ATI RN Mental Health Nursing

A charge nurse is discussing mental status examinations with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching?

A. "To assess cognitive ability, I should ask the client to count backward by 7."

B. "To assess affect, I should observe the client's facial expression."

C. "To assess language ability, I should instruct the client to write a sentence."

D. "To assess remote memory, I should have the client repeat a list of objects."

ATI RN Mental Health Nursing Modules Ch. 1 Application Exercises

D. "To assess remote memory, I should have the client repeat a list of objects."

Asking the client to repeat a list of objects is appropriate to assess immediate, rather than remote, memory.

ATI RN Mental Health Nursing Modules Ch. 1 Application Exercises

A nurse is planning care for a client who has a mental health disorder. Which of the following is appropriate to include as a psychobiological intervention?

A. Assist the client with systematic desensitization therapy.

B. Teach the client appropriate coping mechanisms.

C. Assess the client for comorbid health conditions.

D. Monitor the client for adverse effects of medications.

ATI RN Mental Health Nursing Modules Ch. 1 Application Exercises

D. Monitor the client for adverse effects of medications.

Assisting with systematic desensitization therapy is a cognitive and behavioral.

Teaching appropriate coping mechanisms is a counseling or health teaching.

Assessing for comorbid health conditions is health promotion and maintenance.

D. Monitoring for adverse effects of medications is an example of a psychobiological intervention.

ATI RN Mental Health Nursing Modules Ch. 1 Application Exercises

A nurse in an outpatient mental health clinic is preparing to conduct an initial client interview. When conducting the interview, which of the following is the highest priority action?

A. Respect the client's need for personal space.

B. Identify the client's perception of her mental health status.

C. Include the client's family in the interview.

D. Teach the client about her current mental health disorder.

ATI RN Mental Health Nursing Modules Ch. 1 Application Exercises

B. Identify the client's perception of her mental health status.

A. Appropriate, but not highest priority.

B. Assessment is the priority action when taking the nursing process approach. Identifying the client's perception of her mental health status provides important information about the client's psychosocial history.

C. Appropriate, but not highest priority.

D. Appropriate, but not highest priority.

ATI RN Mental Health Nursing Modules Ch. 1 Application Exercises

A nurse is told during change-of-shift report that a client is stuporous. When assessing the client, which of the following is an expected finding?

A. The client arouses briefly in response to a sternal rib.

B. The client has a Glasgow Coma Scale score less than 7.

C. The client exhibits decorticate rigidity.

D. The client is alert but disoriented to time and place.

ATI RN Mental Health Nursing Modules Ch. 1 Application Exercises

A. The client arouses briefly in response to a sternal rib.

A. A client who is stuporous requires vigorous or painful stimuli to elicit a response.

B. <7 on GCS indicates comatose, not stuporous, level of consciousness.

C. Abnormal posturing = comatose.

D. Stuporous /= alert.

ATI RN Mental Health Nursing Modules Ch. 1 Application Exercises

A nurse is planning a peer group discussion about the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). Which of the following is appropriate to include in the discussion? (SATA)

A. The DSM-5 is used to identify mental health disorders.

B. The DSM-5 establishes diagnostic criteria.

C. The DSM-5 indicates recommended pharmacological treatment.

D. The DSM-5 assists nurses in planning care.

E. The DSM-5 indicates expected assessment findings.

ATI RN Mental Health Nursing Modules Ch. 1 Application Exercises

A, B, D, E.

The DSM-5 is used as a diagnostic tool, establishes diagnostic criteria, used by nurses to plan, implement, and evaluate care, and identifies expected findings for mental health disorders.

It does not indicate pharmacological treatment.

ATI RN Mental Health Nursing Modules Ch. 1 Application Exercises

Which of the following is an example of a client who requires emergency admission to a mental health facility?

