N3381 - Psychiatric Mental Health Prep
Exam 2 Questions With Already Passed
Solutions.
The nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse
notes that the admission nurse documented the client is experiencing anxiety as a result of a situational
crisis. The nurse plans care for the client, determining that this type of crisis could be caused by which
event?
1.Witnessing a murder
2.The death of a loved one
3.A fire that destroyed the client's home
4.A recent rape episode experienced by the client - Answer The death of a loved one
Rationale:A situational crisis arises from external rather than internal sources. External situations that
could precipitate a crisis include loss or change of a job, the death of a loved one, abortion, change in
financial status, divorce, addition of new family members, pregnancy, and severe illness. Options 1, 3,
and 4 identify adventitious crises. An adventitious crisis refers to a crisis of disaster, is not a part of
everyday life, and is unplanned and accidental. Adventitious crises may result from a natural disaster
(e.g., floods, fires, tornadoes, earthquakes), a national disaster (e.g., war, riots, airplane crashes), or a
crime of violence (e.g., rape, assault, murder in the workplace or school, bombings, or spousal or child
abuse).
The nurse is conducting an initial assessment of a client in crisis. When assessing the client's perception
of the precipitating event that led to the crisis, which is the most appropriate question?
1. "With whom do you live?"
2."Who is available to help you?"
3."What leads you to seek help now?"
4."What do you usually do to feel better?" - Answer "What leads you to seek help now?"
,Rationale:The nurse's initial task when assessing a client in crisis is to assess the individual or family and
the problem. The more clearly the problem can be defined, the better the chance a solution can be
found. The correct option would assist in determining data related to the precipitating event that led to
the crisis. Options 1 and 2 assess situational supports. Option 4 assesses personal coping skills.
The nurse is creating a plan of care for a client in a crisis state. When developing the plan, the nurse
should consider which factor?
1. A crisis state indicates that the client has a mental illness.
2. A crisis state indicates that the client has an emotional illness.
3. Presenting symptoms in a crisis situation are similar for all clients experiencing a crisis.
4. A client's response to a crisis is individualized and what constitutes a crisis for one client may not
constitute a crisis for another client. - Answer A client's response to a crisis is individualized and what
constitutes a crisis for one client may not constitute a crisis for another client.
Rationale: Although each crisis response can be described in similar terms as far as presenting symptoms
are concerned, what constitutes a crisis for one client may not constitute a crisis for another client,
because each is a unique individual. Being in the crisis state does not mean that the client has a mental
or emotional illness.
A newly admitted client is exhibiting signs and symptoms associated with a loss of physical functioning,
although no such loss can be confirmed medically. This situation supports which mental health
diagnosis?
1. Depression
2. Somatization disorder
3. Post-traumatic stress disorder
4. Obsessive-compulsive disorder - Answer Somatization disorder
Rationale: Emotional turmoil expressed in physical signs is the hallmark of somatization disorder. None
of the other options are associated with loss of physical function.
,A client who has recently lost her spouse says, "No one cares about me anymore. All the people I loved
are dead." Which response demonstrates an understanding of therapeutic communication when dealing
with a grieving client?
1. "I certainly care about you."
2. "You must be feeling all alone at this point."
3. "I don't believe that and neither should you."
4. "It isn't unusual to feel alone when you are grieving." - Answer "You must be feeling all alone at this
point."
Rationale:The client is experiencing loss and is feeling hopeless. The therapeutic response by the nurse is
the one that attempts to translate words into feelings. None of the remaining options encourage the
client to discuss feelings but rather minimize and/or trivialize the feelings expressed.
A depressed client who appeared sullen, distraught, and hopeless a few days ago now suddenly appears
calm, relaxed, and more energetic. Which is the nurse's best initial action with regard to the client's
altered demeanor?
1.Continue to assess the client's behaviors and document clearly in the chart.
2.Report to the psychiatrist that the client is adapting to the unit and is feeling safe.
3.Notify the health team of these observations and alert them to the suspicion that the client is
contemplating suicide.
4.Engage the client in one-to-one supervision, share with the client the observations that have been
assessed, and ask whether the client is thinking about suicide. - Answer Engage the client in one-to-one
supervision, share with the client the observations that have been assessed, and ask whether the client
is thinking about suicide.
Rationale: The sudden change in the depressed client's mood and affect may indicate that the client has
come to a decision about suicide. The only way to be sure is to ask the client directly. Eliminate options
that present strategies that would be used with any client. Avoid options that make unfounded
assumptions such as a meaning of the behavior. Notifying others of your concern may be necessary at
some point but does nothing to address the problem directly.
, The nurse is performing an assessment on a 16-year-old female client who has been diagnosed with
anorexia nervosa. Which statement, made by the client, would the nurse identify as necessitating further
assessment on a priority basis?
1."I check my weight every day without fail."
2."I've been told that I am 10% below ideal body weight."
3."I exercise 3 to 4 hours every day to keep my slim figure."
4."My best friend was in the hospital with this disease a year ago." - Answer "I exercise 3 to 4 hours
every day to keep my slim figure."
Rationale:Exercising 3 to 4 hours every day is excessive physical activity and unrealistic for a 16-year-old
girl. The nurse needs to immediately assess this statement further to find out why the client feels the
need to exercise this much to maintain her figure. It is not considered abnormal to check weight every
day. Many clients with anorexia nervosa check their weight 20 times or more each day. A body weight
15% below the ideal weight or less is most significant with anorexia nervosa. Although it is unfortunate
that the client's best friend had the disease, this is not considered a major threat to the client's physical
well-being
Which assessment data would indicate that a client is most at risk for suicide?
1.The client demonstrates impulsiveness.
2.The client is disorganized in actions and thoughts.
3.The client has an immediate plan for a suicide attempt.
4.The client has a history of unsuccessful suicide attempts. - Answer The client has an immediate plan
for a suicide attempt.
Rationale:Having a plan, particularly if the method is immediate and available, places the client at very
high risk. Clients also at higher risk include those with a history of a dual diagnosis of mental illness and
substance abuse; those with a personal or family history of suicide attempts, depression, or alcoholism;
or those with a history of psychotic episodes. Although impulsiveness, disorganization in actions and
thoughts, and previous suicide attempts are related to suicide risk, these are not data that makes the
client most at risk from the options provided.
