NUR 2474 RASMUSSEN MENTAL HEALTH FINAL EXAM TEST BANK with 100% Verified Solutions for 2024/2025

Mental Health Final 1: The nurse is caring for a client diagnosed with somatic symptom disorder. The client continues to focus on his severe back pain. Which of the following is the most therapeutic nursing intervention? Explain alternative interventions that are available for back pain. Confront the client with the negative feelings that have been determined. Allow the client to discuss physical concerns and then redirect to coping skills for stress. Tell the client there is no cause for the pain except emotional stress. 2: A nurse is preparing to administer haloperidol 75mg IM per week. Available is haloperidol decanoate 100mg/mL for injection. How many mL should the nurse administer per dose? (round to nearest hundredth or two decimal places) 0.75 3: While caring for a teenage client with attention deficit hyperactivity disorder who is at high risk for self harm due to poor judgement, high risk taking behaviors, and impulsivity. Which of the following is the priority nursing intervention? Develop a no harm contract with the client and encourage participation in all unit activities Schedule a regular nurse client session daily to discuss daily goals Have the client sit within direct line of sight with the staff, only during meal times Have a staff member assigned for one on one observation at all times 4: Which of the following statements by the nurse who cares for children with psychiatric disorders is a concern? Since I have been caring for this child he has become less agitated When a child becomes violent, I also need to protect the other children I know exactly how the child feels, since I went through the same thing I have to be careful not to become attached and show favoritism 5: A child diagnosed with oppositional defiant disorder begins to yell at staff members when asked to leave the group therapy because of inappropriate behaviors. Which nursing intervention would be most appropriate? accompany the child to a quiet area to decrease external stimuli lOMoAR cPSD | institutes occlusion following the facilities protocol allow the child to remain in Group therapy and continue to monitor assist the child in recognizing how to separate feelings from reactions 6: a 16 year old is admitted to the adolescent unit with a diagnosis of conduct disorder. This condition is often manifested by what behavior? Verbal aggression and expressing the need for independence physical aggression and violation of others inability to complete age appropriate tasks anger related to restrictive rules 7: the nurse is caring for a client with a factitious disorder imposed on another person, which of the following statements by the client would the nurse expect? I made my daughter sick because no one was paying us any attention my friend now has a new friend, so I have nothing to do with her my son has asthma, and I become anxious when he has trouble breathing I've been sick for so long, and no one can help me 8: the nurse is caring for a client with attention deficit hyperactivity disorder. The client has been prescribed methylphenidate. Which of the following symptoms are side effects the nurse will monitor for? Select all that apply Sedation Headache decreased appetite decrease blood pressure insomnia 9: when planning the care of a 6 year old child diagnosed with oppositional defiant disorder, the nurse should include which method of therapy? Mindfulness exercises lOMoAR cPSD | cognitive therapy behavior modification emotive therapy 10: Has been prescribed you buspirone for a new diagnosis of generalized anxiety disorder (GAD). Which statement by the client indicates an understanding of the medication? I will let my physician know if I become addicted I will only need to take this when I feel anxious I should begin to feel better in a few days I will need to take this medication for a while before I see how well it works for me 11: a female client expresses to the nurse that she feels like she didn't do enough to prevent the loss of her father. Which of the following interventions should the nurse use to address the clients feelings? Encourage the client to remain strong to support the other family members review the circumstances of the loss and the reality that it could not be prevented explain that this feeling is a pathological defense that will prevent the client from progressing through the stages of grief role play the events and assist the client with understanding the decisions leading to the loss 12: the nurse observes a client diagnosed with anorexia nervosa doing repeated, vigorous sit-ups in her room period what is the most therapeutic intervention by the nurse? Allow the client to continue exercise interrupt the routine and offer to walk with her tell the client exercise is not allowed restrict the client from her room 13: client is prescribed diazepam as needed (PRN) for panic disorder. Which of the following facts would cause the nurse to question the order? The client has been diagnosed with irritable bowel syndrome with (IBS) client states she is allergic to meperidine lOMoAR cPSD | the client had a severe addiction problem in the past lithium carbonate has also been prescribed 14: the nurse is assessing the client in a fugue state. Which assessment findings would the nurse recognize as most significant to experiencing a fugue state? Depersonalization episode history of childhood trauma recent history of severe trauma depressive symptoms 15: a child is diagnosis being on the autistic spectrum. Which clinical manifestation should the nurse expect? Select all that apply inability to express themselves appropriate nonverbal communication repetitive body movements inability to maintain eye contact hallucinations 16: the client is admitted with a diagnosis of dependent personality disorder. Which question by the nurse indicates an understanding of the essential features of the disorder? Are you afraid of being alone? Do you find you don't want praise for your accomplishments? Do you feel awkward in social situations? Do you have problems expressing your feelings? 