A. A client with schizophrenia who has frequent hallucinations.

B. A client with symptoms of depression who attempted suicide a year ago.

C. A client with borderline personality disorder who assaulted a homeless man with a metal rod.

D. A client with bipolar disorder who paces quickly down the sidewalk while talking to himself.

ATI RN Mental Health Nursing Modules Ch. 2 Application Exercises

C. A client with borderline personality disorder who assaulted a homeless man with a metal rod.

Hallucinations, depression, and/or pacing does not constitute clear reason for emergency commitment.

ATI RN Mental Health Nursing Modules Ch. 2 Application Exercises

A client tells a student nurse, "Don't tell anyone, but I hid a sharp knife under my mattress in order to protect myself from my roommate, who is always yelling at me and threatening me." Which of the following actions should the nurse take?

A. Keep the client's communication confidential, but talk to the client daily, using therapeutic communication to convince him to admit to holding the knife.

B. Keep the client's communication confidential, but watch the client and his roommate closely.

C. Tell the client that this must be reported to health care staff because it concerns the health and safety of the client and others.

D. Report the incident, but do not inform the client of the intention to do so.

ATI RN Mental Health Nursing Modules Ch. 2 Application Exercises

C. Tell the client that this must be reported to health care staff because it concerns the health and safety of the client and others.

The information cannot be kept confidential and the client must be informed that this will be reported to the health care staff.

• This is a serious safety issue that must be reported to the staff. Using the principle of veracity, the student tells this client truthfully what must be done regarding the issue.

ATI RN Mental Health Nursing Modules Ch. 2 Application Exercises

A nurse decides to put a client who has psychosis in seclusion overnight because the unit is very short-staffed, and the client frequently fights with other clients. This is an example of:

A. beneficence.

B. a tort.

C. a facility policy.

D. justice.

ATI RN Mental Health Nursing Modules Ch. 2 Application Exercises

B. a tort.

Beneficence: doing good for a client.

Tort: a civil wrong that violates a client's civil rights.

If a policy, the facility would be in violation of federal and state statute, and the nurse could be held responsible.

Justice: action involving the fair and equal treatment of clients.

ATI RN Mental Health Nursing Modules Ch. 2 Application Exercises

A nurse is caring for a client in restraints. Which of the following statements are appropriate documentation? (SATA)

A. " Client ate most of his breakfast."

B. "Client was offered 8oz of water every hr."

C. "Client shouted at assistive personnel."

D. "Client received chlorpromazine (Thorazine) 15mg by mouth at 1000."

E. "Client acted out after lunch."

B, C, D: Objective data is correct, not subjective.

ATI RN Mental Health Nursing Modules Ch. 2 Application Exercises

A nurse hears a newly licensed nurse discussing a client's hallucinations in the hallway with another nurse. Which of the following actions should the nurse take first?

A. Notify the nurse manager.

B. Tell the nurse to stop discussing the behavior.

C. Provide an in-service program about confidentiality.

D. Complete an incident report.

ATI RN Mental Health Nursing Modules Ch. 2 Application Exercises

B. Tell the nurse to stop discussing the behavior.

The nurse should notify the nurse manager, provide in-service, and complete an incident report, but these actions are not the first to take.

ATI RN Mental Health Nursing Modules Ch. 2 Application Exercises

A charge nurse is conducting a class on therapeutic communication to a group of newly licensed nurses. Which of the following responses by the newly licensed nurse requires additional teaching regarding nonverbal communication?

A. Personal space

B. Posture

C. Eye contact

D. Intonation

ATI RN Mental Health Nursing Modules Ch. 3 Application Exercises

D. Intonation

Personal space, posture, and eye contact is a part of nonverbal behavior.

• Intonation is the tone of one's voice and can communicate a variety of feelings.

ATI RN Mental Health Nursing Modules Ch. 3 Application Exercises

A nurse is communicating with a client on the acute mental health facility. The client states, "I can't sleep. I stay up all night." The nurse responds, "You are having difficulty sleeping?" Which of the following therapeutic communication techniques is the nurse demonstrating?

