NURS 171 UWORLD MENTAL HEALTH QUIZ Questions and Answers
1. A nurse is admitting a child and observes multiple irregular bruises. Which action should the
... [Show More] nurse take next?
1. Ask parents to leave the room during the admission process 2. Continue with a detailed interview and physical examination 3. Notify the charge nurse and the social worker
4. Promise not to tell anyone if the child reveals abuse
2. A client with obsessive-compulsive disorder (OCD) has been cleaning a bathroom for most of the morning. When the roommate demands that the client leave the bathroom so that the roommate can shower, the client becomes angry and says, "You can't make me leave, everything is still dirty." What is the best nursing action?
1. Engage other staff members to remove the client from the bathroom
2. Give a reminder that the client has been cleaning the bathroom for 1½ hours and it is time to take a break
3. Tell the client that the bathroom is very clean and that this behavior is unreasonable 4. Tell the roommate to use the shower in another room
3. A nursing home client with major depressive disorder reports difficulty going to sleep until late at night. The client gets up, paces the hallway, wrings the hands, and appears teary. What interventions should be included in the client's nursing care plan? Select all that apply.
1. Allow the client to receive at least 20 minutes of natural sunlight each day 2. Encourage the client to take naps during the day to make up for lost sleep 3. Have the client engage in strenuous physical exercise just before bedtime 4. Spend time with the client in a quiet environment just before bedtime
5. Suggest that the client take a warm bath before going to bed
4. The nurse cares for a client newly diagnosed with acute stress disorder following a traumatic event. Which of the following communications by the nurse are appropriate? Select all that apply.
1. "How has this situation affected your relationships with family and friends?" 2. "It is important to focus on coping strategies and not dwell on the event." 3. "It is normal to experience difficult symptoms after a traumatic event."
4. "Please tell me about your current use of alcohol and any drugs."
5. "Share with me any thoughts or plans of self-harm that you have had."
5. The nurse is speaking with the spouse of a client following a family discussion with the health care provider about the client's terminal condition and eligibility for hospice care. The spouse states, "I don't think I can make this decision right now. What would you do?" How should the nurse respond?
1. "I find it helpful to investigate the options. I will get you a pamphlet about hospice services."
2. "It's hard to say what the best decision is, but I know hospice provides wonderful care."
3. "These decisions are challenging. Tell me your spouse's beliefs about end-of-life." 4. "You seem overwhelmed. I'll contact a chaplain to come and talk with you about the options."
6. A recently widowed client becomes tearful at a routine clinic visit and states, "I just can't get over my spouse's death." Which of the following responses by the nurse are appropriate? Select all that apply.
1. "A friend of mine passed away recently. I know how hard losses can be." 2. "I see that you're upset. I will step out while you process these feelings." 3. "It may take a while, but coming to terms with loss gets easier with time." 4. "This is a difficult time. Tell me about how you have been coping."
5. "What are your thoughts about attending a grief support group?"
7. The nurse on the mental health unit recognizes the use of which defense mechanism when a client leaves a stressful family meeting and immediately begins to verbally abuse a roommate?
1. Compensation
2. Displacement
3. Projection
4. Reaction formation
8. The nurse in the outpatient treatment facility evaluates the plan of care for a client with alcohol use disorder. Which of the following client statements indicate positive progress toward recovery? Select all that apply.
1. "Drinking led to my divorce and the loss of my children." 2. "I am in control now; I drink only on special occasions." 3. "I will have no desire to drink once I get over my divorce."
4. "My focus is now on fitness training and going back to college." 5. "When cravings occur, I call my Alcoholics Anonymous sponsor."
9. A client with a history of major depressive disorder with psychotic features was rescued before jumping off a dam. The client is pacing, picking at the arms, and repeatedly mumbling, "I have to die. You cannot stop me." When the health care provider recommends electroconvulsive therapy (ECT) as the initial treatment, the client's spouse says to the nurse, "I can't allow such a cruel treatment. Why can't they just give my spouse medication?" Which is the best response by the nurse?
1. "ECT is safe and your spouse will not feel anything."
2. "It could take up to 3 weeks for medication to become effective." 3. "Your spouse could die by not receiving this treatment."
4. "Your spouse is very ill and ECT might be the best treatment at this time. What are your concerns about ECT?"
10. The nurse plans care for a client newly admitted with obsessive-compulsive disorder who is repeatedly counting magazines in the commons room. Which of the following should the nurse include in the initial plan of care? Select all that apply.
1. Assist the client to identify circumstances that increase anxiety 2. Provide positive feedback when the client attends a group activity 3. Refrain from judgmental comments about counting magazines 4. Remove the magazines from the commons room
5. Teach the client how to use the technique of thought stopping
11. The nurse is reviewing the records of an adolescent client. Which findings suggest that the client may need referral for depression screening? Select all that apply.
