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1. A 40-year-old male client diagnosed with schizophrenia and alcohol dependence has not had any visitors or phone calls since admission. He reports he has no family that cares about him and was livin... g on the streets prior to this admission. According to Erikson's theory of psychosocial development, which stage is the client in at this time? A. Isolation. B. Stagnation. C. Despair. D. Role confusion. The client is in Erikson's "Generativity vs. Stagnation" stage (age 24 to 45), and meeting the task includes maintaining intimate relationships and moving toward developing a family (B). (A) occurs in young adulthood (age 18 to 25), (C) occurs in maturity (age 45 to death), and (D) occurs in adolescence (age 12 to 20). These are all stages that occur if individuals are not successfully coping with their psychosocial developmental stage. Points Earned: 1/1 Correct Answer: B Your Response: B 2. An anxious client expressing a fear of people and open places is admitted to the psychiatric unit. What is the most effective way for the nurse to assist this client? A. Plan an outing within the first week of admission. B. Distract her whenever she expresses her discomfort about being with others. C. Confront her fears and discuss the possible causes of these fears. D. Accompany her outside for an increasing amount of time each day. The process of gradual desensitization by controlled exposure to the situation which is feared (D), is the treatment of choice in phobic reactions. (A and C) are far too aggressive for the initial treatment period and could even be considered hostile. (B) promotes denial of the problem, and gives the client the message that discussion of the phobia is not permitted. Points Earned: 0/1 Correct Answer: D Your Response: C 3. On admission, a highly anxious client is described as delusional. The nurse understands that delusions are most likely to occur with which class of disorder? A. Neuroti c. B. Personality. C. Anxiety. D. Psychotic. Delusions are false beliefs associated with psychotic behavior, and psychotic persons are not in touch with reality (D). (A, B, and C) are mental health disorders which are not associated with a break in reality, nor with hallucinations (false sensations such as hearing, or seeing) or delusions (false beliefs). Points Earned: 1/1 Correct Answer: D Your Response: D 4. A child is brought to the emergency room with a broken arm. Because of other injuries, the nurse suspects the child may be a victim of abuse. When the nurse tries to give the child an injection, the child's mother becomes very loud and shouts, "I won't leave my son! Don't you touch him! You'll hurt my child!" What is the best interpretation of the mother's statements? The mother is A. regressing to an earlier behavior pattern. B. sublimating her anger. C. projecting her feelings onto the nurse. D. suppressing her fear. Projection is attributing one's own thoughts, impulses, or behaviors onto another--it is the mother who is probably harming the child and she is attributing her actions to the nurse (C). The mother may be immature, but (A) is not the best description of her behavior. (B) is substituting a socially acceptable feeling for an unacceptable one. These are not socially acceptable feelings. The mother may be suppressing her fear (D) by displaying anger, but such an interpretation cannot be concluded from the data presented. Points Earned: 0/1 Correct Answer: C Your Response: A 5. A male client is admitted to a mental health unit on Friday afternoon and is very upset on Sunday because he has not had the opportunity to talk with the healthcare provider. Which response is best for the nurse to provide this client? A. Let me call and leave a message for your healthcare provider. B. The healthcare provider should be here on Monday morning. C. How can I help answer your questions? D. What concerns do you have at this time? It is best for the nurse to call the healthcare provider (A) because clients have the right to information about their treatment. Suggesting that the healthcare provider will be available the following day (B) does not provide immediate reassurance to the client. The nurse can also implement offer to assist the client (C and D), but the highest priority intervention is contacting the healthcare provider. Points Earned: 0/1 Correct Answer: A Your Response: C 6. A male client is admitted to the mental health unit because he was feeling depressed about the loss of his wife and job. The client has a history of alcohol dependency and admits that he was drinking alcohol 12 hours ago. Vital signs are: temperature, 100° F, pulse 100, and BP 142/100. The nurse plans to give the client lorazepam (Ativan) based on which priority nursing diagnosis? A. Risk for injury related to suicidal ideation. B. Risk for injury related to alcohol detoxification. C. Knowledge deficit related to ineffective coping. D. Health seeking behaviors related to personal crisis. The most important nursing diagnosis is related to alcohol detoxification (B) because the client has elevated vital signs, a sign of alcohol detoxification. Maintaining client safety related to (A) should be addressed after giving the client Ativan for elevated vital signs secondary to alcohol withdrawal. (C and D) can be addressed when immediate needs for safety are met. Points Earned: 1/1 Correct Answer: B Your Response: B 7. The nurse suspects child abuse when assessing a 3-year-old boy and noticing several small, round burns on his legs and trunk that might be the result of cigarette burns. Which parental behavior provides the greatest validation for such suspicions? A. The parents' explanation of how occurred is different from the chi explanation of how they occurre B. The parents seem to dismiss the severity of the child's burns, saying they are and have not posed any problem. C. The parents become very anxious when the nurse suggests that the child may admitted for further evaluation. D. The parents tell the nurse that the child was burned in a house fire which is i with the nurse's observation of the type of burn. (D) provides the most validation. The parent's explanation (subjective data) is incompatible with the objective data (small round burns on the legs and trunk). (A) provides only subjective data, and the child's explanation could be influenced by factors such as age, fear, or