Mental Health
Mental Health Principles
A patient doesn’t wish to work with a certain nurse because that nurse reminds the patient of
their mother. What behavior is the patient exhibiting?
1. Countertransference
2. Agitation
3. Nonmaleficence
4. Transference
2
Mental Health Principles
A patient doesn’t wish to work with a certain nurse because that nurse reminds the patient of
their mother. What behavior is the patient exhibiting?
1. Countertransference
2. Agitation
3. Nonmaleficence
4. Transference – the phenomenon of a patient unconsciously projecting feelings about a
person from their past onto someone in the present.
3
Mental Health Principles
Which component of the mental status exam is the nurse assessing when noting that a
patient is calm and relaxed?
1. Speech
2. Mood
3. Behavior
4. Thought processing
4
Mental Health Principles
Which component of the mental status exam is the nurse assessing when noting that a
patient is calm and relaxed?
1. Speech
2. Mood
3. Behavior – Noting the patient is calm and relaxed is part of the behavioral component of
the mental status exam.
4. Thought processing
5
Mental Health Principles
Which of the following is a nontherapeutic response to a patient?
1. Why are you so angry?
2. Can you tell me more about that?
3. I hear you saying you’re having difficulty focusing.
4. That sounds like it must be really difficult.
6
Mental Health Principles
Which of the following is a nontherapeutic response to a patient?
1. Why are you so angry? – The nurse should avoid asking “why” questions, as these can
appear to be judgmental.
2. Can you tell me more about that?
3. I hear you saying you’re having difficulty focusing.
4. That sounds like it must be really difficult.
7
Mental Health Principles
A patient is experiencing anxiety accompanied by a sense of doom, hallucinations, trembling,
and diaphoresis. What level of anxiety is this patient experiencing?
1. Panic level
2. Severe
3. Mild
4. Moderate
8
Mental Health Principles
A patient is experiencing anxiety accompanied by a sense of doom, hallucinations, trembling,
and diaphoresis. What level of anxiety is this patient experiencing?
1. Panic level – Panic level anxiety can be accompanied by hallucinations, delusions,
tremors, sweating, and a sense of impending doom.
2. Severe
3. Mild
4. Moderate
9
Mental Health Principles
A support group for families affected by suicide is an example of which type of prevention?
1. Tertiary prevention
2. Secondary prevention
3. Quaternary prevention
4. Primary prevention
10
Mental Health Principles
A support group for families affected by suicide is an example of which type of prevention?
1. Tertiary prevention – Tertiary prevention in mental health focuses on the period after a
mental health disorder or crisis has already occurred and can include support for families
affected.
2. Secondary prevention
3. Quaternary prevention
4. Primary prevention
11
Mental Health Principles
The nurse teaches a parenting class in the community for first-time parents. Which level of
prevention is this?
1. Secondary prevention
2. Tertiary prevention
3. Primary prevention
4. Quaternary prevention
12
Mental Health Principles
The nurse teaches a parenting class in the community for first-time parents. Which level of
prevention is this?
1. Secondary prevention
2. Tertiary prevention
3. Primary prevention – in mental health, primary prevention is focused on increasing
patients’ exposure to protective factors, such as education on how to handle a stressful
life event, such as the birth of a new baby.
4. Quaternary prevention
13
Mental Health Principles
Which of the following patients may provide their informed consent?
1. A 32-year-old who has been involuntarily admitted
2. An 82-year-old with dementia
3. A 21-year-old who has been drinking
4. A 14-year-old patient in the emergency room
14
Mental Health Principles
Which of the following patients may provide their informed consent?
1. A 32-year-old who has been involuntarily admitted
2. An 82-year-old with dementia
3. A 21-year-old who has been drinking
4. A 14-year-old patient in the emergency room
A patient may not provide informed consent if they are <18 years old, under the influence of
drugs or alcohol, or actively experiencing dementia or delirium.
15
Mental Health Principles
Which type of crisis is experienced by a patient whose home was destroyed in a flood?
1. Maturational crisis
2. Situational crisis
3. Sociocultural crisis
4. Adventitious crisis
16
Mental Health Principles
Which type of crisis is experienced by a patient whose home was destroyed in a flood?
1. Maturational crisis
2. Situational crisis
3. Sociocultural crisis
4. Adventitious crisis – one related to rare, unexpected happenings in life, such as a natural
disaster
17
Mental Health Principles
During which phase of the nurse/client relationship should the nurse discuss confidentiality
and establish boundaries?
1. The collaborative phase
2. The orientation phase
3. The termination phase
4. The working phase
18
Mental Health Principles
During which phase of the nurse/client relationship should the nurse discuss confidentiality
and establish boundaries?
1. The collaborative phase
2. The orientation phase is the point at which a nurse should establish boundaries and
discuss confidentiality.
3. The termination phase
4. The working phase
19
Mental Health Principles
When doing an admission assessment, the nurse identifies that the patient’s caretaker has
failed to provide them with sufficient access to food and medical care. Which type of abuse
has the patient experienced?
1. False imprisonment
2. Neglect
3. Emotional abuse
4. Financial abuse
20
Mental Health Principles
When doing an admission assessment, the nurse identifies that the patient’s caretaker has
failed to provide them with sufficient access to food and medical care. Which type of abuse
has the patient experienced?
1. False imprisonment
2. Neglect is characterized by a caretaker failing to provide for a patient’s basic needs,
including food and medical care.
3. Emotional abuse
4. Financial abuse
21
Mental Health Principles
Which of the following is not appropriate patient teaching for a patient taking an
anticholinergic medication?
1. Increase fiber intake
2. Decrease fluid intake
3. Wear sunglasses when outdoors
4. Avoid hot environments
22
Mental Health Principles
Which of the following is not appropriate patient teaching for a patient taking an
anticholinergic medication?
1. Increase fiber intake
2. Decrease fluid intake – patients taking anticholinergic medications should wear
sunscreen and sunglasses, avoid excessively hot environments, suck on sugarless
candy, or chew gum for dry mouth, and increase their fiber and fluid intake to prevent
constipation.
3. Wear sunglasses when outdoors
4. Avoid hot environments
23
Mental Health Principles
A patient may feel a sense of loss and grief during which phase of group therapy?
1. Working phase
2. Termination phase
3. Collaborative phase
4. Orientation phase
24
Mental Health Principles
A patient may feel a sense of loss and grief during which phase of group therapy?
1. Working phase
2. Termination phase – during the termination phase of group therapy, the patient may feel a
legitimate sense of loss or grief.
3. Collaborative phase
4. Orientation phase
25
Mental Health Principles
Which type of crisis is experienced by a patient who experiences the sudden death of a loved
one?
1. Maturational crisis
2. Situational crisis
3. Adventitious crisis
4. Sociocultural crisis
26
Mental Health Principles
Which type of crisis is experienced by a patient who experiences the sudden death of a loved
one?
1. Maturational crisis
2. Situational crisis – occurs as a result of unexpected trauma, such as the loss of a loved
one
3. Adventitious crisis
4. Sociocultural crisis
27
Mental Health Principles
After informed consent has been obtained, the patient has additional questions about their
procedure. How should the nurse proceed?
1. Contact the provider to answer the questions
2. Answer the patient’s questions
3. Provide the patient with written educational material
4. Provide the patient with a copy of the informed consent they signed
28
Mental Health Principles
After informed consent has been obtained, the patient has additional questions about their
procedure. How should the nurse proceed?
1. Contact the provider to answer the questions – the provider is responsible for answering
any questions about a procedure, even after informed consent has been obtained.
2. Answer the patient’s questions
3. Provide the patient with written educational material
4. Provide the patient with a copy of the informed consent they signed
29
Mental Health Principles
A nurse causes harm to a patient by accidentally administering the wrong medication to a
patient. What is the name of this tort?
1. Assault
2. Battery
3. Malpractice
4. Negligence
30
Mental Health Principles
A nurse causes harm to a patient by accidentally administering the wrong medication to a
patient. What is the name of this tort?
1. Assault
2. Battery
3. Malpractice occurs when a nurse fails to competently perform their medical duties and in
so doing, harms the patient.
4. Negligence
31
Mental Health Principles
The patient reports experiencing grief when their last child leaves home to go to college.
Which type of crisis is this patient experiencing?
1. Sociocultural crisis
2. Maturational crisis
3. Situational crisis
4. Adventitious crisis
32
Mental Health Principles
The patient reports experiencing grief when their last child leaves home to go to college.
Which type of crisis is this patient experiencing?
1. Sociocultural crisis
2. Maturational crisis – occurs when a person has difficulty coping with the normal process
of development or changes in life, such as a child leaving home.
3. Situational crisis
4. Adventitious crisis
33
Mental Health Principles
Which defense mechanism is characterized by the voluntary blocking of unpleasant
feelings?
1. Sublimation
2. Suppression
3. Repression
4. Projecting
34
Mental Health Principles
Which defense mechanism is characterized by the voluntary blocking of unpleasant
feelings?
1. Sublimation
2. Suppression is the voluntary blocking of unpleasant feelings.
3. Repression
4. Projecting
35
Mental Health Principles
A patient states that after losing his wife three years ago, he has kept her things exactly as
they are and finds it difficult to leave the house or even get out of bed. Which type of grief is
the patient experiencing?
