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NURSING 1950 Mental Health Module 3 Exam Questions
and Answers- SRTC
1. A patient became severely depressed when the last of the family's six children
moved out of the home 4 months ago. The patient repeatedly says, "No one cares about me. I'm not worth anything." Which response by the nurse would be the most helpful? "I'll sit with you for 10 minutes now and 10 minutes after lunch to help you feel that I care about you." Spending time with the patient at intervals throughout the day shows acceptance by the nurse and will help the patient establish a relationship with the nurse. The therapeutic technique is "offering self." Setting definite times for the therapeutic contacts and keeping the appointments show predictability on the part of the nurse, an element that fosters trust building.
2. A patient became depressed after the last of the family's six children moved
out of the home 4 months ago. Select the best initial outcome for the nursing diagnosis Situational low self-esteem related to feelings of abandonment. The patient will: verbalize realistic positive characteristics about self by (date). Low self-esteem is reflected by making consistently negative statements about self and self-worth. Replacing negative cognitions with more realistic appraisals of self is an appropriate intermediate outcome.
3. A patient diagnosed with major depression says, "No one cares about me
anymore. I'm not worth anything." Today the patient is wearing a new shirt and has neat, clean hair. Which remark by the nurse supports building a positive self- esteem for this patient? "You're wearing a new shirt." Patients with depression usually see the negative side of things. The meaning of compliments may be altered to "I didn't look nice yesterday," or "They didn't like my other shirt." Neutral comments such as making an observation avoid negative interpretations.
4. An adult diagnosed with major depression was treated with medication and
cognitive behavioral therapy. The patient now recognizes how passivity contributed to the depression. Which intervention should the nurse suggest? Social skills training Social skill training is helpful in treating and preventing the recurrence of depression. Training focuses on assertiveness and coping skills that lead to positive reinforcement from others and development of a patient's support system.
5. Priority interventions for a patient diagnosed with major depression and
feelings of worthlessness should include: careful unobtrusive observation around the clock Approximately two-thirds of people with depression contemplate suicide. Patients with depression who exhibit feelings of worthlessness are at higher risk. Regular planned observations of the patient diagnosed with depression may prevent a suicide attempt on the unit.
6. When counseling patients diagnosed with major depression, an advanced
practice nurse will address the negative thought patterns by using: cognitive behavioral therapy Cognitive behavioral therapy attempts to alter the patient's dysfunctional beliefs by focusing on positive outcomes rather than negative attributions. The patient is also taught the connection between thoughts and resultant feelings. Research shows that cognitive behavioral therapy involves the formation of new connections between nerve cells in the brain and that it is at least as effective as medication.
7. A patient says to the nurse, "My life doesn't have any happiness in it anymore.
I once enjoyed holidays, but now they're just another day." The nurse documents this report as an example of: anhedonia Anhedonia is a common finding in many types of depression. It refers to feelings of a loss of pleasure in formerly pleasurable activities.
8. A patient diagnosed with major depression began taking a tricyclic
antidepressant 1 week ago. Today the patient says, "I don't think I can keep taking these pills. They make me so dizzy, especially when I stand up." The nurse will: teach the patient strategies to manage postural hypotension Drowsiness, dizziness, and postural hypotension usually subside after the first few weeks of therapy with tricyclic antidepressants. Postural hypotension can be managed by teaching the patient to stay well hydrated and rise slowly. Knowing this information may convince the patient to continue the medication.
9. A patient diagnosed with depression is receiving imipramine (Tofranil) 200 mg
qhs. Which assessment finding would prompt the nurse to collaborate with the health care provider regarding potentially hazardous side effects of this drug? Urinary retention
During the immediate post-treatment period, the patient is recovering from general anesthesia; hence, the priority need is to establish and support physiological stability.
15. A nurse provided medication education for a patient diagnosed with major
depression who began a new prescription for phenelzine (Nardil). Which behavior indicates effective learning? The patient: confers with a pharmacist when selecting over-the-counter medications Over-the-counter medicines may contain vasopressor agents or tyramine, a substance that must be avoided when the patient takes MAOI antidepressants. Medications for colds, allergies, or congestion or any preparation that contains ephedrine or phenylpropanolamine may precipitate a hypertensive crisis.
16. Major depression resulted after a patient's employment was terminated. The
patient now says to the nurse, "I'm not worth the time you spend with me. I am the most useless person in the world." Which nursing diagnosis applies? Situational low self-esteem The patient's statements express feelings of worthlessness and most clearly relate to the nursing diagnosis of situational low self-esteem.
