had a good long drug-free time, but it sounds as if the doctorneeds to reorder your medication at once.”B) “If you’ve been able to be drug free all this time, you probably don’t need to restart themedicine. You probably just need some therapy to help you manage stress.”C) “Well, it’s been more than 4 years, so you’ve done really well. Sounds like you’re rightabout getting depressed again, though. Can you tell me what’s been happening with youlately?”D) “Well, it’s similar to when a client is battered — things have to boil over before the policecan act — so you need to be suicidal to get admitted to a hospital or hurt yourself beforethe doctor can restart the medication.”Feedback: CORRECTRationale: The therapeutic response is the one in which the nurse validates the client’s drug-free time. In addition, in the correct option the nurse validates the client’s self-assessmentand supports and offers positive reinforcement. Finally the nurse begins to assess the clientcompletely and attempts to identify precipitants. By stating, “Well, you really have had agood long drug-free time, but it sounds as if the doctor needs to reorder your medication atonce,” the nurse is premature in determining that the medication needs to be restarted; athorough assessment must be performed first. In stating, “If you’ve been able to be drugfree all this time, you probably don’t need to restart the medicine. You probably just needsome therapy to help you manage stress,” the nurse jumps to giving advice and offeringsuggestions without performing a complete assessment. In stating, “Well, it’s similar towhen a client gets battered — things have to boil over before the police can act — so youneed to be suicidal to get admitted to a hospital or hurt yourself before the doctor canrestart the medication,” the nurse provides an incorrect statement and sarcasticinformation.Test-Taking Strategy: Use your knowledge of therapeutic communication techniques and thesteps of the nursing process, remembering that assessment is the first step. The only optionthat involves the process of assessment is the correct option. Review therapeuticcommunication techniques if you had difficulty with this question.References: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31,286-287). St. Louis: Mosby.Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing: Acommunication approach to evidence-based care (p. 221). St. Louis: Saunders.Cognitive Ability: ApplyingClient Needs: Psychosocial IntegrityIntegrated Process: Communication and DocumentationContent Area: Mental HealthPoints Earned: 1.0/1.017.
  15. 15. A client who delivered a baby 4 months ago says, “I keep thinking that this boy is some sortof demon. All he does is cry. It’s as if I can’t feed him enough or satisfy him in any way. Mydaughter never gave me this kind of trouble. I really can’t stand it.” Which statement by thenurse is most important?A) “Have you been having any thoughts of hurting your baby?”B) “Do you think that something physically wrong is causing your baby to cry?”C) “Do you think that your baby cries so frequently because he’s not getting enoughnourishment from breastfeeding?”D) “You say that he doesn’t seem to be satisfied. Do you feel that this is significantlydifferent from when your daughter was a baby?”Feedback: CORRECTRationale: The most important statement is the one in which the nurse assesses the clientfor her risk of harming the baby. This client may be experiencing postpartum depression,and the rumination over the baby could lead the mother to harm the baby. The statementsin the incorrect options change the subject and close off expressions of concern by theclient.Test-Taking Strategy: Use the process of elimination. Noting the words “I really can’t standit” in the question will direct you to the correct option. Review assessment of the client atrisk for harming others if you had difficulty with this question.References: Fortinash, K. & Holoday-Worret, P. (2008). Psychiatric mental health nursing (4thed., p. 225). St. Louis: Mosby.Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., p. 286). St. Louis:Mosby.Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Communication and DocumentationContent Area: Mental HealthPoints Earned: 1.0/1.018.An alcoholic client who has been admitted to the mental health unit states to the nurse,“The judge made me come in here. My blood alcohol level was only 0.20% when the coppulled me over in my car.” Which statement by the nurse is most appropriate?A) “Did you ask the judge to clarify his decision to make you come here?”B) “This limit means that you had consumed enough alcohol to put you close to the legalintoxication level. You were lucky because you just missed that level.”C) “Well, the legal limit is much less than that, so you avoided a drunken driving charge bycoming here. Seems to me that the judge treated you pretty leniently by allowing you totake refuge here. Don’t you agree?”
  16. 16. D) “This level means that you consumed several drinks of alcohol and would be experiencingdepressed motor function of the brain. You would have been staggering and clumsy andyour judgment would have been impaired, but you seem to feel that the judge wasunreasonable for sending you here.”Feedback: INCORRECTRationale: In most states (although the blood alcohol level, or BAL—designated as theindicator of intoxication—does vary), the legal alcohol limit is 0.08%. The most appropriateresponse is the one that teaches the client about his blood alcohol level and directs him tofocus on his action and behaviors. In asking, “Did you ask the judge to clarify his decision tomake you come here?” the nurse seeks clarification from the client, which closes off theexpression of feelings by changing the focus of the discussion. In stating, “This readingmeans that you had consumed enough alcohol to put you close to the legal intoxicationlevel. You were lucky because you just missed that level,” the nurse gives inaccurateinformation about the BAL. In responding, “Well, the legal limit is much less than that, soyou avoided a drunken driving charge by coming here. Seems to me that the judge treatedyou pretty leniently by allowing you to take refuge here. Don’t you agree?” the nurse givesopinions and is judgmental, then asks for agreement in a sarcastic style of communication.Test-Taking Strategy: Use the process of elimination and your knowledge of BAL. Recallingthat in most states the legal alcohol limit is 0.08% will direct you to the correct option.Review the BAL if you had difficulty with this question.Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., p. 419). St.Louis: Mosby.Cognitive Ability: ApplyingClient Needs: Physiological IntegrityIntegrated Process: Nursing Process/ImplementationContent Area: Mental HealthPoints Earned: 0.0/1.019.An adolescent client has graduated high school and is preparing to leave home to attendcollege. The adolescent is distressed about this life change. The nurse plans to implementcrisis interventions, knowing that this situation is characteristic of:A) A situational crisisB) An individual crisisC) A maturational crisisD) An adventitious crisisFeedback: CORRECT
  17. 17. Rationale: A maturational crisis involves the normal life transitions that produce changes inindividuals and how they perceive themselves, their roles, and their status. A situationalcrisis occurs when a specific external event disturbs an individuals psychologicalequilibrium. An adventitious crisis is an unpredictable tragedy that occurs without warning.An individual may experience crisis; however, there is no formal type of crisis known as"individual crisis."Test-Taking Strategy: Use the process of elimination and your knowledge of the various typesof crises. Focus on the data in the question to direct you to the correct option. Review thedescription of the types of crises if you had difficulty with this question.Reference: Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing:A communication approach to evidence-based care (pp. 366, 367). St. Louis: Saunders.Cognitive Ability: ApplyingClient Needs: Psychosocial IntegrityIntegrated Process: Nursing Process/PlanningContent Area: Mental HealthPoints Earned: 1.0/1.020.A heroin addict who overdoses on the drug is brought into the emergency department. Theclient is having seizures, and the nurse notes that his pupils are dilated. Which of thefollowing interventions does the nurse anticipate that the emergency department physicianwill prescribe?A) Gastric lavageB) Intravenous fluidC) Naloxone (Narcan)D) Ammonium chlorideFeedback: CORRECTRationale: An opioid antagonist such as naloxone would be prescribed to treat a heroinoverdose to reverse central nervous system depression. Gastric lavage is used for oraloverdose of or oral poisoning with certain substances. Intravenous fluid is a generalintervention in many situations. Ammonium chloride is used to acidify the urine of a clientwho overdoses on amphetamines.Test-Taking Strategy: Focus on the subject, an overdose of heroin. Recalling that naloxone isan opioid antagonist will direct you to the correct option. Review this medication and thetreatment for heroin overdose if you had difficulty with this question.References: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., p. 1057). St. Louis: Saunders.