1. Anticipatory grief
2. Disenfranchised grief
3. Complicated grief
4. Normal grief
36
Mental Health Principles
A patient states that after losing his wife three years ago, he has kept her things exactly as
they are and finds it difficult to leave the house or even get out of bed. Which type of grief is
the patient experiencing?
1. Anticipatory grief
2. Disenfranchised grief
3. Complicated grief – with complicated grief, painful emotions of loss don’t improve with
time, persist for longer than one year, and are so severe that the patient may have
difficulty resuming their normal life.
4. Normal grief
37
Mental Health Principles
The nurse on an inpatient mental health unit is admitting a patient who reports they just lost
their job and are feeling hopeless. What should the nurse assess first?
1. Suicide risk
2. Support systems
3. Previous coping skills
4. Psychiatric history
38
Mental Health Principles
The nurse on an inpatient mental health unit is admitting a patient who reports they just lost
their job and are feeling hopeless. What should the nurse assess first?
1. Suicide risk – hopelessness is a sign of impending suicide and the loss of a job puts the
patient at higher risk. Therefore, the priority for the nurse to determine is the patient’s
thoughts or plans of suicide.
2. Support systems
3. Previous coping skills
4. Psychiatric history
39
Mental Health Principles
A school nurse notes that a child has frequent absences from school, often steals food from
other children, and wears clothes that are inappropriate for the weather. Which type of abuse
does the nurse expect the child is experiencing?
1. Financial abuse
2. Neglect
3. Emotional abuse
4. Sexual abuse
40
Mental Health Principles
A school nurse notes that a child has frequent absences from school, often steals food from
other children, and wears clothes that are inappropriate for the weather. Which type of abuse
does the nurse expect the child is experiencing?
1. Financial abuse
2. Neglect – Children who are the victims of neglect may have frequent absences from
school, beg or steal food or money, have unclean clothes, body odor or poor hygiene, and
wear inappropriate clothes for the weather.
3. Emotional abuse
4. Sexual abuse
41
Mental Health Principles
Which of the following is not required care for a restrained patient?
1. Take off all restraints for 15 minutes every 2 hours.
2. Provide range of motion exercises every 2 hours.
3. Take vital signs every 2 hours.
4. Assess the patient every 15 minutes.
42
Mental Health Principles
Which of the following is not required care for a restrained patient?
1. Take off all restraints for 15 minutes every 2 hours. Restrained patients should be
assessed every 15 minutes, and have vital signs, range of motion exercises, fluids, and
toileting every 2 hours. Restraints should never be fully removed until there is no longer a
need for restraints.
2. Provide range of motion exercises every 2 hours.
3. Take vital signs every 2 hours.
4. Assess the patient every 15 minutes.
43
Mental Health Principles
A patient states that after yelling at their wife, they try to make things better by bringing her
flowers, and doing household chores. Which type of defense mechanism is this?
1. Repression
2. Suppression
3. Undoing
4. Displacement
44
Mental Health Principles
A patient states that after yelling at their wife, they try to make things better by bringing her
flowers and doing household chores. Which type of defense mechanism is this?
1. Repression
2. Suppression
3. Undoing is the defense mechanism by which one attempts to “cancel out” an
unacceptable behavior.
4. Displacement
45
Mental Health Principles
A patient with a terminal diagnosis says to the nurse “if I can just live long enough to walk
my daughter down the aisle, I’ll be okay with this.” What stage of grief is the patient
experiencing?
1. Anger
2. Depression
3. Bargaining
4. Denial
46
Mental Health Principles
A patient with a terminal diagnosis says to the nurse “if I can just live long enough to walk
my daughter down the aisle, I’ll be okay with this.” What stage of grief is the patient
experiencing?
1. Anger
2. Depression
3. Bargaining – the patient attempts to regain some control over their situation by
negotiating or even “making a deal” with a higher power.
4. Denial
47
Mental Health Principles
A suicide hotline is an example of which level of prevention?
1. Tertiary prevention
2. Primary prevention
3. Secondary prevention
4. Quaternary prevention
48
Mental Health Principles
A suicide hotline is an example of which level of prevention?
1. Tertiary prevention
2. Primary prevention
3. Secondary prevention is focused on providing support to those at a high risk of
experiencing a mental health issue, such as the use of a suicide hotline.
4. Quaternary prevention
49
Mental Health Principles
A provider gives an order for non-violent restraints. How soon after this order must the
provider perform an in-person assessment of the patient?
1. 4 hours
2. 12 hours
3. 24 hours
4. 1 hour
50
Mental Health Principles
A provider gives an order for non-violent restraints. How soon after this order must the
provider perform an in-person assessment of the patient?
1. 4 hours
2. 12 hours
3. 24 hours – A provider must perform an in-person assessment of the patient within 24
hours of giving an order for non-violent restraints.
4. 1 hour
51
Mental Health Principles
A competent adult patient who was involuntarily admitted to an inpatient mental health
facility refuses their medications. What should the nurse do next?
1. Administer the medications despite their refusal.
2. Contact the provider.
3. Restrain the patient.
4. Document the refusal.
52
Mental Health Principles
A competent adult patient who was involuntarily admitted to an inpatient mental health
facility refuses their medications. What should the nurse do next?
1. Administer the medications despite their refusal.
2. Contact the provider.
3. Restrain the patient.
4. Document the refusal. Despite the involuntary admission, a competent adult patient still
has the right to refuse medication.
53
Mental Health Principles
A patient tells the nurse that when he gets angry, he takes out that frustration by hitting a
punching bag instead of yelling at others. Which type of defense mechanism is this?
1. Repression
2. Regression
3. Displacement
4. Sublimation
54
Mental Health Principles
A patient tells the nurse that when he gets angry, he takes out that frustration by hitting a
punching bag instead of yelling at others. Which type of defense mechanism is this?
1. Repression
2. Regression
3. Displacement
4. Sublimation is a defense mechanism in which unacceptable urges are transformed into
more productive and acceptable behaviors.
55
Mental Health Principles
A patient is refusing their medication. The nurse pushes them to the ground in order to
administer the IM medication, and in doing so causes the patient to strike their head and lose
consciousness. Which tort has the nurse committed?
1. Battery
2. Negligence
3. Malpractice
4. Assault
56
Mental Health Principles
A patient is refusing their medication. The nurse pushes them to the ground in order to
administer the IM medication, and in doing so causes the patient to strike their head and lose
consciousness. Which tort has the nurse committed?
1. Battery is physically touching a patient without their consent and causing harm to that
patient.
2. Negligence
3. Malpractice
4. Assault
57
Mental Health Principles
The nurse honestly answers a patient who asks about the possible side effects of a
medication. Which ethical principle is the nurse using?
1. Autonomy
2. Beneficence
3. Nonmaleficence
4. Veracity
58
Mental Health Principles
The nurse honestly answers a patient who asks about the possible side effects of a
medication. Which ethical principle is the nurse using?
1. Autonomy
2. Beneficence
3. Nonmaleficence
4. Veracity is the ethical principle of telling the truth.
59
Mental Health Principles
At which level of anxiety is learning possible?
1. Severe
2. Panic
3. Mild
4. Moderate
60
Mental Health Principles
At which level of anxiety is learning possible?
1. Severe
2. Panic
3. Mild – A patient experiencing mild anxiety may still be able to learn.
4. Moderate
61
Mental Health Principles
A nurse is caring for a patient who is experiencing auditory hallucinations. Which of the
following should be the nurse’s initial response?
1. “I know you hear voices, but I do not.”
2. “How often do you hear the voices?”
3. “What are the voices telling you?”
4. “The voices are part of your illness.”
62
Mental Health Principles
A nurse is caring for a patient who is experiencing auditory hallucinations. Which of the
following should be the nurse’s initial response?
1. “I know you hear voices, but I do not.”
2. “How often do you hear the voices?”
3. “What are the voices telling you?” - If the patient is experiencing auditory hallucinations,
it’s important to ask what the voices are saying. Command hallucinations may place the
patient or others at risk.”
4. “The voices are part of your illness.”
63
Mental Health Principles
A patient is yelling at the nurse and the nurse states, “If you don’t stop yelling at me, I’m
going to tie you down.” Which tort has the nurse committed?
1. Battery
2. Malpractice
3. Assault
4. Negligence
64
Mental Health Principles
A patient is yelling at the nurse and the nurse states, “If you don’t stop yelling at me, I’m
going to tie you down.” Which tort has the nurse committed?
1. Battery
2. Malpractice
3. Assault is a threat made against a patient.
4. Negligence
65
Mental Health Principles
A five-year-old child begins wetting the bed after the arrival of a new baby into the family.
Which type of defense mechanism is the child experiencing?
1. Regression
2. Sublimation
3. Suppression
4. Projecting
66
Mental Health Principles
A five-year-old child begins wetting the bed after the arrival of a new baby into the family.
Which type of defense mechanism is the child experiencing?
1. Regression is a defense mechanism where a person deals with stress by reverting to a
previous stage of development or acting in an age-inappropriate way.
2. Sublimation
3. Suppression
4. Projecting
67
Mental Health Therapies
Which class of anxiolytics is only appropriate for short-term use?
1. SSRIs
2. Atypical anxiolytics
3. SNRIs
4. Benzodiazepines
68
Mental Health Therapies
Which class of anxiolytics is only appropriate for short-term use?
