Mental Health Questions

Chapter 15

Mental Health Questions

61. The nurse helps a client with a diagnosis of obsessive-compulsive disorder prepare for bed. One hour later, the client calls the nurse and says he is feeling anxious and asks the nurse to sit and talk for a while. The nurse should take which most appropriate action?

1. Sit and talk with the client.

2. Ask the client if he would like an antianxiety medication.

3. Ask an unlicensed assistive personnel (UAP) to sit with the client.

4. Tell the client that it is time for sleep and that they will talk tomorrow.

Level of Cognitive Ability:

Client Needs:

Psychosocial Integrity

Integrated Process:

Content Area:

ANSWER: 1

Rationale:

The most appropriate nursing action is to sit and talk if the client is expressing anxiety. Antianxiety medication may be necessary, but this is not the most appropriate nursing action. A UAP may not be able to alleviate the client’s anxiety. Option 4 is an inappropriate action and places the client’s feelings on hold.

Test-Taking Strategy:

Note the strategic words most appropriate, and use therapeutic communication techniques. Recalling that it is best to address the client’s feelings assists in directing you to the correct option. Review: care of the client with obsessive-compulsive disorder.

Tip for the Beginning Nursing Student:

Obsessive-compulsive disorder is an anxiety disorder that is characterized by obsessions (ideas, emotions, or impulses that repetitively and insistently force themselves into consciousness) or compulsions (recurrent irresistible impulses to perform some act) that interfere with the individual’s normal routine. Therapeutic communication techniques, which promote and encourage the client to communicate and share his or her feelings with the nurse, should be used when caring for a client. You will learn about therapeutic and nontherapeutic communication techniques in your fundamentals of nursing course and about obsessive-compulsive disorder in your mental health nursing course.

References

deWit, Kumagai (2013), p. 1046; Keltner, Schwecke, Bostro (2011), pp. 62-65, 305.

62. The nurse is performing an admission interview on a client being admitted to the mental health unit and discovers that the client experienced a severe emotional trauma 1 month ago and is now experiencing paralysis of the right arm. What is the priority nursing action?

1. Refer the client to group therapy.

2. Encourage the client to talk about his feelings.

3. Encourage the client to move and use the arm.

4. Assess the client for organic causes of the paralysis.

Level of Cognitive Ability:

Client Needs:

Physiological Integrity

Integrated Process:

Nursing Process/Implementation

Content Area:

ANSWER: 4

Rationale:

The priority action is to assess for any physiological cause of the paralysis. Although the client may be referred to group therapy, this is not the priority action. Although a component of the plan of care is to encourage the client to discuss feelings, this also is not the priority action. It is not appropriate to encourage the client to use the arm without ruling out a physiological cause of the paralysis.

Test-Taking Strategy:

Note the strategic word priority. Use Maslow’s Hierarchy of Needs theory to remember that physiological needs are the first priority. Also use the steps of the nursing process. The correct option is the only one that addresses a physiological need and assessment/data collection, the first step in the nursing process. Review: conversion disorder.

Tip for the Beginning Nursing Student:

A conversion disorder is a somatoform disorder characterized by a loss or alteration of physical functioning without evidence of organic impairment. A conversion disorder can result after a traumatic experience. You will learn about conversion disorders in your mental health nursing course.

References

Fortinash, Holoday-Worret (2012), p. 207; Linton (2012), p. 1306.

63. The nurse is developing a plan of care for a client admitted to the mental health unit with a diagnosis of obsessive-compulsive disorder who is experiencing severe anxiety. What should the nurse identify as the priority intervention in the plan of care?

1. Monitor for repetitive behavior.

2. Encourage active participation in care.

3. Educate the client about self-care demands.

4. Establish a trusting and therapeutic nurse–client relationship.

Level of Cognitive Ability:

Client Needs:

Psychosocial Integrity

Integrated Process:

Content Area:

ANSWER: 4

Rationale:

The priority nursing action is to establish a trusting and therapeutic relationship with the client. The remaining options are appropriate components of the plan of care but are not the priority. A trusting nurse–client relationship needs to be established first.