  18. 18. Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing: Acommunication approach to evidence-based care (p. 338). St. Louis: Saunders.Cognitive Ability: AnalyzingClient Needs: Psychosocial IntegrityIntegrated Process: Nursing Process/PlanningContent Area: Mental HealthPoints Earned: 1.0/1.021.A client in a retirement center rings the night alarm and says to the nurse, “Look at this oldman! He keeps breaking into my apartment! You’ve got to get him to stay out of here so Ican sleep.” Which statement by the nurse would be most therapeutic?A) “Why not just throw him out yourself and lock up once and for all?”B) “Now, you know that you’re always seeing things and people at night who aren’t there.”C) “This must be very troubling to you, but I can’t see the old man. Perhaps I could staywith you for an hour or so while you try to rest.”D) “I’m sure you’re very frightened right now. Do you recall my telling you that this is calledsundowner syndrome? Go to sleep and he’ll leave your apartment.”Feedback: CORRECTRationale: The most therapeutic nursing response is the one that expresses empathy andhelps orient the client to reality. It also offers self, builds trust, and provides support for theclient’s distress. In asking, “Why not just throw him out yourself and lock up once and forall?” the nurse reinforces the hallucination and delusional thinking by responding as if theold man is really there. In stating, “Now, you know that you’re always seeing things andpeople at night who aren’t there,” the nurse is patronizing and belittling in responding to theclient’s concerns, a nontherapeutic communication. In responding, “I’m sure that you’revery frightened right now. Do you recall my telling you that this is called sundownersyndrome? Go to sleep and he’ll leave your apartment,” the nurse is lecturing the client andgiving advice, which is not therapeutic.Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. Theonly option that addresses the client’s fears and feelings is the correct option. Reviewtherapeutic communication techniques if you had difficulty with this question.References: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31). St. Louis: Mosby.Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing: Acommunication approach to evidence-based care (p. 480). St. Louis: Saunders.Cognitive Ability: ApplyingClient Needs: Psychosocial Integrity
  19. 19. Integrated Process: Communication and DocumentationContent Area: Mental HealthPoints Earned: 1.0/1.022.A schizophrenic client is seen seemingly talking to someone who isn’t there. Which nursingstatement would be most therapeutic initially?A) “Today is my birthday. Would you like to go on an outing with my family?”B) “You need to wash up and get ready to go to supper in the cafeteria with the other clientsnow.”C) “I’ve noticed your eyes darting back and forth, and I wondered whether you might behearing voices.”D) “You were telling me yesterday that your mother died last June of cancer. Can you tellme more about that?”Feedback: INCORRECTRationale: The most therapeutic nursing statement is the one in which the nurse addressesthe client’s behavior and asks whether the client is hearing voices. With this statement, thenurse also assesses the client’s behavior. If the client is hearing voices, the nurse preventsreinforcement of the hallucinatory thinking by telling the client that he or she does not hearthem. In asking, “Today is my birthday. Would you like to go on an outing with my family?”the nurse nontherapeutically changes the focus from the client. In stating, “You need towash up and get ready to go to supper in the cafeteria with the other clients now,” the nurseignores the client’s obvious psychotic behavior and directs the client to socialize with others.Such an intervention is not usually positive, because it floods the client with stimuli thatmay contribute to an escalation of psychotic behavior. In asking, “You were telling meyesterday that your mother died last June of cancer. Can you tell me more about that?” thenurse uses distraction, summarization, and refocusing.Test-Taking Strategy: Note the strategic word “initially” and eliminate the options that areunrelated to the client’s behavior. Also, focus on the data in the question. The correct optionis the only one that addresses the client’s behavior. Review care of the client who ishallucinating if you had difficulty with this question.Reference: Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing:A communication approach to evidence-based care (pp. 287, 288). St. Louis: Saunders.Cognitive Ability: ApplyingClient Needs: Psychosocial IntegrityIntegrated Process: Communication and DocumentationContent Area: Mental Health
  20. 20. Points Earned: 0.0/1.023.A nurse brings a meal tray to a psychotic client in his hospital room. The client refuses themeal and says, “I’m not eating any more poisoned food while I’m vacationing here. I’mstarting on a fast to stay healthy and alive.” Which nursing intervention would be mostappropriate initially?A) Taking the tray away and canceling all meals until further noticeB) Having the client eat with other clients in the community dining roomC) Eating some of the food from the client’s tray to prove that it isn’t poisonedD) Telling the client that the psychiatrist will be called for a prescription for a tube feedingFeedback: INCORRECTRationale: Having the client eat with other clients in the community room decreases theamount of time in which the client can stay isolated and engage in suspicious thinking. Ofthe options provided, this would be the initial intervention. It does not guarantee that theclient will eat but does reduce the client’s isolation time. Taking the tray away and cancelingall meals until further notice and eating some of the food off the client’s tray to prove that itisn’t poisoned are both incorrect because they support the client’s delusional thinking.Telling the client that the psychiatrist will be called for a prescription for a tube feeding isincorrect because it is a premature action that would lead to a regressive struggle with theclient and is also a threat to the client.Test-Taking Strategy: Note the strategic word “initially.” First eliminate the option in whichthe nurse threatens the client. From the remaining options, eliminate options the optionsthat are comparable or alike and support the client’s delusional thinking, a nontherapeuticintervention. Review care of the psychotic client if you had difficulty with this question.Reference: Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing:A communication approach to evidence-based care (p. 289). St. Louis: Saunders.Cognitive Ability: ApplyingClient Needs: Psychosocial IntegrityIntegrated Process: Nursing Process/ImplementationContent Area: Mental HealthPoints Earned: 0.0/1.024.A nurse caring for a schizophrenic client is assessing the client’s ability to control distortedthought processes. Which of the following findings indicates a positive outcome?