A. Offering general leads

B. Summarizing

C. Focusing

D. Restating

ATI RN Mental Health Nursing Modules Ch. 3 Application Exercises

D. Restating

A. Takes direction.

B. Enhances understanding.

C. Concentrates attention to one single point.

D. Restating allows the nurse to repeat the main idea expressed.

ATI RN Mental Health Nursing Modules Ch. 3 Application Exercises

A nurse is communicating with a newly admitted client. Which of the following is a barrier to therapeutic communication?

A. Offering advice

B. Reflecting meaning

C. Listening attentively

D. Giving information

ATI RN Mental Health Nursing Modules Ch. 3 Application Exercises

A. Offering advice

A. Advice tends to interfere with the client's ability to make personal decisions and choices.

B. Reflection encourages client to make choices.

C. Skill of listening is important.

D. Giving information informs client of needed facts.

ATI RN Mental Health Nursing Modules Ch. 3 Application Exercises

A nurse is conducting therapy with several clients and their families. Effective communication with clients and families is based on:

A. discussing in-depth topics with which the client feels comfortable.

B. using silence to avoid unpleasant or difficult topics.

C. attending to verbal and nonverbal behaviors.

D. requiring the client and family to ask for feedback.

ATI RN Mental Health Nursing Modules Ch. 3 Application Exercises

C. attending to verbal and nonverbal behaviors.

A. Often, very brief conversations are most effective.

B. Silence is to allow the client time for reflection or to convey nonverbal support.

C. Attending to verbal and nonverbal behaviors is necessary for effective communication.

D. Not an effective technique.

ATI RN Mental Health Nursing Modules Ch. 3 Application Exercises

When a family asks a nurse for reassurance about a client's condition, which of the following is an appropriate response?

A. "I think your son is getting better. What have you noticed?"

B. "I'm sure everything will be okay. It just takes time to heal."

C. "I'm not sure what's wrong. Have you asked the doctor about your concerns?"

D. "I understand you're concerned. Let's discuss what concerns you specifically."

ATI RN Mental Health Nursing Modules Ch. 3 Application Exercises

D. "I understand you're concerned. Let's discuss what concerns you specifically."

A, B, C: Interjects nurse's opinion, causing family to withhold their thoughts and feelings.

D. A therapeutic response reflects upon, and accepts, the family's feelings, and it allows the members to clarify what they are feeling.

ATI RN Mental Health Nursing Modules Ch. 3 Application Exercises

A nurse is caring for a client who smokes and has lung cancer. The client reports, "I'm coughing because I have that cold that everyone has been getting. "which of the following defense mechanisms is the client using?

A. Reaction formation

B. Denial

C. Displacement

D. Sublimation

ATI RN Mental Health Nursing Modules Ch. 4 Application Exercises

B. Denial

A. Reaction formation: overcompensating/demonstrating the opposite behavior of what is felt.

B. This is an example of denial, which is pretending the truth is not reality to manage anxiety of acknowledging what is real.

C. Displacement: shifting feelings related to an object, person, or situation to another less threatening object, person, or situation.

D. Sublimation: dealing with unacceptable feelings/impulses by unconsciously substituting acceptable forms of expression.

ATI RN Mental Health Nursing Modules Ch. 4 Application Exercises

A nurse is obtaining informed consent for a client who has just learned she mus have a breat biopsy. The client is perspiring and pale, has a respiratory rate of 30/min, and says, "I don't quite understand what you're trying to tell me." The nurse should assess the client' s anxiety as which of the following?

A. Mild

B. Moderate

C. Sever

D. Panic

ATI RN Mental Health Nursing Modules Ch. 4 Application Exercises

B. Moderate

A. Mild: person's ability to understand information may actually increase.

B. Moderate anxiety decreases problem-solving and may hamper one's ability to understand information. Vital signs may increase somewhat, and the person is visibly anxious.

C. Severe: restlessness, decreased perception, and an inability to take direction.

D. Panic: completely distracted, unable to function, and may lose touch with reality.

ATI RN Mental Health Nursing Modules Ch. 4 Application Exercises

A nurse is caring for a client who is experiencing moderate anxiety. Which of the following is an appropriate nursing intervention when trying to give necessary information to the client?