Test-Taking Strategy:

Focus on the strategic word priority, and note that the client is being admitted to the mental health unit. Recalling that a nurse–client relationship needs to be developed first, assists in directing you to the correct option. Review: care to the client with obsessive-compulsive disorder.

Tip for the Beginning Nursing Student:

Obsessive-compulsive disorder is an anxiety disorder that is characterized by obsessions (ideas, emotions, or impulses that repetitively and insistently force themselves into consciousness) or compulsions (recurrent irresistible impulses to perform some act) that interfere with the individual’s normal routine. The first step in providing therapeutic care for the client is to establish a trusting and therapeutic relationship. If trust is established, the client is more likely to communicate with the nurse. You will learn about the techniques for establishing a trusting and therapeutic relationship with a client in your fundamentals of nursing course and about obsessive-compulsive disorder in your mental health nursing course.

References

deWit, Kumagai (2013), pp. 1046-1047; Keltner, Schwecke, Bostro (2011), p. 353.

64. The nurse is preparing to care for a client admitted to the mental health unit with a diagnosis of dementia and notes that the client has difficulty carrying out activities of daily living effectively. The nurse should plan for which outcome in caring for the client?

1. The client will feed self with cueing within 24 hours.

2. The client will be oriented to place by the time of discharge.

3. The client will be free of hallucinations by the time of discharge.

4. The client will correctly identify objects in his or her room by the time of discharge.

Level of Cognitive Ability:

Client Needs:

Physiological Integrity

Integrated Process:

Nursing Process/Planning

Content Area:

ANSWER: 1

Rationale:

Option 1 identifies an outcome directly related to the client’s ability to care for self. Options 2, 3, and 4 are not related to carrying out activities of daily living.

Test-Taking Strategy:

Note the relationship between the subject, the client experiencing difficulty carrying out activities of daily living and the correct option. Noting that options 2 and 4 are comparable or alike will assist in eliminating these options. From the remaining options, use Maslow’s Hierarchy of Needs theory. The correct option addresses a physiological need. Review: care of the client with dementia.

Tip for the Beginning Nursing Student:

Dementia is a term that describes an organic mental disorder characterized by cognitive impairments that are generally of gradual onset and are irreversible. Activities of daily living are activities performed during the course of a normal day, such as bathing, dressing, and eating. An inability to perform activities of daily living can occur as a result of dementia, which you will learn about in your mental health nursing course.

References

deWit, Kumagai (2013), pp. 1090-1091; Varcarolis, Halter (2010), pp. 390, 376-377.

65. A client experiencing delusions of being poisoned is admitted to the hospital. The client shows no evidence of dehydration and malnutrition at this time. The nurse prepares a plan of care for the client and should include which client need as the priority?

1. Self-esteem needs

2. Physiological needs

3. Safety and security needs

4. Love and belonging needs

Level of Cognitive Ability:

Client Needs:

Safe and Effective Care Environment

Integrated Process:

Nursing Process/Planning

Content Area:

ANSWER: 3

Rationale:

The maintenance of safety is an important consideration when working with clients who have delusions. No data in the question indicate that options 1, 2, and 4 require immediate attention.

Test-Taking Strategy:

Note the strategic word priority and note the words shows no evidence of dehydration and malnutrition. Use Maslow’s Hierarchy of Needs theory. Safety takes precedence if a physiological need does not exist. This will direct you to the correct option. Review: care of the client experiencing delusions.

Tip for the Beginning Nursing Student:

A delusion is a false belief that is firmly maintained by a client even though the belief is not shared by others. The nurse should not attempt to obtain a logical explanation about the delusion from the client. Only the client understands the logic behind the delusion, yet he or she is not able to express it until the delusion has reached conscious awareness. You will learn about delusions and how to deal with a client experiencing them in your mental health nursing course.

References

deWit, Kumagai (2013), p. 1104; Keltner, Schwecke, Bostro (2011), pp. 222-223.

66. An older woman is admitted to the acute psychiatric unit with a diagnosis of moderate depression. The client is unclean, her hair is uncombed, and she is inappropriately dressed. She is accompanied by her adult daughter who is very upset about her mother’s lack of interest in her appearance. The nurse appropriately alleviates the daughter’s concern by making which statement?