1. Client has had school disciplinary issues due to absenteeism and angry outbursts 2. Client has lost approximately 8 lb (3.64 kg) over the last 3 weeks without trying 3. Client is often found sleeping during class or activities
4. Client quit sports despite receiving previous athletic awards and trophies 5. Client voices concern about appearance related to facial acne
12. The nurse is providing care to a client experiencing posttraumatic stress disorder following a terrorist attack at the client's place of worship. What is the priority nursing action?
1. Acknowledge the client's feelings of anger 2. Assess the client's support system
3. Encourage the client to talk about the trauma 4. Offer the client a PRN sleep medication
13. A newly admitted client with schizophrenia has been exhibiting severe social withdrawal, odd mannerisms, and regressive behavior. The client is sitting alone in the room when the nurse enters, says "good morning," and proceeds to sit down next to the client. Without responding, the client stands up and starts to leave. Which of the following actions is best for the nurse to take?
1. Ask where the client is going
2. Immediately follow the client out the door
3. In a loud voice, direct the client to come back to the room 4. Remain silent and allow the client to leave
14. The nurse is presenting an in-service educational session on child abuse and neglect to a class of certified home health aides. Which of the following statements should the nurse include when discussing the characteristics of the typical perpetrator of child abuse? Select all that apply.
1. "Abusers often have a history of growing up in an environment of domestic violence." 2. "Abusers often have a history of substance abuse."
3. "Child abusers always present as being agitated or out of control." 4. "Most child abusers have a sense of low self-esteem."
5. "Teenage parents are particularly vulnerable to abusing their children."
15. The nurse is developing a plan of care for a 16-year-old client with bulimia nervosa. Which interventions would be included in the plan of care? Select all that apply.
1. Allow client to remain on current laxatives 2. Assess client for electrolyte imbalances
3. Be alert to hidden or discarded food wrappers
4. Do not allow client to keep a food diary during hospitalization 5. Monitor client for 1-2 hours after each meal in a central area
16. The nurse cares for a client who just had surgical excision and biopsy of a tumor. The biopsy results show that the tumor is malignant, but the client has not yet been informed by the health care provider. The client asks the nurse, "Am I going to die?" Which statement by the nurse is appropriate?
1. "I know how anxious you must be. Watching some television might help you relax." 2. "Tell me more about your thoughts and feelings regarding the situation."
17. An adolescent client is brought to the emergency department by the parents after being found making superficial cuts along the side of an arm with a razor blade. There are several minor cuts in various stages of healing on the client's forearms. Which statements are appropriate for the nurse to make to the client's parents? Select all that apply.
1. "Everything is going to be all right."
2. "Tell me about when you started noticing this behavior." 3. "We have the bleeding under control."
4. "Why didn't you bring your child in sooner?" 5. "You must be very upset after seeing this."
18. The nurse on the mental health unit receives report about a client diagnosed with schizophrenia who is experiencing a delusion of reference. Which client statement supports this symptom?
1. "I need for you to get rid of these bugs that are crawling under my skin." 2. "Hear that? She told me to kill my father."
3. "That song is a message sent to me in secret code."
4. "Those Martians are trying to poison me with the tap water."
19. The nurse is caring for a client with bulimia nervosa. Which is the most important time for the nurse to monitor the client's behavior?
1. During 1-2 hours after each meal 2. During every meal
3. During the evening meal 4. During the overnight hours
20. A client with social anxiety disorder is receiving treatment at the local community mental health center. Which situation most likely caused the client to seek therapy?
1. The client and spouse are soon moving into a new neighborhood
2. The client's boss has asked the client to represent the company at an upcoming convention
3. The client's primary health care provider (HCP) of 30 years is retiring and the client will be seeing a new HCP
4. The client's son is getting married in a few months
21. A client recently diagnosed with schizophrenia is brought to the mental health clinic by the identical twin sibling for the first follow-up visit after hospitalization. The client's sibling says to the nurse, "I read that schizophrenia runs in families. I guess I'm doomed." Which is the best response by the nurse?
1. "At the moment, I would worry more about how your sibling is doing."
2. "The odds are about 50-50 that you will come down with the disease as well." 3. "Would you like to talk to a health care provider about this?"
4. "You are at risk for the disease. However, there are other factors that contribute to the development of schizophrenia."
22. A client with a history of obsessive-compulsive personality disorder (OCPD) is seeking treatment for a gastrointestinal disorder and is scheduled for a colonoscopy at 10:00 AM. Due to a computer glitch, the procedure is postponed to 3:00 PM. Which response would be characteristic of an individual with OCPD?
1. "How dare they change my appointment? I insist that the procedure be done at 10:00 AM."
2. "That's fine. I can come in whenever it is convenient for everyone."