1. SSRIs
2. Atypical anxiolytics
3. SNRIs
4. Benzodiazepines – Due to the risk for addiction, benzodiazepines should only be used for
the short-term management of anxiety.
69
Mental Health Therapies
Which medication is indicated to both treat depression and for smoking cessation?
1. Quetiapine
2. Buproprion
3. Trazadone
4. Sertaline
70
Mental Health Therapies
Which medication is indicated to both treat depression and for smoking cessation?
1. Quetiapine
2. Buproprion is indicated in the treatment of depression and to aid in smoking cessation.
3. Trazadone
4. Sertraline
71
Mental Health Therapies
Which of the following medications may be used in the long-term treatment of a patient with
opioid use disorder?
1. Disulfiram
2. Naloxone
3. Acamprosate
4. Buprenorphine
72
Mental Health Therapies
Which of the following medications may be used in the long-term treatment of a patient with
opioid use disorder?
1. Disulfiram
2. Naloxone
3. Acamprosate
4. Buprenorphine is indicated for long-term treatment of opioid use disorder. Naloxone is
only indicated to reverse acute opioid toxicity. Acamprosate and disulfiram are not
indicated in the management of opioid use disorder.
73
Mental Health Therapies
A nurse is teaching a patient prescribed a SSRI for their depression about supplement use
during therapy. What supplement should the patient be advised not to take with their
medication?
1. Vitamin D
2. Magnesium
3. Ginseng
4. St. John’s Wort
74
Mental Health Therapies
A nurse is teaching a patient prescribed a SSRI for their depression about supplement use
during therapy. What supplement should the patient be advised not to take with their
medication?
1. Vitamin D
2. Magnesium
3. Ginseng
4. St. John’s Wort increases the risk of serotonin syndrome and should not be taken with
psychiatric medications that increase serotonin levels.
75
Mental Health Therapies
Which of the following medications may be used for acute alcohol withdrawal?
1. Diazepam
2. Disulfiram
3. Acamprosate
4. Naltrexone
76
Mental Health Therapies
Which of the following medications may be used for acute alcohol withdrawal?
1. Diazepam – Benzodiazepines such as diazepam may be indicated for patients
experiencing acute alcohol withdrawal.
2. Disulfiram
3. Acamprosate
4. Naltrexone
77
Mental Health Therapies
A nurse is caring for a patient with opioid use disorder. The patient has decreased
respirations and seems sedated. What should the nurse give this patient for opioid toxicity?
1. Flumazenil
2. Acamprosate
3. Naltrexone
4. Naloxone
78
Mental Health Therapies
A nurse is caring for a patient with opioid use disorder. The patient has decreased
respirations and seems sedated. What should the nurse give this patient for opioid toxicity?
1. Flumazenil
2. Acamprosate
3. Naltrexone
4. Naloxone is the antidote for opioid toxicity.
79
Mental Health Therapies
Which lab test should be closely monitored in a patient taking carbamazepine?
1. Basic metabolic panel (BMP)
2. Hepatic function panel
3. Troponin
4. Complete blood count (CBC)
80
Mental Health Therapies
Which lab test should be closely monitored in a patient taking carbamazepine?
1. Basic metabolic panel (BMP)
2. Hepatic function panel
3. Troponin
4. Complete blood count (CBC) – Carbamazepine is known to cause blood dyscrasias, so a
complete blood count is an appropriate lab test to monitor for this complication.
81
Mental Health Therapies
Which of the following lithium serum levels is indicative of lithium toxicity?
1. 1. 8 mEq/L
2. 1.3 mEq/L
3. 1.0 mEq/L
4. 0.7 mEq/L
82
Mental Health Therapies
Which of the following lithium serum levels is indicative of lithium toxicity?
1. 1. 8 mEq/L The therapeutic range of lithium is 0.6-1.2 mEq/L; however, true toxicity does
not occur until serum levels are > 1.5 mEq/L.
2. 1.3 mEq/L
3. 1.0 mEq/L
4. 0.7 mEq/L
83
Mental Health Therapies
A nurse is caring for a patient taking lithium. Which of the following symptoms may indicate
the lithium toxicity?
1. Weight gain
2. Coarse tremors
3. Polyuria
4. Nausea
84
Mental Health Therapies
A nurse is caring for a patient taking lithium. Which of the following symptoms may indicate
the lithium toxicity?
1. Weight gain
2. Coarse tremors – Nausea, polyuria, and weight gain are expected side effects of lithium.
Signs of lithium toxicity include course tremors, confusion, hypotension, seizures, and
tremors.
3. Polyuria
4. Nausea
85
Mental Health Therapies
Which of the following lithium serum levels is considered therapeutic?
1. 0.3 mEq/L
2. 1.4 mEq/L
3. 2.0 mEq/L
4. 0.8 mEq/L
86
Mental Health Therapies
Which of the following lithium serum levels is considered therapeutic?
1. 0.3 mEq/L
2. 1.4 mEq/L
3. 2.0 mEq/L
4. 0.8 mEq/L The therapeutic range of lithium is 0.6 – 1.2 mEq/L. Levels below 0.6 mEq/L are
considered subtherapeutic.
87
Mental Health Therapies
A nurse is caring for a patient taking lorazepam. The nurse is assessing the patient and notes
respiratory depression. Which medication should be given as an antidote?
1. Acetylcysteine
2. Naloxone
3. Activated charcoal
4. Flumazenil
88
Mental Health Therapies
A nurse is caring for a patient taking lorazepam. The nurse is assessing the patient and notes
respiratory depression. Which medication should be given as an antidote?
1. Acetylcysteine
2. Naloxone
3. Activated charcoal
4. Flumazenil – The antidote for benzodiazepines (e.g., lorazepam) is flumazenil.
89
Mental Health
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?
1. Begin to teach relaxation techniques
2. Encourage the client to discuss the assault
3. Remain with the client until the anxiety decreases
4. Place the client in a quiet room alone to decrease stimulation
90
Mental Health
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?
1. Begin to teach relaxation techniques
2. Encourage the client to discuss the assault
3. Remain with the client until the anxiety decreases
4. Place the client in a quiet room alone to decrease stimulation
This client is in a severe state of anxiety. When a client is in a severe or panic state of anxiety, it is
crucial for the nurse to remain with the client. The client in a severe state of anxiety would be unable
to learn relaxation techniques. Discussing the assault at this point would increase the client's level of
anxiety further. Placing the client in a quiet room alone may also increase the anxiety level.
91
Mental Health
The home health nurse visits a client at home and determines that the client is dependent on drugs.
During the assessment, which action would the nurse take to plan appropriate nursing care?
1. Ask the client about the reason for taking the illicit drugs
2. Ask the client about the amount of drug use and its effect
3. Ask the client how long they thought they could take drugs without someone finding out.
4. Not ask any questions for fear that the client is in denial and will throw the nurse out of the home.
92
Mental Health
The home health nurse visits a client at home and determines that the client is dependent on drugs.
During the assessment, which action would the nurse take to plan appropriate nursing care?
1. Ask the client about the reason for taking the illicit drugs
2. Ask the client about the amount of drug use and its effect
3. Ask the client how long they thought they could take drugs without someone finding out.
4. Not ask any questions for fear that the client is in denial and will throw the nurse out of the home.
Whenever the nurse carries out an assessment for a client who is dependent on drugs, it is best for
the nurse to attempt to elicit information by being nonjudgmental and direct. Option 1 is incorrect
because it is judgmental and off-focus, and reflects the nurse's bias. Option 3 is incorrect because it
is judgmental, insensitive, and aggressive, which is nontherapeutic. Option 4 is incorrect because it
indicates passivity on the nurse's part and uses rationalization to avoid the therapeutic nursing
intervention.
93
Mental Health
Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that
apply.
1. Monitor vital signs
2. Provide a safe environment
3. Address hallucinations therapeutically
4. Provide stimulation in the environment
5. Provide reality orientation as appropriate
6. Maintain NPO (Nothing by mouth status)
94
Mental Health
Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply.
1. Monitor vital signs
2. Provide a safe environment
3. Address hallucinations therapeutically
4. Provide stimulation in the environment
5. Provide reality orientation as appropriate
6. Maintain NPO (Nothing by mouth status)
When the client is experiencing withdrawal from alcohol, the priority for care is to prevent the client from
harming self or others. The nurse would monitor the vital signs closely and report abnormal findings. The
nurse would provide a low-stimulation environment to maintain the client in as calm a state as possible. The
nurse would reorient the client to reality frequently and would address hallucinations therapeutically.
Adequate nutritional and fluid intake need to be maintained.
95
Mental Health
The nurse determines that the spouse of an alcoholic client is benefiting from attending an Al-Anon
group if the nurse hears the spouse make which statement?
1. “I no longer feel that I deserve the beatings my spouse inflicts on me”
2. “My attendance at the meetings has helped me to see that I provoke my spouse’s violence”
3. “I enjoy attending the meetings because they get me out of the house and away from my spouse”
4. “I can tolerate my spouse’s destructive behaviors now that I know they are common among
alcoholics”
96
Mental Health
The nurse determines that the spouse of an alcoholic client is benefiting from attending an Al-Anon
group if the nurse hears the spouse make which statement?
