MENTAL HEALTH NURSING D.

Walk away and approach the client in a few

minutes before the food gets cold.

1) When the nurse detects that a client is using

defense mechanisms, the nurse should make 5) The treatment goal for a client with severe anxiety
which of these interpretations of the client’s will have been achieved when the client
behavior? demonstrates which of these behaviors?

A. The client is attempting to reestablish A. The client recognizes the source of the
emotional equilibrium. anxiety.

B. The client is using self-defeating measures. B. The client is able to use the anxiety
constructively.
C. The client is demonstrating illness.
C. The client can function without any sense of
D. The client is asking for support from
anxiety.
significant others.
D. The client identifies the physical effects of the
anxiety.
2) A client addicted to morphine is being treated for
withdrawal symptoms. The drug commonly
administered for opiate withdrawal is: 6) Nurse Athirah is caring for a client with depression
who has not responded to antidepressant
A. Tranxene (chlorazepate)
medication. The nurse anticipates that what
B. Methadone treatment procedure may be prescribed?

C. Narcan (naloxone) A. Neuroleptic medication

D. Antabuse (disulfiram) B. Short term seclusion

C. Psychosurgery

3) A client has an Axis I diagnosis of major depression. D. Electroconvulsive therapy

Which of the following features would be most
crucial for the nurse to assess?
7) The nurse is observing the movements of a client
A. Sleep disturbance
receiving Thorazine (chlorpromazine). The client
B. Feelings of worthlessness continually paces and rocks back and forth when
sitting. The nurse recognizes that the client is
C. Difficulty with concentration experiencing:
D. Suicidal ideation A. Oculogyric crisis

B. Akathesia
4) A client with acute mania exhibits euphoria, C. Dystonia
pressured speech, and flight of ideas. The client
has been talking to the nurse nonstop for 5 D. Bradykinesia
minutes and lunch has arrived on the unit. Which
of the following would the nurse do next?

A. Excuse self while telling the client to come to

the dining room for lunch.

B. Tell the client he needs to stop talking

because it’s time to eat lunch.

C. Do not interrupt the client but wait for him to

finish talking.
8) The physician orders fluoxetine (Prozac) orally C. Instruct the client to go to her room and
every morning for a 72-year-old client with change clothes.
depression. The nurse would expect the physician
D. Escort the client to her room and assist with
to order which of the following dosages for this
choosing appropriate attire.
client?

A. 0.5 mg
12) The morning staff of an inpatient psychiatric unit
B. 10 mg
has just completed the change of shift report. The
C. 25 mg nurse should give priority to assessing the client:

D. 30 mg A. With schizophrenia having auditory

hallucinations

B. Scheduled for electroconvulsive therapy

9) The friend of a client with depression and suicidal
ideation asks the nurse, “How should I act around C. With a lithium level of 1.8 mEq/L
her?”
D. Receiving Thorazine (chlorpromazine) with a
Which of the following responses by the nurse
WBC of 7,500 cu mm
would be best?

A. “Try to cheer her up.”

13) A male client who is experiencing disordered
B. “Be caring and genuine.”
thinking about food being poisoned is admitted to
C. “Control your expressions.” mental health unit. The nurse uses which
communication technique to encourage the client
D. “Avoid asking how she’s feeling.”
to eat dinner?

A. Focusing on self-disclosure of own food

10) Chlorpromazine (Thorazine) is prescribed for a preference.
client. Which of the following, if observed in the
B. Using open ended question and silence.
client, would suggest chlorpromazine (Thorazine)
toxicity? C. Offering opinion about the need to eat.