  21. 21. A) The client is able to identify when hallucinations or delusions are real.B) The client can describe in detail the frequency and context of the hallucinatory anddelusional behavior.C) The client can describe the hallucinations and delusions in detail and is able to interactwith others and share in their delusional systems.D) The client can identify the recurrence of hallucinations, can refrain from responding tothem, and reports a significant decrease in the incidence of hallucinations.Feedback: CORRECTRationale: Identifying the reoccurrence of hallucinations, refraining from responding to them,and reporting a significant decrease in the incidence of hallucinations are all positive clientoutcomes. Other positive outcomes include appropriately interacting with others,demonstrating thinking that is based in reality, and grasping others’ ideas. The other optionsare incorrect because they are not positive outcomes with regard to the client’s ability tocontrol distorted thought processes and focus on the reality of the distorted thoughtprocesses.Test-Taking Strategy: Use the process of elimination. Focus on the subject, the client’s abilityto control distorted thought processes. The correct option is the only one that identifiescontrol. Review care of the client who is experiencing distorted thought processes if you haddifficulty with this question.Reference: Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing:A communication approach to evidence-based care (p. 288). St. Louis: Saunders.Cognitive Ability: EvaluatingClient Needs: Psychosocial IntegrityIntegrated Process: Nursing Process/EvaluationContent Area: Mental HealthPoints Earned: 1.0/1.025.A schizophrenic client says, “I feel like I’m rotting away inside and all of my organs arerusting.” Which type of delusion does the nurse identify in the client’s statement?A) SomaticB) JealousyC) PersecutionD) Idea of referenceFeedback: CORRECTRationale: Somatic delusions are false beliefs that one’s body is changing in an unusual way,such as rusting or rotting away. The most therapeutic intervention in such a situation is togain the client’s cooperation in taking the antipsychotic medication prescribed by thepsychiatrist. A delusion of jealousy is the false belief that one’s significant other is being
  22. 22. unfaithful. A delusion of persecution is the false belief that one is being singled out for harmby others. This usually takes the form of a plot by individuals in power against the person. Aclient subject to ideas of reference misconstrues trivial events and remarks so that he orshe may attach personal significance to them.Test-Taking Strategy: Use the process of elimination and your knowledge of the various typesof delusions. Note the data in the question and remember that the client is describing aphysiological manifestation. This will direct you to the correct option. Review the differenttypes of delusions if you had difficulty with this question.Reference: Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing:A communication approach to evidence-based care (p. 280). St. Louis: Saunders.Cognitive Ability: AnalyzingClient Needs: Psychosocial IntegrityIntegrated Process: Nursing Process/AssessmentContent Area: Mental HealthPoints Earned: 1.0/1.026.A schizophrenic client attending a support group held by a clinic nurse says to the nurse andthe group, “I’ve been laid off from my job at the factory, and so have 300 other people, soI’ll have to get a new job. For now, there’s unemployment.” Which statement by the nursewould be most therapeutic at this time?A) “It seems that the stock market is responsible for mass unemployment in our factory-based city.”B) “I’m sorry to hear that you’ve lost your job. Why not make an appointment to come inand talk with me this week?”C) “How do people feel about this loss of employment? Does anyone in the group whoexperienced this have any advice?”D) “Have other people in the group been feeling the job crunch this week? When changeslike this occur, it’s best to increase the number of your appointments with me for a shorttime.”Feedback: INCORRECTRationale: The nurse is leading a support group for schizophrenic clients, so it is important toaddress every group member when possible and not single out one member for specialattention. The correct option is open-ended, encourages group sharing of experiences andsupport, and teaches the members about the need to increase visits whenever scheduleschange abruptly and create stressful situations. In stating, “It seems that the stock marketis responsible for mass unemployment in our factory-based city,” the nurse changes thefocus from feelings and experiences to intellectualize, a nontherapeutic intervention. Inresponding, “I’m sorry to hear that you’ve lost your job. Why not make an appointment tocome in and talk with me this week?” the nurse expresses sympathy rather than empathy
  23. 23. and personalizes the invitation for an appointment that may cause jealousy among the otherclients in the group. In asking, “How do people feel about this loss of employment? Doesanyone in the group who experienced this have any advice?” the nurse asks a question ofthe group that is off focus.Test-Taking Strategy: Focus on the environment of the question, a support group. The onlyoption that addresses all members of the group is the correct option. It is also the umbrellaoption. Review the functions of support groups if you had difficulty with this question.Reference: Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing:A communication approach to evidence-based care (pp. 39, 40). St. Louis: Saunders.Cognitive Ability: ApplyingClient Needs: Psychosocial IntegrityIntegrated Process: Nursing Process/ImplementationContent Area: Mental HealthPoints Earned: 0.0/1.027.A schizophrenic client arrives for a scheduled appointment with the mental health nurse.The nurse notes that the client’s hygiene is poor and that the client is having difficultyconcentrating on what the nurse is saying and responding appropriately. Which nursingintervention would be most appropriate?A) Saying nothing and contacting the psychiatrist to sign a commitment orderB) Saying, “I notice that you don’t seem to be caring for yourself. Are you taking yourmedication?”C) Giving the client his antipsychotic medication and asking him to return in the morning fora follow-up visitD) Asking, “Will you voluntarily admit yourself for a couple of days so that you canstraighten out your medicine and thinking?”Feedback: CORRECTRationale: When the nurse’s observations indicate that the client is noncompliant with hismedicine, the most appropriate intervention is the one in which the nurse makesobservations and assesses noncompliance. Saying nothing and contacting the psychiatrist tosign a commitment order is inappropriate. Commitment proceedings may be necessary ifthe client is a danger to self or others. Giving the client his antipsychotic medication andasking him to return in the morning for a follow-up visit is inappropriate because the clientneeds assessment and intervention immediately. Waiting until the next morning does notmeet the client’s immediate needs. In asking, “Will you voluntarily admit yourself for acouple of days so that you can straighten out your medicine and thinking?” the nurse asksthe client to enter the hospital voluntarily. This intervention is premature, because furtherassessment of the client is needed.