1. “I no longer feel that I deserve the beatings my spouse inflicts on me”
2. “My attendance at the meetings has helped me to see that I provoke my spouse’s violence”
3. “I enjoy attending the meetings because they get me out of the house and away from my spouse”
4. “I can tolerate my spouse’s destructive behaviors now that I know they are common among
alcoholics”
Al-Anon support groups are a protected, supportive opportunity for spouses and significant others to
learn what to expect and to obtain excellent pointers about successful behavioral changes. The
correct option is the healthiest response because it exemplifies an understanding that the alcoholic
partner is responsible for their own behavior and cannot be allowed to blame family members for
loss of control. Option 2 is incorrect because the nonalcoholic partner should not feel responsible
when the spouse loses control. Option 3 indicates that the group is viewed as an escape, not as a
place to work on issues. Option 4 indicates codependence.
97
Mental Health
The nurse is monitoring a hospitalized client who abuses alcohol. Which findings would alert the
nurse to the potential for alcohol withdrawal delirium?
1. Hypotension, ataxia, hunger
2. Stupor, lethargy, muscle rigidity
3. Hypotension, coarse hand tremors, lethargy
4. Hypertension, changes in LOC, hallucinations
98
Mental Health
The nurse is monitoring a hospitalized client who abuses alcohol. Which findings would alert the
nurse to the potential for alcohol withdrawal delirium?
1. Hypotension, ataxia, hunger
2. Stupor, lethargy, muscle rigidity
3. Hypotension, coarse hand tremors, lethargy
4. Hypertension, changes in LOC, hallucinations
Symptoms associated with alcohol withdrawal delirium typically include anxiety, insomnia, anorexia,
hypertension, disorientation, hallucinations, changes in level of consciousness, agitation, fever, and
delusions.
99
Mental Health
The nurse has been closely observing a client who has been displaying aggressive behaviors. The
nurse observes that the behavior displayed by the client is escalating. Which nursing intervention
is most helpful to this client at this time? Select all that apply.
1. Initiate confinement measures
2. Acknowledge the client’s behavior
3. Assist the client to an area that is quiet
4. Maintain a safe distance from the client
5. Allow the client to take control of the situation
100
Mental Health
The nurse has been closely observing a client who has been displaying aggressive behaviors. The nurse
observes that the behavior displayed by the client is escalating. Which nursing intervention is most helpful
to this client at this time? Select all that apply.
1. Initiate confinement measures
2. Acknowledge the client’s behavior
3. Assist the client to an area that is quiet
4. Maintain a safe distance from the client
5. Allow the client to take control of the situation
During the escalation period, the client's behavior is moving toward loss of control. Nursing actions include
taking control, maintaining a safe distance, acknowledging behavior, moving the client to a quiet area, and
medicating the client if appropriate. To initiate confinement measures during this period is inappropriate.
Initiation of confinement measures, if needed, is most appropriate during the crisis period.
101
Mental Health
A nurse attends an educational session on family violence. Which statement by the nurse indicates
a need for further teaching concerning family violence?
1. “Abusers use fear and intimidation”
2. “Abusers usually have poor self esteem”
3. “Abusers are often jealous or self-centered
4. “Abusers are more often from low-income families”
102
Mental Health
A nurse attends an educational session on family violence. Which statement by the nurse indicates
a need for further teaching concerning family violence?
1. “Abusers use fear and intimidation”
2. “Abusers usually have poor self esteem”
3. “Abusers are often jealous or self-centered
4. “Abusers are more often from low-income families”
Personal characteristics of abusers include low self-esteem, immaturity, dependence, insecurity, and
jealousy. Abusers often use fear and intimidation to the point at which their victims will do anything
just to avoid further abuse. The statement that abuse occurs more often in lower socioeconomic
groups is incorrect.
103
Mental Health
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 stop using
drugs." Which response by the nurse would be therapeutic?
1. “You have said this many times before!”
2. “Tell me what makes you feel you are ready.”
3. “I am so glad to hear you talking this way. I will let your psychiatrist now.”
4. “I need to see changes in you before I believe you are ready to stop using drugs.”
104
Mental Health
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 stop using
drugs." Which response by the nurse would be therapeutic?
1. “You have said this many times before!”
2. “Tell me what makes you feel you are ready.”
3. “I am so glad to hear you talking this way. I will let your psychiatrist now.”
4. “I need to see changes in you before I believe you are ready to stop using drugs.”
Clients with a long history of drug abuse need to demonstrate motivation to change the behavior, not
just verbalization of the intent to change the behavior. The therapeutic response by the nurse would
be directed at assisting the client to look at the behaviors that indicate the change. The correct
option is the only one that will provide this direction to the client.
105
Mental Health
The client diagnosed with alcoholism has been prescribed medication therapy to assist in the
maintenance of sobriety. The nurse will provide the client with education focused on which
medication that will most likely be prescribed?
1. Clonidine
2. Disulfiram
3. Pyridoxine Hydrochloride
4. Chlordiazepoxide hydrochloride
106
Mental Health
The client diagnosed with alcoholism has been prescribed medication therapy to assist in the
maintenance of sobriety. The nurse will provide the client with education focused on which
medication that will most likely be prescribed?
1. Clonidine
2. Disulfiram
3. Pyridoxine Hydrochloride
4. Chlordiazepoxide hydrochloride
Disulfiram is a medication used for alcoholism, and it aids in the maintenance of sobriety. Clonidine
is an antihypertensive medication. Pyridoxine hydrochloride is used in the treatment of vitamin
B6 deficiency. Chlordiazepoxide hydrochloride is an antianxiety medication (a benzodiazepine) that
is used in the management of acute alcohol withdrawal symptoms.
107
Mental Health
When would the nurse determine that it will be safe to remove the restraints from a client who
demonstrated violent behavior?
1. Administered medication has taken effect.
2. The client verbalizes the reasons for the violent behavior.
3. The client apologizes and tells the nurse that it will never happen again.
4. No aggressive behavior has been observed for 1 hour after the release of two of the extremity
restraints.
108
Mental Health
When would the nurse determine that it will be safe to remove the restraints from a client who
demonstrated violent behavior?
1. Administered medication has taken effect.
2. The client verbalizes the reasons for the violent behavior.
3. The client apologizes and tells the nurse that it will never happen again.
4. No aggressive behavior has been observed for 1 hour after the release of two of the extremity
restraints.
The best indicator that the behavior is controlled is the fact that the client exhibits no signs of
aggression after partial release of restraints. The remaining options do not ensure that the client has
controlled the behavior.
109
Mental Health
A 15-year-old pregnant, unwed client tells the nurse, "My life was unbearable before I met my
partner. One of my parents beats me every day, and my other parent has sexually abused me since
I was 10 years old!" Which response is appropriate for the nurse to make?
1. "Why didn't you just report your parents for this abuse?“
2. "What are you saying? Your parents abused you, so you got pregnant?“
3. "It seems that you needed your partner’s help to separate from your family.“
4. "Sounds as if you decided to have a baby so you'd have someone for yourself."
110
Mental Health
A 15-year-old pregnant, unwed client tells the nurse, "My life was unbearable before I met my
partner. One of my parents beats me every day, and my other parent has sexually abused me since
I was 10 years old!" Which response is appropriate for the nurse to make?
1. "Why didn't you just report your parents for this abuse?“
2. "What are you saying? Your parents abused you, so you got pregnant?“
3. "It seems that you needed your partner’s help to separate from your family.“
4. "Sounds as if you decided to have a baby so you'd have someone for yourself.“
Adolescent pregnancy outside marriage can arise from low self-esteem, fears of inadequacy, and
desperation to escape from an abusive and dysfunctional family. The most therapeutic
communication technique is the one that uses restatement and repeats the main thought that the
client expressed. This assures the client that the nurse is listening and is attempting to validate what
the client has said. The remaining options are nontherapeutic because they reflect a knowledge
deficit on the nurse's part, imply bias, are insensitive, or place responsibility on the adolescent.
111
Mental Health
A 10-year-old referred for evaluation after drawing sexually explicit scenes says to the psychiatric
nurse, "I just felt like it." Which response by the nurse is focused on assessing for abuse-related
symptoms?
1. "Well, a picture paints a thousand words.“
2. "You just felt like destroying your textbooks?“
3. "Your parents and teachers are very concerned about your drawings.“
4. "I am concerned about you. Are you now or have you ever been abused?"
112
Mental Health
A 10-year-old referred for evaluation after drawing sexually explicit scenes says to the psychiatric
nurse, "I just felt like it." Which response by the nurse is focused on assessing for abuse-related
symptoms?
1. "Well, a picture paints a thousand words.“
2. "You just felt like destroying your textbooks?“
3. "Your parents and teachers are very concerned about your drawings.“
4. "I am concerned about you. Are you now or have you ever been abused?“
The behaviors that this child engaged in are a warning signal of distress. The correct option is the
only one that specifically addresses abuse. The remaining options are insensitive, not focused on
the possible sexual abuse, or too indirect to be useful.
113
Mental Health
The nurse is planning care for a client who has a history of violent behavior and is at risk for harming
others. Which intervention presents a need for follow-up because it could potentially present a
danger to the client, health care providers, and others on the nursing unit?