3. "This is unacceptable. I had my whole day planned out." 4. "Why are they doing this to me?"
23. Which clinical manifestations would the nurse identify with severe anorexia nervosa? Select all that apply.
1. Amenorrhea
2. Fluid and electrolyte imbalances 3. Heat intolerance
4. Presence of lanugo 5. Refusal to exercise
6. Weight loss of 25% below normal weight
24. The nurse is caring for a new mother whose infant has been diagnosed with Down syndrome. The client says to the nurse, "I'm so worried. My husband is so devastated that he won't even look at the baby." What is the best response by the nurse?
1. "Both of you will benefit from supportive counseling." 2. "How are you feeling about your baby?"
3. "I will have the doctor speak to your husband."
4. "Why do you think your husband feels this way?"
25. A client with borderline personality disorder says to the nurse, "You're the only one I trust around here. The others don't know what they are doing and they don't care about anyone except themselves. I only want to talk with you." What is the priority action for the client's nursing care plan?
1. Assign different staff members to care for the client each day
2. Continue assigning the client's stated preferred nurse to care for the client
3. Frequently reassure the client that all staff members are competent in their jobs 4. Reinforce unit rules and consequences of inappropriate behaviors
26. A client recently admitted to an inpatient unit for treatment of alcoholism says to the nurse, "I only came here to get away from my nagging spouse. Sometimes I think my spouse is the one who should be here. I can stop drinking any time I want." The nurse recognizes that the client is exhibiting which of the following defense mechanisms?
1. Denial and projection
2. Rationalization and depression 3. Regression and displacement
4. Sublimation and reaction formation
27. The emergency department registered nurse is triaging a client for the risk of suicide. The client had thoughts of self-injury yesterday but is not sure today. Which of the following would be considered a known risk factor for suicide in this client? Select all that apply.
1. Constantly hearing voices saying client is worthless 2. Deliberately took an overdose 1 year ago
3. Has a gun at home
4. Married with 3 children
5. Participation in religious activities
6. Unemployed and unable to find a job
28. A client is brought to the emergency department after the spouse finds the client locked in the car inside their garage with the motor running. The spouse says to the nurse, "If I hadn't come home early from work, my spouse would be dead. I can't believe this is happening." What is the best response by the nurse?
1. "Do you have any relatives or close friends who can help you through this?" 2. "Has your spouse seemed depressed lately?"
3. "This has been very overwhelming for you. What are you feeling right now?"
4. "Well, you did find your spouse. You need to focus on helping your spouse get better."
29. A client on a medical unit recently received a diagnosis of end-stage renal disease and was told of the need to go on dialysis. This morning the client was found in the bathroom trying to commit suicide by hanging using hospital gown ties. The client was stabilized and transferred to the psychiatric unit. Which of the following is the highest priority nursing action for this client?
1. Assess the client's risk for another suicide attempt
2. Encourage the client to express current feelings about the medical diagnosis 3. Place the client in a private room near the nurses' station
4. Provide continuous one-to-one observation with the client
30. The nurse is caring for a client with a history of heroin abuse. Which clinical finding may indicate withdrawal?
1. Constipation
2. Constricted pupils
3. Drowsiness
4. Tachycardia
31. The spouse brings a client to the emergency department due to erratic behavior and expressions of despair. The emergency department is extremely busy with many clients. When the triage nurse asks if the client feels suicidal
now, the client shrugs the shoulders. What initial action should the triage nurse take?
1. Ask the client to make a verbal contract to not harm self 2. Document that the client is not currently suicidal
3. Place the client in an inside hallway with one-on-one observation 4. Return the client to the waiting room with the spouse
32. The nurse is planning care for an 11-year-old admitted for surgical treatment of a fractured femur. The child also has attention-deficit hyperactivity disorder, predominantly inattentive type. What is the priority nursing action?
1. Encourage the child to keep up with school work 2. Give the child a written schedule of daily activities 3. Limit the number of visitors
4. Provide verbal explanations of what to expect during hospitalization
33. A client with generalized anxiety disorder is referred to outpatient mental health department for cognitive behavioral therapy (CBT). The CBT includes which interventions and strategies? Select all that apply.
1. Desensitization to a specific stimulus or situation
2. Discussing the interpersonal difficulties that have led to the client's psychological problems
3. Helping the client develop insight into the psychological causes of the disorder 4. Relaxation techniques
5. Self-observation and monitoring
6. Teaching new coping skills and techniques to reframe thinking
34. A client recently diagnosed with schizophrenia is hospitalized. The client appears distraught and says to the nurse, "The voices are bad today...they are so angry with me." Which of the following is the best response by the nurse?
1. "Do you need something to help you calm down?"
2. "Don't pay any attention to the voices. Let's go into the dayroom." 3. "The voices are not real. Tell them to go away."
