NUR2488 Mental Health
Nursing Exam 1
Question 1
A fully developed outcome for a client goal would include: (SATA)
Selected
Answers:
Answers:
Response
Feedback:
Time sensitive
Measurable
terms
Initial
assessment
Attainable for
client
Time sensitive
Measurable
terms
Initial
assessment
Identifying data
Attainable for
client
No. Outcomes need to take into account the patient's culture,
values, and ethical beliefs. Specifically, outcomes are stated in
attainable and measurable terms and include a time estimate
for attainment".
Question 2
The nurse understands a client could be at risk for serotonin syndrome
when taking which of the following medications in addition to over the
counter medications or herbal supplements?
Selected
Answer:
Answers:
Haloperid
ol
Sertraline
0 out of 1 points
0 out of 1 points
Response
Feedback:
Haloperid
ol
Trazadon
e
Venlafaxi
ne
No. Sertraline (Zoloft) is an SSRI, and when combined with
over the counter medications or herbal supplements could
increase the clients risk for developing serotonin syndrome.
Question 3
A 4-year-old child grabs toys from siblings, saying, “I want that toy now!”
The siblings cry and the child’s parent becomes upset with the behavior.
Using Freudian theory, a nurse can interpret the child’s behavior as a
product of impulses originating in the:
Selected
Answer:
Answers:
Response
Feedback
:
Ego
Id
Ego
Superego
Preconsci
ous
No. The id operates on the pleasure principle, seeking
immediate gratification of impulses. The ego acts as a mediator
of behavior and would weigh the consequences of the action,
perhaps determining that taking the toy is not worth the
parent’s wrath. The superego would oppose the impulsive
behavior as “not nice.” The preconscious is a level of
awareness.
Question 4
Which expected client outcome should a nurse identify as being correctly
formulated?
Selected
Answer:
Answers:
Client will initiate interaction with one peer during free time
within 2 days.
Client will feel happier by discharge.
Client will demonstrate two relaxation techniques.
Client will verbalize triggers to anger by end of session.
0 out of 1 points
1 out of 1 points
Response
Feedback
:
Client will initiate interaction with one peer during free time
within 2 days.
Yes. The statement “Client will initiate interaction with one peer
during free time within 2 days” is an example of a correctly
formulated expected outcome. Outcomes should be
measurable, realistic, client-focused goals that include a time
frame. Appropriate nursing interventions are guided by client
outcomes.
Question 5
A voluntarily hospitalized patient tells the nurse, “Get me the forms for
discharge against medical advice so I can leave now.” Which is the nurse’s
best response?
Selected
Answer:
Answers:
Response
Feedback
:
“I will get them for you, but let’s talk about your decision to
leave treatment.”
“I can’t give you those forms without your health care
provider’s knowledge.”
“I’ll get the forms for you right now and bring them to your
room.”
“Since you signed your consent for treatment, you may
leave if you desire.”
“I will get them for you, but let’s talk about your decision to
leave treatment.”
Yes. A patient who has been voluntarily admitted as a
psychiatric inpatient has the right to demand and obtain release
in most states. However, as a patient advocate, the nurse is
responsible for weighing factors related to the patient’s wishes
and best interests. By asking for information, the nurse may be
able to help the patient reconsider the decision. The statement
that discharge forms can’t be given without the health care
provider’s knowledge is not true. Facilitating discharge without
consent is not in the patient’s best interests before exploring
the reason for the request.
Question 6
The client is being admitted to the inpatient psychiatric unit. The nurse
conducts a mental status examination. Which of the following items are
included in this examination? (Select all that apply)
Selected
Answers:
Appearance
Mood and Affect
1 out of 1 points
0 out of 1 points
Answers:
Response
Feedback:
Physical Exam
Cognition
Appearance
Mood and Affect
Thought
Physical Exam
Cognition
Personal information, appearance, behavior, speech, mood and affect, thought,
perceptual disturbances and cognition are all parts of a mental status exam. Physical
assessment would not be included with the MSE. (Chapter 7, p 103-104)
Question 7
A client with schizophrenia has recently begun a new medication,
clozapine (Clozaril). Which signs and symptoms of a potentially fatal side
effect will the nurse teach the client about?