17. A patient diagnosed with major depression does not interact with others
except when addressed, and then only in monosyllables. The nurse wants to show nonjudgmental acceptance and support for the patient. Which communication technique will be effective? Make observations Making observations about neutral topics such as the environment draws the patient into the reality around him or her but places no burdensome expectations for answers on the patient. Acceptance and support are shown by the nurse's presence.
18. A patient being treated for depression has taken 300 mg amitriptyline
(Elavil) daily for a year. The patient calls the case manager at the clinic and says, "I stopped taking my antidepressant 2 days ago. Now I am having cold sweats, nausea, a rapid heartbeat, and nightmares." The nurse will advise the patient to: "Take a dose of your antidepressant now and come to the clinic to see the health care provider." The patient has symptoms associated with abrupt withdrawal of the tricyclic antidepressant. Taking a dose of the drug will ameliorate the symptoms. Seeing the health care provider will allow the patient to discuss the advisability of going
off the medication and to be given a gradual withdrawal schedule if discontinuation is the decision.
19. Which documentation for a patient diagnosed with major depression
indicates the treatment plan was effective? Slept 6 hours uninterrupted. Sang with activity group. Anticipates seeing grandchild. Sleeping 6 hours, participating with a group, and anticipating an event are all positive events.
20. A patient was diagnosed with seasonal affective disorder (SAD). During
which month would this patient's symptoms be most acute? January The days are short in January, so the patient would have the least exposure to sunlight. Seasonal affective disorder is associated with disturbances in circadian rhythm.
21. A patient diagnosed with depression repeatedly tells staff, "I have cancer. It's
my punishment for being a bad person." Diagnostic tests reveal no cancer. Select the priority nursing diagnosis. Risk for suicide A patient diagnosed with depression who feels so worthless as to believe cancer is deserved is at risk for suicide.
22. A patient diagnosed with major depression refuses solid foods. In order to
meet nutritional needs, which beverage will the nurse offer to this patient? Milk Milk is the only beverage listed that provides protein, fat, and carbohydrates. In addition, milk is fortified with vitamins.
23. During a psychiatric assessment, the nurse observes a patient's facial
expression is without emotion. The patient says, "Life feels so hopeless to me. I've been feeling sad for several months." How will the nurse document the patient's affect and mood? Affect flat; mood depressed Mood refers to a person's self-reported emotional feeling state. Affect is the emotional feeling state that is outwardly observable by others.
blood pressure.
29. Transcranial Magnetic Stimulation (TCM) is scheduled for a patient
diagnosed with major depression. Which comment by the patient indicates teaching about the procedure was effective? "I might be a little dizzy or have a mild headache after each procedure." Transcranial Magnetic Stimulation (TCM) treatments take about 30 minutes. Treatments are usually 5 days a week. Patients are awake and alert during the procedure. After the procedure, patients may experience a headache and lightheadedness.
30. The admission note indicates a patient diagnosed with major depression has
anergia and anhedonia. For which measures should the nurse plan? (Select all that apply)
**- Instilling a sense of hopefulness
- Assisting with self-care activities
- Accommodating psychomotor retardation** Anergia refers to a lack of energy. Anhedonia refers to the inability to find pleasure or meaning in life; thus, planning should include measures to accommodate psychomotor retardation, assist with activities of daily living, and instill hopefulness.
31. A student nurse caring for a patient diagnosed with depression reads in the
patient's medical record, "This patient shows vegetative signs of depression." Which nursing diagnoses most clearly relate to the vegetative signs? Select all that apply.
**- Imbalanced nutrition: less than body requirements
- Sexual dysfunction
- Self-care deficit
- Insomnia** Vegetative signs of depression are alterations in body processes necessary to support life and growth, such as eating, sleeping, elimination, and sexual activity. These diagnoses are more closely related to vegetative signs than diagnoses associated with feelings about self.
32. A patient diagnosed with major depression shows vegetative signs of
depression. Which nursing actions should be implemented? Select all that apply.
**- Offer laxatives if needed.
- Monitor food and fluid intake.
- Provide a quiet sleep environment.**
The correct options promote a normal elimination pattern. Although excessive intake of stimulants such as caffeine may make the patient feel jittery and anxious, small amounts may provide useful stimulation.
33. A patient being treated with paroxetine (Paxil) 50 mg po daily for depression
reports to the clinic nurse, "I took a few extra tablets earlier today and now I feel bad." Which assessments are most critical? Select all that apply.
**- Vital signs
- Presence of abdominal pain and diarrhea
- Hyperactivity or feelings of restlessness** The patient is taking the maximum dose of this SSRI and has ingested an additional unknown amount of the drug. Central serotonin syndrome must be considered. Symptoms include abdominal pain, diarrhea, tachycardia, elevated blood pressure, hyperpyrexia, increased motor activity, and muscle spasms. Central serotonin syndrome may progress to a full medical emergency if not treated early.