A. Reassure the client that everything will be okay.

B. Use a low-pitched voice and speak slowly.

C. Ignore the client's anxiety so that she will not be embarrased.

D. Demonstrate a calm manner while using simple and clear language.

ATI RN Mental Health Nursing Modules Ch. 4 Application Exercises

D. Demonstrate a calm manner while using simple and clear language.

A. Not appropriate.

B. For severe - panic.

C. Ignoring is not appropriate.

D. Giving information simply and calmly will help the client grasp essential facts.

ATI RN Mental Health Nursing Modules Ch. 4 Application Exercises

A nurse is talking with a client who is at risk for suicide following the death of his spouse. Which of the following statements by the nurse is appropriate?

A. "I feel very sorry for the loneliness you must be experiencing."

B. "Suicide is not the appropriate way to cope with loss."

C. "Losing someone close to you must be very upsetting."

D. "I know how difficult it is to lose a loved one."

ATI RN Mental Health Nursing Modules Ch. 5 Application Exercises

C. "Losing someone close to you must be very upsetting."

A. Nurse's feelings, is sympathetic and not empathetic.

B. Implies judgment, not empathetic/therapeutic.

C. This statement is an empathetic response that attempts to understand the client's feelings.

D. Nurse's experiences.

ATI RN Mental Health Nursing Modules Ch. 5 Application Exercises

A nurse is in the working phase of a therapeutic relationship with a client who has methamphetamine use disorder. Which of the following indicates transference behavior?

A. The client asks the nurse whether she will go out to dinner with him.

B. The client accuses the nurse of telling him what to do just like his ex-girlfriend.

C. The client reminds the nurse of a friend who died from substance overdose.

D. The client becomes angry and threatens harm to himself.

ATI RN Mental Health Nursing Modules Ch. 5 Application Exercises

B. The client accuses the nurse of telling him what to do just like his ex-girlfriend.

A. Need to discuss boundaries.

B. When a client view s the nurse as having chracteristics of another person who has been significant to his personal life, such as his ex-girlfriend, this indicates transference.

C. Countertransference.

D. Need for safety intervention.

ATI RN Mental Health Nursing Modules Ch. 5 Application Exercises

A charge nurse is discussing the characteristics of a nurse-client relationship with a newly licensed nurse. Which of the following are appropriate to include in the discussion? (SATA)

A. The needs of both participants are met.

B. An emotional commitment exists between the participants.

C. It is goal-directed.

D. Behavioral change is encouraged.

E. A termination date is established.

ATI RN Mental Health Nursing Modules Ch. 5 Application Exercises

C, D, E: Therapeutic: Goal-directed, behavioral change encouraged, and a termination date.

A. Supposed to focus on the needs of the client.

B. Emotional commitment = intimate/social relationship instead of therapeutic.

ATI RN Mental Health Nursing Modules Ch. 5 Application Exercises

A nurse is planning care for the termination phase of a nurse-client relationship. Which of the following actions is appropriate to include in the plan of care?

A.

A nurse is working in a community mental health facility. Which of the following services are appropriate for clients to receive? (SATA)

A. Educational groups

B. Medication dispensing programs

C. Individual counseling programs

D. Detoxification programs

E. Crisis intervention

ATI RN Mental Health Nursing Modules Ch. 6 Application Exercises

A, B, C:

Detoxification programs → partial hospitalization program.

Crisis intervention → community treatment (ACT) program.

ATI RN Mental Health Nursing Modules Ch. 6 Application Exercises

A nurse is caring for several clients who are attending community-based mental health programs. Which of the following clients should the nurse plan to visit first?

A. A client who recently burned her arm while using a hot iron at home.

B. A client who requests that her antipsychotic medication be changed due to some new side effects.

C. A client who says he is hearing a voice that tells him he is not worthy of living anymore.

D. A client who tells the nurse he experienced symptoms of severe anxiety before and during a job interview.

ATI RN Mental Health Nursing Modules Ch. 6 Application Exercises

C:

Client is at greatest risk for self-harm. Others have needs, but not as high priority.