1. Facing the client when providing care
2. Assigning the client to the room at the end of the hall
3. Ensuring that a security officer is available at all times if needed
4. Keeping the door to the client’s room open when providing care to the client
114
Mental Health
The nurse is planning care for a client who has a history of violent behavior and is at risk for harming
others. Which intervention presents a need for follow-up because it could potentially present a
danger to the client, health care providers, and others on the nursing unit?
1. Facing the client when providing care
2. Assigning the client to the room at the end of the hall
3. Ensuring that a security officer is available at all times if needed
4. Keeping the door to the client’s room open when providing care to the client
The client would be placed in a room near the nurses' station and not at the end of a long, relatively
unprotected corridor. The nurse would not become isolated with a potentially violent client. The
nurse would never turn away from the client, and the door to the client's room would be kept open. A
security officer would be within immediate call in case violent behavior appears imminent.
115
Mental Health
Which statement by the client best reflects the development of an effective coping response style
and effective processing of information for a hospitalized client participating in Alcoholics
Anonymous (AA)?
1. "I know I'm ready to be discharged. I feel as if I can say no and leave a group of friends if they
are drinking. No problem.“
2. "I'll keep all my appointments and go to all my AA groups; I'll do everything I'm supposed to.
Nothing will go wrong that way.“
3. "I'm looking forward to leaving here. I will miss all of you. So, I'm happy and I'm sad, I'm excited,
and I'm scared. I know that I have to work hard to be strong and that not everyone will be as
helpful as you people.“
4. "This group has really helped a lot. I know it will be different when I go home. But I'm sure that
my family and friends will all help me in the same way the people in this group have. They'll all
help me. I know they will. They won't let me go back to old ways."
116
Mental Health
Which statement by the client best reflects the development of an effective coping response style and
effective processing of information for a hospitalized client participating in Alcoholics Anonymous (AA)?
1. "I know I'm ready to be discharged. I feel as if I can say no and leave a group of friends if they are
drinking. No problem.“
2. "I'll keep all my appointments and go to all my AA groups; I'll do everything I'm supposed to. Nothing will
go wrong that way.“
3. "I'm looking forward to leaving here. I will miss all of you. So, I'm happy and I'm sad, I'm excited, and I'm
scared. I know that I have to work hard to be strong and that not everyone will be as helpful as you
people.“
4. "This group has really helped a lot. I know it will be different when I go home. But I'm sure that my family
and friends will all help me in the same way the people in this group have. They'll all help me. I know they
will. They won't let me go back to old ways.“
In the defense mechanism of denial, the person denies reality. Avoid an option that identifies the client
demonstrating denial or relying on concrete, inflexible behavior or on being heavily dependent on others to
manage the addiction. The client demonstrates reality in the statement in the correct option.
117
Mental Health
During a group therapy session a client begins to yell, "I can't listen to this. You people are no
different from the ones I have to deal with at home." What is the nurse's immediate action?
1. Inform the yelling client to leave the group immediately.
2. Call security personnel to the session to ensure everyone’s safety.
3. Ask the other clients to describe how the aggressive yelling made them feel.
4. Firmly reinforce limits on behavior, stating that aggressive yelling will not be tolerated.
118
Mental Health
During a group therapy session a client begins to yell, "I can't listen to this. You people are no
different from the ones I have to deal with at home." What is the nurse's immediate action?
1. Inform the yelling client to leave the group immediately.
2. Call security personnel to the session to ensure everyone’s safety.
3. Ask the other clients to describe how the aggressive yelling made them feel.
4. Firmly reinforce limits on behavior, stating that aggressive yelling will not be tolerated.
The client is displacing anger. The nurse sets limits on behavior, reinforces group rules, and ensures
physical safety and a sense of control. Requiring the client to leave the group would be an
immediate action if the client presents with escalating behavior. The question presents no data
indicating such behavior. Calling security and exploring the responses of other clients are premature
actions at this point. Exploration may occur later in the group process.
119
Mental Health
During a support group session, a client says, "My partner hit me a lot, but when my partner
threatened to start hitting our kids, I stabbed my partner. No jury will believe me because my partner
can lie to anyone and be believed." If no one in the group responds, which statement is the
therapeutic response by the nurse?
1. "Abuse is a horribly difficult thing to experience. Can anyone in the group relate to what the client
is feeling?“
2. "Yes. Everyone here was ill-used and abused, but what makes you think that this is a reason to
stab someone?“
3. "Everyone agrees that you couldn't let your partner hurt your children. But is there anything you
would do differently?“
4. "Your story is very much like every person’s here. The problem is getting a jury to see that you
were justified in stabbing him."
120
Mental Health
During a support group session, a client says, "My partner hit me a lot, but when my partner threatened to start
hitting our kids, I stabbed my partner. No jury will believe me because my partner can lie to anyone and be
believed." If no one in the group responds, which statement is the therapeutic response by the nurse?
1. "Abuse is a horribly difficult thing to experience. Can anyone in the group relate to what the client is feeling?“
2. "Yes. Everyone here was ill-used and abused, but what makes you think that this is a reason to stab someone?“
3. "Everyone agrees that you couldn't let your partner hurt your children. But is there anything you would do
differently?“
4. "Your story is very much like every person’s here. The problem is getting a jury to see that you were justified in
stabbing him.“
The therapeutic response is one that uses reflection and facilitates the client's feelings. In addition, a supportive
response that encourages and supports other clients to connect or relate by responding to the client's statement is
therapeutic. Comparing the client’s experience to that of others and stating that the client’s response to the abuse
was not an appropriate option is insensitive and judgmental and will not promote communication.
121
Mental Health
The spouse of an alcoholic client is attending a support group and says to the group members, "It's
all very well for everyone to label me an enabler, but if I didn't call my spouse in sick at work, my
spouse would have lost the job. Where would we be then?" Which statement by the nurse co-leader
would be therapeutic?
1. "Does anyone in the group want to respond to that?“
2. "So you only call your spouse in sick because you are worried about money?“
3. "Hasn't the group discussed this before? What conclusion did you all come to?“
4. "It is a difficult situation, but do you agree that enabling creates codependency?"
122
Mental Health
The spouse of an alcoholic client is attending a support group and says to the group members, "It's
all very well for everyone to label me an enabler, but if I didn't call my spouse in sick at work, my
spouse would have lost the job. Where would we be then?" Which statement by the nurse co-leader
would be therapeutic?
1. "Does anyone in the group want to respond to that?“
2. "So you only call your spouse in sick because you are worried about money?“
3. "Hasn't the group discussed this before? What conclusion did you all come to?“
4. "It is a difficult situation, but do you agree that enabling creates codependency?“
The spouse of an alcoholic client is attending a support group and says to the group members, "It's
all very well for everyone to label me an enabler, but if I didn't call my spouse in sick at work, my
spouse would have lost the job. Where would we be then?" Which statement by the nurse co-leader
would be therapeutic?
123
Mental Health
A heroin-addicted client who is taking methadone hydrochloride discontinues the methadone without
consulting the primary health care provider. The client says to the nurse, "I thought I didn't need the
methadone after 1 year. I had a job and was even saving money. I can't believe I ruined everything."
Which statement by the nurse is therapeutic?
1. "It sounds as if everything you do is either all or nothing.“
2. "Talk to your counselor; maybe everything isn't ruined yet.“
3. "You will need to restart your recovery, starting from the beginning.“
4. "We need to prepare you to recognize those things that trigger you to relapse."
124
Mental Health
A heroin-addicted client who is taking methadone hydrochloride discontinues the methadone without
consulting the primary health care provider. The client says to the nurse, "I thought I didn't need the
methadone after 1 year. I had a job and was even saving money. I can't believe I ruined everything."
Which statement by the nurse is therapeutic?
1. "It sounds as if everything you do is either all or nothing.“
2. "Talk to your counselor; maybe everything isn't ruined yet.“
3. "You will need to restart your recovery, starting from the beginning.“
4. "We need to prepare you to recognize those things that trigger you to relapse.“
The therapeutic statement is the one that helps the client to reframe with more moderation. In
reframing, the nurse focuses on the positive aspects of learning to overcome failure. The nurse must
avoid being condescending or overly negative. The nurse uses an example of one support system
that exists to redirect the faulty thinking. However, the nurse does not have the ability to know
whether the counselor is supportive, so this is not the therapeutic statement.
125
Mental Health
An alcohol-troubled client says, "The 12 Steps of Alcoholics Anonymous (AA) meeting really upset
me. I had to go for a drink after 1 hour with those people; they're fanatics!" Which statement by the
nurse would be therapeutic?
1. "You think AA is for fanatics?“
2. "It sounds as if you look for any reason to drink!“
3. "Not any one strategy for remaining sober is best for everyone.“
4. "I agree. AA is definitely not for you if you find it is a trigger to drink."
126
Mental Health
An alcohol-troubled client says, "The 12 Steps of Alcoholics Anonymous (AA) meeting really upset
me. I had to go for a drink after 1 hour with those people; they're fanatics!" Which statement by the
nurse would be therapeutic?
1. "You think AA is for fanatics?“
2. "It sounds as if you look for any reason to drink!“
3. "Not any one strategy for remaining sober is best for everyone.“
4. "I agree. AA is definitely not for you if you find it is a trigger to drink.“
The therapeutic statement is the one that does not cause a regressive struggle between nurse and
client, which would result in dispute and another drinking excuse. By allowing the client to be in
control, the nurse is able to reflect on the core problem and provide an opportunity to continue with
the discussion about treatment options. The nurse would avoid confrontational statements, which
can result in a regressive struggle. Agreeing with the client's rationalization is nontherapeutic. When
the nurse paraphrases the statement regarding fanatics, the response becomes aggressive and
sarcastic.