17: a nurse is teaching a group of students about the risk factors and complications of anorexia nervosa. Which of the following complications should be stressed as the most serious? Increase risk of mortality family relationships depression lOMoAR cPSD | ineffective coping 18: a child drowned while swimming in a local lake two years ago. Which behavior best indicates the child's parents are mourning an effective way? They throw flowers on the lake at each anniversary date of the incident they forbid their other children from going swimming they sealed their child's room and will not allow anyone to change it they keep a play set for the deceased child at the family dinner table 19: a child diagnosed with oppositional defiant disorder is spiteful, vindictive, and argumentative and has a history of aggression towards others. Which of the following would be a priority nursing concern? Impaired social skills during group therapy ineffective coping and dealing with negative behaviors poor impulse control leading towards violence of others refusal to engage actively in the treatment plan 20: a four year old child states to the nurse, “if I can make a big enough wish, my dad won't be dead anymore.” what is the conclusion made by the nurse? The child is voicing thoughts that are normal for children this age the child is making up a story, so sad feelings will not be as painful this is magical thinking, generally used by older children the child is repeating something he heard the other children say 21: a 79 year old client admits that his daughter hits him while helping him dress each morning. What is the appropriate nursing action? The family member is to be charged for this offense it is a requirement that he be removed for his safety the nurse is required to make sure the proper authority is informeda competency hearing must be scheduled for the client lOMoAR cPSD | 22: the nurse is conducting a presentation for family members on personality disorders. What would be included in this presentation? Select all that apply personality disorders only occur as a product of certain home environments personality traits can be challenging to change medications can quickly treat the problematic symptoms of personality disorders stress has an impact on daily behaviors and attitudes personality traits are formed early in life 23: Client is diagnosed with agoraphobia. Which question indicates the nurse understands the etiology related to this disorder? Do you struggle to control impulses? Were your parents supportive of your endeavors? Can you share the places that cause you fear? Do you ever feel like your mind goes blank? 24. A school age child is talking with her grandmother, who is dying. What should the nurse say to the child? Although she cannot hear you, she can feel your presence even though she may not answer you, she can hear you hold her hand since she probably can't hear you talk to her loudly so she can hear you 25. A client is diagnosed with antisocial personality disorder. She has a violent verbal, physical threatening outburst in the dayroom of the unit when the nurse explains she cannot smoke in the hospital. What is the priority action the nurse should take? Insist that she immediately give him the cigarettes remove all other clients from the dayroom to ensure safety use a firm, controlling approach and explaining the rules call for help to restrain the client lOMoAR cPSD | 26. the nurse is working with a client who is preoccupied with perfection, cannot discard anything, and has trouble relaxing. Which of the following personality disorders is being described within this example? Antisocial histrionic narcissistic obsessive compulsive 27. The nurse has determine systematic desensitization is the therapy being used to treat the client with acrophobia. How is this demonstrated? Gradual exposure to higher areas visualizing going up steep places discussing past trauma at certain heights being regularly exposed to high places 28. Nurses caring for a client experiencing panic level anxiety. The nurse understands which of the following nursing actions should be considered a priority? Client turn alone to recollect themselves guide the client through relaxation techniques stay with the client and reduce stimuli in the room Ask the family member what the trigger for the anxiety was MISSING QUESTIONS 29 AND 30 (posted double pictures of 31 and 32) 29. What behavior by the client diagnosed with bulimia nervosa indicates progress and treatment? Verbalizing feelings 30. 