Mental Health Exam 2

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A nurse is caring for a client who reports acute, moderate anxiety. Which of the following is the priority nursing action?

1. remain with the client
2. provide a diverting activity
3. encourage verbalization of feelings
4. instruct the client to remember past coping mechanisms
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Terms in this set (51)
A nurse is caring for a client who reports acute, moderate anxiety. Which of the following is the priority nursing action?

1. remain with the client
2. provide a diverting activity
3. encourage verbalization of feelings
4. instruct the client to remember past coping mechanisms
1. remain with the client

Rationale:
The greatest risk to this client is self-injury from impulsive behavior
Which of the following findings in the client's medical record are consistent with antisocial personality disorder? (Select all that apply)
...
Which of the following findings in the client's medical record indicates the client has bulimia nervosa? (select all that apply)

A. Sinus rhythm
B. Premature ventricular contractions
C. Potassium 3.2
D. BMI 20.1
A. sinus rhythm
C. potassium 3.2
What are some of the types of family dynamics that may predispose a person to antisocial personality disorder?
1. Chaotic home environment
2. Parental deprivation during the first 5 years of life
3. Separation due to parental delinquency appears to be more highly correlated with the disorder than parental loss from other causes
4. Presence or intermittent appearance of inconsistent impulsive parents, not the loss of a consistent parent, is environmentally most damaging
A nurse in a mental health facility is planning care for a client who has obsessive-compulsive disorder (OCD) and is newly admitted to the unit. Which of the following actions should the nurse plan to take regarding the client's compulsive behaviors?

A. Isolate the client for a period of time
B. Confront the client about the senseless nature of the repetitive behaviors
C. Plan the client's schedule to allow time for rituals
D. Set strict limits on the behaviors so that the client can conform to the unit rules and schedules
C. Plan the client's schedule to allow time for rituals
The nurse working with a client with antisocial personality disorder would expect which of the following behaviors
Exploitation of other clients, seeking special privileges, superficial friendliness towards others
A nurse is assessing an adolescent female client who has anorexia nervosa. Which of the following findings should the nurse expect?

A. Tachycardia
B. Constipation
C. Metrorrhagia
D. Hyperkalemia
B. Constipation
Which is a probable cause for dissociative identity disorder (DID) in a client?

1. Alcohol abuse
2. History of abuse as a child
3. Drug abuse and overmedication
4. Detachment with respect to surroundings
2. History of abuse as a child
The client's mother says, "My daughter is possessed by spirits which make her act differently." Which condition may the nurse suspect in this client?

1. Factitious disorder
2. Conversion disorder
3. Dissociative amnesia
4. Dissociative identity disorder
4. Dissociative identity disorder

Rationale:
Dissociative identity disorder in some cultures is described as an experience of possession. It is characterized by the presence of two or more personalities. As the client is said to behave differently, the nurse may suspect the client to be suffering from dissociative identity disorder
A nurse is caring for a newly admitted client who has obsessive-compulsive disorder (OCD). Which of the following actions should the nurse take first?