127
Mental Health
A client who is recovering from benzodiazepine dependence says, "I've lost so many people. First,
my sibling dies of cancer; then my spouse leaves me for a 20-year-old. I wish I had one of those pills
right now." Which statement by the nurse would be therapeutic?
1. "Can you tell me what you think the pills can do for you?“
2. "It sounds as if you feel that all of this has just happened to you.“
3. "It must have been a terrible loss for you when your sibling died.“
4. "How did your spouse’s interest in a younger person make you feel?"
128
Mental Health
A client who is recovering from benzodiazepine dependence says, "I've lost so many people. First,
my sibling dies of cancer; then my spouse leaves me for a 20-year-old. I wish I had one of those pills
right now." Which statement by the nurse would be therapeutic?
1. "Can you tell me what you think the pills can do for you?“
2. "It sounds as if you feel that all of this has just happened to you.“
3. "It must have been a terrible loss for you when your sibling died.“
4. "How did your spouse’s interest in a younger person make you feel?“
In the correct option, the nurse reflects back to the client what the client is verbalizing and assists
the client to assess coping strategies. It is nontherapeutic for the nurse to change the focus from the
client's expression of feelings related to the benzodiazepine. Asking the client to self-assess own
behavior in events is premature.
129
Mental Health
The spouse of an alcohol-dependent client says, "If anyone had said I'd be henpecked, I'd have
called them a liar, but now I realize that I'm codependent." Which statement by the nurse would be
therapeutic?
1. "Did you know that more people identify with just what you are saying?“
2. "Which of the features that describe codependence caused you to recognize that?“
3. "Can you tell me more about that? You see yourself as being codependent with your spouse?“
4. "Have you discussed your feelings with your spouse? What does your spouse think about what
you've said?"
130
Mental Health
The spouse of an alcohol-dependent client says, "If anyone had said I'd be henpecked, I'd have called
them a liar, but now I realize that I'm codependent." Which statement by the nurse would be therapeutic?
1. "Did you know that more people identify with just what you are saying?“
2. "Which of the features that describe codependence caused you to recognize that?“
3. "Can you tell me more about that? You see yourself as being codependent with your spouse?“
4. "Have you discussed your feelings with your spouse? What does your spouse think about what you've
said?“
This question describes the spouse of an alcohol-dependent client who is developing awareness of their
codependency. Codependency consists of an individual’s becoming preoccupied with the needs and
concerns of another to the exclusion of their own needs. The therapeutic statement seeks clarification and
summarizes and focuses the client on own concerns and discoveries. When the nurse provides a social
response that is nontherapeutic, it does not focus on the client’s feelings. Intellectual questioning does not
facilitate expression of feelings. Asking questions that are off-focus from the client’s feelings are
nontherapeutic because they constitute probing. The nurse will gather this information, but by gaining the
trust of the client, not by probing.
131
Mental Health
A client's alcohol consumption suggests the development of a tolerance for alcohol. Which
statement supports the existence of an alcohol tolerance problem?
1. "I've never drunk so much that I've passed out.“
2. "I'm just a social drinker. I seldom drink when I'm alone.“
3. "I don't have to drink to feel good. I drink because I like the way it tastes.“
4. "I have a cocktail after work, wine with dinner, and no more than two drinks to sleep."
132
Mental Health
A client's alcohol consumption suggests the development of a tolerance for alcohol. Which
statement supports the existence of an alcohol tolerance problem?
1. "I've never drunk so much that I've passed out.“
2. "I'm just a social drinker. I seldom drink when I'm alone.“
3. "I don't have to drink to feel good. I drink because I like the way it tastes.“
4. "I have a cocktail after work, wine with dinner, and no more than two drinks to sleep.“
This question describes an escalating drinking problem that results in tolerance—a need for higher
and higher doses to achieve the desired effect of the alcohol. Alcohol dependence involves losing
control over alcohol drinking, as in passing out. Drinking for the taste or seldom drinking alone
describes social drinking, which is a social term that laypersons use to describe someone who
drinks at the high end of the normal range.
133
Mental Health
A battered wife says, "My spouse is a bully and a cheater and certainly doesn't provide for our
family, but has never beat me up, so I don't think I can say my spouse abusive." Which response by
the nurse is therapeutic?
1. "Don't be so gullible. Your spouse is an abuser.“
2. “How is it that your spouse can maneuver you like that?“
3. "Do you believe that there are other forms of abuse besides the physical kind?“
4. "Most emotionally battered spouses begin to heal once they start to identify the abusive
behaviors.“
134
Mental Health
A battered wife says, "My spouse is a bully and a cheater and certainly doesn't provide for our
family, but has never beat me up, so I don't think I can say my spouse abusive." Which response by
the nurse is therapeutic?
1. "Don't be so gullible. Your spouse is an abuser.“
2. “How is it that your spouse can maneuver you like that?“
3. "Do you believe that there are other forms of abuse besides the physical kind?“
4. "Most emotionally battered spouses begin to heal once they start to identify the abusive
behaviors.“
This question describes the victimized spouse of a perpetrator who uses multiple ways to control the
victim. The correct option reflects and then provides an opportunity to share feelings. It is
inappropriate for the nurse to chastise the client or respond in a sarcastic manner. It is
nontherapeutic for the nurse to offer an observation that intellectualizes the situation since it does
not facilitate the expression of feelings. Probing may cause the client to feel belittled.
135
Mental Health
A client who has a history of being sexually assaulted is found sucking a thumb while rocking in the
bed and does not respond to verbal communication. The nurse would recognize that this behavior
demonstrates which coping mechanism?
1. Fantasy
2. Regression
3. Displacement
4. Compensation
136
Mental Health
A client who has a history of being sexually assaulted is found sucking a thumb while rocking in the
bed and does not respond to verbal communication. The nurse would recognize that this behavior
demonstrates which coping mechanism?
1. Fantasy
2. Regression
3. Displacement
4. Compensation
Regression is a coping mechanism in which a client returns to an earlier, less threatening level of
adaptation (development). Fantasy is the gratification of frustrated desires, achievement, and
relationships by substituting them with daydreams and imagery. Displacement is the discharge of
pent-up feelings onto something or someone else less threatening than the original source of the
feelings. Compensation is excelling in one area to counterbalance deficiencies in another area.
137
Mental Health
The nurse is performing an assessment on a client being admitted with a diagnosis of alcohol
dependence who reports it's been 6 hours since the last drink. The information supports which
assumption about the appearance of withdrawal symptoms?
1. The danger time has passed
2. Signs may appear at anytime
3. The next hour could be critical
4. Withdrawal has likely already started
138
Mental Health
The nurse is performing an assessment on a client being admitted with a diagnosis of alcohol
dependence who reports it's been 6 hours since the last drink. The information supports which
assumption about the appearance of withdrawal symptoms?
1. The danger time has passed
2. Signs may appear at anytime
3. The next hour could be critical
4. Withdrawal has likely already started
Alcohol withdrawal is most likely to occur within the first 6 to 8 hours after abrupt cessation; however,
it can occur over the next several days. Therefore, the option suggesting the danger has passed as
well as the one suggesting that a specific time can be predicted can be eliminated. The option that
withdrawal has already started is not supported by the information presented.
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Mental Health
Thiamine supplementation and other nutritional vitamin support measures are prescribed for clients
who have been using alcohol to prevent or decrease the risk of which complication?
1. Cirrhosis
2. Delirium tremors
3. Esophageal varices
4. Wernicke-Korsakoff syndrome
140
Mental Health
Thiamine supplementation and other nutritional vitamin support measures are prescribed for clients
who have been using alcohol to prevent or decrease the risk of which complication?
1. Cirrhosis
2. Delirium tremors
3. Esophageal varices
4. Wernicke-Korsakoff syndrome
Wernicke-Korsakoff syndrome is the only item in the options that is directly and significantly
associated with severe nutritional deficits, particularly of B vitamins. Delirium tremens may be
partially attributed to nutritional deficits but will not occur unless alcohol withdrawal ensues. The
other options are sequelae of chronic alcohol abuse but are owing to other effects on the
gastrointestinal system.
141
Mental Health
Soon after an assault, a client is assessed in the emergency department with behavior that is
associated with severe anxiety. Which client behaviors support this level of anxiety?
1. Believes the attacker is in the emergency department
2. Detached, requiring gentle probing to respond to questions
3. Is pacing while describing the situation using a rapid speech pattern
4. Talks about being "panic stricken" that something else "bad" will happen
142
Mental Health
Soon after an assault, a client is assessed in the emergency department with behavior that is
associated with severe anxiety. Which client behaviors support this level of anxiety?
1. Believes the attacker is in the emergency department
2. Detached, requiring gentle probing to respond to questions
3. Is pacing while describing the situation using a rapid speech pattern
4. Talks about being "panic stricken" that something else "bad" will happen
he client who has severe anxiety has significant somatic complaints, ineffective functioning, loud or
rapid speech, and purposeless activity. Option 1 describes fear and paranoia. Option 2 is
characteristic of a withdrawn client or a client with depression. Option 4 describes a panic state.