34. A nurse wants to teach alternative coping strategies to a patient
experiencing severe anxiety. Which action should the nurse perform first? Lower the patient's current anxiety. A patient experiencing severe anxiety has a markedly narrowed perceptual field and difficulty attending to events in the environment.
35. A patient experiencing moderate anxiety says, "I feel undone." An
appropriate response for the nurse would be: "I'm not sure I understand. Give me an example." Increased anxiety results in scattered thoughts and an inability to articulate clearly.
36. A patient fearfully runs from chair to chair crying, "They're coming! They're
coming!" The patient does not follow the staff's directions or respond to verbal interventions. The initial nursing intervention of highest priority is to: provide for the patient's safety Safety is of highest priority because the patient experiencing panic is at high risk for self-injury related to increased non-goal-directed motor activity, distorted perceptions, and disordered thoughts.
42. A patient is experiencing moderate anxiety. The nurse encourages the
patient to talk about feelings and concerns. What is the rationale for this intervention? Concerns stated aloud become less overwhelming and help problem solving begin.
43. A nurse assesses a patient with a tentative diagnosis of generalized anxiety
disorder. Which question would be most appropriate for the nurse to ask? "Do you find it difficult to control your worrying?" Patients with generalized anxiety disorder frequently engage in excessive worrying.
44. A patient in the emergency department shows disorganized behavior and
incoherence after a friend suggested a homosexual encounter. In which room should the nurse place the patient? An interview room furnished with a desk and two chairs Individuals experiencing severe to panic-level anxiety require a safe environment that is quiet, non-stimulating, structured, and simple.
45. A person has minor physical injuries after an auto accident. The person is
unable to focus and says, "I feel like something awful is going to happen." This person has nausea, dizziness, tachycardia, and hyperventilation. What is the person's level of anxiety? Severe The person whose anxiety is severe is unable to solve problems and may have a poor grasp of what is happening in the environment.
46. Two staff nurses applied for a charge nurse position. After the promotion
was announced, the nurse who was not promoted said, "The nurse manager had a headache the day I was interviewed." Which defense mechanism is evident? Projection Projection is the hallmark of blaming, scapegoating, prejudicial thinking, and stigmatizing others.
47. A patient tells a nurse, "My new friend is the most perfect person one could
imagine: kind, considerate, and good-looking. I can't find a single flaw." This patient is demonstrating: Idealization Idealization is an unconscious process that occurs when the individual attributes exaggerated positive qualities to another.
48. A patient experiences a sudden episode of severe anxiety. Of these
medications in the patient's medical record, which is most appropriate to give as a prn anxiolytic? lorazepam (Ativan) Lorazepam is a benzodiazepine used to treat anxiety. It may be given as a prn medication.
49. Two staff nurses applied for promotion to nurse manager. The nurse not
promoted initially had feelings of loss but then became supportive of the new manager by helping make the transition smooth and encouraging others. Which term best describes the nurse's response? Altruism Altruism is the mechanism by which an individual deals with emotional conflict by meeting the needs of others and receiving gratification vicariously or from the responses of others.
50. A person who feels unattractive repeatedly says, "Although I'm not beautiful,
I am smart." This is an example of: Compensation Compensation is an unconscious process that allows us to make up for deficits in one area by excelling in another area to raise self-esteem.
51. A person speaking about a rival for a significant other's affection says in an
emotional, syrupy voice, "What a lovely person. That's someone I simply adore." The individual is demonstrating: reaction formation Reaction formation is an unconscious mechanism that keeps unacceptable feelings out of awareness by using the opposite behavior.
57. A person who has been unable to leave home for more than a week because
of severe anxiety says, "I know it does not make sense, but I just can't bring myself to leave my apartment alone." Which nursing intervention is appropriate? Teach the person to use positive self-talk techniques. Positive self-talk, a form of cognitive restructuring, replaces negative thoughts such as "I can't leave my apartment" with positive thoughts such as "I can control my anxiety."
58. A nurse assesses an individual who commonly experiences anxiety. Which
comment by this person indicates the possibility of obsessive-compulsive disorder? "I check where my car keys are eight times." Recurring doubt (obsessive thinking) and the need to check (compulsive behavior) suggest obsessive-compulsive disorder.
59. When alprazolam (Xanax) is prescribed for a patient who experiences acute
anxiety, health teaching should include instructions to: avoid alcoholic beverages Drinking alcohol or taking other anxiolytics along with the prescribed benzodiazepine should be avoided because depressant effects of both drugs will be potentiated.
