Philadelphia University
Faculty of Nursing
2nd Semester, 2014/2015
Mental health –Psychiatric nursing (910342)
2nd exam
Student Name:
Student Number:
Time: (50) minutes
Total score:
/20
Please write the all answers in this page
Q1:
/15
Q1
Q2
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Q5
Q11
Q12
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Q15
Q2:
Q3: /1
123Q4: /1
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Q7
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Q10
/3
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1-
Q6
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A nurse observes an acutely psychotic client scratching at his arms with his
fingernails until his arms bleed. When asked what is happening, the client states he is
trying to let the evil spirits out of his body. He is easily redirected by the nurse, but
resumes scratching when the nurse leaves his side. The nurse orders 1:1 supervision
of the client to keep him from harming himself. Which principle of bioethics was
applied in this situation?
1. Justice
2. Fidelity
3. Beneficence
4. Veracity
Correct Answer: 3
The nurse educator is teaching a group of students about the ethical dilemma of
involuntary commitment. Which of the following would the educator use as a
situation that would support the use of an involuntary commitment?
1. The client uses profanity when angry
2. The client self-medicates with marijuana
3. The client has threatened family members
4. The client reports auditory hallucinations
Correct Answer: 3
Rationale 1: Involuntary commitment is reserved for those individuals who are
dangerous to self or others or unable to meet their basic needs. The threats to the
client’s family are considered a danger to others. The client’s use of profanity, reports
of auditory hallucinations, or the use of marijuana are not criteria for involuntary
commitment.
A client is voluntarily admitted to the mental health unit. The nurse knows that this
means:
1. The client gave informed consent for hospitalization.
2. The client has signed away all civil rights.
3. The client will need a court hearing within seven days.
4. The client has to remain hospitalized for three days.
Correct Answer: 1
Rationale 1: Voluntary admission occurs when the client has completed a written
application for admission. The client retains all civil rights and will not require a court
hearing. The length of stay will vary, but the client can give written notice of intent to
terminate treatment.
The nurse observes a client who is becoming increasingly upset. He is rapidly pacing, hyperventilating,
clenching his jaw, wringing his hands, and trembling. His speech is high pitched and random; he seems
preoccupied with his thoughts. He is pounding his fist into his other hand. The nurse identifies his
anxiety level as
a. Mild
b. Moderate
c. Severe
d. Panic
Which symptom would indicate that a client is delirious?
1. Dehydration
2. Illusions or hallucinations
3. Unsteady gait
4. Slurred speech
Correct Answer: 2
Rationale 1: Delirium is an acute sudden-onset disorder that includes symptoms of
perceptual disturbances like illusions and hallucinations. Dehydration is a cause and
not a symptom of delirium. Slurred speech is a common symptom of cerebrovascular
accident. An unsteady gait is a symptom of many neuromuscular diseases and is seen
in later stages of dementia.
A client has dementia of the Alzheimer's type. He is no longer able to walk, and he
does not recognize family members, even his wife of 52 years, when they visit him.
He attempts to communicate with agitated behaviors or with occasional incoherent
vocalizations. Which stage of the illness is the client in?
1. Late-stage dementia
2. Early-stage dementia
3. Middle-stage dementia
4. Late-stage confusion
Correct Answer: 4
Rationale 2: Late-stage dementia is characterized by a loss of ambulation abilities,
severe memory impairments, and communication that is limited and incoherent.
Early-stage dementia does not have the severe memory loss. Clients with middlestage dementia are still able to ambulate. Late-stage confusion is not a recognized
stage of dementia of the Alzheimer’s type.
A new nurse asks the difference between dementia and delirium. The best response is:
1. The cause of delirium is unknown.
2. Delirium develops over several weeks.
3. Delirium is often confused with depression in clients over the age of 60.
4. Delirium is a common occurrence in hospitalized clients over the age of 60.
Correct Answer: 4
Rationale 1: Delirium is an acute rapid-onset condition with an etiology that can be
traced to a known cause. Removal of the cause will usually result in complete
recovery. Delirium is commonly experienced by hospitalized clients over the age of
60.
