Saunders Mental Health Questions with Answers
A client is admitted with a recent history of severe anxiety following a home invasion and robbery. During the initial assessment interview, which statement by the client should indicate to the nurse the possible diagnosis of posttraumatic stress diso...
Saunders Mental Health Questions
with Answers
A client is admitted with a recent history of severe anxiety following a home invasion
and robbery. During the initial assessment interview, which statement by the client
should indicate to the nurse the possible diagnosis of posttraumatic stress disorder?
Select all that apply. - Answer-- I keep reliving the robbery."
- "I see his face everywhere I go."
- "I might have died over a few dollars in my pocket."
The emergency department nurse is caring for a client who has been identified as a
victim of physical abuse. In planning care for the client, which is the priority nursing
action? - Answer-Removing the client from any immediate danger
The nurse assesses a client with the admitting diagnosis of bipolar affective disorder,
mania. Which client symptoms require the nurse's immediate action? - Answer-Nonstop
physical activity and poor nutritional intake
The nurse is performing an assessment on a client with dementia. Which piece of data
gathered during the assessment indicates a manifestation associated with dementia? -
Answer-Use of confabulation
confabulation - Answer-the act of filling in memory gaps by making up stories
The nurse is caring for a client with anorexia nervosa. Which behavior is characteristic
of this disorder and reflects anxiety management? - Answer-Observing rigid rules and
regulations
A depressed client verbalizes feelings of low self-esteem and self-worth typified by
statements such as "I'm such a failure. I can't do anything right." How should the nurse
plan to respond to the client's statement? - Answer-Identify recent behaviors or
accomplishments that demonstrate the client's skills.
A client with diabetes mellitus is told that amputation of the leg is necessary to sustain
life. The client is very upset and tells the nurse, "This is all my health care provider's
fault. I have done everything I've been asked to do!" Which nursing interpretation is best
for this situation? - Answer-An expected coping mechanism
A client experiencing a great deal of stress and anxiety is being taught to use self-
control therapy. Which statement by the client indicates a need for further teaching
about the therapy? - Answer-"This form of therapy provides a negative reinforcement
when the stimulus is produced."
,The nurse is caring for a client who is at risk for suicide. What is the priority nursing
action for this client? - Answer-Provide authority, action, and participation.
A client comes to the emergency department after an assault and is extremely agitated,
trembling, and hyperventilating. What is the priority nursing action for this client? -
Answer-Remain with the client until the anxiety decreases.
The nurse is developing a plan of care for a client who was experiencing anxiety after
the loss of a job. The client is now verbalizing concerns regarding the ability to meet role
expectations and financial obligations. What is the priority nursing problem for this
client? - Answer-Lack of ability to cope effectively
Which statement made by an unlicensed assistive personnel (UAP) indicates to the
registered nurse that the UAP understands the concepts related to suicide? - Answer-
"Discussing suicide with a client is not harmful."
Which client is at greatest risk for committing suicide? - Answer-A client with metastatic
cancer
Which statement by the nurse indicates a need for further teaching concerning family
violence? - Answer-"Abusers are more often from low-income families."
Which pre-electroconvulsive therapy intervention will the nurse implement for a
hospitalized client? - Answer-Assure that an electrocardiogram is performed within 24
hours.
A nursing student is assisting with the care of a client with a chronic mental illness. The
nurse informs the student that a behavior modification approach (operant conditioning)
will be used in treatment for the client. Which statement by the student indicates a need
for further information about the therapy? - Answer-"It uses negative reinforcement."
The nurse in the mental health unit is performing an assessment in a client who has a
history of multiple physical complaints involving several organ systems. Diagnostic
studies revealed no organic pathology. The care plan developed for this client will reflect
that the client is experiencing which disorder? - Answer-Somatization disorder
Somatization disorder - Answer-is characterized by a long history of multiple physical
problems with no satisfactory organic explanation. Emotional turmoil expressed in
physical signs is the hallmark of somatization disorder. A psychological issue that
causes to report physical symptoms such as pain
The mental health nurse is meeting with a client who has a long history of abusing
drugs. During the session the client says to the nurse, "I'm feeling much better now, and
I'm ready to go straight." Which response by the nurse would be therapeutic? - Answer-
"Tell me what makes you feel that you are ready.
, A client diagnosed with depression shares with the outclinic nurse, "I lost my job this
week and can't pay my rent. My daughter is my only family, but I don't want to burden
her with my problems." Which response by the nurse would effectively address the
client's concern? - Answer-"Wouldn't you want to know if your daughter was having
difficulties so you could help if you could?"
During a therapy session a client with a personality disorder says to the nurse, "You
look so nice today. I love how you do your hair, and I love that perfume you're wearing."
Which response by the nurse would best address this breech of boundaries? - Answer-
"The focus of today's session is on your issues, so let's get started."
The nurse assigned to care for a female client diagnosed with acute depression would
be appropriate in making which statement to the client? - Answer-"You're wearing a new
blouse."
The nurse should plan which goals of the termination stage of group development?
Select all that apply. - Answer-- the group evaluates the experience.
- The group explores members' feelings about the group and the impending separation.
A client diagnosed with terminal cancer says to the nurse, "I'm going to die, and I wish
my family would stop hoping for a cure! I get so angry when they carry on like this. After
all, I'm the one who's dying." Which response by the nurse is therapeutic? - Answer-
"You're feeling angry that your family continues to hope for you to be cured?"
When reviewing the admission assessment, the nurse notes that a client was admitted
to the mental health unit involuntarily. Based on this type of admission, the nurse should
provide which intervention for this client? - Answer-Monitor closely for harm to self or
others.
The nurse in the mental health unit plans to use which therapeutic communication
techniques when communicating with a client? Select all that apply. - Answer--Restating
- Listening
- Maintaining neutral responses
- Providing acknowledgment and feedback
A client is participating in a therapy group and focuses on viewing all team members as
equally important in helping the clients to meet their goals. The nurse is implementing
which therapeutic approach? - Answer-Milieu therapy
The nurse is working with a client who despite making a heroic effort was unable to
rescue a neighbor trapped in a house fire. Which client-focused action should the nurse
engage in during the working phase of the nurse-client relationship? - Answer-Inquiring
about and examining the client's feelings for any that may block adaptive coping
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