ATI RN Mental Health Nursing Modules Ch. 6 Application Exercises

A nurse is working on promotion of healthy coping skills with older adult clients who had all previously been hospitalized for severe depression and are now in a residential care facility. The nurse should recognize that this is an example of which of the following?

A. Primary prevention

B. Secondary prevention

C. Tertiary prevention

D. Mental status examination

ATI RN Mental Health Nursing Modules Ch. 6 Application Exercises

C:

Primary: preventing initial onset of a mental health problem.

Secondary: early detection of disease.

Tertiary: Prevention of further problems in clients already diagnosed with mental illness.

Mental Status Examination: Not type of prevention.

ATI RN Mental Health Nursing Modules Ch. 6 Application Exercises

A nurse is caring for a group of clients. Which of the following clients should a nurse consider for referral to an assertive community treatment (ACT) group?

A. A client in an acute care mental health facility who has fallen several times while running down the hallway.

B. A client who lives at home and keeps "forgetting" to come in for his monthly antipsychotic injection for schizophrenia.

C. A client in a day treatment program who says he is becoming more anxious during group therapy.

D. A client in a weekly grief support group who says she still misses her deceased husband who has been dead for 3 months.

ATI RN Mental Health Nursing Modules Ch. 6 Application Exercises

B:

For clients who are noncompliant with traditional therapy.

ATI RN Mental Health Nursing Modules Ch. 6 Application Exercises

A nurse in an acute mental health facility is caring for a client who has a severe mental illness and soon will be ready for discharge but still requires supervision much of the time. The client's wife works all day but is home by late afternoon. Which of the following should the nurse suggest as appropriate follow-up care?

A. Receiving daily care from a home health aide.

B. Having a weekly visit from a nurse case worker.

C. Attending a partial hospitalization program.

D. Visiting a community mental health center on a daily basis.

ATI RN Mental Health Nursing Modules Ch. 6 Application Exercises

C:

Partial hospitalization program can provide adequate care and supervision during the day and allow the patient to be tended to at night at home with a responsible family member.

ATI RN Mental Health Nursing Modules Ch. 6 Application Exercises

A nurse is teaching a client who has an anxiety disorder and is scheduled to begin classical psychoanalysis. Which of the following client statements indicates an understanding of this form of therapy?

A. "Even if my anxiety improves, I will need to continue this therapy for 6 weeks."

B. "The therapists will focus on my past relationships during our sessions."

C. "Psychoanalysis will help me reduce my anxiety by changing my behaviors."

D. "This therapy will address my conscious feelings about stressful experiences."

ATI RN Mental Health Nursing Modules Ch. 7 Application Exercises

B:

Classical psychoanalysis :

- many sessions, months to years.

- focuses on past relationships to identify the cause of the anxiety disorder.

- assesses unconscious thoughts and feelings.

ATI RN Mental Health Nursing Modules Ch. 7 Application Exercises

2. A nurse is discussing free association as a therapeutic tool with a client who has major depressive disorder. Which of the following client statements indicates understanding of this technique?

A. "I will write down my dreams as soon as I wake up."

B. "I may begin to associate my therapists with important people in my life."

C. "I can learn to express myself in a nonaggressive manner."

D. "This therapy will address my conscious feelings about stressful experiences."

ATI RN Mental Health Nursing Modules Ch. 7 Application Exercises

D:

Free association is the spontaneous, uncensored verbalization of whatever comes to the client's mind.

ATI RN Mental Health Nursing Modules Ch. 7 Application Exercises

A nurse is preparing to implement cognitive reframing techniques for a client who has an anxiety disorder. Which of the following are appropriate to include in the plan of care? (SATA)

A. Priority restructuring

B. Monitoring thoughts

C. Diaphramatic breathing

D. Journal keeping

E. Meditation

ATI RN Mental Health Nursing Modules Ch. 7 Application Exercises

A, B, D:

Others are behavioral therapy. Surprise: Journal keeping is a cognitive reframing technique.