A. Tremors D. Verbalizing reasons that the client may not

choose to eat.
B. Sore tongue

C. Rash
14) A young woman is admitted for the first time with
D. Hoarseness
a diagnosis of catatonic schizophrenia and is
receiving chlorpromazine (Thorazine) daily. She is
to go home for a weekend pass. What is the most
11) The client with bipolar disorder, manic phase important instruction to give her relative to her
appears at the nurse’s station wearing a medications?
transparent shirt, miniskirt, high heels, 10
bracelets, and 8 necklaces. Her makeup is A. “Use a sunscreen lotion, and do not drink
overdone and she is not wearing underwear. A alcoholic beverages.”
pair of inverted underpants is plopped on her head.
B. “Do not drink wine and beer or eat hard
Which of the following would be the nurse’s best
cheeses.”
response?
C. “Stay away fro persons with colds and
A. Tell the client to dress appropriately while out
infections, and report any rashes
of her room.
immediately.”
B. Ask the client to put on hospital pajamas until
D. “Drink plenty of orange juice, and take your
she can dress appropriately.
pills with milk.”
15) In attempting to establish a therapeutic 19) Which word best describes the type of
relationship with a child who may be autistic, the schizophrenia identified by marked negativism,
nurse should expect to encounter which of these rigidity, excitement, stupor, or posturing?
problems?
A. Catatonic
A. Hallucinations
B. Undifferentiated
B. Impaired hearing
C. Disorganized
C. Bizarre behavior
D. Paranoid
D. Clinging to others

20) The nurse is discussing the diet and nutrition with

16) When developing the teaching plan for the family a client who’s taking lithium and tells him that he
of a client with severe depression who is to receive should include adequate amounts of which
ECT, which of the following would the nurse nutrient in his diet?
include?
A. Sugar
A. Some temporary confusion and disorientation
B. Salt
immediately after a treatment is common.
C. Protein
B. During an ECT treatment session, the client is
at risk of aspiration. D. Fiber
C. Clients with severe depression usually do not
respond to ECT.
21) A young woman was referred to the psychiatrist by
D. The client will not be able to breathe her family physician because she is fearful of
independently during a treatment. getting into elevators. During the course of
therapy, it was discovered that her initial fear was
of men and that it had changed to elevators.
17) Nurse June is caring for a female client who Which of the following mechanisms is
experience false sensory perceptions with no basis demonstrated by this change?
in reality. This perception is known as:
A. Repression
A. Hallucinations
B. Identification
B. Delusions
C. Projection
C. Loose associations
D. Displacement
D. Neologisms

22) The nurse identifies a nursing diagnosis of

18) When assessing a client who is receiving tricyclic
antidepressant therapy, which of the following
would alert the nurse to the possibility that the
client is experiencing anticholinergic effects?
A. Tremors and cardiac arrhythmias.
B. Sedation and delirium.
C. Respiratory depression and convulsions.
Self-Care Deficit related to apathy, as evidenced by
inability to shower and dress self for a female
client with schizophrenia. Which of the following
outcomes would the nurse expect as most
therapeutic for the client to achieve by the end of
4 days?
A. Verbalize the need to shower and dress
herself.

D. Urine retention and blurred vision. B. Recognize the need to shower and dress
herself.
 C. Explain reasons for showering and dress 26) A client is diagnosed with a somatoform disorder.
herself. This diagnosis has which primary gain?

D. Perform showering and dressing for herself. A. Illness allows reprieve from responsibilities.

B. Sick role allows for dependency needs to be

met.
23) During a home visit, the nurse discovers that the
client is less verbal, less active, less responsive to C. The symptoms may serve to control others to
the directions, severely anxious, and more stabilize relationships.
stuporous. The nurse interprets these findings as
D. The client becomes increasingly socialized.
indicating that the client is having exacerbation of
which of the following types of schizophrenia?

A. Disorganized 27) A client who has been receiving haloperidol

(Haldol) for 2 days develops muscular rigidity,
B. Paranoid
altered consciousness, a temperature of 103°F
C. Undifferentiated (39.4°C), and trouble breathing on day 3. The
nurse interprets these findings as indicating which
D. Catatonic
of the following?

A. Neuroleptic malignant syndrome

24) A client’s condition is becoming stabilized after an
B. Tardive dyskinesia
episode of substance-induced delirium. During the
initial recovery period, the nurse should assess the C. Extrapyramidal side effects
client for which psychosocial health problem?
D. Drug-induced parkinsonism
A. Flashbacks

B. Depression
28) A 22-year-old client is being admitted with a
C. Nightmares diagnosis of brief psychotic disorder. Two weeks
ago, his girlfriend broke off their engagement and
D. Dissociation
cancelled the wedding. Given the Diagnostic and
Statistical Manual of Mental Disorders, 4th edition,
text revised (DSM-IV-TR) criteria for this disorder,
25) The nurse is assessing a 22-month-old child who is the nurse expects to find which of the following
thought to be autistic. During an interview with data during the interview with the client?
the nurse, the child’s mother makes all of the
following statements about his behavior until he A. Current treatment for pneumonia.
was 1 year old. Which statement most strongly
B. Regular use of alcohol and marijuana.
suggests that the child may be autistic?
C. Evidence of delusions and hallucinations.
A. “He was a good baby and rarely cried when I
left the room.” D. A history of chronic depression.

