Mental Health Chap 9

The nurse asks the client a series of questions upon entry into a mental health care system. This action is an example of which phase of the nursing process?

a. Evaluation

b. Assessment

c. Intervention

d. Planning

b

A nurse administers antidepressant medication to a client in an assisted-living facility. This is an example of which phase of the nursing process?

a. Intervention

b. Assessment

c. Planning

d. Diagnosis

a

Following completion of a male clients series of group therapy sessions, the nurse periodically talks with the client to determine whether he has any signs of relapse of his previous problems. This action by the nurse is an example of:

a. Planning

b. Assessment

c. Intervention

d. Diagnosing

b

During a session with a female client with a diagnosis of social phobia, she talks about how proud she is of herself because she was finally able to shop at the grocery store. The nurse documents the events and knows that this would be considered which phase of the nursing process?

a. Assessment

b. Planning

c. Intervention

d. Evaluation

d

The treatment team meets with a client for the first time and determines, with the clients input, a nursing diagnosis, goal, and steps to reach this goal. In addition to a nursing diagnosis, the treatment team has completed which phase of the nursing process?

a. Evaluation

b. Intervention

c. Planning

d. Assessment

c

Without assessment of six specific aspects of an individuals being, the mental health nurses scope of care is narrow and limited in effectiveness. These aspects include social, physical, cultural, intellectual, emotional, and spiritual areas of a persons life, known as a(n) __________ assessment.

a. Complete

b. Accurate

c. Holistic

d. Psychiatric

c

The nurse is reviewing information regarding a female client that was obtained with the psychiatric assessment tool. The clients ability to provide food and shelter for herself is included in which area of the assessment?

a. Appraisal of health and illness

b. Coping responses, discharge planning needs

c. Knowledge deficits

d. Previous psychiatric treatment

b

During an interview with a 15-year-old female client admitted for depression, the nurse expresses her disappointment when she to learns that the client recently became pregnant and then had an abortion. The nurse is contradicting the effective interview guideline of:

a. Paying close attention to the clients nonverbal communication

b. Avoiding making assumptions

c. Avoiding ones personal values that may cloud professional judgment

d. Setting clear client goals

c

A male client with a history of schizophrenia was admitted to the mental health facility after he was found on the street in a confused state and was uncooperative when approached by the police. One of the first assessments that should be performed on this client upon admission is a _____ assessment.

a. Physical

b. Sociocultural

c. Psychosocial

d. Psychiatric

a

During the mental status examination, the nurse observes that the client rapidly changes from one idea to another related thought. Which disordered thinking process is the client displaying?

a. Delusions

b. Perseveration

c. Confabulation

d. Flight of ideas

d

When reviewing the nursing notes from the previous shift, the nurse notices notations indicating that the client was experiencing a somnolent level of consciousness. The clients behavior would be described as:

a. Falling asleep easily and only awakening with strong verbal stimuli

b. Frequently sleeping and awakening only to strong physical stimuli

c. Unresponsive to any verbal or painful stimuli

d. Having alternating periods of excitability and drowsiness

a

During the mental status assessment, the nurse hands the client a piece of paper that reads Please raise your left hand. If the client follows the command, the nurse has just assessed which ability of the client?

a. Abstract thinking

b. Reading

c. General knowledge

d. Memory

b

According to the DSM-IV-TR Axis guidelines, clinical disorders are described as:

a. Dependent, antisocial personality disorders, and levels of retardation

b. Educational, housing, legal, and economic problems

c. Heart and digestive disorders

d. Mood disorder, substance abuse, and schizophrenic disorders

d

A score of 1 to 10 on the global assessment functioning (GAF) scale would indicate that a client was at risk for:

a. Mild difficulty in focusing

b. Mild difficulty in handling social situations

c. Hurting himself or others

d. Serious impairment in social and occupational functioning

c

A client with a history of delusions demonstrates which of the following behaviors?

a. Shifts from laughing to crying with no apparent cause

b. Insists the government is out to harm them

c. Has trouble remembering what he had for breakfast

d. Expresses a constant fear of dying

b

A client complains to the nurse that he has been fired from his fourth job in 10 months because his bosses and co-workers didnt understand him. While he once had a few close friends, he no longer associates with them for the same reason. His level of functioning on the global assessment of functioning (GAF) scale would be:

a. 71-80; transient symptoms

b. 61-70; some mild symptoms

c. 41-50; serious symptoms

d. 1-10; persistent danger of hurting self or others

c

The nurse suspects the client is experiencing a manic episode based on which of the following observations?

a. Clothing is very colorful and mismatched, and client cannot sit in chair during interview.

b. Hair is not combed, clothing is dirty, and client has no interest in surroundings.

c. Client repeatedly washes her hands and picks at a button on her shirt.

d. Client expresses fear that someone is waiting outside the room to harm her.

a

A client seen in the emergency department is noted to be stuporous. Which of the following assessment findings would be of most concern?

a. Elevated blood pressure

b. Elevated cholesterol levels

c. New exercise routine

d. Painting furniture in a windowless room

d

Upon entrance into a mental health care system, clients are thoroughly assessed, and this is followed by the development of a mental health treatment plan. Which of the following are purposes of the treatment plan? (Select all that apply.)

a. Proof of care for insurance reimbursement purposes

b. A means of monitoring the clients progress

c. An instrument for communication and coordination of care

d. A guide for planning and implementation of care

e. Evaluating the effectiveness of interventions

b, c, d, e

The assessment phase of the nursing process refers to the phase when data collection occurs. Which methods does the nurse use to collect data? (Select all that apply.)

a. Interpreting client behaviors

b. Interviewing the client and significant others

c. Observing client behavior

d. Performing physical assessment

e. Reviewing diagnostic testing results

b, c, d, e

During the sociocultural assessment of a client who is entering a mental health program, the nurse focuses on which information related to the client? (Select all that apply.)

a. Education

b. Income

c. Ethnicity

d. Age

e. Gender

f. Medications

g. Previous diagnoses

h. Belief system

a, b, c, d, e, h

Short-term memory loss is seen in which of the following disorders? (Select all that apply.)

a. Depression

b. Dissociative disorder

c. Conversion disorder

d. Alzheimers disease

e. Anxiety

a, d, e