  24. 24. Test-Taking Strategy: Use the process of elimination. Eliminate the options that arecomparable or alike and involve a delay in addressing the client’s needs. To select from theremaining options, focus on the data in the question and choose the one that addressesobservations made by the nurse. Review care of the schizophrenic client and observationsthat indicate medication noncompliance if you had difficulty with this question.Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31).St. Louis: Mosby.Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing: Acommunication approach to evidence-based care (p. 279). St. Louis: Saunders.Cognitive Ability: ApplyingClient Needs: Psychosocial IntegrityIntegrated Process: Nursing Process/ImplementationContent Area: Mental HealthPoints Earned: 1.0/1.028.A postpartum client says to the nurse, “Sometimes I hear voices telling me to kill my babyto save her all the heartache I’ve been through.” Which statement by the nurse would bemost therapeutic?A) “The voices will disappear in a few weeks as your hormones stabilize.”B) “This must be very distressing to you. Can you tell me more about the voices?”C) “It is so good that you shared your feelings and thoughts with me. I’m going to help youget immediate attention for your voices.”D) “You will want to tell the doctor about them when you visit him next week. He is veryinterested in these voices and will want to help you with them.”Feedback: INCORRECTRationale: The client is experiencing serious postpartum psychosis and commandhallucinations. They require immediate medical attention and intervention for the protectionof both the mother and her baby. In stating, “The voices will disappear in a few weeks asyour hormones stabilize,” the nurse disregards serious clinical manifestations. Inresponding, “This must be very distressing to you. Can you tell me more about the voices?”the nurse is trying to obtain additional data, but the client’s statement indicates apsychiatric emergency that requires immediate intervention. In stating, “You will want to tellthe doctor about them when you visit him next week. He is very interested in these voicesand will want to help you with them,” the nurse delays and refers the client to a psychiatrist1 week from now, an intervention that may be too late for the mother and baby.Test-Taking Strategy: Focus on the words “voices telling me to kill my baby.” The only optionthat provides immediate attention to this serious statement is the correct option. Reviewinterventions for the client who indicates the possibility of self-harm or harm to others if youhad difficulty with this question.
  25. 25. Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., p. 286). St.Louis: Mosby.Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Mental HealthPoints Earned: 0.0/1.029.A schizophrenic client exhibits confused and unintelligible speech. Which nursing statementwould be most therapeutic?A) “Got it. The ‘blinks’ are ‘taking over’ the ‘bumpers.’”B) “I can’t understand what you’re saying. You have to talk more clearly!”C) “This morning you are participating in the tree-decorating ceremony for the unit.”D) “I can’t understand you. Are you asking me to stay with you while you eat supper?”Feedback: CORRECTRationale: The most therapeutic technique for assisting a client whose speech is confusedand unintelligible is to emphasize what is happening in the here and now and involve theclient in simple reality-based activities. “Got it. The ‘blinks’ are ‘taking over’ the ‘bumpers’”is unintelligible speech on the part of the nurse and reinforces the client’s behavior. Instating, “I can’t understand what you’re saying. You have to talk more clearly!” the nursebegins with an appropriate response, but demanding that the client speak more clearly isinappropriate. In responding, “I can’t understand you. Are you asking me to stay with youwhile you eat supper?” the nurse is guessing at what the client has said.Test-Taking Strategy: Use the process of elimination. First eliminate the option that isunintelligible. Next eliminate the option that is demanding that the client speak more clearly.As you choose from the remaining options, remember that a schizophrenic client whoexhibits confusion and unintelligible speech should be involved in simple reality-basedactivities. Review care of the client with schizophrenia if you had difficulty with thisquestion.Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., p. 348). St.Louis: Mosby.Cognitive Ability: ApplyingClient Needs: Psychosocial IntegrityIntegrated Process: Nursing Process/Implementation
  26. 26. Content Area: Mental HealthPoints Earned: 1.0/1.030.A schizophrenic client says to the nurse, “I keep getting these thoughts and hearing voices.They worry and consume me so that I can’t always stop myself like my doctor told me to.”Which intervention would the nurse suggest as a distraction technique?A) “Pretend that you’re on the phone and talk to the voices.”B) “Have you tried to count back from 100 or listen to music?”C) “The next time this happens, try telling the voices to go away.”D) “Tell the voices that you will only listen to them just before you watch television at 8:30in the evening.”Feedback: CORRECTRationale: Distracting ways of coping with voices include reading aloud, describing an objectin detail, listening to music, and watching television. Having the client try to count backfrom 100 or listen to music will assist in distraction. In the remaining options, the nursesuggests interacting techniques that reinforce the client’s belief that the voices are real.Test-Taking Strategy: Use the process of elimination. Eliminate the options that arecomparable or alike and indicate that the voices are real. Review care of the schizophrenicclient who is hallucinating if you had difficulty with this question.Reference: Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing:A communication approach to evidence-based care (p. 288). St. Louis: Saunders.Cognitive Ability: ApplyingClient Needs: Psychosocial IntegrityIntegrated Process: Nursing Process/ImplementationContent Area: Mental HealthPoints Earned: 1.0/1.031.A nurse plans outcomes for a client who is being treated for psychosis. Which of thefollowing steps would be included during the stable or discharge phase of treatment?A) Evaluation of neurological statusB) Use of directive communications with the clientC) Administration of acute psychotropic medicationsD) Keeping the client active with hobbies, exercise, and work
  27. 27. Feedback: INCORRECTRationale: Desired outcomes for a psychotic client during the stable or discharge phase oftreatment include maintenance of a consistent sleeping pattern; avoidance of caffeine andalcohol; maintenance of daily and weekly routines, including enjoyable activities; and aregular medication schedule. Evaluation of neurological status, the use of directivecommunications, and the administration of acute psychotropic medications with the clientare all active-phase interventions.Test-Taking Strategy: Use the process of elimination and focus on the subject, the stable ordischarge phase of treatment. First eliminate the option that contains the word “acute.” Toselect from the remaining options, focus on the subject. Evaluation of neurological statusand use of directive communications with the client are part of the acute phase oftreatment. Review interventions for the client with psychosis who is preparing for dischargeif you had difficulty with this question.References: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., p. 233).St. Louis: Mosby.Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing: Acommunication approach to evidence-based care (p. 293). St. Louis: Saunders.Cognitive Ability: ApplyingClient Needs: Psychosocial IntegrityIntegrated Process: Nursing Process/PlanningContent Area: Mental HealthPoints Earned: 0.0/1.032.A schizophrenic client is admitted to the inpatient psychiatric unit. The client is exhibitingclang associations, word salad, and loose associations. Which problem does the nurserecognize that the client is experiencing?A) Defensive copingB) Inability to cope effectivelyC) Sensory perception alterationsD) Inability to communicate effectivelyFeedback: CORRECTRationale: Clang associations, word salad, and loose associations are language disturbancesthat indicate a client’s inability to communicate effectively. These manifestations are notassociated with coping or sensory alterations.Test-Taking Strategy: Focus on the data in the question. Eliminate the options that arecomparable or alike: Defensive coping is the same as inability to cope effectively. To selectfrom the remaining options, recall that clang associations, word salad, and loose
