Mental health Final

What level of anxiety enhances learning and focus?

Mild anxiety.

A client is speaking with a shaky voice and has selective attention. What level of anxiety are they likely experiencing?

Moderate anxiety.

What is the nursing priority for a client experiencing severe anxiety?

Ensure safety; avoid teaching.

A client is running aimlessly and appears detached from reality. What level of anxiety is this, and what should the nurse do first?

Panic anxiety; stay with the client, use grounding techniques, and reduce stimuli.

List 3 symptoms of Generalized Anxiety Disorder (GAD).

Excessive worry, fatigue, muscle tension.

What differentiates obsessions from compulsions in OCD?

Obsessions = intrusive thoughts; compulsions = repetitive behaviors.

What is systematic desensitization used for?

Treating phobias through gradual exposure and relaxation.

What is the first nursing action for a client expressing suicidal ideation?

Ask directly if they are thinking of hurting themselves.

Name 3 common symptoms of major depressive disorder.

Anhedonia, changes in sleep/appetite, fatigue.

Why are SSRIs preferred over TCAs and MAOIs?

Fewer side effects and better safety profile.

What are major side effects of SSRIs?

Nausea, sexual dysfunction, insomnia, increased suicide risk early on.

Which antidepressant class can cause a hypertensive crisis with tyramine-containing foods?

MAOIs.

What are the symptoms of serotonin syndrome?

Agitation, hyperreflexia, fever, tachycardia, muscle rigidity.

Differentiate between maturational, situational, and adventitious crises.

Maturational: Life transitions (e.g., marriage).
Situational: Unexpected life events (e.g., job loss).
Adventitious: Disasters or violence (e.g., hurricane, assault).

What is the primary nursing goal during crisis intervention?

Restore pre-crisis functioning or higher.

How long does a typical crisis last?

4–6 weeks.

What are the four phases of crisis development?

Exposure, increased anxiety, failed coping, disequilibrium.

What is the goal of a therapeutic milieu?

Promote healing through structure, safety, and social interaction.

What are essential components of a safe milieu?

Predictability, physical/emotional safety, structured activities.

Why are inpatient stays sometimes ineffective for full milieu therapy?

Modern stays are often too short for deep behavioral change.

What are effective teaching strategies for clients with mental illness?

Use simple language, repetition, involve support systems.

What should be included in medication education?

Purpose, side effects, adherence importance, when to seek help.

Give 3 examples of social determinants that affect mental health.

Poverty, trauma, lack of access to care.

What is a dual diagnosis?

Co-occurring mental illness and substance use disorder.

What is a key nursing approach when working with substance-using clients?

Nonjudgmental attitude, motivational interviewing, referrals.

Give an example of an open-ended question.

“Tell me more about how you’re feeling.”

What is the purpose of using silence in therapeutic communication?

Allows the client time to process and reflect.

Which communication technique involves repeating the client’s words?

Reflection.

What are 3 nontherapeutic communication techniques?

Giving advice, false reassurance, changing the subject.

What is the nurse’s priority during the orientation phase?

Establish trust and clarify roles.

What occurs during the working phase?

Client expresses feelings, develops insight, works toward goals.

What marks the termination phase?

Client gains independence, reflects on growth, prepares for discharge.

What does the MSE evaluate?

A client’s current cognitive, emotional, and psychological functioning.

What is the difference between mood and affect?

Mood = internal feeling (subjective); affect = observed expression.

What must be documented exactly as spoken by the client?

Suicidal or homicidal ideation statements.

What is the difference between voluntary and involuntary admission?

Voluntary = client consents; Involuntary = client admitted without consent for safety.

What does the Tarasoff ruling require nurses to do?

Warn the identifiable person if a client threatens harm.

Name 3 exceptions to client confidentiality.

Danger to self or others, child/elder abuse, court order.

What is the principle of autonomy?

Respecting a client’s right to make their own decisions.

What is beneficence?

Promoting the well-being of the client.

What is nonmaleficence?

The obligation to do no harm.

What is the nurse’s ethical duty in unsafe practice?

Report it per facility and legal guidelines.

What is the least restrictive intervention hierarchy?

Verbal de-escalation → seclusion → restraints.

What is required before applying physical restraints?

A provider’s order.

How often must a restrained adult be checked?

At least every 15 minutes.

What must be documented during restraint use?

Behavior, interventions tried, provider orders, assessments.

When answering mental health questions, what is usually the top priority?

Safety.

What is the best initial nursing action when a client is in distress?

Stay with the client and assess.

What should you do before choosing an intervention?

Assess the situation and client needs.

How should the nurse approach medication refusal by a voluntary client?

Respect their autonomy and assess reasoning unless safety is compromised.