ATI RN Mental Health Nursing Modules Ch. 7 Application Exercises

A nurse is caring for a client who has a new prescription for disulfiram (Antabuse) for the treatment of his alcohol use disorder. The nurse informs the client that this medication can cause nausea and vomiting if he drinks alcohol This form of treatment is an example of which of the following?

A. Aversion therapy

B. Flooding

C. Biofeedback

D. Dialectical behavior therapy

ATI RN Mental Health Nursing Modules Ch. 7 Application Exercises

A:

Aversion therapy pairs a maladaptive behavior with unpleasant stimuli to promote a change in behavior.

Flooding: planned exposure to an undesirable stimulus in an attempt to turn off the anxiety response.

Biofeedback is a behavioral therapy to control pain, tension, and anxiety.

Dialectical behavior therapy is a cognitive-behavioral therapy for clients who have a personality disorder and exhibit self-injurious behavior.

ATI RN Mental Health Nursing Modules Ch. 7 Application Exercises

A nurse is assisting with systematic desensitization for a client who has an extreme fear of elevators. Which of the following is appropriate when implementing this form of therapy?

A. Demonstrate riding in an elevator, and then ask the client to imitate the behavior.

B. Advise the client to say "stop" out loud every time he begins to feel an anxiety response related to an elevator.

C. Gradually expose the client to an elevator while practicing relaxation techniques.

D. Stay with the client in an elevator until his anxiety response diminishes.

ATI RN Mental Health Nursing Modules Ch. 7 Application Exercises

C:

A=modeling

B=thought stopping

D=flooding

ATI RN Mental Health Nursing Modules Ch. 7 Application Exercises

A nurse wants to use democratic leadership with a group whose purpose is to learn appropriate conflict resolution techniques. The nurse is correct in implementing this form of group leadership when she demonstrates which of the following actions?

A. Observes group techniques without interfering with the group process.

B. Discusses a technique and then directs members to practice the technique.

C. Asks for group suggestions of techniques and then supports discussion.

D. Suggests techniques and asks group members to reflect on their use.

ATI RN Mental Health Nursing Modules Ch. 8 Notes

C:

Laissez-faire: allows the group process to progress without any attempt by the leader to control the direction of the group.

Autocratic leadership: controls the direction of the group.

Democratic leadership: supports group interaction and decision making to solve problems.

ATI RN Mental Health Nursing Modules Ch. 8 Notes

A nurse is planning group therapy for clients dealing with bereavement. Which of the following should the nurse include in the initial phase? (SATA)

A. Encourage the group to work toward goals.

B. Define the purpose of the group.

C. Discuss termination of the group.

D. Identify informal roles of members within the group.

E. Establish an expectation of confidentiality within the group.

ATI RN Mental Health Nursing Modules Ch. 8 Notes

B, C, E:

Working phase: work toward goals, identify informal roles

ATI RN Mental Health Nursing Modules Ch. 8 Notes

A nurse is working on an acute mental health unit forms a group to focus on self-management of medications. At each of the meetings, two of the members use the opportunity to discuss their common interest in gambling on sports. This is an example of which of the following?

A. Triangulation

B. Group process

C. Subgroup

D. Hidden agenda

ATI RN Mental Health Nursing Modules Ch. 8 Notes

D:

Triangulation: third party is drawn into a relationship with two members whose relationship is unstable.

Group process: the verbal and nonverbal communication that occurs within the group during group sessions.

Subgroup: a small number of people within a larger group who function separately from that group.

Hidden agenda: when some group members have a different goal than the stated group goals. The hidden agenda is often disruptive to the effective functioning of the group.

ATI RN Mental Health Nursing Modules Ch. 8 Notes

A nurse is conducting a family therapy session. The adolescent son tells the nurse that he plans ways to make his sister look bad so his parents will think he's the better sibling, which he believes will give him more privileges. The nurse should identify this dysfunctional behavior as which of the following?

A. Placation

B. Manipulation

C. Blaming

D. Distraction

ATI RN Mental Health Nursing Modules Ch. 8 Notes

B:

Placation: the dysfunctional behavior of taking responsibility for problems to keep peace among family members.

