Chapter 09: Mental Health, Violence, and Substance Use Disorder

A nursing instructor is discussing mental health assessment with a class of nursing students. While reviewing risk factors for mental illness, what would the instructor be sure to identify as a factor that cannot be changed?

A. Age

The nurse is admitting a client to the hospital following a motor vehicle collision in which alcohol may have been a contributing factor. What tool might the nurse use to assess whether alcohol is a problem in this client's life?

C. CAGE

The nurse suspects substance abuse in an adult client who has been admitted to the emergency department following a motor vehicle collision. What is the reason the nurse would administer the CAGE tool to this client?

D. The CAGE tool addresses the client's denial

When a nurse asks a client "Do you have any thoughts of wanting to harm or kill yourself?" for what is the nurse assessing?

C. Suicide risk

While assessing a new client in the clinic area, the nurse administers the SAD PERSONAS. For what is the nurse most likely assessing?

D. Risk of suicide

The nurse is assessing a client in the clinic who reports hearing "voices." What would be the most important assessment to make?

A. The nature of the voices

What collection of factors are the most common causes for visual hallucinations?

B. Medication side effects, alcohol withdrawal, and Parkinson's disease

The nursing instructor talks with the student nurse on the adult psychiatric unit. The student tells the instructor that cradle cap appears to be around a specific client's face. The instructor explains that this may be an indication of long-term lack of care because of what disorder?

D. Schizophrenia

An adult arrives at the psychiatric clinic in an unkempt state. An assessment notes clubbed fingers and nicotine stained fingertips. The client's history includes emphysema. What nursing diagnosis might the nurse use in this client's plan of care?

A. Poor cognition related to poor oxygenation

A nurse is conducting a mini-Cog examination (MMSE) on an older adult client. What is this nurse assessing for? (Select all that apply.)

C. Recall

D. Language

E. Registration

When administering a mini-Cog examination (MMSE), what score would indicate cognitive impairment?

D. 23 or less

The nurse notes an acute change in an adult client's mental status. The client has gone from being coherent and oriented to person, place, and time to having very disorganized thought processes. The client has become delirious. What are the possible effects of delirium on the client?

C. Increased risk for suicide

The nurse notes that a client's conversation is often incoherent and wandering, with thoughts that seem illogical and inconsistent. What would these abnormal indications signify to the nurse?

A. The client is thinking less efficiently

A client reports, "bugs are crawling under my skin." The nurse knows that this tactile hallucination is usually associated with what?

B. Methamphetamine use

What type of family violence is among the most common type that children experience?

B. Sibling violence

A woman comes to the emergency department with a broken humerus. The client lives in an area with a high crime rate and low socioeconomic demographic. During the examination, the client states, "I was fighting with my husband. He pushed me and I fell, landing on the coffee table. That is how I broke my arm." Why might this client be so forthcoming in her disclosure of violence?

A. Decreased social stigma about violence

What open-ended question might be helpful when assessing abuse with a client demonstrating discomfort discussing the issue?

D. "What would you like me to know?"

During the assessment of an adult woman at the clinic, the nurse finds indications that the client is a victim of abuse. When documenting findings, the nurse knows that it is important to be what? (Select all that apply.)

C. Descriptive

D. Non-biased

E. Detailed

An older adult client confined to a wheelchair is admitted to the hospital after a fall down a flight of stairs. The client is found to have multiple abrasions and bruises in various stages of healing. Abuse is suspected, and an Elder Assessment Inventory is performed. For what risk factors is the nurse assessing? (Select all that apply.)

A. Strained mental health of caregiver

B. Financial issues

C. Cognitive decline

A caregiver brings a handicapped client to the ED reporting the presence of an altered level of consciousness and the client's refusal to eat. When the client is found to be severely dehydrated, the nurse suspects neglect and asks the caregiver several questions regarding the client's activities, diet, and care. The caregiver states, "I didn't know it could hurt him if he didn't drink anything." This is an example of what kind of abuse?

C. Unintentional

Nursing students are learning about human violence. The instructor is explaining key differences among various forms and how the differences affect assessment and intervention. What would the instructor explain is a key difference between violence against older adults and intimate partner violence?

A. Perpetrator

Who are the major perpetrators of human trafficking?

C. Individuals who own and manage commercial "sex trade" businesses

What qualities does the type of aggression called "punking" or "bullying" have? (Select all that apply.)

B. The behavior is intended to shame the victim.

C. The behavior can be both physically and verbally abuse.

D. The behavior occurs in public.

E. Is common in middle school and high school.