  28. 28. associations are signs of disturbed thought process and impaired verbal communication,which will direct you to the correct option. Review the characteristics of schizophrenia if youhad difficulty with this question.References: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., p. 338).St. Louis: Mosby.Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing: Acommunication approach to evidence-based care (p. 281). St. Louis: Saunders.Cognitive Ability: AnalyzingClient Needs: Psychosocial IntegrityIntegrated Process: Nursing Process/AssessmentContent Area: Mental HealthPoints Earned: 1.0/1.033.A 24-year-old schizophrenic client says, “I was in college and suddenly I was hearing voicestelling me I was no good and that I should jump off the bridge by our college. My parentscame and got me when I called them. We thought that I had inadvertently taken drugs at aparty or something. My psychiatrist says that if I can improve, I can return to college nextsemester.” Which of the following guidelines does the nurse plan to incorporate into teachingof the client and family about self-care on the client’s return to college?A) Compliance with the treatment regimen, immediate reporting of any relapse signs,avoidance of alcohol and drugs, and living a balanced lifestyleB) Telling all friends about the illness so that they support the client’s avoidance of alcoholand drugs and help the client maintain a balanced lifestyleC) Limiting college attendance to commuter status to maintain a supportive family groupand avoiding drugs, alcohol, and the strain of socializationD) Compliance with treatment, immediate reporting of any relapse signs, avoidance ofalcohol and drugs, and socialization with one supportive friendFeedback: CORRECTRationale: Self-care guidelines for the client include compliance with the treatment regimen,immediate reporting of any relapse signs, avoidance of alcohol and drugs, and living abalanced lifestyle. Telling all friends about the illness so that they can support the client’savoidance of alcohol and drugs and help the client maintain a balanced lifestyle is incorrect.Although the closest supportive friends need to know and understand the illness, noteverybody does. Limiting college attendance to commuter status to maintain a supportivefamily group and avoiding drugs, alcohol, and the strain of socialization is incorrect. Notallowing the client to be independent and follow a normal growth and development patternwould retard the client’s growth. Socializing with one supportive friend is incorrect becauseit is best to bring as many supportive persons to the client as possible.
  29. 29. Test-Taking Strategy: Use the process of elimination and focus on the data in the questionand the subject, self-care. Eliminate the options that contain the words “one,” “all,” and“limiting". Also note that the correct option is the umbrella option. Review care of the clientwith schizophrenia if you had difficulty with this question.Reference: Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing:A communication approach to evidence-based care (p. 293). St. Louis: Saunders.Cognitive Ability: ApplyingClient Needs: Psychosocial IntegrityIntegrated Process: Teaching and LearningContent Area: Mental HealthPoints Earned: 1.0/1.034.A schizophrenic client in the psychiatric inpatient unit is yelling, “The CIA is trying to kill me.I know they’re plotting to kill me so they can overthrow the government.” On the basis ofthe client’s statement, which clinical manifestation would the nurse document in the clientrecord?A) Demonstrates paranoiaB) Exhibits ideas of referenceC) Evidence of persecutory delusionsD) Evidence of ideas of somatic delusionsFeedback: CORRECTRationale: A persecutory delusion is the false belief that one is being singled out for harm byothers, generally in the form of a plot by other people against the client. Paranoia is anintense and strongly defended irrational suspicion. An idea of reference is the misconstruingof trivial events in order to give them personal significance. A somatic delusion is the falsebelief that the body is changing in an unusual way (e.g., rotting inside).Test-Taking Strategy: Use the process of elimination. Focus on the client’s statement andnote the relationship between the words “trying to kill me” in the question and“persecutory” in the correct option. Review the characteristics of schizophrenia if you haddifficulty with this question.Reference: Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing:A communication approach to evidence-based care (pp. 280, 289). St. Louis: Saunders.Cognitive Ability: UnderstandingClient Needs: Psychosocial IntegrityIntegrated Process: Nursing Process/Assessment
  30. 30. Content Area: Mental HealthPoints Earned: 1.0/1.035.A manic client who tends to be manipulative says angrily, “You had better let me out ofhere, or I’m going to call my lawyer. My boss has good friends with the owners of this tin-pot place you call a ‘mind holism respite.’” Which statement by the nurse would be mosttherapeutic?A) “When you can speak to me without yelling and being aggressive, I’ll be happy to speakwith you.”B) “Just get your anger out with me, because we’re not going to allow you be dischargeduntil you calm down.”C) “Do threats and name-calling usually work for you? Do people tend to listen to you anddo as you order them to?”D) “I know that you feel that you’re doing your very best right now, but you are yelling.Take some time out and some deep breaths, and I’ll speak to you in half an hour.”Feedback: INCORRECTRationale: Anger is an emotional response to the perception of frustration of desires, threatto one’s needs (emotional or physical), or a challenge. It reflects rage, hostility, and thepotential for physical or verbal destructiveness. With manipulative clients, solutions thatprovide options and empathy work best. An authoritarian style in which the nurse labelsaggression is inappropriate and is not effective with such clients. Additionally, the remainingoptions may further anger the client and escalate the client’s behavior.Test-Taking Strategy: Use the process of elimination. Eliminate the options that arecomparable or alike and may further anger the client. Also note that the correct optionprovides praise to the client and provides an option for dealing with the client’s behavior.Review interventions to defuse anger if you had difficulty with this question.Reference: Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing:A communication approach to evidence-based care (p. 429). St. Louis: Saunders.Cognitive Ability: ApplyingClient Needs: Psychosocial IntegrityIntegrated Process: Nursing Process/ImplementationContent Area: Mental HealthPoints Earned: 0.0/1.0
  31. 31. 36.A client in a mental health unit gets into a fight with another client over the use of the publictelephone on the unit. The client is accused of making two telephone calls and staying onthe telephone for 1 hour. Which of the following interventions by the nurse would be mosttherapeutic?A) Taking telephone privileges away from both clients for the day and giving them time-outsin their roomsB) Saying to the clients, “Okay, this is the last straw. Neither of you may use the telephoneuntil tomorrow, and then only with a nurse timing you.”C) Saying to the clients, “Go to your rooms, both of you. I don’t want to hear anything moreabout the telephone on this unit for at least 2 hours.”D) Saying to the clients, “You may each use the phone for 10 minutes. I will time the callsfor both of you. Do you both agree to abide by my decision?”Feedback: CORRECTRationale: The most therapeutic intervention is the one in which the nurse gives analternative solution and asks for the clients’ cooperation. If this approach fails, the nursemust eliminate the phone privilege for both clients and give time-outs to deescalate thesituation.Taking telephone privileges away from both clients for the day and giving themtime-outs in their rooms is nontherapeutic because the nurse is not being empathetic. Instating, “Okay, this is the last straw. Neither of you may use the telephone until tomorrow,and then only with a nurse timing you,” the nurse displays anger and is nontherapeutic inpunishing the clients. In responding, “Go to your rooms, both of you. I don’t want to hearanything more about the telephone on this unit for at least 2 hours,” the nurse isnontherapeutically authoritarian and does not provide empathy.Test-Taking Strategy: Use the process of elimination. Eliminate the options that arecomparable or alike in that the nurse acts in a punishing and authoritarian way. Also, notethat the correct option is the only option that provides an alternative solution for bothclients. Review measures for dealing with an angry client if you had difficulty with thisquestion.Reference: Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing:A communication approach to evidence-based care (p. 430). St. Louis: Saunders.Cognitive Ability: ApplyingClient Needs: Psychosocial IntegrityIntegrated Process: Nursing Process/ImplementationContent Area: Mental HealthPoints Earned: 1.0/1.037.
