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Mental Health Quiz 2 Questions with Certified Solutions Graded A+.
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Mental Health Quiz 2 Questions with Certified Solutions Graded A+.
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Mental Health Quiz2 Questions with
Certified Solutions
Graded A+
Denning [Date] [Course title]
,•Accompanied by a friend, an emergency department client arrives by ambulance. The client is shouting
incoherently and fighting against restraints. The friend reports that the client "went crazy" about an
hour after taking a pill bought earlier in the day. Which of the following actions should the nurse take
first?
1.Take vital signs
2.Check orientation
3.Start intravenous (IV) fluids
4.Administer sedative medication - Answer: •Answer: 1
The highest priority is given to nursing interventions that will maintain life; therefore, basic physiological
needs must be addressed initially with baseline vital signs. Checking the level of orientation
(option 2) is important but does not provide any new information to the nurse. Nutrition and fluid
balance
(option 3) may be maintained by IV therapy once vital signs are evaluated and a physician's order is
obtained. Sedative medications
(option 4) may complicate an attempt to identify the original cause of the client's symptoms.
•A delirious client was recently released from wrist and ankle restraints. Suddenly, the client begins to
beat the sheets and yell, "Get those bugs away from me! They're all over! Get them!" The best initial
response by the nurse is:
1."What kind of bugs are on you?"
2."Those are just little bugs, they won't hurt you."
3."You're seeing bugs because you are sick, but I don't see any bugs on you."
4."Just hold very still and the bugs will crawl away." - Answer: •Answer: 3
The client is experiencing tactile hallucinations. The most appropriate response is option 3, which
orients the client to the reality of being sick and reassures the client of safety. By making statements
that essentially agree that the bugs exist
(options 1, 2, and 4), the nurse is communicating that the hallucinated objects are real. This could make
the client feel even more frightened.
•The nurse would formulate which of the following as the most appropriate nursing diagnosis for a
client with a medical diagnosis of delirium caused by a systemic infection?
, 1.Disturbed self-esteem and independent functioning
2.Risk for caregiver role strain related to lack of respite and financial resources
3.Confusion related to changing family roles and financial strain
4.Interrupted thought processes related to elevated temperature - Answer: •Answer: 4
Most cognitive impairments seen in delirium are physiological in origin; therefore, the identified
problem and all its effects should be reflected in a complete nursing diagnosis.
Options 1, 2, and 3 are more reflective of the psychosocial processes associated with dementia.
•A client says, "I have a very small drink every morning to calm my nerves and stop my hands from
trembling." The nurse concludes that this client is describing which of the following?
1. An anxiety disorder
2. Tolerance
3. Withdrawal
4. Alcohol abuse - Answer: •Answer: 3 Withdrawal. Taking a drink in the morning to steady one's nerves
is a sign of physical dependence and is done to avoid withdrawal symptoms. Tremors are one of the ten
symptoms of alcohol withdrawal listed in the Clinical Institute Withdrawal Assessment of alcohol
symptoms.
•A client who abuses alcohol tells a nurse, "I'm sure I can become a social drinker." What is the most
appropriate response by the nurse?
1. " When do you think you can become a social drinker?"
2. " What makes you think you'll learn to drink normally?"
3. " Does your alcohol use cause major problems in your life?"
4. " How many alcoholic beverages can a social drinker consume?" - Answer: •3. This question may help
the client recall the problematic results of using alcohol and the reasons the client began treatment.
Asking when he believes he can become a social drinker will only encourage the addicted person to deny
the problem and develop an unrealistic, self-defeating goal. Asking how many alcoholic beverages a
social drinker can consume and why the client thinks he can drink normally will encourage the addicted
person to defend himself and deny the problem.
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