Selected
Answer:
Answers:
Response
Feedback:
Blurring vision and muscular
weakness
Blurring vision and muscular
weakness
Sore throat, fever, and malaise
Tremor, shuffling gait, and neck
stiffness
Fine tremor, tinnitus, and
nausea
Yes. These are symptoms of agranulocytosis, which is a
potentially fatal disorder in which the client's white blood cell
count drops to extremely low levels. This places the client at
great risk for infections.
Question 8
Which information suggests that caution is necessary in prescribing a
benzodiazepine to an anxious client?
Selected
Answer:
Answers:
The client has a history of diabetes
mellitus.
The client has a history of alcohol
dependence.
The client has a history of diabetes
mellitus.
1 out of 1 points
0 out of 1 points
Response
Feedback:
The client has a history of
schizophrenia.
The client has a history of
hypertension.
No. Tolerance and psychological dependence are common
problems with the long-term use of benzodiazepines. They
should be used cautiously with clients who have a history of
substance abuse.
Question 9
A brother calls to speak to his sister who has been admitted to the
psychiatric unit. The nurse connects him to the community phone and the
sister is summoned. Later the nurse realizes that the brother was not on
the client’s approved call list. What law has the nurse broken?
Selected
Answer:
Answers:
Response
Feedback:
The Health Insurance Portability and
Accountability Act
The National Alliance for the Mentally Ill Act
The Tarasoff Ruling
The Health Insurance Portability and
Accountability Act
The Good Samaritan Law
The nurse has violated the Health Insurance Portability and
Accountability Act (HIPAA) by revealing that the client had been
admitted to the psychiatric unit. The nurse should not have
provided any information without proper consent from the
client.
Question 10
The client attempted suicide by overdosing on pain medication. Once the
client ingested the medication, she decided that she did not want to die
and she sought immediate treatment. Once the client recovered from the
physical effects of overdose, the client voluntarily sought inpatient mental
health treatment. Which of the following statements is true of voluntary
admission?
Selected
Answer:
Answers:
The client retains the right to request release
The client is required to stay a minimum of 72
hours
The client must have certification by two or more
1 out of 1 points
1 out of 1 points
Response
Feedback
:
physicians
Only a judge can determine if the client is able to
be discharged
The client retains the right to request release
Yes. Release from the hospital depends on the patient’s
admission status. All clients have the right to request release;
thereby negating a 72 hour length of stay. It may not be
granted if there is a civil commitment process. Certification is
required by physicians or judges in a commitment process.
(Chapter 6 pp 82-83)
Question 11
A nurse says to a client, “Things will look better tomorrow after a good
night’s sleep.” This is an example of which communication technique?
Selected
Answer:
Answers:
Response
Feedback
:
The nontherapeutic technique of giving
reassurance
The therapeutic technique of giving
advice
The therapeutic technique of defending
The nontherapeutic technique of
presenting reality
The nontherapeutic technique of giving
reassurance
Yes. The nurse’s statement, “Things will look better tomorrow
after a good night’s sleep,” is an example of the nontherapeutic
communication technique of giving reassurance. Giving
reassurance indicates to the client that there is no cause for
anxiety, thereby devaluing the client’s feelings.
Question 12
A patient is involuntarily admitted to a psychiatric unit after calling a
friend and saying, “I’ve got a gun and I’m going to shoot myself.” Which of
the following rights has the patient lost temporarily?
Selected
Answer:
Answers:
The right to leave the hospital without
medical approval
The right to communicate with family
members
Freedom of speech
1 out of 1 points
1 out of 1 points
Response
Feedback:
The right to refuse medications
The right to leave the hospital without
medical approval
Yes. If a patient is admitted involuntary, she cannot leave
without medical or court approval. The patient still retains the
rights to communicate with family, refuse medication and
speak her mind.
Question 13
A depressed client states, “I have a chemical imbalance in my brain. I
have no control over my behavior. Medications are my only hope to feel
normal again.” Which nursing response is appropriate?
Selected
Answer:
Answers:
Response
Feedback
:
“Medications are one way to address chemical imbalances.
Environmental and interpersonal factors can also have an
impact on biological factors.”
“Medications are one way to address chemical imbalances.
Environmental and interpersonal factors can also have an
impact on biological factors.”
“Because biological factors are the sole cause of depression,
medications will improve your mood.”
“Environmental factors have been shown to exert the most
influence in the development of depression.”
“Researchers have been unable to demonstrate a link between
nature (biology and genetics) and nurture (environment).”