B. “He slept very well after each feeding.”

C. “He spit out every new food the first time I 29) A client complains of chronic lower back pain and
gave it to him.” fatigue and has seen multiple care providers
without relief of symptoms. The client insists that
D. “He started to walk without learning to crawl
something is “terribly wrong.” Which action should
first.”
the nurse take first?

A. Refer the client for a psychiatric evaluation.

B. Initiate group therapy for behavior

modification.
 C. Obtain a thorough health assessment to rule D. Tell her that she will be restrained if she
out physical illnesses. continues to wander.

D. Refer the client to physiotherapy.

33) A client admitted with a diagnosis of

30) A client with bipolar disorder is taking lithium and
tells the nurse, “I can stop taking the medicine
when I feel better.” Which response by the nurse
is best?
A. “That’s correct. When you feel better, you can
stop taking the medication.”
schizoaffective disorder, manic phase who is
currently taking fluoxetine (Prozac), valproic acid
(Depakote), olanzapine (Zyprexa) as ordered has
has an increase in manic symptoms in the last
week. The psychiatrist orders a valproic acid blood
level to be drawn stat. The nurse understands the
rationale for this order as which of the following?

B. “Take the medication for 1 week after you
feel better to be sure there’s enough
medication in your system.”
C. “Bipolar clients may take lithium indefinitely
to prevent relapses.”
D. “This medication is given as needed. That
means that you can take it when you feel that
you need it.”
A. All clients taking valproic acid need periodic
valproic acid levels drawn.
B. Fluoxetine can decrease the effectiveness of
the valproic acid.
C. A decrease in the level of valproic acid could
explain the increase in manic symptoms.
D. The valproic acid level is needed before a
short course of lorazepam (Ativan) for
agitation is ordered.

31) To initiate a relationship with a child who may be

autistic, the nurse would probably be most
34) A client with major depression is to be discharged
effective by using which of these approaches?
home tomorrow. When preparing the client’s
A. Playing peek-a-boo discharge plan, which of the following areas would
be most important for the nurse to review with
B. Having him point to designated body parts the client?
C. Sitting with him A. Future plans for going back to work.
D. Playing an action game like Ring around the B. A conflict encountered with another client.
Rosy
C. Results of psychological testing.

D. Medication management with outpatient

32) The nurse is caring for a 75-year-old widow follow-up.
admitted to the psychiatric hospital by her
daughter, who became concerned when her
mother began to talk in a confused manner about
35) The laboratory calls the nurse stating that a
her husband who has been dead for seven years.
client’s imipramine level is within the therapeutic
In the hospital, especially at night, the client
range. The nurse interprets this as indicating that
wanders into the toilet looking for her husband.
the client’s serum concentration is within which of
What is the most appropriate action for the nurse
the following ranges?
to take when this woman wanders into the toilet?
A. 50 to 150mg/mL
A. Lock the door to the toilet.
B. 151 to 250 mg/mL
B. Tell her to stay in her bed except for meals.
C. 251 to 350 mg/mL
C. Take her by the hand and guide her back to
her bed. D. 351 to 450 mg/mL
36) The nurse is caring for an elderly woman admitted 40) A newly admitted client with paranoid
with chronic organic brain disease. When her schizophrenia is pacing and wringing his hands. He
daughter visits, she asks, “Are you my maid?” How states that another client is out to get him. Then
should the nurse describe the client’s behavior? he says, “Protect me. Select me. Reject me.”
Which of the following nursing diagnosis would be
A. Impaired judgment
most appropriate?
B. Disorientation
A. Disturbed Sensory Perception related to
C. Impairment of abstract thinking paranoia as evidenced by thinking a client is
out to get him.
D. Delusions
B. Impaired Verbal Communication related to
severe anxiety as evidenced by clang
37) Lithium carbonate is ordered for a client with associations.
overactive behavior. The nurse should observe the C. Delayed Growth and Development related to
client for which of these side effects? mild anxiety as evidenced by incomplete
A. Diarrhea sentences.