A. Discuss alternative coping strategies with the client
B. Identify precipitating factors for ritualistic behaviors
C. Intrust the client on relaxation techniques for use when anxiety increases
D. Provide a structured activity schedule for the client
B. Identify precipitating factors for ritualistic behaviors
Which medication is the first-line treatment of choice for clients with post-traumatic stress disorder (PTSD)? A. Fluoxetine B. Propranolol C. Alprazolam D. CarbamazepineA. Fluoxetine Rationale: Fluoxetine is a selective serotonin reuptake inhibitor (SSRI). SSRIs are considered the first line treatment of choice for PTSD due to their efficacy, tolerability, and safety ratingsWhich is the most appropriate nursing intervention for a client with a nursing diagnosis of risk for self-mutilation?After a traumatic event, a client reports paralysis in his left arm. The laboratory reports of the client indicate that there is no underlying organic pathology. Which disorder might the nurse suspect in this client? 1. Factious disorder 2. Conversion disorder 3. Illness anxiety disorder 4. Somatic symptom disorder2. Conversion disorderWhich therapy may help the client recognize and modify trauma-related thoughts? A. Group therapy B. Cognitive Therapy C. Prolonged exposure (PE) D. Eye movement desensitization and reprocessing (EMDR) therapyB. Cognitive therapyA nurse manager is discussing the care of a client who has a personality disorder with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?C. " I should practice limit-setting to help prevent client manipulation" Rationale: When caring for a client who has a personality disorder, limit-setting is appropriate to help prevent client manipulationA client is admitted with post-traumatic stress disorder following a fire in his home in which family members died. Which of the following should the nurse recognize as an adaptive defense mechanism? A. The client begins reading a book when he experiences hand tremors in response to loud noises B. The client makes a decision to postpone a needed surgery C. The client focuses on discussing his daily routine when asked about the fire D. The client develops stomach pains when fire is seen on televisionA. The client begins reading a book when he experiences hand tremors in response to loud noiseWhat does the nurse suspect in the client who is depressed, shows aggressive tendencies toward others, and destroys items without permission?Adjustment disorder with mixed disturbance of emotions and conduct Rationale: A client with adjustment disorder with mixed disturbance of emotions and conduct is depressed and shows disturbances in conduct such as violating the rights of others.The registered nurse is teaching a group of nurses about psychological trauma. Which statement would the registered nurse include in the lesson? A. "Dissociative amnesia may be related to neurological amnesia." B. "Traumatic experiences overcome the capacity to cope by any means other than dissociation." C. "Repressing distressed mental contents from conscious awareness may lead to dissociative behaviors." D. "Genetic factors of pathological and nonpathological dissociative capacity may be associated with dissociative identity disorder."B. "Traumatic experiences overcome the capacity to cope by any means other than dissociation."Once the physical condition is no longer life threatening, which statement is true regarding the treatment of choice for maladaptive eating behaviors?A nurse on the psychiatric unit is assessing a client who has moderate anxiety disorder. Which of the following findings should the nurse expect? A) Rapid speech B) Chills C) Distorted perceptual field D) Urinary frequencyD) Urinary frequencyWhich nursing intervention will the nurse provide to reduce the anxiety and maladaptive behavior of a client with somatic symptom disorder? A. Initially fulfilling the client's most urgent dependency needs B. Helping the client identify ways to achieve recognition from others C. Providing pain medication to the client as prescribed D. Accepting that the physical complaint is real, even though it is inaccurateA. Initially fulfilling the client's most urgent dependency needsA nurse is planning discharge for a client who has borderline personality disorder. Which of the following interventions should be included for this client? A. Dialectical behavior therapy B. Behavioral contract C. Bibliotherapy D. Safety planA. Dialectical behavior therapy Rationale: dialectical behavior therapy is appropriate for the treatment of clients with borderline personality disorder and is often part of the discharge planWhich of the following would you expect to see with a patient diagnosed with Acute Stress Disorder (Select all that apply)- intrusion -dissociative -avoidance -arousalSelect the therapy that involves a complex, eclectic treatment that combines the concepts of cognitive, behavioral, and interpersonal therapies with Eastern mindfulness practices.Dialectic Behavior TherapyThe nurse is preparing a care plan for a patient diagnosed with anorexia nervosa. Select the most appropriate nursing intervention for someone with this disorderA nurse is discussing comorbidities associated with eating disorders with a newly admitted client. Which of the following conditions should the nurse include in the discussion? (Select all that apply.)a. anxiety b. obsessive compulsive disorder e. depressionA nurse at a walk-in mental health clinic is assessing a client experiencing severe anxiety. The nurse should recognize the client might exhibit which of the following manifestations?Threatening Behavior Rationale: The client experiencing severe anxiety can have feelings of confusion and impending doom. The client may feel the need to be aggressive and defensive, speaking with loud, rapid speech and possibly making threats and demands of others.A client with antisocial personality disorder is, exhibiting