Psych exam 1 practice questions
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45 Terms
A nurse in an outpatient mental health clinic is preparing to conduct an initial client interview. When conducting the interview, which of the following actions should the nurse identify as the priority?
Identify the client's perception of their mental health status
3 multiple choice options
A person called 911 reporting people were controlling their mind with microwaves. Which psychiatric symptom best describes the person's experience of "microwaves"?
Delusion
3 multiple choice options
Which intervention would the nurse perform first while caring for a client who has extreme suspiciousness due to paranoid delusions?
Encourage the client to communicate what they are feeling
3 multiple choice options
A client with schizophrenia says to the nurse, "My dad in heaven is telling me to go to New York." What is the best response of the nurse in this situation?
"Even though the voice are real to you, I am unable to hear any voices speaking."
3 multiple choice options
A client newly admitted to the psychiatric unit reports they have been seeing visions of them killing their parents. What should be the nurse’s first intervention?
Assess the client's safety toward self and others
3 multiple choice options
The nurse is interviewing a client on the psychiatric unit. The client tilts their head to the side, stops talking in mid-sentence, and listens intently. The nurse recognizes from these signs that the client is likely experiencing which of the following?
Auditory hallucinations
3 multiple choice options
A client displaying loose associations is overstimulated on the psychiatric unit and the nurse cannot understand what they are trying to say. What are appropriate interventions to help the situation?
[Select all that apply]
Talk in clear, concise sentences, Restate to the client what you do understand the client is saying, and Take the client to their room and lower the lights in the client's room
2 multiple choice options
The nurse placed a client with a diagnosis of catatonia in a chair with a plate with utensils in front of the client. The client is mute, grimacing, and keeps picking the fork up and then putting the fork back down. What is the most helpful nursing action?
Put food on a utensil, bring it to the client's mouth, and ask them to chew and then swallow the food
3 multiple choice options
The nurse is caring for a client with schizophrenia. Orders include 5 mg haloperidol (Haldol) IM STAT and then 2 mg benztropine (Cogentin) PO BID PRN. Because benztropine was ordered on a PRN basis, what is the need for this medication?
If the client develops muscle spasms.
3 multiple choice options
A client started the long-acting injectable form of haloperidol (Haldol Decanoate) a week ago. They are diaphoretic and not responding to questions. The client’s vital signs are as follows: BP 170/100, P 110, T 104.2°F. What is the priority nursing intervention?
Hold all antipsychotics and contact the health care team immediately
3 multiple choice options
Which of the following action is required to dispense clozapine (Clozaril) to a client?
[Select all that apply]
White blood cell count is assessed biweekly after six months, Initially only a 1-week supply of clozapine is dispensed at a time, Absolute neutrophil count is assessed weekly when treatment is initiated
The nurse is educating the family of a client diagnosed with schizophrenia about the importance of antipsychotic medication compliance. Which statement indicates that learning has occurred?
"My brother is less likely to relapse if he takes the medication, but it can still happen."
3 multiple choice options
Which nursing intervention would assist the client experiencing bothersome hallucinations with medication adherence?
Reminding the client that the medication addresses the bothersome hallucinations.
3 multiple choice options
A client has been compliant with risperidone (Risperdal) 4 mg QHS for the past year. On assessment, the nurse notes that the client has bizarre facial and tongue movements. Which is a priority nursing intervention?
Notify the health care team that you noticed abnormal, involuntary movements.
3 multiple choice options
A client is prescribed aripiprazole (Abilify) 10 mg QAM. The client complains of sedation and dizziness. The client’s vital signs are blood pressure 100/60 mm Hg, pulse 80, respiration rate 20, and temperature 97.4°F. Which nursing diagnosis takes priority?
Risk for injury R/T orthostatic hypotension.
3 multiple choice options
A nurse is assessing a client in the mental health clinic 6 months after the client's discharge from in-patient psychiatric treatment for schizophrenia. The client has no active symptoms but has a flat affect and has recently been placed on disability. What should the nurse document?
"The client is not acutely psychotic but is displaying the negative symptom of diminished facial expression."
3 multiple choice options
A client taking olanzapine (Zyprexa) has a nursing diagnosis of altered sensory perception R/T command auditory hallucinations. Which outcome would be appropriate for this client's problem?
The client will notify staff members of bothersome hallucinations.
3 multiple choice options
A client states to the nurse, "I see headless people walking down the hall at night." Which nursing response is appropriate?
"It must be frightening. I realize this is real to you, but I don't see headless people here."
3 multiple choice options
A client is in the active phase of schizophrenia and is paranoid. Which nursing intervention would aid in facilitating other interventions?
Assign consistent staff members.
3 multiple choice options
Which of the following are functions of assertive community treatment (ACT)?
It promotes continuity of outpatient care, reduces the use of inpatient services, and increases the stability of people with serious mental illness
2 multiple choice options
Which patient would a nurse refer to partial hospitalization? An individual who:
states, "I'm not sure I can avoid using alcohol when my spouse goes to work every morning."