60. The nurse assesses a patient who complains of loneliness and episodes of
anxiety. Which statement by the patient is mostly likely if this patient also has agoraphobia? "Being afraid to go out seems ridiculous, but I can't go out the door." Individuals who are agoraphobic generally acknowledge that the behavior is not constructive and that they do not really like it.
61. A patient diagnosed with obsessive-compulsive disorder has this nursing
diagnosis: Anxiety related to as evidenced by inability to control compulsive cleaning. Which phrase correctly completes the etiological portion of the diagnosis? persistent thoughts about bacteria, germs, and dirt Many compulsive rituals accompany obsessive thoughts. The patient uses these rituals for anxiety relief.
62. A patient performs ritualistic hand washing. Which action should the nurse
implement to help the patient develop more effective coping? Encourage the patient to participate in social activities. Because obsessive-compulsive patients become overly involved in the rituals, promotion of involvement with other people and activities is necessary to improve coping.
63. For a patient experiencing panic, which nursing intervention should be
implemented first? Provide calm, brief, directive communication. Calm, brief, directive verbal interaction can help the patient gain control of overwhelming feelings and impulses related to anxiety.
64. A child was placed in a foster home after being removed from abusive
parents. The child is apprehensive and overreacts to environmental stimuli. The foster parents ask the nurse how to help the child. Which interventions should the nurse suggest? Select all that apply.
**- Use a calm manner and low voice.
- Maintain simplicity in the environment.
- Explain and reinforce reality to avoid distortions.**
65. A nurse plans health teaching for a patient with generalized anxiety disorder
who begins a new prescription for lorazepam (Ativan). What information should be included? Select all that apply.
**- Caution in use of machinery
- The importance of caffeine restriction
- Avoidance of alcohol and other sedatives**
66. Which assessment questions would be most appropriate for the nurse to ask
a patient with possible obsessive-compulsive disorder? Select all that apply.
**- "Are there others in your family who must do things in a certain way to feel comfortable?"
- "Is it difficult to keep certain thoughts out of your awareness?"
- "Do you do certain things over and over again?"**
67. The nurse assesses an adult who is socially withdrawn and hoards. Which
nursing diagnoses most likely apply to this individual? Select all that apply.
Symptoms of adjustment disorder run the gamut of all forms of distress including guilt, depression, and anger. Anger may protect the bereaved from facing the devastating reality of loss.
72. A wife received news that her husband died of heart failure and called her
family to come to the hospital. She angrily tells the nurse who cared for him, "He would still be alive if you had given him your undivided attention." Select the nurse's best intervention. Say to the wife, "I understand you are feeling upset. I will stay with you until your family comes." The nurse builds trust and shows compassion in the face of adjustment disorders. Therapeutic responses provide comfort. The nurse should show patience and tact while offering sympathy and warmth.
73. A child drowned while swimming in a local lake 2 years ago. Which behavior
indicates the child's parents have adapted to their loss? The parents: throw flowers on the lake at each anniversary date of the accident Resilience refers to positive adaptation or the ability to maintain or regain mental health despite adversity. Loss of a child is among the highest-risk situations for an adjustment disorder and maladaptive grieving. The parents who throw flowers on the lake on each anniversary date of the accident are openly expressing their feelings.
74. A store clerk was killed during a robbery 2 weeks ago. His widow, who has a
long history of schizoaffective disorder, cries spontaneously when talking about his death. Select the nurse's most therapeutic response. "The unexpected death of your husband is very painful. I'm glad you are able to talk about your feelings." The patient is expressing feelings related to the loss, and this is an expected and healthy behavior. This patient is at risk for a maladaptive response because of the history of a serious mental illness, but the nurses priority intervention is to form a therapeutic alliance and support the patients expression of feelings.
75. Which scenario demonstrates a dissociative fugue?
After being caught in an extramarital affair, a man disappeared but then reappeared months later with no memory of what occurred while he was missing. The patient in a dissociative fugue state relocates and lacks recall of his life before
the fugue began. Often fugue states follow traumatic experiences and sometimes involve assuming a new identity. Such persons at some point find themselves in their new surroundings, unable to recall who they are or how they got there. A feeling of detachment from ones body or from the external reality is an indication of depersonalization disorder.
76. The nurse who is counseling a patient with dissociative identity disorder
should understand that the assessment of highest priority is: risk for self-harm Assessments that relate to patient safety take priority. Patients with dissociative disorders may be at risk for suicide or self-mutilation, so the nurse must be alert for indicators of risk for self-injury.