31. A client has been sullen and withdrawn since receiving the news of her cancer diagnosis. As the nurse enters the room, the client ask for assistance with a shower. Which comment by the nurse is the most appropriate? If you look better, you might feel better too lOMoAR cPSD | taking a shower might wash away some of that gloom and doom I will be glad to assist. I'll be right back with your supplies your spouse will be glad to see that you're feeling better 32. The nurse is caring for a client who has just been injured by her male partner. Client states this is the first time he has been physically abusive, but he apologized and has since sent her flowers. What is the intervention by the nurse? Ask the client about the level of stress she is experiencing give the client a list of anger management resources teach the client the cycle of battering suggest the client and her partner both take some time to evaluate the relationship 33. A female adolescent client says to the nurse, “hey, you stupid blonde, what are you looking at?” Which of the following responses would be inappropriate for the nurse to make? What's that all about? I don't understand that comment That kind of language is unacceptable don't you ever talk to me like that again 34. A seven year old male without any other diagnosed problem engages in jaw clenching, rocking back and forth, and unable to engage in physical contact. The nurse recognizes these symptoms of which of the following conditions? Stereotypic movement disorder attention deficit hyperactivity disorder tourette's disorder autism spectrum disorder 35. a nurse working on an inpatient psychiatric unit observes a client diagnosed with obsessive compulsive disorder(OCD) rearranging the magazines in the dayroom. The nurse understands this action is primarily meant to do which of the following? Show the other clients how to stay organized lOMoAR cPSD | temporarily reducing anxiety the client is feeling ensure a structured and orderly environment show the nursing staff they can emotions 36. 7 year old male client has severe bruising on his arms and injury to his abdomen. The nurse should consider child abuse at the parents act in what manner? Telling seeking trigger a parents remain with the child throughout the assessment The parents of the delay seeking treatment The parents ask the child to explain what happened the parents show concern for the child 37. A client has blindness related to conversion disorder. To assist the client with eating, which of the following interventions should the nurse implement? Address the needs of other clients in the dining room, then feed this client establish a buddy system with other clients who can feed this client at each meal place the food tray on the table in front of the client expect the client to feed himself after explaining the arrangement of the food tray 38. A child had no start on the autism spectrum may experience repetitive behaviors. Which of the following are examples of repetitive behavior which could be observed? Select all that apply avoiding body contact language delays spinning in circles limited function play flapping their hands 39. A client weighs 190 pounds. What is the client's weight in kilograms? Record answer to the nearest 10th or one decimal place. 86.4 lOMoAR cPSD | 40. what is the difference between post traumatic stress disorder(PTSD) and acute stress disorder? And acute stress disorder, the symptoms start and end within 1 month after the traumatic events in PTSD, the symptoms start immediately after the traumatic events hypervigilance and flashbacks are less frequent and acute stress disorder the traumatic events in PTSD are less severe than those in acute stress disorder 41. What is the priority nursing intervention when providing care to the client who was brought to the emergency department after sexual assault? Call a chaplain to provide support collect a history of the attack get the consent for the forensic examination ensure safety of the client in a private room 42. Which statement by the nurse in the emergency department indicates a firm knowledge base regarding intimate partner violence? Abused women are attracted to abusive men abused individuals have a dependent personality disorder power and control are the central dynamics of abuse verbal abuse always proceeds to physical abuse 43. Client is diagnosed with terminal cancer. Which situation should the nurse assess as reflecting Kubler- Ross’s grief stage of anger? The client is a devoted Catholic but refuses to attend church and states that his faith has failed him the client registers for an Ironman marathon to be held in nine months The client gathers family to plan a funeral and make last wishes known the client promises God to give up smoking if allowed to live long enough to witness a grand childbirth 44. What are the effective interventions to facilitate autonomy for a client diagnosed with the eating disorder? Provide the client with limited information regarding progress lOMoAR cPSD | have the client give input when establishing the expected outcomes provide flexibility and activities of daily living prohibit the client from making some decisions about eating rules 45. The parent of a child with attention deficit hyperactivity disorder (ADHD) tells them nurse that the child does not follow directions well. What strategy would be best for the nurse to recommend? Teach a child to be assertive and not to resist instructions by those in authority consider developing a daily schedule plan with the child place the child in timeout for at least 20-30 minutes try having the child repeat the instructions before starting the task 46. A child is admitted