  32. 32. A nursing instructor enters a classroom to begin class and finds two students yelling andphysically assaulting each other. Which intervention by the instructor would be mostappropriate?A) Walking out of the classroom and asking the secretary to call security, then telling all ofthe students to leave and go to the nursing laboratoryB) Getting the class to leave with her and sending everyone to the nursing laboratory, thencalling security to the classroom and reentering to observe what is happening with the twostudents.C) Telling the class, “Take a break. I’ll come and get you to restart class as soon as I can,”then closing the classroom door, refusing to let anyone else in, and asking a passinginstructor to get securityD) Telling the class to go to the nursing laboratory at once, then asking a student to tell thenursing secretary to have security come to the classroom, and asking the students who arefighting to stop fighting and take their seatsFeedback: CORRECTRationale: The first concern is to ensure student safety, so in the correct option the studentsare directed to go to the nursing laboratory. Someone is asked to notify security, and thenthe instructor determines whether the students who are fighting can obey the direction tostop and take a seat. Leaving the classroom without attempting to verbally direct thestudents to stop fighting results in an unsafe environment for the students who are fighting.Although closing the classroom door might be helpful in discouraging other students fromwatching the fight, it is not generally considered a safe intervention to bar access to an exitwhen violence has erupted.Test-Taking Strategy: Focus on the information in the question and recall that safety is thepriority. The correct option is the only one that provides safety to all involved. Reviewinterventions for a violent situation if you had difficulty with this question.Reference: Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing:A communication approach to evidence-based care (pp. 429, 430). St. Louis: Saunders.Cognitive Ability: ApplyingClient Needs: Psychosocial IntegrityIntegrated Process: Nursing Process/ImplementationContent Area: Mental HealthPoints Earned: 1.0/1.038.A student calls the campus crisis hotline and tells the nurse, “I went out to a sorority partylast week and drank too much. Someone raped me, but when I told my folks about it, theyacted like it was my fault. I feel so dirty and used.” Which statement by the nurse would bemost therapeutic?A) “Would you come in to talk with me in the strictest confidence?”
  33. 33. B) “I believe that you can feel a lot better about yourself. Won’t you come in to see metomorrow?”C) “Parents always feel that their daughters could never be raped. I could talk to them foryou, if you’ll let me.”D) “You’ve had an awful experience, but it’s not your fault that it happened. Can you comein and talk to me about it in more detail?”Feedback: CORRECTRationale: Rape is vaginal or anal penetration against the victim’s will and consent. Thestudent is in crisis and needs counseling. Her call seems to be the result of her being unableto turn to her parents as she might have been able to in the past. The nurse needs to letthe student know that the rape was not her fault. Many students overdrink but are notraped just because they were inebriated. By asking, “Would you come in to talk with me inthe strictest confidence?” the nurse assures confidentiality, but this option is nontherapeuticbecause a bridge of trust has not yet been established with the client. In responding, “Ibelieve that you can feel a lot better about yourself. Won’t you come in to see metomorrow?” the nurse offers opinions on outcomes and delays treatment, which isnontherapeutic. In responding, “Parents always feel that their daughter could never beraped. I could talk to them for you, if youll let me,” the nurse lectures the student on whyher parents are not supportive without ever having met them. This answer is nontherapeuticand insensitive.Test-Taking Strategy: Use the process of elimination and your knowledge of therapeuticcommunication techniques. The correct option, the umbrella option, acknowledges theclient’s experience, informs the client that the rape was not her fault, expresses support,and provides immediate treatment. Review interventions for the client who is a victim ofabuse if you had difficulty with this question.Reference: Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing:A communication approach to evidence-based care (p. 408). St. Louis: Saunders.Cognitive Ability: ApplyingClient Needs: Psychosocial IntegrityIntegrated Process: Nursing Process/ImplementationContent Area: Mental HealthPoints Earned: 1.0/1.039.A psychiatric nurse is playing a card game with a client in the day room. The client states tothe nurse, "The voice in my head is telling me that youre cheating." Which of the followingresponses by the nurse is therapeutic?A) "I do not hear any voices. Has the voice said anything else?"B) "Is the voice telling you to do anything?"C) "It isnt possible for people to hear voices in their head."