Yes. The nurse should advise the client that medications are one
treatment approach to address biological factors, but there are
other factors that affect mood. The nurse should educate the
client on environmental and interpersonal factors that can lead
to depression and the potential for psychological treatments to
have a positive impact on biological factors
Question 14
During an intake interview, which question would assist the nurse in
gathering data about the client’s judgment?
Selected
Answer:
Answers:
“If you found a stamped, addressed envelope in the street,
what would you do?”
“Do you know what day and season it is now?”
“On a scale of 1 to 10, how would you rate your stress
1 out of 1 points
1 out of 1 points
Response
Feedback
:
level?”
“What does the phrase ‘a rolling stone gathers no moss’
mean to you?”
“If you found a stamped, addressed envelope in the street,
what would you do?”
Yes. In the assessment phase of the nursing process, the nurse
collects comprehensive health data that are pertinent to the
client’s health or situation. The nurse presents a situation that
requires the client to make a judgment call and can assess
appropriate judgment on the basis of the client’s action choice.
Question 15
A nursing instructor asks a student to describe the nursing process when
initiating care of a client. The student nurse understands the nursing
process order to be correctly identified as:
Selected
Answer:
Answers:
Response
Feedback
:
Assessment, Nursing Diagnosis, Outcomes, Planning,
Implementation, Evaluation
Assessment, Nursing Diagnosis, Outcomes, Planning,
Implementation, Evaluation
Assessment, Medical Diagnosis, Implementation, Planning,
Outcomes and Evaluation
Assessment, Nursing Diagnosis, Implementation, Planning,
Outcomes, and Evaluation
Assessment, Medical Diagnosis, Planning, Outcomes,
Implementation and Evaluation
Yes. The nursing process as is follows: assessment, nursing
diagnosis, outcomes, planning, implementation, and evaluation.
It should not include medical diagnoses. Identifying the
outcomes allows for planning followed by implementation.
Evaluations needs to occur after nursing interventions have
been implemented.
Question 16
During an intake assessment, a nurse asks both physiological and
psychosocial questions. The client angrily responds, “I’m here for my
heart, not my head problems.” Which is the nurse’s best response?
Selected
Answer:
Answers:
“Why are you concerned about these types of questions?”
“It’s just a routine part of our assessment. All clients are asked
1 out of 1 points
0 out of 1 points
Response
Feedback:
these questions, you need to answer them.”
“Why are you concerned about these types of questions?”
“Psychological factors, like excessive stress, have been found
to affect medical conditions.”
“We can skip these questions, if you like. It isn’t imperative
that we complete this section.”
No. The nurse should attempt to educate the client on the
negative effects of excessive stress on medical conditions. It is
not appropriate to skip either physiological or psychosocial
questions, as this would lead to an inaccurate assessment.
Question 17
A mother rescues two of her four children from a house fire. In an
emergency department, she cries, “I should have gone back in to get
them. I should have died, not them.” Which of the following responses by
the nurse is an example of reflection?
Selected
Answer:
Answers:
Response
Feedback
:
“The smoke was too thick. You couldn’t have gone back
in.”
“The smoke was too thick. You couldn’t have gone back
in.”
“You’re feeling guilty because you weren’t able to save
your children.”
“Focus on the fact that you could have lost all four of
your children.”
“It’s best if you try not to think about what happened.
Try to move on.”
No. The best response by the nurse is, “You’re experiencing
feelings of guilt because you weren’t able to save your
children.” This response utilizes the therapeutic communication
technique of reflection, which identifies a client’s emotional
response and reflects these feelings back to the client so that
they may be recognized and accepted.
Question 18
An entry level registered nurse works with patients in a community
setting. Which groups should this nurse expect to lead? (Select all that
apply.)
Selected
Answers:
Symptom
management
0 out of 1 points
1 out of 1 points
Answers:
Response
Feedback:
Family therapy
Psychotherapy
Self-care
Symptom
management
Family therapy
Medication
education
Psychotherapy
Self-care
Yes. Symptom management, medication education, and selfcare
groups
represent
psychoeducation,
which
is
provided
by
the
basic
level
registered
nurse.
Family
therapy
and
psychotherapy
would
be
provided
by
advanced
practice
registered
nurses
Question 19
A client has been involuntarily admitted to an inpatient behavioral health
unit. During this admission, which of the following rights does the client
still retain? (Select all that apply.)
