Chapter 56. Mental Health Function, Assessment, and Therapeutic Measures My Nursing Test Banks

Chapter 56. Mental Health Function, Assessment, and Therapeutic Measures

Multiple Choice
Identify the choice that best completes the statement or answers the question.

____ 1. A patient with a suspected mental health disorder having blood drawn to check electrolyte levels asks what blood work have to do with mental health. Which response by the nurse is correct?
a. Electrolyte imbalances are the cause of certain mental health disorders.
b. Some mental health disorders cause the electrolytes to be out of balance.
c. The doctor wants to make sure your symptoms are not caused by a physical problem.
d. People with mental illnesses frequently take illicit drugs that can cause electrolyte imbalances.
____ 2. The nurse is assisting a patient identify coping mechanisms. What general definition of coping is the nurse most likely using with this patient?
a. The way one adapts to a stressor
b. The adaptation to mental health problems
c. The use of specific mechanisms to reduce anxiety
d. The development of unconscious behaviors to reduce psychological distress
____ 3. A student feels anxious about being unprepared for an upcoming test. Which action is a positive response to this anxiety?
a. Canceling nonessential activities for 3 days to study
b. Staying up all night the night before the test to study
c. Borrowing notes from another student who has had the class in the past
d. Choosing not to worry about studying because grades have been good so far
____ 4. A patient who has been diagnosed with a mental illness tells the nurse about plans to find a voodoo doctor. How should the nurse respond?
a. You know voodoo doctors cant really help you. Dont waste your money.
b. Be sure to mention your plan to your psychiatrist. It is important to follow up with that treatment plan also.
c. Research has shown that voodoo can effectively treat many mental health disorders. That decision is up to you.
d. I do not think using voodoo is safe. I would recommend you think about it carefully before contacting a voodoo doctor.
____ 5. After being admitted for a surgical procedure a patient with a history of schizophrenia becomes extremely agitated when other patients are around and believes that others want to cause the patient harm. Which intervention should the nurse use to provide a therapeutic milieu for the patient?
a. Place the patient in a private room.
b. Request an order for antipsychotic medications.
c. Help the patient clarify the meaning of the feelings.
d. Suggest the patient be scheduled for a psychotherapy session.
____ 6. A patient recovering from electroconvulsive therapy (ECT) for severe depression is confused and wants to know what has been done. What action by the nurse is best?
a. Administer a sedative to help calm the patient.
b. Call the physician and report the patients response.
c. Explain that the patient is in the hospital and has just had ECT.
d. Encourage the patient to go back to sleep until the pre-procedure medication has worn off.
____ 7. A student is angry about failing a test at school and accuses the teacher of trying to fail everyone. What type of response is the student demonstrating?
a. Anger
b. Denial
c. Projection
d. Repression
____ 8. After talking with a patient being evaluated for a mental health disorder, the nurse says, It sounds as if you are feeling angry. Which therapeutic communication technique is the nurse employing?
a. Restating
b. Reflecting
c. Giving recognition
d. Offering a general lead
____ 9. During initial assessment of mental health status, the nurse asks a patient to interpret a familiar proverb and explain what it means. Which area/aspect of the patients mental status is the nurse assessing?
a. Memory
b. Judgment
c. Mood and affect
d. Level of awareness and orientation
____ 10. A young mother is angry with the mess her son has made in his room. She yells at him and tells him to stay in his room until it is cleaned up. About 20 minutes later, the mother enters the boys room offering him milk and cookies. Which ego defense mechanism is the mother using?
a. Restitution
b. Regression
c. Reaction formation
d. Conversion reaction
____ 11. A patient with schizophrenia states, Im going to the fribity to see a megnat. What term should the nurse use to describe this language?
a. Imagery
b. Soliloquy
c. Neologisms
d. Conversions
____ 12. While providing care a teenage mother expresses ambivalence about her new role as a parent. Which response by the nurse is best?
a. Ill call the social worker so you can discuss adoption.
b. Tell me more about how you feel when you hold the baby.
c. Parenthood is certainly not for everyone, you shouldnt feel guilty about that.
d. Im sure your own parents felt the same way when you were small, you should talk to your mom.
____ 13. During a mental status assessment a patient cannot remember the name of a childhood neighborhood. In which aspect of the assessment is the patient demonstrating an alteration?
a. Speech
b. Memory
c. Orientation
d. Mood and affect
____ 14. Staff on a mental health unit routinely uses positive and negative reinforcement when caring for patients with mental health disorders. What needs to be done before the staff can implement these approaches?
a. Have a health care provider order to use the approaches.
b. Ensure all patients have medication orders for sedatives.
c. Place a set of 4 point restraints within each patients room.
d. Have the patient sign a consent form agreeing to this approach.
Multiple Response
Identify one or more choices that best complete the statement or answer the question.