Panic is associated with a feeling of dread and terror and a sense of impending doom.
143
Mental Health
When assessing a client for a possible physical dependency on alcohol, the nurse would ask which
priority question?
1. “Are you drinking more than you did 5 years ago?”
2. “How do you feel when you haven’t had a drink all day?”
3. “Does your drinking ever cause you problems with your family?”
4. “Do you ever feel that you really need a drink to calm your nerves?”
144
Mental Health
When assessing a client for a possible physical dependency on alcohol, the nurse would ask which
priority question?
1. “Are you drinking more than you did 5 years ago?”
2. “How do you feel when you haven’t had a drink all day?”
3. “Does your drinking ever cause you problems with your family?”
4. “Do you ever feel that you really need a drink to calm your nerves?”
Physical dependency results in withdrawal symptoms; therefore, the option addressing that topic is
the priority question. An increase in alcohol consumption may be an indicator of alcohol tolerance.
Alcohol abuse is described as being willing to continue the use of alcohol regardless of the problems
that doing so causes. Needing a drink to calm the nerves is an indicator of a psychological
dependency.
145
Mental Health
Which are the most likely characteristics of a client who abuses alcohol? Select all that apply.
1. Does not seek needed treatment
2. Is not married
3. Abuses drugs as well as alcohol
4. Employed in a minimal wage job
5. History of at least one suicide attempt
146
Mental Health
Which are the most likely characteristics of a client who abuses alcohol? Select all that apply.
1. Does not seek needed treatment
2. Is not married
3. Abuses drugs as well as alcohol
4. Employed in a minimal wage job
5. History of at least one suicide attempt
A person who abuses alcohol is at a high risk for self-inflicted injury, and simultaneous use of more
than one substance is very common. Few of those abusing alcohol receive needed treatment.
Alcoholics are found at all economic strata and occur equally among married and single clients.
147
Mental Health
The nurse explains to a group of clients that methamphetamine abuse results in which vascular
system dysfunction?
1. Emboli
2. Hypotension
3. Thrombophlebitis
4. Impaired wound healing
148
Mental Health
The nurse explains to a group of clients that methamphetamine abuse results in which vascular
system dysfunction?
1. Emboli
2. Hypotension
3. Thrombophlebitis
4. Impaired wound healing
Methamphetamine abuse causes vasoconstriction, resulting commonly in poor wound healing and
hypertension. Thrombophlebitis and emboli are not results of vasoconstriction and are not
associated with methamphetamine.
149
Mental Health
A client with a history of opiate abuse asks the nurse, "Why do I crave this stuff so much?" The
nurse responds, knowing that the client's craving is a result of which factor?
1. Development of tolerance for the drug
2. Lack of naturally occurring endorphins
3. Client’s psychological dependency on opiates
4. Typical abuse pattern for central nervous system depressants
150
Mental Health
A client with a history of opiate abuse asks the nurse, "Why do I crave this stuff so much?" The
nurse responds, knowing that the client's craving is a result of which factor?
1. Development of tolerance for the drug
2. Lack of naturally occurring endorphins
3. Client’s psychological dependency on opiates
4. Typical abuse pattern for central nervous system depressants
Craving opiates is a result of the diminished production of endorphins that occurs with long-term
abuse of the drug. Tolerance is the need for increased amounts of the drug to achieve the desired
effects. Psychological dependency is the emotional need for the drug. Cravings are not typical of all
central nervous system depressant abuse.
151
Mental Health
The nurse would be prepared to manage which occurrence unique to the abuse of hallucinogenic
drugs?
1. Flashbacks
2. Amotivational syndrome
3. Enhanced physical strength
4. Absence of pain perception
152
Mental Health
The nurse would be prepared to manage which occurrence unique to the abuse of hallucinogenic
drugs?
1. Flashbacks
2. Amotivational syndrome
3. Enhanced physical strength
4. Absence of pain perception
Flashbacks, the recurrence of perceptual distortions, are unique to the use of hallucinogenic drugs.
Enhanced physical strength and the inability to feel pain are indicative of phencyclidine use,
whereas marijuana abuse can result in amotivational syndrome.
153
Mental Health
When working with the client who has two family members with a history of substance abuse, the
nurse would identify which assessment data as a primary biological factor?
1. The client is a 25-year-old
2. The client is employed as a firefighter
3. The client is of non-American descent
4. The client has two family members who have abused
154
Mental Health
When working with the client who has two family members with a history of substance abuse, the
nurse would identify which assessment data as a primary biological factor?
1. The client is a 25-year-old
2. The client is employed as a firefighter
3. The client is of non-American descent
4. The client has two family members who have abused
Family history of substance abuse is considered the key biological factor in affecting individual
abuse. The remaining options do not have the same degree of effect as does the correct option.
155
Mental Health
Which short-term initial goals would be realistic for a client who was recently sexually
abused? Select all that apply.
1. The client will keep scheduled appointments
2. The client’s physical wounds will begin to heal properly
3. The client will verbalize feelings about the abusive event
4. The client will resolve feelings of anxiety related to the event
5. The client will participate in the various aspects of the treatment plan
156
Mental Health
Which short-term initial goals would be realistic for a client who was recently sexually
abused? Select all that apply.
1. The client will keep scheduled appointments
2. The client’s physical wounds will begin to heal properly
3. The client will verbalize feelings about the abusive event
4. The client will resolve feelings of anxiety related to the event
5. The client will participate in the various aspects of the treatment plan
Resolving feelings triggered by the event will take time and therapy, so it is considered a long-term
goal. Short-term goals include the beginning stages of dealing with the rape trauma. Clients will be
expected initially to keep appointments, participate in care, begin to explore feelings, and begin to
heal any physical wounds that were inflicted at the time of the rape
157
Mental Health
Which is the best therapeutic approach for the nurse to use in crisis counseling?
1. Reassuring
2. Passive listening
3. Exploration of early life experiences
4. Active, with a focus on the current situation
158
Mental Health
Which is the best therapeutic approach for the nurse to use in crisis counseling?
1. Reassuring
2. Passive listening
3. Exploration of early life experiences
4. Active, with a focus on the current situation
During crisis counseling, the best approach for the nurse to use is an active one, with a focus on the
current situation. The remaining options would be inconsistent with the acute needs that emerge in a
crisis. Passive listening would be contrary to the individual's acute stress and disorganization.
Exploring the past would be insensitive to the current crisis and would be exploitative of a client in
acute distress. Although reassurance may be needed, what is most important about the nurse's
response in a crisis is the need for a direct focus on immediate needs.
159
Mental Health
A client comes to the clinic after losing all personal belongings in a hurricane. The nurse notes that
the client is coping ineffectively with the situation. Which are the most realistic goals for this
client? Select all that apply.
1. The client will develop adaptive coping patterns
2. The client will identify a realistic perception of stressors
3. The client will cease to have negative feelings about the event
4. The client will express and share feelings regarding the present crisis
5. The client will identify effective coping patterns that have worked in the past
160
Mental Health
A client comes to the clinic after losing all personal belongings in a hurricane. The nurse notes that
the client is coping ineffectively with the situation. Which are the most realistic goals for this
client? Select all that apply.
1. The client will develop adaptive coping patterns
2. The client will identify a realistic perception of stressors
3. The client will cease to have negative feelings about the event
4. The client will express and share feelings regarding the present crisis
5. The client will identify effective coping patterns that have worked in the past
The feelings of negativity related to the loss caused by the hurricane are unlikely to stop; lessening
with time is the only reasonable possibility. The remaining options present a positive movement
toward increased self-esteem and problem solving without requiring a total shift in realistic
perceptions
161
Mental Health
A client is diagnosed with rape trauma syndrome. The nurse plans care based on which syndromeassociated fact?
1. The client has experienced more than one sexual assault
2. The client routinely incorporates foreign objects in the sex act
3. The client actively and commonly initiates situations in which sex is forced
4. The client regularly reexperiences the events associated with the assault
162
Mental Health
A client is diagnosed with rape trauma syndrome. The nurse plans care based on which syndromeassociated fact?
1. The client has experienced more than one sexual assault
2. The client routinely incorporates foreign objects in the sex act
3. The client actively and commonly initiates situations in which sex is forced
4. The client regularly reexperiences the events associated with the assault
The major trauma of rape or sexual assault involves the victim's emotional reaction to being
physically forced to do something against their will. The life-threatening nature of the crime and
feelings of helplessness, loss of control, and experiencing the self as an object of the perpetrator's
rage combine to produce the victim's overpowering fear and stress. In this syndrome, which has
been called rape trauma syndrome, the client reexperiences the trauma, as evidenced by recurrent
recollections of the event. The remaining options are not associated with rape trauma syndrome.
163
Mental Health
The nurse is assigned to care for a chemically dependent client who has the potential for violent
episodes. In planning care for the client, which action by the nurse would receive priority?
1. Speaks slowly to the client
2. Projects an attitude of calmness
3. Bargains to prevent the violent episodes
4. Moves quietly when approaching the client
164
Mental Health
The nurse is assigned to care for a chemically dependent client who has the potential for violent
episodes. In planning care for the client, which action by the nurse would receive priority?