behaviors that include manipulation of others to fulfill own desires, inability to form close personal relationships, a frequent lack of success in life events, passive aggressiveness, and overt aggressiveness. Which nursing diagnosis is most appropriate for this client?A nurse is caring for a client who has borderline personality disorder (BPD). As part of the client's plan of care, the nurse reviews the day's schedule with the client each morning. As the nurse begins to review the schedule with the client, the client says, "Why don't you shut up already? I can read it myself, you know!" Which of the following responses should the nurse give the client? A. "We do this every day. Why are you so angry with me this morning?" B. "I dont like it when you address me with that tone of voice." C. "I know you can, but are you going to read it or not?" D. "Fine. Here is the schedule, and I will expect you to be on time to your therapies."B. "I dont like it when you address me with that tone of voice." Rationale: BPD is described as an emotionally unstable personality. Clients who have BPD might show a wide range of impulsive behaviors in all aspects of their lives, including self-destructive behaviors. The client in this situation has overstepped a limit by addressing the nurse in a less-than-respectful tone of voice. This therapeutic response calls to the client's attention the inappropriate behavior and sets appropriate limits for further communication. This is the best approach to continue communication with this client.A nurse in the emergency department is caring for a client who reports chest pain, headache, and shortness of breath. He continues to state, "I don't know why my wife left me." The client receives a diagnosis of anxiety. The nurse realizes the client's findings support which level of anxiety? A) Mild B) Moderate C) Severe D) PanicC) SevereWhen planning care for a patient with PTSD, the all of following nursing intervention should be implemented except:Which medical conditions are empirically validated for eye movement desensitization and reprocessing (EMDR) psychotherapy? (select all that apply) A. seizures B. psychosis C. adjustment disorder D. acute stress disorder E. post-traumatic stress disorderD. acute stress disorder E. post-traumatic stress disorder ASD occurs after being the witness or victim of a natural or fabricated disaster, violent accident, or combat. EMDR is empirically validated in ASD.PTSD is accompanied by a natural or fabricated disaster, violent death, combat, or accident. EMDR is empirically validated in PTSD.All of the following physiological signs may be associated with the excessive vomiting of the purging syndrome EXCEPT:(These are all signs of excessive vomiting of the purging syndrome) -dehydration -electrolyte imbalance -erosion of tooth enamel -Some individuals develop calluses on the dorsal surface of their hands, typically on their knuckles, secondary to long term, repeated self-inducing vomiting.A nurse is caring for a client who is experiencing a crisis related to anxiety. Which of the following actions should the nurse take? (Select all that apply).Establish rapport with the client Identify the cause of the anxiety Validate the client's feelingsA nurse is planning care for a client who has generalized anxiety disorder. Which of the following intervention should the nurse implement to promote relaxation? A) Assist the client in practicing meditation. B) Recognize the client's spiritual preferences. C) Encourage the client to identify his positive qualities. D) Help the client to identify his previous accomplishments.A) Assist the client in practicing meditation.A client is diagnosed with disturbed personal identity in which one of the personalities is suicidal. Which nursing intervention would protect the client from self-harm? 1. Seeking assistance from a strong-willed personality 2. Helping the client to understand the existence of subpersonalities 3. Helping the client to identify stressful situations 4. Assisting the subpersonalities to understand that their existence will not be destroyed1. Seeking assistance from a strong-willed personalityA nurse is planning care for a client who has dependent personality disorder. Which of the following actions should the nurse plan to take? A. Monitor the client closely to prevent self-mutilation B. Set limits to prevent exploitation of other clients C. Discourage flamboyant or seductive behaviors D. Give positive feedback when client is assertive with staff or clientsD. Give positive feedback when client is assertive with staff or clients Rationale: The client who has dependent personality disorder has great difficulty demonstrating assertive behavior and commonly relies on others to make decisions. The nurse should encourage the client to be more assertive and independent.A nurse is assessing a client who has posttraumatic stress disorder (PTSD) following a sexual assault. Which of the following is an expected finding? A) Sleeping 12 hr or more each day. B) Increasing sense of attachment to others. C) Constant need to talk about the event. D) Increasing feelings of anger.D) Increasing feelings of angerA nurse is preparing a client who has chronic anxiety for discharge from the psychiatric unit. Which of the following instructions should the nurse include in the client's discharge plan? 1. contact the crisis counselor once a week 2. identify anxiety-producing situations 3. try to repress feelings of anxiety 4. eliminate stress and anxiety from daily life2. identify anxiety-producing situations Rationale: treatment for anxiety disorders includes helping the client recognize signs that her anxiety level is rising and the triggers that cause this type of reactionA nurse is caring for a client who was involved in heavy combat and observed war casualties. The nurse should suspect that the client is suffering from posttraumatic stress disorder (PTSD) if the client makes which of the following statements?"In my dreams, all I can see are the wounded reaching out and trying to grab me."A nurse on an inpatient eating disorders unit is caring for a client who has anorexia nervosa and has a body mass index of 17.2. Which of the following actions should the nurse take? (Select all that apply.) a. Provide the client with small meals frequently. b. Monitor the client's weight daily. c. Allow the client to choose the meals she will eat. d. Stay with the client during meals and for 1 hr after. e. offer specific privileges for sustained weight gain.a. Provide the client with small meals frequently. b. Monitor the client's weight daily. c. Allow the client to choose the meals she will eat. d. Stay with the client during meals and for 1 hr after.Which of these does the psychodynamic theory of conversion disorder propose? 