____ 15. The nurse is preparing to establish a relationship with a newly admitted patient. On which qualities should the nurse focus when creating this nursepatient relationship? (Select all that apply.)
a. Humor
b. Respect
c. Honesty
d. Empathy
e. Sympathy
f. Friendship
____ 16. The nurse is caring for a patient experiencing anxiety. Which techniques should the nurse use when instructing on progressive muscle relaxation therapy? (Select all that apply.)
a. Start at the head and neck.
b. End with the lower extremities.
c. Play soft music to aid with relaxation.
d. Systematically tense and relax muscle groups.
e. Imaging a pleasurable experience from the past.
____ 17. The nurse is caring for a patient who is verbalizing concerns related to a difficult relationship. Which responses by the nurse will block communication and should be avoided? (Select all that apply.)
a. Using silence
b. Asking why
c. Changing the subject
d. Agreeing or disagreeing
e. Verbalizing the implied
____ 18. The nurse is caring for a patient experiencing depression. Which neurotransmitters should the nurse consider being decreased in this patient? (Select all that apply.)
a. Serotonin
b. Dopamine
c. Substance P
d. Acetylcholine
e. Norepinephrine
____ 19. After collecting data the nurse is concerned that a patient is at risk for developing a mental illness. What findings caused the nurse to come to this conclusion? (Select all that apply.)
a. Difficulty thinking
b. Discussed the use of daily exercise to deal with stress
c. Made statements indicating being out of touch with reality
d. Expressed remorse in having to leave a pet dog with a neighbor
e. Explaining a lack of friends because everyone is jealous of the patient
____ 20. A patient diagnosed with a mental illness is being considered for psychotherapy. What should the nurse realize are the goals for this treatment? (Select all that apply.)
a. Relaxing the body
b. Improve social interactions
c. Clarify the meaning of events
d. Reduce emotional discomfort
e. Enhance performance in situations
____ 21. The nurse is visiting the home of a patient with a mental health disorder. What should the nurse ensure during this home visit? (Select all that apply.)
a. Status of suicide ideation
b. Ability to provide self-care safely
c. Patients risk of falling in the home
d. Number of family members who visit
e. Compliance with prescribed medications

Chapter 56. Mental Health Function, Assessment, and Therapeutic Measures
Answer Section

MULTIPLE CHOICE

1. ANS: C
Some mental health symptoms can be caused by physical illness. Laboratory tests are done to rule out problems such as electrolyte imbalances, hypothyroidism, infections, dehydration, drug toxicity, or pregnancy. A. B. Electrolyte imbalances can cause symptoms but do not cause mental illness. D. There is no evidence in the question that the patient takes illicit drugs.

PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application

2. ANS: A
Coping is the way one adapts psychologically, physically, and behaviorally to a stressor. B. C. D. These statements might be a part of coping however does not capture the best general definition.

PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application

3. ANS: A
Canceling nonessential activities to study helps the student reach the goal of knowing the information and passing the test. A. Not worrying will not help the student pass the test. B. Staying up all night will cause the student to be tired and not think clearly. C. Borrowing notes may help but is not as reliable as a book or other good study habits.

PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application

4. ANS: B
Giving advice is not the role of the nurse. The nurse can help the patient to explore options or focus thinking. In this instance, the nurse can refer the comment to the psychiatrist, who is licensed to make treatment recommendations. A. D. These statements imply that the nurse knows what is best. C. This statement does not strengthen the patient-care provider relationship.

PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application

5. ANS: A
A therapeutic milieu is an environment that provides containment, support, structure, involvement, and validation during the patients stay. In this case, it will help keep the patient psychologically safe while undergoing care for a physiological problem. B. The patient is likely already receiving antipsychotic agents. C. D. Psychotherapy and exploring feelings are not the priority at this timekeeping the patient safe for surgery is the priority.

PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application

6. ANS: C
The patient may feel confused and forgetful immediately after ECT. This can be from a combination of the ECT and the medication that was used before the treatment. A. B. D. The nurse should be truthful in responding to the patients questions. These responses avoid and do not answer the patients question.

PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application

7. ANS: C
Projection is blaming others. It is a mental or verbal finger-pointing at another for the patients own problem. D. Repression is an unconscious burying or forgetting mechanism. B. Denial is an unconscious refusal to see reality. A. Anger is a response, usually to a perceived threat.

PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis

8. ANS: A
Restating is a therapeutic communication technique that repeats the main idea of what the patient has verbalized. D. A general lead is a statement such as I see . . . or Go on . . . B. Reflecting refers a statement or question back to the patient. C. Giving recognition acknowledges something the patient has done.

PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis

9. ANS: B
Judgment refers to a patients ability to make appropriate decisions about his or her situation or to understand concepts and is often tested by asking the meaning of a proverb. D. Awareness and orientation are assessed by asking questions related to person, place, and time. A. Memory is tested by asking the patient to recall recent or remote events. C. Mood and affect are assessed by determining if the patients expression, body language, and emotional condition match the patients circumstances.

PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application

10. ANS: A
Restitution attempts to make amends for a behavior one thinks is unacceptable, to reduce feelings of guilt. B. Regression is turning to an earlier, less stressful time in life. C. Reaction formation involves developing a trait or belief that is opposite to something the patient cannot have (overcompensation). D. A conversion reaction channels psychological discomfort into physical symptoms.

PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis

11. ANS: C
Words that the patient makes up are called neologisms. A. B. D. These terms do not describe the action of the patient making up words.

PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application

12. ANS: B
Therapeutic communication is accomplished through the deliberate use of verbal and nonverbal techniques. The technique of focusing involves concentrating on a single idea or event, in this instance, how the young woman feels when she holds the infant. A. C. D. The other responses are not patient focused, are closed-ended, and do not exemplify therapeutic communication techniques.

PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application

13. ANS: B
The patient is demonstrating an alteration in memory. Inability to accurately perform long-term recall exercises may indicate symptoms of delirium or dementia. A. Speech is the appropriate use of words and terms. C. Orientation is an assessment of present place, person, and time. D. Mood and affect are the objective and subjective assessment of the patients stated feelings and emotions.

PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis

14. ANS: D
The use of positive and negative reinforcement is a type of behavior management. The staff must be sure to avoid violating the Patients Bill of Rights when performing behavior management with patients. A signed consent from the patient is advised when using this form of therapy. A. The health care provider (HCP) does not need to specifically order these approaches. B. Medications for orders are not needed before implementing these approaches. C. Restraints need to be prescribed by an HCP before using.

PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application

MULTIPLE RESPONSE

15. ANS: B, C, D
Three qualities are essential for caregivers: empathy, which is the ability to identify with the patients feelings without actually experiencing them with the patient; unconditional positive regard (respect); and genuineness or honesty. E. F. Friendship and sympathy (feeling sorry for the patient) are not necessarily therapeutic. A. Humor may not be perceived as intended by patients with mental health disorders and is best used cautiously.

PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application

16. ANS: B, D, E
For progressive muscle therapy, patients are taught to start at the head and neck and systematically tense and then relax muscle groups as they progress toward the lower extremities. Soft music may enhance the patients ability to fully relax. E. Imaging a pleasurable experience from the past is used in guided imagery.

PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application

17. ANS: B, C, D
Asking why, changing the subject, and agreeing or disagreeing can block communication. A. E. Appropriate use of silence and verbalizing the implied are therapeutic.

PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis

18. ANS: A, B, D
Norepinephrine, dopamine, and serotonin may be decreased in depression. C. D. Acetylcholine and substance P may be increased.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

19. ANS: A, C, E
Mental illness can be defined as experiencing impaired ability to think, difficulty coping with reality, and difficult forming personal relationships. B. D. These findings indicate a strong mental health.

PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis

20. ANS: B, D, E
The goals of psychotherapy include reduce the patients emotional discomfort, increasing the level of the patients social functioning, and increasing the ability of the patient to behave or perform in a manner appropriate to the situation. A. Body relaxation occurs with progressive muscle relaxation therapy. C. Clarifying the meaning of events occurs in psychodynamic therapy.

PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis

21. ANS: A, B, C, E
When making a visit to the home of a patient with a mental health disorder, the nurse should analyze the patients level of suicide ideation including a plan, means, or access to something to use to commit suicide, the ability to provide self-care safely or the need for additional services, the patients risk of falling in the home, and ability to comply with prescribed medication regime. D. The number of family members who routinely visit the patient is not essential during the nurses home visit.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Application

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