4. "What are the voices saying to you?"
35. The nurse is preparing discharge instructions for a client with a history of alcohol abuse on the third day after an emergency appendectomy. The nurse suspects delirium tremens based on which assessment data? Select all that apply.
1. Bradypnea
2. Diaphoresis
3. Hallucinations
4. Lethargy
36. The nurse is caring for a dying child on a palliative unit. Which statement by the nurse is most important to make to the parents immediately following the death of their child?
1. "Finding support with other local grieving parents can be helpful."
2. "Self care is important at this time. Take a break while the staff completes care." 3. "Some parents like to cuddle and speak to the child. Take the time you need." 4. "This must be a very difficult time. How have you dealt with loss in the past?"
37. The clinic nurse speaks with the spouse of a client being treated for alcohol use disorder. Which statements by the spouse indicate codependence? Select all that apply.
1. "I am focusing on my new hobby and my friends in the book club."
2. "I left and didn't awaken my spouse, who went back to sleep after turning off the alarm clock."
3. "I try to get up early and keep the children from being too loud in the mornings." 4. "If I didn't get so stressed about my job, my spouse wouldn't drink so much."
5. "When my spouse was sick, I called and rescheduled clients so my spouse could rest."
38. The nurse performs an initial assessment on a client with suspected post- traumatic stress disorder. Which assessments would support this diagnosis? Select all that apply.
1. Difficulty concentrating
2. Feeling detached from others 3. Feeling lethargic and apathetic
4. Flashbacks of the traumatic event 5. Persistent angry, fearful mood
39. A client with a diagnosis of schizophrenia with catatonia has recently been admitted to the psychiatric unit. Which of the following is the priority nursing diagnosis?
1. Impaired social interaction
2. Impaired verbal communication 3. Risk for deficient fluid volume 4. Risk for impaired skin integrity
40. A client is receiving nasogastric tube feedings as nutritional rehabilitation for anorexia nervosa. After a weigh-in, the client learns of gaining 2 lb (0.9 kg) and
says to the nurse, "See what your force feeding has done to me? I'm fatter and uglier than ever." What is the best action by the nurse?
1. Have the client keep a journal and write about feelings
2. Initiate one-on-one supervision of the client during feedings
3. Remind the client that gaining weight means being able to go home 4. Say that the client is not fat and ugly
41. The nurse is caring for a client who entered the psychiatric emergency department in a state of acute psychosis after ingesting illicit substances. The parents ask the nurse if the client will develop schizophrenia. What is the most appropriate response by the nurse?
1. "I know it must be terrible to see your son like this, but he will be fine." 2. "Most people have permanent side effects after an episode like this." 3. "Your son will have to remain here for observation until we know more."
4. "Your son would be fine right now if he had not taken these drugs."
42. The nurse assesses a pediatric client and finds bruises in various stages of healing on the back and legs. When questioned about the bruises the child begins to cry and states, "Somebody did things to me." Which of the following communications by the nurse is appropriate? Select all that apply.
1. "How long have your parents been doing things to you?"
2. "Tell me about what happened. I promise not to tell anyone." 3. "This is terrible. Whoever did this to you will be sorry."
4. "What happened is not your fault. You are not to blame."
5. "You did the right thing by telling me. You are not in trouble."
43. The emergency department nurse cares for a client with multiple bruises, a possible arm fracture, and a facial laceration. The client's spouse is at the bedside and appears angry. Which action is the priority at this time?
1. Call social services to assist the client in community resources for domestic violence victims
2. Clean the facial laceration and prepare to assist the health care provider with suture placement
3. Have the spouse leave the room so that the client can be spoken with and examined in private
4. Place the arm in a shoulder sling for immobilization and prepare for an immediate x- ray
44. The school nurse is called to the classroom to assist with a 7-year-old with attention-deficit hyperactivity disorder who is throwing books and hitting the other children. What is the best initial action for the nurse to take?
1. Administer a PRN dose of methylphenidate 2. Ask the child to blow up a balloon
3. Give the child a "time out" in a quiet place
4. Reinforce the consequences of disruptive behaviors
45. A client has been admitted to the acute inpatient psychiatric unit with a diagnosis of major depressive disorder (unipolar depression). The nurse understands that this diagnosis was made because the client has been exhibiting at least 1 of which of the 2 key clinical findings daily for at least 2 weeks?
1. Daily sleep disturbance or significant weight loss 2. Decreased ability to think or low energy
3. Depressed mood or loss of interest or pleasure
4. Thoughts of worthlessness or recurrent thoughts of death
46. The nurse is caring for a client admitted with abdominal pain, who has been diagnosed with somatic symptom disorder after a thorough evaluation finds no medical cause for the symptoms. Which intervention should the nurse include in the plan of care? [Show Less]