imagination. The parent's apparent lack of concern (B) is inconclusive, but the nurse's opinion of the parents' reaction is subjective and could be wrong. (C) might provide a clue that child abuse occurred, but the nurse must remember that most parents are anxious about their child being hospitalized. Points Earned: 0/1 Correct Answer: D Your Response: C 8. A male client with schizophrenia tells the nurse that the voices he hears are saying, "You must kill yourself." To assist the client in coping with these thoughts, which response is best for the nurse to provide? A. Tell yourself that the voices are unreasonable. B. Exercise when you hear the voices. C. Talk to someone when you hear the voices. D. The voices aren't real, so ignore them. The nurse should teach the client to use self-talk to disprove the voices (A). Although (B) may be helpful, the client's concrete thinking may make it difficult to understand this suggestion. Clients with schizophrenia have difficulty initiating interaction with others (C). Auditory hallucinations are often relentless, so it is difficult to ignore them (D). Points Earned: 0/1 Correct Answer: A Your Response: C 9. Which statement about contemporary mental health nursing practice is accurate? A. There is one approved theoretica for psychiatric nursing practice. B. Psychiatric nursing has yet to be recognized as a core mental health disciplin C. Contemporary practice of psychiatric nursing is primarily focused on inpatie D. The psychiatric nursing client may be an individual, family, group, organizat community. Mental health nursing is not only concerned with one-on-one interactions. Psychiatric stressors can impact and be reflected in the overall direction, activities, and responses involving families, groups, and entire communities (D). (A, B, and C) are incorrect statements about the status of mental health nursing. Points Earned: 0/1 Correct Answer: D Your Response: C 10. The nurse is planning discharge for a male client with schizophrenia. The client insists that he is returning to his apartment, although the healthcare provider informed him that he will be moving to a boarding home. What is the most important nursing diagnosis for discharge planning? A. Ineffective denial related to situational anxiety. B. Ineffective coping related to inadequate support. C. Social isolation related to difficult interactions. D. Self-care deficit related to cognitive impairment. The best nursing diagnosis is (A) because the client is unable to acknowledge the move to a boarding home. (B, C, and D) are potential nursing diagnoses, but denial is most important because it is a defense mechanism that keeps the client from dealing with his feelings about living arrangements. Points Earned: 0/1 Correct Answer: A Your Response: B 11. The nurse should hold the next scheduled dose of a client's haloperidol (Haldol) based on which assessment finding(s)? A. Dizziness when standing. B. Shuffling gait and hand tremors. C. Urinary retention. D. Fever of 102° F. A fever (D) may indicate neuroleptic malignant syndrome (NMS), a potentially fatal complication of antipsychotics. The healthcare provider should be contacted before administering the next dose of Haldol. (A, B, and C) are all adverse effects of Haldol which can be managed. Points Earned: 0/1 Correct Answer: D Your Response: B 12. A male client with mental illness and substance dependency tells the mental health nurse that he has started using illegal drugs again and wants to seek treatment. Since he has a dual diagnosis, which person is best for the nurse to refer this client to first? A. The emergency room nurse. B. His case manager. C. The clinic healthcare provider. D. His support group sponsor. The case manager (B) is responsible for coordinating community services, and since this client has a dual diagnosis, this is the best person to describe available treatment options. (A) is unnecessary, unless the client experiences behaviors that threaten his safety or the safety of others. (C and D) might also be useful, but it is most important at this time that a treatment program be coordinated to meet this client's needs. Points Earned: 0/1 Correct Answer: B Your Response: D 13. A 45-year-old male client tells the nurse that he used to believe that he was Jesus Christ, but now he knows he is not. Which response is best for the nurse to make? A. Did you really believe you were Jesus Christ? B. I think you're getting well. C. Others have had similar thoughts when under stress. D. Why did you think you were Jesus Christ? (C) offers support by assuring the client that others have suffered as he has (also the principle on which Alcoholics Anonymous acts). (A) is belittling. (B) is making an inappropriate judgment. You may have narrowed your choices to (C and D). However, you should eliminate (D) because it is a "why" question, and the client does not know why! Points Earned: 0/1 Correct Answer: C Your Response: D 14. A 72-year-old female client is admitted to the psychiatric unit with a medical diagnosis of major depression. Which statement by the client should concern the nurse and require further assessment? A. I think my cat is going to die. B. I don't feel like eating this morning. C. I just went to my friend's funeral. D. Don't you have more important things to do? Sometimes a client will use an analogy to describe themselves, and (A) would be an indication for conducting a suicide assessment. (B) could have a variety of etiologies, and while further assessment is indicated, this statement does not indicate potential suicide. Normal grief process differs from depression, and at this client's age peer/cohort deaths are more frequent, so (C) would be within normal limits. (D) is an expression of low self-esteem typical of depression. (B, C, and D) are examples of decreased energy and mood levels which would negate suicide ideation at this time. Points Earned: 0/1 Correct Answer: A Your Response: C 15. A male adolescent is admitted with bipolar disorder after being released from jail for assault with a deadly weapon. When the nurse asks the teen to identify his reason for the assault, he replies, "Because he made me mad!" Which goal is best for the nurse to include in the client's plan of care? The client will A. outline methods for managing anger. B. control impulsive actions toward self and others. [Show More]

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