B. Rhinitis D. Defensive Coping related to noncompliance as

evidenced by pacing and wringing of hands.
C. Glycosuria

D. Rash
41) When working with clients who are experiencing
chronic mental illnesses, which of the following
38) A client with a history of depression demonstrates would the nurse expect to be generally
some inconsistent symptoms of cognitive unnecessary for this client population?
impairment. The nurse should expect which A. Community-based treatment programs.
situation when the depression is treated?
B. Psychosocial rehabilitation.
A. Delusional thinking ceases
C. Employment opportunities.
B. Recognition of objects improves
D. Custodial care in long-term hospitals.
C. Memory problems resolve

D. Suicidal ideation is no longer a problem

42) Chlorpromazine hydrochloride (Thorazine) is
prescribed for a young adult with schizophrenia.
39) A schizophrenic client states, “The voices keep For three days, the chlorpromazine (Thorazine) is
talking to me. They’re telling me that I have to to be administered intramuscularly. Before
leave here and that I shouldn’t talk to you. Don’t administering chlorpromazine (Thorazine)
you hear what they’re saying?” intramuscularly to the client, the nurse should
Which response is best? make which of these assessments?

A. “You didn’t take your medicine this morning, A. Checking his blood pressure
did you?” B. Testing his urine for glucose
B. “The voices aren’t real. You’re sick and they’re C. Testing his patellar reflexes
part of your illness.”
D. Checking laboratory results for his serum
C. “Are you hearing voices again?” potassium level
D. “I don’t hear the voices, but I see that you are
upset.”
43) While a client is taking chlorpromazine (Thorazine), C. “Sometimes we have to ht bottom before
he should be observed for which of these things get better.”
symptoms?
D. “you sound like you’re feeling very sad. Are
A. Pseudoparkinsonism you thinking about harming yourself?”

B. Dehydration

C. Manic excitement 47) An adolescent with a diagnosis of severe anorexia

nervosa is now on the adolescent psychiatric unit
D. Urinary incontinence
after being in intensive care to achieve fluid and
electrolyte balance. In developing the nursing care
plan, which of the following will be of highest
44) A client with schizophrenia has been prescribed priority?
risperidone (Risperdal). The client’s symptoms
include hallucinations, delusions, and withdrawal. A. Weighing her before and after each meal
The medication will help improve which
B. Observing her for two hours after each meal
symptoms?
C. Teaching her the elements of good nutrition
A. Negative symptoms
D. Recording her food intake
B. Positive symptoms

C. Negative and positive symptoms

48) A man who is being treated for paranoia walks
D. Paranoid symptoms
toward the nurse’s desk and observes the nurse
making a telephone call. A few minutes later, he
accuses the nurse of having called the police. How
45) A young woman has admitted herself to the should the nurse interpret his behavior?
psychiatric unit for treatment of Valium addiction.
A schedule of drug withdrawal is ordered by the A. Projection
doctor. Which of the following may the nurse
B. Reaction formation
expect to see as the Valium dose is decreased?
C. Transference
A. Decreased blood pressure
D. Ideas of reference
B. Tremors and hyperactivity

C. Increase in appetite
49) A young woman who has a washing ritual has been
D. Grandiosity
late for breakfast each of the three days since
admission. What is the most appropriate nursing
intervention?
46) Three days after admission for treatment of
Valium addiction, a young woman briefly left the A. Give her a choice of getting to breakfast on
hospital to talk to a visitor. Her psychiatrist has time or not eating breakfast.
threatened to discharge her for noncompliance
B. Restrict her privileges if she is late again.
with the treatment program. The client seems very
despondent, refusing to get out of bed. The C. Get her up early so she can complete her
evening nurse finds the client crying, “I’ve screwed washing ritual before breakfast.
everything up. It’s hopeless. It’s no use.” In
D. Insist that she stop washing her hands and go
responding the client, which of the following
to breakfast.
would be most appropriate?

A. “You’ve screwed everything up?”

B. “Why do you feel it’s no use?”

50) Following withdrawal from alcohol, a client is to
receive disulfiram (Antabuse). The medication is
prescribed for which of these purposes?

A. To minimize the effects of alcohol

B. To improve detoxification by the liver

C. To increase her utilization of vitamins

D. To help her refrain from drinking alcohol