77. A patient states, "I feel detached and weird all the time. It is as though I am
looking at life through a cloudy window. Everything seems unreal. It really messes up things at work and school." This scenario is most suggestive of which health problem? Depersonalization disorder Depersonalization disorder involves a persistent or recurrent experience of feeling detached from and outside oneself. Although reality testing is intact, the experience causes significant impairment in social or occupational functioning and distress to the individual.
78. The unlicensed assistive personnel (UAP) says to the nurse, "That patient
with amnesia looks fine, but when I talk to her, she seems vague. What should I be doing for her?" Select the nurse's best reply. "Use short, simple sentences and keep the environment calm and protective." Disruptions in ability to perform activities of daily living, confusion, and anxiety are often apparent in patients with amnesia. Offering simple directions to promote activities of daily living and reduce confusion helps increase feelings of safety and security. A calm, secure, predictable, protective environment is also helpful when a person is dealing with a great deal of uncertainty. Recollection of memories should proceed at its own pace, and the patient should only gradually be given information about her past.
79. A patient diagnosed with depersonalization disorder tells the nurse, "It's
starting again. I feel as though I'm going to float away." Which intervention would be most appropriate at this point?
the nurses follow-up assessment. Suicide is a high risk among military personnel diagnosed with posttraumatic stress disorder.
84. A soldier returned home from active duty in a combat zone in Afghanistan
and was diagnosed with posttraumatic stress disorder (PTSD). The soldier says, "If there's a loud noise at night, I get under my bed because I think we're getting bombed." What type of experience has the soldier described? Flashback Flashbacks are dissociative reactions in which an individual feels or acts as if the traumatic event were recurring. Illusions are misinterpretations of stimuli, and although the experience is similar, it is better termed a flashback because of the diagnosis of PTSD.
85. A soldier returned 3 months ago from Afghanistan and was diagnosed with
posttraumatic stress disorder (PTSD). Which social event would be most disturbing for this soldier? Fireworks display on July 4th The exploding noises associated with fireworks are likely to provoke exaggerated responses for this soldier.
86. A soldier served in combat zones in Iraq during 2010 and was deployed to
Afghanistan in 2013. When is it most important for the nurse to screen for signs and symptoms of posttraumatic stress disorder (PTSD)? Screening should be on-going PTSD can have a very long lag time, months to years. Screening should be on- going.
87. A soldier in a combat zone tells the nurse, "I saw a child get blown up over a
year ago, and I still keep seeing bits of flesh everywhere. I see something red, and the visions race back to my mind." Which phenomenon associated with posttraumatic stress disorder (PTSD) is the soldier describing? Reexperiencing Spontaneous or cued recurrent, involuntary, and intrusive distressing memories of the traumatic events are often associated with PTSD. The soldier has described intrusive thoughts and visions associated with reexperiencing the traumatic event.
88. A soldier who served in a combat zone returned to the U.S. The soldier's
spouse complains to the nurse, "We had planned to start a family, but now he won't talk about it. He won't even look at children." The spouse is describing which
symptom associated with posttraumatic stress disorder (PTSD)? Avoidance Physiological reactions to reminders of the event that include persistent avoidance of stimuli associated with the trauma results in the individuals avoiding talking about the event or avoiding activities, people, or places that arouse memories of the trauma. Avoidance is exemplified by a sense of foreshortened future and estrangement.
89. A soldier returned home last year after deployment to a war zone. The
soldier's spouse complains, "We were going to start a family, but now he won't talk about it. He will not look at children. I wonder if we're going to make it as a couple." Select the nurse's best response. "Posttraumatic stress disorder often strains relationships. Here are some community resources for help and support." Posttraumatic stress disorder precipitates changes that often lead to divorce. Its important to provide support to both the veteran and spouse.
90. Which assessment finding best supports dissociative fugue? The patient
states: "I cannot recall why I'm living in this town." The patient in a fugue state frequently relocates and assumes a new identity while not recalling previous identity or places previously inhabited.
91. After major reconstructive surgery, a patient's wounds dehisced. Extensive
wound care was required for 6 months, causing the patient to miss work and social activities. Which pathophysiology would be expected for this patient? Dysfunction of the: hippocampus The scenario presents chronic and potentially debilitating stress. If arousal continues unabated, neuronal changes occur that alter the neural circuitry of the prefrontal cortex, reducing the size the hippocampus so that memory is impaired.
92. Relaxation techniques help patients who have experienced major traumas
because they: engage the parasympathetic nervous system In response to trauma, the sympathetic arousal symptoms of rapid heart rate and rapid respiration prepare the person for flight or fight responses. Afterward, the