Rationale 2: Delirium is an acute rapid-onset condition with an etiology that can be
traced to a known cause. Removal of the cause will usually result in complete
recovery. Delirium is commonly experienced by hospitalized clients over the age of
60.
A son brought his 73-year-old widowed father into the emergency room. The client
has congestive heart failure but is under the care of a physician and has been in good
health. The son was called in by the fire department after they put out a small cooking
fire at the client’s home. The firefighters reported that they found the client sitting in a
chair mumbling incoherently, unaware of the fire and smoke. The client now appears
to be drifting in and out of consciousness and is having problems keeping his attention
on any one task. In this situation, the client is probably suffering from:
1. Dementia.
2. Cerebrovascular accident.
3. Delirium.
4. Depression.
Correct Answer: 3
Rationale 1: Delirium is an abrupt-onset type of confusional state marked by
disorientation, impaired attention, and fluctuating consciousness. Speech may be
slurred and disjointed. Dementia has a slow onset. Depression is not marked by
fluctuating consciousness. There are physical symptoms, but fluctuating
consciousness is not typical in clients who have experienced cerebrovascular accident.
Which change in mental status is consistently seen in delirious individuals that
differentiates it from dementia?
1. Apraxia
2. Disorientation to self
3. Clouding of consciousness
4. Impaired short-term memory
Correct Answer: 3
Rationale 1: People with delirium have fluctuating consciousness, but people with
dementia are as attentive as they can be and do not have clouded consciousness until
terminal stages. Impaired short-term memory is consistently seen in dementia.
Apraxia is the loss of purposeful movement without loss of muscle power or
coordination and may or may not be seen in delirium. Disorientation to self is seen in
amnesiac disorders.
Which change in mental status is consistently seen in delirious individuals that
differentiates it from dementia?
1. Apraxia
2. Disorientation to self
3. Clouding of consciousness
4. Impaired short-term memory
Correct Answer: 3
Rationale 1: People with delirium have fluctuating consciousness, but people with
dementia are as attentive as they can be and do not have clouded consciousness until
terminal stages. Impaired short-term memory is consistently seen in dementia.
Apraxia is the loss of purposeful movement without loss of muscle power or
coordination and may or may not be seen in delirium. Disorientation to self is seen in
amnesiac disorders.
Which questions would assist the nurse in developing self-awareness when working
with clients who have cognitive disorders?
Standard Text: Select all that apply.
1. How do the clients with cognitive disorders feel about working with me?
2. How do I feel about working with clients with cognitive disorders?
3. What do the clients like about working with me?
4. How can I help the client who is confused?
Which answer choice, when placed in the blank, creates a correct statement?
The nurse maintaining a ______________ attitude will be more likely to understand
the experiences and difficulties of a client with schizophrenia.
1. sympathetic
2. enmeshed
3. complementary
4. nonjudgmental
Correct Answer: 4
Rationale 1: The nurse maintaining a nonjudgmental attitude will be more likely to
understand the experiences and difficulties of a client with schizophrenia. Being
sympathetic, becoming enmeshed, or maintaining a complementary attitude are
nontherapeutic interventions and will negatively affect the nurse–client relationship.
Q: matching the term with its appropriate definition
Term
1- Anhedonia d
Definition
a- Feelings of indifference toward people, activities and
events
2- Catatonia e
b- Absence of any facial expression that would indicated
emotions or mood
3- Apathy a
c- Absence of will, ambition, or drive to take action or
accomplish task
4- Flat effect b
d- Feeling no joy or pleasure from life or any activities
or relationship
5- Blunted affect
f
e- Psychologically induced immobility occasionally
marked by period of agitation or excitement
f- Restricted range of emotional feelings, tone, or mood
Q: Define the mean of "positive symptoms" of schizophrenia and give two examples?
–
Excess or distortion of normal functioning
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Aberrant response
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Hallucination
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Delusions
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Disordered speech and behavior
Q2: What are the factors to be considered when trying to understand a client’s stress?
•
personality factors,
•
cognitive factors,
•
physical factors,
•
environmental factors,
•
cultural factors,
•
and coping strategies