1. Speaks slowly to the client
2. Projects an attitude of calmness
3. Bargains to prevent the violent episodes
4. Moves quietly when approaching the client
If a client has the potential for episodes of violence, the nurse would avoid bargaining or making
promises to the client. Additionally, the nurse would not judge or criticize the client. Speaking softly
to the client and moving quietly when nearing the client identify appropriate nursing actions in the
care of the client who has the potential for violence. However, projecting calmness is the priority and
encompasses the other two options.
165
Mental Health
Which client behavior demonstrates denial of a sexual abuse event?
1. Pacing while mumbling profanities
2. Minimizing the severity of the event
3. Being confused about the details of the event
4. Sitting quietly and calmy reading a magazine
166
Mental Health
Which client behavior demonstrates denial of a sexual abuse event?
1. Pacing while mumbling profanities
2. Minimizing the severity of the event
3. Being confused about the details of the event
4. Sitting quietly and calmy reading a magazine
Denial is a response by a victim of sexual abuse. It is described as an adaptive and protective
reaction and may be identified by a calm and quiet behavior in the client. The remaining options all
present some recognition that the event actually occurred.
167
Mental Health
Several nurses are engaged in an assignment report when a client with a history of aggressive
behavior approaches the nurses' station. The client becomes very loud and offensive, and demands
to be seen by the psychiatrist immediately. Which intervention will address the needs of both the
client and the milieu?
1. Inform the client that the behavior is unacceptable
2. Offer to assist the client to an examination room until the psychiatrist is notified
3. Assure the client that the psychiatrist will be called as soon as the report is completed
4. Tell the client to wait in own room, and inform the client that a nurse will come when the report is
finished
168
Mental Health
Several nurses are engaged in an assignment report when a client with a history of aggressive
behavior approaches the nurses' station. The client becomes very loud and offensive, and demands
to be seen by the psychiatrist immediately. Which intervention will address the needs of both the
client and the milieu?
1. Inform the client that the behavior is unacceptable
2. Offer to assist the client to an examination room until the psychiatrist is notified
3. Assure the client that the psychiatrist will be called as soon as the report is completed
4. Tell the client to wait in own room, and inform the client that a nurse will come when the report is
finished
Safety of the client, other clients, and staff is of prime concern when dealing with a client who may
be angry and demanding. Offering to assist the client to an examination room until the psychiatrist is
notified is, in effect, an isolation technique that allows for separation from others and provides a less
stimulating environment where the client can maintain dignity. The remaining options place the
client's concern on hold and will only cause the behavior to escalate.
169
Mental Health
During a group session, a client threatens to "punch every one of you." Which is the
appropriate initial nursing action?
1. Call security to come to the session immediately
2. Require the client to leave the group immediately
3. Remind the client that punching anyone is a reason for being placed into seclusion
4. Remind the client that talking about personal anger is appropriate, but acting on it is not
170
Mental Health
During a group session, a client threatens to "punch every one of you." Which is the
appropriate initial nursing action?
1. Call security to come to the session immediately
2. Require the client to leave the group immediately
3. Remind the client that punching anyone is a reason for being placed into seclusion
4. Remind the client that talking about personal anger is appropriate but acting on it is not
If a client threatens to act out physically during a group session, the client would be told that they
can talk about their anger but cannot act on it during the group session. Because the client’s action
was a threat, it is best for the nurse to deal with the behavior. The remaining options are not
appropriate as initial reactions.
171
Mental Health
A client was raped a few weeks ago but still feels "as if it just happened to me." Which response
would the nurse make to the client?
1. “It is very, very hard to get over these types of feelings after being raped.”
2. “What do you think you would do to reduce the likelihood that you will be raped again.”
3. “Tell me more about what happened and what causes you to feel as if the rape just occurred.”
4. “It’s hard, but try to keep a sense of perspective. After all, it’s been awhile since the rape
occurred.”
172
Mental Health
A client was raped a few weeks ago but still feels "as if it just happened to me." Which response
would the nurse make to the client?
1. “It is very, very hard to get over these types of feelings after being raped.”
2. “What do you think you would do to reduce the likelihood that you will be raped again.”
3. “Tell me more about what happened and what causes you to feel as if the rape just occurred.”
4. “It’s hard, but try to keep a sense of perspective. After all, it’s been awhile since the rape
occurred.”
The correct option explores the client's thoughts and feelings directly and fully. At the same time, it
conveys an unhurried, nonjudgmental, and supportive attitude that is therapeutic. The client needs
reassurance that these feelings are normal and may be expressed in this safe care environment.
Avoid any option that places the client's feelings on hold, blocks further communication, or is likely to
increase the client's fear.
173
Mental Health
The nurse is assigned to a client who is pacing, agitated, and using aggressive gestures and rapid
speech. The nurse would determine that which action is the priority of care at this time?
1. Providing the other clients on the unit with a sense of comfort and safety
2. Providing a safe place for the client to pace that is away from the other clients
3. Offering the client a less stimulated area in which to calm down and gain control
4. Assisting in caring for the client in a controlled environment, such as a quiet room
174
Mental Health
The nurse is assigned to a client who is pacing, agitated, and using aggressive gestures and rapid
speech. The nurse would determine that which action is the priority of care at this time?
1. Providing the other clients on the unit with a sense of comfort and safety
2. Providing a safe place for the client to pace that is away from the other clients
3. Offering the client a less stimulated area in which to calm down and gain control
4. Assisting in caring for the client in a controlled environment, such as a quiet room
Safety for the client and other clients is the priority. The correct option is the only choice that
addresses the client's and other clients' safety needs. This action also focuses on the client's need
to pace and safely physically work off anxious feelings. None of the other options addresses the
needs of all the clients.
175
Mental Health
A postsurgical client with a history of heavy alcohol intake has returned to the nursing unit. Which
signs/symptoms of delirium tremens would the nurse plan to continuously assess for?
1. Coarse hand tremor, agitation, hallucinations, and hypotension
2. Hypotension, ataxia, muscular rigidity, and tactile hallucinations
3. Hypotension, stupor, agitation, headache, and auditory hallucinations
4. Fever, hypertension, changes in level of consciousness, and hallucinations
176
Mental Health
A postsurgical client with a history of heavy alcohol intake has returned to the nursing unit. Which
signs/symptoms of delirium tremens would the nurse plan to continuously assess for?
1. Coarse hand tremor, agitation, hallucinations, and hypotension
2. Hypotension, ataxia, muscular rigidity, and tactile hallucinations
3. Hypotension, stupor, agitation, headache, and auditory hallucinations
4. Fever, hypertension, changes in level of consciousness, and hallucinations
The symptoms associated with delirium tremens (DTs) typically are anxiety, insomnia, anorexia,
hypertension, disorientation, visual or tactile hallucinations, changes in level of consciousness,
agitation, fever, and delusions. Therefore, the remaining options are incorrect.
177
Mental Health
The nurse working in a detoxification unit is admitting a client for alcohol withdrawal. The client's
spouse states, "I don't know why I don't get out of this rotten situation." Which response by the nurse
addresses the spouse's concerns?
1. “This is not a good time to make that decision.”
2. “What would your spouse think about your decision?”
3. “What aspects of this situation are the most difficult for you?
4. “You seem to have a good grip on this situation. You probably need to get out.”
178
Mental Health
The nurse working in a detoxification unit is admitting a client for alcohol withdrawal. The client's
spouse states, "I don't know why I don't get out of this rotten situation." Which response by the nurse
addresses the spouse's concerns?
1. “This is not a good time to make that decision.”
2. “What would your spouse think about your decision?”
3. “What aspects of this situation are the most difficult for you?
4. “You seem to have a good grip on this situation. You probably need to get out.”
The most helpful response is one that encourages the spouse to explore the problem and problemsolve. The correct response would not disregard or redirect focus away from the spouse's concern.
The nurse needs to appear neither to disagree nor agree with the spouse. Giving advice implies that
the nurse knows what is best and can also foster dependency.
179
Mental Health
The nurse would monitor a client with a history of opioid abuse for which signs and symptoms
associated with opioid withdrawal?
1. Increased appetite, irritability, anxiety, restlessness, and altered concentration
2. Tachycardia, mild hypertension and fever, sweating, nausea, vomiting, and marked tremor
3. Depression, high drug craving, fatigue, altered sleep patterns, hypertension, agitation, and
paranoia
4. Increased pulse and blood pressure, low-grade fever, yawning, restlessness, anxiety, diarrhea,
and mydriasis
180
Mental Health
The nurse would monitor a client with a history of opioid abuse for which signs and symptoms
associated with opioid withdrawal?
1. Increased appetite, irritability, anxiety, restlessness, and altered concentration
2. Tachycardia, mild hypertension and fever, sweating, nausea, vomiting, and marked tremor
3. Depression, high drug craving, fatigue, altered sleep patterns, hypertension, agitation, and
paranoia
4. Increased pulse and blood pressure, low-grade fever, yawning, restlessness, anxiety, diarrhea,
and mydriasis
Opioids are central nervous system depressants. They generally cause drowsiness and the feeling
of being out of touch with the world. Withdrawal occurs within 12 hours after the last dose. Option 4
identifies the signs and symptoms associated with opioid withdrawal. Option 1 describes cocaine
withdrawal. Option 2 identifies signs associated with nicotine withdrawal. Option 3 describes alcohol
withdrawal.
181
Thank you
Shannon Krolikowski
shannonkrolikowski@delta.edu