  34. 34. D) "I dont believe that you are hearing voices."Feedback: INCORRECTRationale: When caring for a client experiencing delusions or hallucinations, the nurse shouldlisten to the client, present reality, and collect more data regarding the content of thedelusion and/or hallucination. Stating, "I do not hear any voices. Has the voice saidanything else?" is correct because it presents reality and collects more data from the client.Although stating, "Is the voice telling you to do anything?" collects more data, it does notpresent reality. Stating, "It isnt possible for people to hear voices in their head" and "I dontbelieve that you are hearing voices" are non-therapeutic and do not address the needs orfeelings of the client.Test-Taking Strategy: Use therapeutic communication techniques to answer this question.Recalling that it is important to both present reality and collect more data from a clientactively experiencing delusions and/or hallucinations will assist in directing you to thecorrect option. Review therapeutic communication techniques if you had difficulty with thisquestion.Reference: Vacarolis, E. M., & Halter, M. J. (2010). Foundations of psychiatric mental healthnursing. (6th ed., p. 323). St. Louis: Saunders.Cognitive Ability: ApplyingClient Needs: Psychosocial IntegrityIntegrated Process: Communication and DocumentationContent Area: Mental HealthPoints Earned: 0.0/1.040.A client says to the nurse, “I’m really phobic about flying, so my husband and I alwaysdrove or took the train everywhere. Now he’s been offered a big job in Europe, and if I don’tget over this and fly with him, he says we’re done. I’ll be left to bring up our three childrenby myself.” Which statement by the nurse would be therapeutic?A) “No problem. You can be hypnotized to sleep through your trip.”B) “I’m interested that it took his threat of leaving you to motivate you to seek help.”C) “You seem more anxious and afraid of raising three children alone than of flying.”D) “I can teach you strategies to help master your panic. An antianxiety medicine wouldalso help you.”Feedback: CORRECTRationale: A phobia is a persistent, irrational fear of a specific object, activity, or situationthat leads to a desire for avoidance or actual avoidance of the object, activity, or situation.The nurse can teach strategies, such as relaxation training and thought-stopping, to helpthe client master her anxiety. There are also medications that the psychiatrist can prescribe
  35. 35. to help ease the client’s phobia. In stating, “No problem. You can be hypnotized to sleepthrough your trip,” the nurse provides false reassurance and belittles the client’s worries andfears. In responding, “I’m interested that it took his threat of leaving you to motivate you toseek help,” the nurse uses a nontherapeutic change of subject that can only increase theclient’s anxiety and fear. This response also lowers the client’s trust in her relationship withthe nurse. In stating, “You seem more anxious and afraid of raising three children alonethan of flying,” the nurse changes the subject.Test-Taking Strategy: Use the process of elimination and therapeutic communicationtechniques. Eliminate the options that do not focus on the client’s concern or provide falsereassurance. The correct option is focused on the client’s concern and provides a reasonablesolution. Review therapeutic communication techniques if you had difficulty with thisquestion.References: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., pp. 27-31). St. Louis: Mosby.Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing: Acommunication approach to evidence-based care (p. 141). St. Louis: Saunders.Cognitive Ability: ApplyingClient Needs: Psychosocial IntegrityIntegrated Process: Communication and DocumentationContent Area: Mental HealthPoints Earned: 1.0/1.041.A nurse is trying to deescalate aggressive behavior exhibited by a client with schizophrenia.Which nursing action would be contraindicated in this situation?A) Being assertive with the clientB) Negotiating options with the clientC) Maintaining a nonaggressive postureD) Standing close to the client and telling the client that the behavior is unacceptableFeedback: INCORRECTRationale: To deescalate aggressive behavior, the nurse should maintain calm and anonaggressive posture. The nurse should also give the client clear instructions that are briefand assertive and negotiate options with the client. Negotiation of options allows the clientto feel that he or she has some room in making decisions. The nurse needs to maintainpersonal space and should not stand closer than about 8 feet from the client, which wouldconvey a threatening message.Test-Taking Strategy: Focus on the subject, deescalation of aggressive behavior, and note thestrategic word “contraindicated.” Visualize each of the options in terms of how it might
  36. 36. protect or threaten the client. This will direct you to the correct option. If you had difficultywith this question, review measures to deescalate aggressive behavior.Reference: Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing:A communication approach to evidence-based care (p. 288). St. Louis: Saunders.Cognitive Ability: ApplyingClient Needs: Psychosocial IntegrityIntegrated Process: Nursing Process/ImplementationContent Area: Mental HealthPoints Earned: 0.0/1.042.A client is scheduled to undergo electroconvulsive therapy (ECT). Which client concern is ofthe highest priority?A) FearB) AnxietyC) Distorted body imageD) Risk for impaired breathingFeedback: CORRECTRationale: NPO status for 6 to 8 hours before a procedure, removal of dentures during theprocedure, and administration of medication as prescribed to diminish oral secretions are allsafeguards against aspiration during ECT. Although fear and anxiety could also be concerns,they are not the most important ones. There is no reason to infer that distorted body imageis a consideration.Test-Taking Strategy: Use Maslows Hierarchy of Needs theory to answer the question.Physiological needs are the priority, so select the option that addresses these needs.Additionally, remember the ABCs— airway, breathing, and circulation. Airway is the concernwith the risk of aspiration. If you had difficulty with this question, review procedures relatedto ECT.Reference: Stuart, G. (2009). Principles & practice of psychiatric nursing (9th ed., p. 540). St.Louis: Mosby.Cognitive Ability: AnalyzingClient Needs: Physiological IntegrityIntegrated Process: Nursing Process/AnalysisContent Area: Mental Health
  37. 37. Points Earned: 1.0/1.043.The mother of a child who is taking methylphenidate hydrochloride (Ritalin) tells the schoolnurse that she is administering an over-the-counter (OTC) cough syrup to her son. Whichresponse by the nurse would be appropriate?A) “His cough could be a side effect of the Ritalin.”B) “Your son should never take any medicine, even if it’s OTC.”C) “You may administer a small amount of OTC cough syrup without a problem, but not formore than 3 days.”D) “I think that you should stop giving this medicine to your son until I can check its contentwith the pharmacy.”Feedback: CORRECTRationale: When a client is taking methylphenidate hydrochloride (Ritalin), no OTCmedications should be administered without the approval of the pharmacist or physician.Such medications could contain caffeine, which must be avoided. In stating, “Your sonshould never take any medicine, even if it’s OTC,” the nurse is lecturing and belittling. Instating, “His cough could be a side effect of the Ritalin” or “You may administer a smallamount of OTC cough syrup without a problem, but not for more than 3 days,” the nurseprovides inaccurate information.Test-Taking Strategy: Use the process of elimination. Eliminate the option that contains theclosed-ended word “never.” To select from the remaining options, recall that OTCmedications should not be taken by clients taking prescription medications without theapproval of the physician. Review the contraindications associated with this medication ifyou had difficulty with this question.Reference: Hodgson, B., & Kizior, R. (2010). Saunders nursing drug handbook 2010. (p. 737).St. Louis: Saunders.Cognitive Ability: ApplyingClient Needs: Psychosocial IntegrityIntegrated Process: Nursing Process/ImplementationContent Area: Mental HealthPoints Earned: 1.0/1.044.