3 multiple choice options
Primary prevention in a community mental health setting is exemplified by which of the following concepts?
Teaching physical and psychosocial effects of stress to elementary school students.
3 multiple choice options
Which statement describes secondary prevention within communities?
It relates to using early detection and prompt intervention with individuals experiencing mental illness symptoms.
3 multiple choice options
Which nursing intervention within the community is aimed at reducing the residual defects that are associated with severe or chronic mental illness?
Helping patients connect to various aftercare services such as day treatment programs.
3 multiple choice options
Which activity of the community nurse is aimed at reducing the incidence of mental disorders within the population?
Organizing a training program for elementary school students about the psychosocial effects of drugs
3 multiple choice options
Inpatient psychiatric care focuses on all the following except:
Independent living skills
3 multiple choice options
A nurse manager on a mental health unit is discussing involuntary admissions during a staff meeting. Which of the following statements should the manager include in the discussion?
"Clients who are involuntarily admitted have the right to informed consent."
3 multiple choice options
A nurse is caring for a client admitted to a mental health facility who states, "I don't want to go to the electroconvulsive therapy (ECT) treatment scheduled for tomorrow." Which of the following should be the nurse's response?
"You have the right to refuse the treatment."
3 multiple choice options
The nurse is using the nursing process to care for a patient who is suicidal. Which of the following nursing action is a part of the diagnosis step of the nursing process?
Identifies patient as "At risk for suicide"
3 multiple choice options
The nurse is using the nursing process to care for a patient who is suicidal. Which of the following nursing action is a part of the planning outcomes step of the nursing process?
Identifies that the "Patient will not harm self during hospitalization"
3 multiple choice options
The nurse is using the nursing process to care for a patient who is suicidal. Which of the following nursing action is a part of the implementation step of the nursing process?
Collaborates with the patient to create a safe environment for the patient
3 multiple choice options
The nurse is using the nursing process to care for a patient who is suicidal. Which of the following nursing action is a part of the evaluation step of the nursing process?
Determines if nursing interventions have been appropriate to achieve desired results
3 multiple choice options
As a nurse prepares to administer a medication to a patient, the patient says, "Just leave it on the table. I'll take it when I finish combing my hair." What is the nurse's best response?
Say to the patient, "I must watch you take the medication. Please take it now."
3 multiple choice options
A newly admitted client asks, “Why do we need a unit schedule? I don’t need to go to the coping skills group. I am here to get some rest.” Which is the most appropriate nursing reply?
"Group therapy allows people to come together and gives you the opportunity to practice coping skills."
3 multiple choice options
Which is the overall, priority goal of in-patient psychiatric treatment?
Stabilization and return to the community.
3 multiple choice options
A psychiatric home health nurse received an order to begin regular visits to a depressed 78-year-old patient who lives alone. Which of the following criteria would qualify the patient for home health visits?
The patient is too physically weak to travel without risk of injury.
3 multiple choice options
Which of the following is / are true statement(s) about mental health recovery?
Mental health recovery serves to empower to the patient, is a collaborative process between the nurse and patient, and involves hope because hope gives people the determination to reach their goals
2 multiple choice options
Which outcome, focused on recovery, would be expected in the plan of care for a patient living in the community and diagnosed with a severe persistent mental illness? Within 3 months, the patient will:
report a sense of well-being.
3 multiple choice options
A patient taking chlorpromazine (Thorazine) has a heart rate of 110, blood pressure of 160/92 mm Hg, and temperature of 103.5°F. Which nursing intervention takes priority?
Hold the next dose of chlorpromazine (Thorazine), and call the physician immediately to report the findings.
3 multiple choice options
A nurse is providing discharge teaching for a patient who has schizophrenia and a new prescription for olanzapine (Zyprexa). Which teaching point should the nurse stress?
"Journal your food intake, track your exercise, and monitor your weight while on this medication."
3 multiple choice options
A patient prescribed clozapine (Clozaril) has a nursing diagnosis of risk for injury R/T falls. Which nursing intervention appropriately addresses this patient's problem?
Monitor orthostatic changes in blood pressure.
3 multiple choice options
A nurse is caring for a patient who has schizophrenia and exhibits a lack of grooming and a flat affect. The nurse should expect a prescription for which of the following medications?
Ziprasidone (Geodon)
3 multiple choice options
Which second-generation antipsychotic requires routine absolute neutrophil count monitoring?
Clozapine (Clozaril)
3 multiple choice options
A client has been compliant with risperidone (Risperdal) 4 mg QHS for the past year. On assessment, the nurse notes that the client has bizarre facial and tongue movements. Which is a priority nursing intervention?
Notify the health care team that you noticed abnormal, involuntary movements.
3 multiple choice options
A nurse is assessing a client in the mental health clinic 6 months after the client's discharge from in-patient psychiatric treatment for schizophrenia. The client has no active symptoms but has a flat affect and has recently been placed on disability. What should the nurse document?
"The client is not acutely psychotic but is displaying the negative symptom of diminished
facial expression."
3 multiple choice options