NUR2488 Mental Health Nursing Exam 1 (2023)

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