Selected
Answers:
Answers:
Response
Feedback
:
The right to refuse medications
The right to informed consent
The right to refuse medications
The right to keep all personal items
The right to informed consent
The right to choose the nurse
assigned to them
Yes. The patient has a right to refuse medication and the right
to informed consent even during an involuntary admission. The
patient may not be able to keep all personal items if those
items would present a safety risk to himself or others. Choosing
which staff are assigned to you is not a patient right
Question 20
A mother who is notified that her child was killed in a tragic car accident
states, “I can’t bear to go on with my life.” Which nursing statement
conveys empathy?
Selected
Answer:
“It must be horrible to lose a child, and I’ll stay with you until
your husband arrives.”
1 out of 1 points
1 out of 1 points
Answers:
Response
Feedback
:
“This situation is very sad, but time is a great healer.”
“You are sad, but you must be strong for your other children.”
“Once you cry it all out, things will seem so much better.”
“It must be horrible to lose a child, and I’ll stay with you until
your husband arrives.”
The nurse’s response, “It must be horrible to lose a child, and I’ll
stay with you until your husband arrives,” conveys empathy to
the client. Empathy is the ability to see the situation from the
client’s point of view. Empathy is considered to be one of the
most important characteristics of the therapeutic relationship
Question 21
During the implementation phase of the nursing process, a nurse is
teaching an adult depressed patient with a cochlear implant about
medications. Which modification in the teaching plan would be the most
appropriate for this client?
Selected
Answer:
Answers:
Response
Feedback:
Speaking directly face-toface
Using repetition
Speaking directly face-to-
face
Employing the use of sign
language
Providing large-print
materials
Yes. Speaking face-to-face is an appropriate way to teach
individuals with alterations in hearing.
Question 22
A 22 year old college student is admitted to a hospital following a suicide
attempt and states, “No one will ever love a loser like me.” According to
Erikson’s theory of personality development, a nurse should recognize a
deficit in which developmental stage?
Selected
Answer:
Answers:
Intimacy versus
isolation
Trust versus mistrust
Ego integrity versus
1 out of 1 points
1 out of 1 points
Response
Feedback
:
despair
Intimacy versus
isolation
Initiative versus guilt
Yes. The nurse should recognize that the client who states, “No
one will ever love a loser like me” has not adequately
completed the intimacy versus isolation stage of development.
The intimacy versus isolation stage is presumed to occur in
young adulthood between the ages of 20 and 30 years. The
major developmental task in this stage is to establish intense,
lasting relationships or commitment to another person, cause,
institution, or creative effort.
Question 23
A nursing instructor is teaching about the monoamine category of
neurotransmitters. Which student statement indicates that learning about
the function of norepinephrine has occurred?
Selected
Answer:
Answers:
Response
Feedback:
Norepinephrine functions to regulate arousal, libido, and
appetite.
Norepinephrine functions to regulate movement,
coordination, and emotions.
Norepinephrine functions to regulate mood, cognition, and
perception.
Norepinephrine functions to regulate arousal, libido, and
appetite.
Norepinephrine functions to regulate pain, inflammatory
response, and wakefulness.
No. The functions of norepinephrine include the regulation of
mood, cognition, perception, locomotion, and cardiovascular
function. Norepinephrine has also been implicated in certain
mood disorders such as depression and mania, anxiety states,
and schizophrenia.
Question 24
A nurse is educating a patient about the difference between mental health
and mental illness. Which statement by the patient reflects an accurate
understanding of mental health?
Selected
Answer:
Mental health is successful adaptation to stressors in the
internal and external environment.
0 out of 1 points
1 out of 1 points
Answers:
Response
Feedback:
Mental health is the absence of any stressors.
Mental health is successful adaptation to stressors in the
internal and external environment.
Mental health is incongruence between thoughts, feelings,
and behavior
Mental health is a diagnostic category in the DSM-5.
Yes. Several definitions of mental health exist, but this
definition highlights concepts of successful adaptation to
stressors, including thoughts, feelings, and behaviors that are
age-appropriate and congruent with cultural and societal
norms.