1. Increased incidence is seen in first degree relatives 2. Increased incoming sensory stimuli produce a deficiency of endorphins. 3. Aberrant behaviors associated with the disorder may be due to impairment in information processing. 4. Emotions related to a traumatic event that are not expressed due to moral unacceptability are converted into physical symptoms.4. Emotions related to a traumatic event that are not expressed due to moral unacceptability are converted into physical symptoms.A nurse is caring for an adolescent client who has anorexia nervosa with recent rapid weight loss and a current weight of 90lb. Which of the following statements indicates the client is experiencing the cognitive distortion of personalization? A. "Life isn't worth living if I gain weight." B. "Don't pretend like you don't know how fat I am." C. "If I could be skinny, I know I'd be popular." D. "When I look in the mirror, I see myself as obese."A. "Life isn't worth living if I gain weight." Rationale: This statement reflects the cognitive distortion of catastrophizing because the client'sperception of her appearance or situation is much worse than her current condition.The wife of a client complains that her husband has been found wandering far from home and is sometimes unable to recall information about himself. Which would the nurse suspect as a diagnosis for this client? 1. Dissociative fatigue 2. Conversion disorder 3. Somatic symptom disorder 4. Dissociative identity disorder1. Dissociative fatigueA client is diagnosed with depersonalization-derealization disorder. Which outcome would the nurse expect while planning care for this client? 1. The client can recall all events of his life. 2. The client verbalizes understanding regarding the existence of multiple personalities. 3. The client can demonstrate more adaptive coping strategies to avert dissociative behaviors. 4. The client effectively uses adaptive coping strategies during stressful situations without resorting to physical symptoms.3. The client can demonstrate more adaptive coping strategies to avert dissociative behaviors.A nurse is caring for a client who has anorexia nervosa and overexercises to avoid gaining weight. Which of the following nursing actions should the nurse take?Ask the client to agree to talk to a nurse whenever she feels the urge to exerciseA nurse in an emergency department is assessing a client who has traumatic injuries following an assault. The client sits quietly and calmly in the examination room and states, "I'm fine." The nurse should recognize the client's behavior as which of the following reactions?DenialThe worried mother of an adolescent girl with psychiatric illness says, "She injures her little brother and brings him to me, as if she is very concerned about him." Which psychiatric illness could be suspected in this client? 1. Factitious disorder 2. Illness anxiety disorder 3. Somatic symptom disorder 4. Functional neurological symptom disorder1. Factitious disorderJan presents in the emergency room with complaints of suicidal ideation. The following data is collected by the nurse. Which of these assessment findings suggests that bulimia nervosa might be a health problem? (select all that apply) a. Parotid glands appear enlarged. b. teeth have a "moth eaten" pattern of tooth decay. c. reports that she takes laxatives daily. d. weight is within the expected range.a. Parotid glands appear enlarged. b. teeth have a "moth eaten" pattern of tooth decay. c. reports that she takes laxatives daily. d. weight is within the expected range.A nurse is caring for a young adult client who says he is experiencing increased anxiety and an inability to concentrate. Which of the following responses should the nurse make?It sounds like you are having a difficult timeA nurse is caring for a client who has paranoid personality disorder. Which of the following findings should the nurse expect? (Select all that apply) A. Believes that others are deceiving him B. Desires to be the center of attention C. Views himself as inferior to others D. Demonstrates a grandiose sense of self-importance E. Persistently holds onto grudgesA. Believes that others are deceiving him E. Persistently holds onto grudges Rationale: A client who has a paranoid personality disorder believes, without evidence, that others are deceiving him and worries constantly about trusting those that are close to him. A client who has histrionic personality disorder always desires to be the center of attention, has shallow expression of emotions, and demonstrates self-dramatization. A client who has avoidant personality disorder views himself as inferior to others, worries constantly about being criticized, and does not fully engage in new interpersonal relationships. A client who has narcissistic personality disorder has a grandiose sense of self-importance, lacks empathy, and has a sense of entitlement. A client who has a paranoid personality disorder persistently holds onto grudges and finds hidden demeaning meanings in benign remarks.