  38. 38. A nurse notices a paranoid stare during a conversation with a client. The client then beginsto fidget and gets up to pace around the room. Which of the following actions by the nursewould be beneficial?A) Allowing the client to paceB) Escorting the client to a quiet roomC) Changing the conversation to a less threatening subjectD) Sharing the observation with the client and helping the client recognize and acknowledgehis or her feelingsFeedback: INCORRECTRationale: Sharing observations with clients may help them recognize and acknowledge theirfeelings. Moving the client to a quiet room or changing the subject will not help a clientrecognize his or her behaviors and feelings. Allowing the client to pace provides noassistance and may lead to their becoming out of control.Test-Taking Strategy: Use the process of elimination and therapeutic communicationtechniques. Eliminate the options that do not address the client’s behavior. Rememberingthat the sharing observations with the client and helping the client recognize andacknowledge his or her feelings will be of help to the client who is experiencing paranoidbehaviors. Review care of the paranoid client if you had difficulty with this question.Reference: Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing:A communication approach to evidence-based care (pp. 287, 288). St. Louis: Saunders.Cognitive Ability: ApplyingClient Needs: Psychosocial IntegrityIntegrated Process: Nursing Process/ImplementationContent Area: Mental HealthPoints Earned: 0.0/1.045.A nurse working in a mental health unit reads a client’s medical record and notesdocumentation that the client has been experiencing flashbacks. The nurse interprets this asa classic sign of:A) DepressionB) SchizophreniaC) Post–traumatic stress disorderD) Obsessive-compulsive disorderFeedback: CORRECTRationale: Flashbacks are the classic manifestation of post–traumatic stress disorder, orPTSD, and are not associated with depression, obsessive-compulsive disorder, orschizophrenia.
  39. 39. Test-Taking Strategy: Use the process of elimination and note the strategic word“flashbacks.” Review each option and think about the manifestations of each disorder toanswer correctly. Review the manifestations of each of these disorders if you had difficultywith this question.Reference: Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing:A communication approach to evidence-based care (p. 140). St. Louis: Saunders.Cognitive Ability: AnalyzingClient Needs: Psychosocial IntegrityIntegrated Process: Nursing Process/AssessmentContent Area: Mental HealthPoints Earned: 1.0/1.046.A client arrives in the emergency department in a crisis state. The client demonstrates signsof profound anxiety and is unable to focus on anything but the object of the crisis and theimpact on herself. The nurse plans to focus the initial assessment on:A) Sources of supportB) The object of the crisisC) The client’s coping mechanismsD) The physical condition of the clientFeedback: INCORRECTRationale: The initial priority in the nursing assessment of a client in a crisis state is toassess physical condition, potential for self-harm, and potential for harm to others. Oncethese questions have been answered and the appropriate interventions have been initiated,the nurse may proceed in providing psychosocial care.Test-Taking Strategy: Use Maslow’s Hierarchy of Needs theory. Physiological needs takepriority over other needs. The correct option is the only option that addresses aphysiological need. Review care of the client in crisis if you had difficulty with this question.Reference: Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing:A communication approach to evidence-based care (p. 371). St. Louis: Saunders.Cognitive Ability: ApplyingClient Needs: Psychosocial IntegrityIntegrated Process: Nursing Process/AssessmentContent Area: Mental Health
  40. 40. Points Earned: 0.0/1.047.A nurse has been closely observing a client who has been displaying aggressive behaviorsand notes that the client’s aggressiveness is escalating. Which nursing intervention would beleast helpful to this client at this time?A) Initiating confinement measuresB) Acknowledging the client’s behaviorC) Assisting the client to an area that is quietD) Maintaining a safe distance with the clientFeedback: INCORRECTRationale: During the escalation period, the client’s behavior is moving toward loss ofcontrol. Nursing actions include taking control, maintaining a safe distance, acknowledgingthe behavior, moving the client to a quiet area, and medicating the client as appropriate. Itis not appropriate during this period to initiate confinement measures; this action is mostappropriate during the crisis period.Test-Taking Strategy: Note the strategic words “least helpful” and focus on the data in thequestion. Nursing actions will vary depending on the level of aggressive behavior that theclient is exhibiting. Knowledge of these levels and the appropriate nursing actions isrequired to answer this question. However, focusing on the strategic words will direct you tothe correct option. Review care of the client exhibiting aggressive behavior if you haddifficulty with this question.Reference: Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing:A communication approach to evidence-based care (p. 431). St. Louis: Saunders.Cognitive Ability: ApplyingClient Needs: Psychosocial IntegrityIntegrated Process: Nursing Process/ImplementationContent Area: Mental HealthPoints Earned: 0.0/1.048.A nurse is assigned to care for a client experiencing a crisis. What is the appropriate initialnursing intervention for this client?A) Providing authority and actionB) Displaying an attitude of detachment and efficiencyC) Providing hope and reassurance that the crisis is temporary
  41. 41. D) Demonstrating confidence in the client’s ability to deal with the crisisFeedback: INCORRECTRationale: A crisis is an acute time-limited state of disequilibrium resulting from situational,developmental, or societal sources of stress. A person in this state is temporarily unable tocope with or adapt to the stressor with the use of previously successful problem-solvingmethods. Someone who intervenes in this situation (the nurse) takes over for the client whois not in control and devises a plan (action) to secure and maintain the client’s safety. Thenurse then works collaboratively with the client, demonstrating confidence in the client’sability to cope and providing reassurance that the crisis is temporary. Displaying an attitudeof detachment is inappropriate.Test-Taking Strategy: Use the process of elimination and note the strategic word “initial.” Theclient who experiences a crisis is in acute disequilibrium. Remember, in a crisis, an authorityfigure must emerge to take action. Review crisis intervention and the nurse’s responsibilitiesif you had difficulty with this question.Reference: Varcarolis, E., & Halter, M. (2009). Essentials of psychiatric mental health nursing:A communication approach to evidence-based care (p. 417). St. Louis: Saunders.Cognitive Ability: ApplyingClient Needs: Psychosocial IntegrityIntegrated Process: Nursing Process/ImplementationContent Area: Mental HealthPoints Earned: 0.0/1.049.A home care nurse makes a visit to a client with a diagnosis of depression. The nurse findsthe client unconscious on the floor, with an empty bottle of a prescribed tricyclicantidepressant lying near the client. What action must the nurse take immediately?A) Inducing vomitingB) Calling an ambulanceC) Administering syrup of ipecacD) Counting the pills remaining in the bottleFeedback: CORRECTRationale: An overdose of a tricyclic antidepressant can be fatal, regardless of the amountingested. Serious life-threatening symptoms may develop after an overdose. Immediateemergency medical attention and cardiac monitoring are needed in the event of an overdoseof a tricyclic antidepressant. The nurse would not induce vomiting or administer anything byway of the oral route if the client is unconscious. Counting the remaining pills provides nouseful information and delays necessary and immediate intervention. Additionally, thequestion notes that the bottle of pills is empty.

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