Question 25
The nurse understands a client taking which medication could place a
client at high risk for a life-threatening hypertensive crisis if tyramine is
ingested? (Select All That Apply)
Selected
Answers:
Answers:
Response
Feedback:
A client taking tranylcypromine
(Parnate)
A client taking phenelzine
(Nardil)
A client taking sertraline (Zoloft)
A client taking tranylcypromine
(Parnate)
A client taking isocarboxazid
(Marplan)
A client taking venlafaxine
(Effexor)
A client taking phenelzine
(Nardil)
A client taking sertraline (Zoloft)
No. Isocarboxazid, tranylcypromine, and phenelzine are all
MAOIs, and ingesting foods containing tyramine could place
the client at risk for a life threatening hypertensive crisis.
Question 26
A client was recently admitted to the inpatient unit after a suicide attempt
and has not responded to SSRIs or tricyclic antidepressants. The client
asks the nurse, “I heard about MAOIs (monoamine oxidase inhibitors).
Why can't they be added to what I am on now? Wouldn't adding one
help?” Which is the appropriate nursing response?
0 out of 1 points
1 out of 1 points
Selected
Answer:
Answers:
Response
Feedback:
“Combined use can lead to a life-threatening condition called
a hypertensive crisis.”
“Electroconvulsive therapy (ECT) is your best option at this
point.”
“Combined use can lead to a life-threatening condition called
a hypertensive crisis.”
“There is no reason why an MAOI couldn’t be added to your
therapy.”
“They can't be used together because their mechanisms of
action are very different.”
Yes. If MAOIs are taken with other antidepressants, a
hypertensive crisis could result.
Question 27
A 29-year-old client living with parents has few interpersonal relationships.
The client states, “I have trouble trusting people.” Based on Erikson’s
developmental theory, which should the nurse recognize as true
statements about the client? (Select All That Apply)
Selected
Answers:
Answers:
Response
Feedback:
The client not has progressed beyond the trust versus mistrust
developmental stage.
Developmental deficits in earlier life stages have impaired the
client’s adult functioning.
The client cannot move to the next developmental stage until
mastering all earlier stages
The client not has progressed beyond the trust versus mistrust
developmental stage.
Developmental deficits in earlier life stages have impaired the
client’s adult functioning.
The client cannot move to the next developmental stage until
mastering all earlier stages
The client’s developmental problems began in the intimacy
versus isolation stage.
No. Many individuals with mental health problems are still
struggling to achieve tasks from a number of developmental
stages. Nurses can plan care to assist these individuals to
complete these tasks and move on to a higher developmental
level
Question 28
A patient discloses several concerns and associated feelings. If the nurse
0 out of 1 points
1 out of 1 points
wishes to seek clarification, which comment would be most appropriate?
Selected
Answer:
Answers:
Response
Feedback
:
“Am I correct in understanding
that . . .”
“What are the common
elements here?”
“Tell me again about your
experiences.”
“Am I correct in understanding
that . . .”
“Tell me everything from the
beginning.”
Yes. Asking, “Am I correct in understanding that…” permits
clarification to ensure that both the nurse and patient share
mutual understanding of the communication. Asking about
common elements encourages comparison rather than
clarification. The remaining responses are implied questions
that suggest the nurse was not listening.
@No. Asking, “Am I correct in understanding that…” permits
clarification to ensure that both the nurse and patient share
mutual understanding of the communication. Asking about
common elements encourages comparison rather than
clarification. The remaining responses are implied questions
that suggest the nurse was not listening.
Question 29
The health care provider prescribes an antidepressant for an elderly client,
but nurse notices that the dosage is greater than the usual adult dosage.
Which of the following best describes what action the nurse should take?
Selected
Answer:
Answers:
Response
Feedback
:
Hold the medication until clarified with the health
care provider
Consult a drug reference guide
Implement the order as written
Administer the usual geriatric dosage
Hold the medication until clarified with the health
care provider
Yes. The dosage of antidepressants for older adult patients is
often less than the usual adult dosage. The nurse should
withhold the medication and consult the health care provider
1 out of 1 points
who wrote the order. The nurse’s duty is to intervene and
protect the patient. Consulting a drug reference is unnecessary
because the nurse already knows the dosage is excessive.
Implementing the order is negligent. Giving the usual geriatric
dosage would be wrong; a nurse without prescriptive privileges
cannot change the dosage.
Question 30
Which intervention by a psychiatric nurse best utilizes the ethical principle
of autonomy? The nurse:
Selected
Answer:
Answers:
Response
Feedback
:
Explores alternative solutions with a patient, who then
makes a choice