1. “Hygiene is not important to those who are depressed.”

2. “Client self-esteem needs take priority over appearances.”

3. “Group peer pressure on the unit will soon have your mother attending to her hygiene needs.”

4. “The nurses will assist your mother in meeting hygiene needs until she is able to resume self-care.”

Level of Cognitive Ability:

Client Needs:

Psychosocial Integrity

Integrated Process:

Content Area:

ANSWER: 4

Rationale:

Both the client and her family should know that the nurse will assist the client until the client can resume self-care activities. The client is experiencing psychomotor retardation and decreased energy at this time and requires assistance. Options 1, 2, and 3 will not alleviate the daughter’s concern.

Test-Taking Strategy:

Focus on the subject, alleviating the daughter’s concern, and use Maslow’s Hierarchy of Needs theory. Only the correct option addresses the client’s physiological needs. Review: care of the client with depression.

Tip for the Beginning Nursing Student:

Depression is a state of sadness or grief and can range from mild and moderate states to severe states. The potential for suicidal behavior should always be assessed in a client experiencing depression. You will learn about depression, its many causes, and the nursing care involved in your mental health nursing course.

References

Christensen, Kockrow: Foundations (2011), pp. 1144-1145; Keltner, Schwecke, Bostro (2011), p. 241.

67. The nurse is preparing to care for a woman victimized by physical abuse. The nurse should plan to perform which action first?

1. Support the woman, and facilitate access to a safe environment.

2. Talk to the woman about how and why the abuser became provoked.

3. Reinforce that dealing with the psychological aspects is of the highest priority.

4. Establish firm time lines for the woman to make necessary changes in her life situation.

Level of Cognitive Ability:

Client Needs:

Safe and Effective Care Environment

Integrated Process:

Content Area:

ANSWER: 1

Rationale:

The nurse must provide emotional support to the client and provide measures to ensure a safe environment. Option 2 fosters the notion that the client is at fault. In options 3 and 4, the nurse may be making unreasonable demands, which could cause further distress for the client.

Test-Taking Strategy:

Note the strategic word first. Use Maslow’s Hierarchy of Needs theory to direct you to the correct option. Remember that if a physiological need does not exist in one of the options, then a safety need is the priority. Also, the correct option provides support to the client. Review: care of the client victimized by physical abuse.

Tip for the Beginning Nursing Student:

Physical abuse is a form of violence. In most states the nurse is required to report abuse to legal authorities if abuse is suspected or occurs in a child or older client. If abuse occurs, the priority is to treat any physical injuries sustained. Next it is important to provide support and a safe environment for the victim. You will learn about violence and abuse in your mental health nursing course.

References

deWit, Kumagai (2013), p. 1041; Varcarolis, Halter (2010), pp. 598, 600.

68. A client is scheduled for electroconvulsive therapy (ECT). The client says to the nurse, “I am so afraid that it will hurt and will make me worse off than I am.” The nurse should make which best statement to the client?

1. “Can you tell me what you understand about the procedure?”

2. “Your fears are a sign that you really should have this procedure.”

3. “Try not to worry. This is a well-known and easy procedure for the doctor.”

4. “Those are very normal fears, but please be assured that everything will be okay.”

Level of Cognitive Ability:

Client Needs:

Psychosocial Integrity

Integrated Process:

Content Area:

ANSWER: 1

Rationale:

The correct option is a therapeutic communication technique that explores the client’s feelings, determines the level of client understanding about the procedure, and displays caring. Option 2 demeans the client and does not encourage further sharing by the client. Option 3 diminishes the client’s feelings by directing attention away from the client and to the doctor’s importance. Option 4 does not address the client’s fears and puts the client’s feelings on hold.

Test-Taking Strategy:

Note the strategic word best. Use therapeutic communication techniques, and remember to focus on the client’s feelings and concerns. Option 1 is the only option that addresses the client’s feelings, encourages client verbalization, and displays caring. Review: therapeutic communication techniques.

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Tags: Saunders 2014-2015 Strategies for Test Success Passing Nursing S

Jul 24, 2016 | Posted by admin in NURSING | Comments Off

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