to the inpatient psychiatric unit with a diagnosis of conduct disorder. The nurse would expect to find which of the following symptoms? A history of cruelty towards people and animals constant complaints of physical symptoms such as headaches and abdominal discomfort confabulation when confronted with inappropriate behaviors high anxiety related to the separation from home and of family 47. Hey client diagnosed with dissociative disorder suddenly begins to speak with a child's vocabulary and voice. What interpretation should the nurse make of this behavior? Somatization episode a state of depersonalization malingering behavior attention seeking behavior 48. The nurse is caring for a 12 year old client diagnosed with oppositional defiant disorder. The clients mother asked what type of medication is usually prescribed for this diagnosis. Which of the following isthe most appropriate response by the nurse? Though medications may be used, typically the client will outgrow the behavioral problem without any specific treatment plan though medications may be used to treat symptoms, the focus will be on behavioral therapy lOMoAR cPSD | oftentimes medications such as mood stabilizers are used in a “off label” manner there have been no medications approved for this condition 49. A nurse is preparing to administer buspirone 7.5mg PO every 12 hr 2A client. The amount available is buspirone 15mg/tablet. how many tablets should the nurse administer per dose? Record the answer to the nearest 10th or one decimal place 0.5 50. Newly admitted client diagnosed with somatization disorder ask for his pain medication that is ordered on an as needed basis. What is the nurses best action to this request? Inform the client of recent negative findings Administer the medication as prescribed immediately teach the client deep breathing exercises delay fulfilling the request and see if the pain subsides 51. A 28 year old male client has poor relationships and is suspicious of others. According to erikson's theory of psychological adjustment, at what stage or tasks unmet? Autonomy vs shame and doubt initiative vs guilt industry vs inferiority trust vs mistrust 52. A client with past experiences of eating disorder symptoms uses the ego defense mechanism of sublimation and dealing with this disorder. How is this expressed? She identifies these symptoms and others she tries to forget these past symptoms she states that she doesn't think she had a real problem the client speaks at high schools about her disorder 53. Client states that she is hearing voices that tell her to cut herself. She already has several superficial marks on her wrists from scratching herself with the plastic eating utensils. She will not contract for safety what is the priority nursing intervention? lOMoAR cPSD | Conduct 15 minute checks so she will not get one to one attention she seeks remove the plastic eating utensils from the unit obtain an order for seclusion until she denies suicidal intent place one to one, constant observation to ensure she does not harm herself 54. A nurse is developing a care plan for a client with post-traumatic stress disorder. Which of the following should be completed first? Encourage the client to verbalize thoughts and feelings about the trauma I encourage the client to put the past in proper perspective avoid discussing the traumatic events with the client instruct the client to use distraction techniques to cope with flashbacks 55. A client is prescribed lorazepam 0.5mg four times a day(QID) and 1mg PO every 8 hours PRN. the maximum daily dose of lorazepam should not exceed 4mg daily. this client would be able to receive PRN doses as the maximum number of PRN lorazepam doses. (record as a whole number. Do not use a trailing zero) 2 56. Which of the following is a therapeutic approach to setting limits with clients diagnosed with antisocial personality disorder? Clarify the rules for all and make expectations clear establish restrictive goals for these clients convey acceptance for behavior use a friendly manner and ask for cooperation 57. What factor is a precipitating symptom of depression and suicidal intent in the elderly? Religious concerns bereavement overload fear of death poor self esteem lOMoAR cPSD | 58. A nurse is working with a client with historic personality disorder. Which of the following nursing interventions must be implemented throughout the inpatient day? Having the client approach different staff members for interpretation of unit rules providing multiple options when the client makes frequent requests offering relationship advice setting appropriate limits on maladaptive behaviors 59. A client is diagnosed with obsessive compulsive disorder. Which action by the nurse would increase the client's anxiety? Requesting participation in Group therapy changing the schedule throughout the day asking feedback regarding milieu therapy talking with other staff at the nurses station 60. The family of a 17 year old client diagnosed with anorexia nervosa is encouraged to attend family therapy sessions. The parents state, “we don't have the eating disorder. Why should we attend?”. What is the best response by the nurse? She needs her support right now An eating disorder as a family disorder don't you care about your daughter's well-being? Gaining insight about her illness and what contributes to it will be beneficial 61. The client is ordered venlafaxine 225 mg PO daily. Available on the unit is venlafaxine 75mg tablets. how many tablets will the nurse administer for the daily dose? Record the answer as a whole number. 3 62. The nurse is caring for a client who is prescribed haloperidol 4 mg or early on admission. An oral suspension of haloperidol 2mg/mL is received from the pharmacy. What amount of mL of the oral suspension should the nurse administer to the client? Record the answer as a whole number. 2 lOMoAR cPSD | 63. Which of the following statements best describes a goal of group therapy? The staff could share their personal experiences the members can hear from others who have experienced similar experiences the therapist can demonstrate how physical conditions are affected the need for withdrawal insert effects can be taught 64. A client with antisocial personality disorder states the nurse, “a novice like you can't possibly help me.” What is the best response for the nurse? Where do you plan to go? It's evident you understand my role! What needs do you think I can't meet? The staff here have tried very hard to help you 65. A terminal client expresses concern that his spouse seems distant and continues the activities always carried out with him now without him. The situation is an example of what type of grief? Chronic grieving inhibited grief distorted grief anticipatory grief 66. Client diagnosed with borderline personality disorder is angry that the night shift staff would not let her drink coffee at 3:00 AM. She discusses this in a community meeting and develops a following of clients who demand access to the cafeteria at all hours. How can the nursing staff manage this situation to prevent “splitting”? Allow the clients to vote on the issue eliminate coffee from the unit allow the clients access to the cafeteria at night staff discuss the situation and agree upon consistency lOMoAR cPSD | 67. Which behavior best describes physical aggression? Telling them medication nurse, “I'm not going to take that or any other medication” stomping away from the nurses station, going to the dayroom, and grabbing a pool cue from a client standing at the pool table telling the primary nurse, “when you told me that I could not have a second helping at lunch, I felt angry” bursting into tears, leaving the community meeting, and sitting on the bed hugging a pillow and sobbing 68. It community health nurse is planning a training for post traumatic stress disorder. Which of the following clients would be considered the most vulnerable to post traumatic stress disorder? A 20 year old college student with diabetes mellitus who experienced date rape an 8 year old boy with asthma who recently failed a grade in school a wife of an individual with a severe substance abuse problem a 40 year old widower who has recently lost his wife to cancer 69. Hey client recently lost his wife to COVID-19. Which statement by the client may alert the nurse or the client may be negatively coping with the death? I really enjoy journaling, it lets me get out my feelings avoiding contact with others is easier to deal with I signed up for a yoga class this week I made an appointment to meet with a therapist 70. A client states, “I was diagnosed with panic attacks. I have heard of dissociative disorders. What is the difference?” What is the nurses best response? Panic attacks are associated with guilt, causing anxiety in just associated disorders, the person experiences and involuntary escape from reality characterized by disconnection between thoughts, identity, consciousness, and/ or memory. There are only physiological changes with just sociative disorders there was very little difference between the two disorders lOMoAR cPSD | 71. An elderly client was neglected by family in the home setting. The abuse was reported. What factor would have allowed the client to remain in the home? Since the abuse has not been physical; there is no need to remove the client from the environment only children are removed from the family and home the appropriate agency will possibly monitor for improvement in the situation competent adults can decide to remain in the setting 72. What statement by an elderly client might suggest financial abuse is occurring? My son didn't help when I needed to get up, and I fell my son hasn't done anything to replace my dentures after I gave my son access to my bank account, I noticed he has a brand new car even though I live with my son it seems like we never have enough food in the house 73. A child diagnosed with autism spectrum disorder makes no eye contact, does not respond to verbal directions from the staff members, and constantly twists, spins, and head banks. Which of the following would be the best nursing action? place the child in seclusion as the behavior is unacceptable instructing the child to follow directions from the staff ensuring the child does not receive an injury from body movements showing the child how to maintain eye contact 74. Which assessment data should the school nurse recognizes signs of physical neglect? The child has a sophisticated knowledge of sexual behaviors the child is often absent from school, wears dirty clothes, and seems withdrawn and tired. The child is very insecure and has poor self esteem the child has multiple bruises on various body parts 75. The provider ordered lorazepam 2mg IM stat. Available is lorazepam injection 5mg/mL. How many mL will the nurse administer? (Record answer to the nearest tenth, or one decimal place) 0.4