Manipulation: the dysfunctional behavior of using dishonesty to support an individual agenda.

Blaming: the dysfunctional behavior of blaming others to shift focus away from the individual's own inadequacies.

Distraction: the dysfunctional behavior of inserting irrelevant information during attempts at problem solving.

ATI RN Mental Health Nursing Modules Ch. 8 Notes

A nurse is working with an established group and identifies various member roles. Which of the following should the nurse identify as an individual role?

A. A member who praises input from other members.

B. A member who follows the direction of other members.

C. A member who brags about accomplishments.

D. A mbmer who evaluates the group's performance toward a standard.

ATI RN Mental Health Nursing Modules Ch. 8 Notes

C:

Maintenance role: individual who praises the input of others / is a follower.

Task role: individual who evaluates the group's performance.

ATI RN Mental Health Nursing Modules Ch. 8 Notes

A nurse is preparing to provide an educational seminar on stress to other nursing staff. Which of the following is appropriate to include in the discussion?

A. Excessive stressors cause the client to experience distress.

B. The body's initial adaptive response to stress is denial.

C. The absence of stressors results in homeostasis.

D. Negative, rather than positive, stressors produce a biological response.

ATI RN Mental Health Nursing Modules Ch. 9 Notes

A:

Distress: the result of excessive or damaging stressors, such as anxiety or anger.

Fight-or-flight mechanism: the body's initial adaptive response to stress.

The pressence of some stressors provide interest and purpose to life.

Positive and negative stressors produce biological response in the body.

ATI RN Mental Health Nursing Modules Ch. 9 Notes

A nurse is discussing acute vs. prolonged stress with a client. Which of the following should the nurse identify as an acute stress response? (SATA)

A. Decreased appetite

B. Depressed immune system

C. Increased blood pressure

D. Panic attacks

E. Unhappiness

ATI RN Mental Health Nursing Modules Ch. 9 Notes

A, B, C, E:

Panic attacks indicate a prolonged or maladaptive stress response.

ATI RN Mental Health Nursing Modules Ch. 9 Notes

A nurse is teaching a client about stress-reduction techniques. Which of the following client statements indicates understanding of the teaching?

A. "Cognitive reframing will help me change my irrational thoughts to something positive."

B. "Progressive muscle relaxation uses a mechanical device to help me gain control over my pulse rate."

C. "Biofeedback causes my body to release endorphins so that I feel less stress and anxiety."

D. "Mindfulness allows me to prioritize the stressors that I have in my life so that I have less anxiety."

A:

Cognitive reframing helps the client look at irrational cognitions (thoughts) in a more realistic light and to restructure those thoughts in a more positive way.

Biofeedback, rather than progress muscle training, uses a mechanical device to promote voluntary control over autonomic functions.

Physical exercise, rather than biofeedback, causes a release of endophins that lower anxiety and reduce stress.

Priority restructuring, rather than mindfulness, teaches the client to prioritize differently to reduce the number of stressors.

ATI RN Mental Health Nursing Modules Ch. 9 Notes

A client says she is experiencing increased stress because her significant other is "pressuring me and my kids to go live with him. I love him, but I'm not ready to do that." She also states that her significant other "keeps nagging at my oldest son, which makes me mad, since he's my son, not his." Which of the following should the nurse recommend to promote a change in the client's situation?

A. Learn to practice mindfulness.

B. Use assertiveness techniques.

C. Exercise regularly.

D. Rely on the support of a close friend.

ATI RN Mental Health Nursing Modules Ch. 9 Notes

B:

Mindfulness, regular exercise, and social support are appropriate to decrease the client's stress. However, it does not change the client's situation.

Assertive communication allows the client to assert her feelings and then make a change in the situation.

ATI RN Mental Health Nursing Modules Ch. 9 Notes

A nurse is caring for a client who states, "I'm so stressed at work because of my coworker. He expects me to finish his work because he's too lazy!" When discussing appropriate communication, which of the following statements by the client to his coworker indicates client understanding?

A. "You really should complete your own work. I don't think it's right to expect me to complete your responsibitilies."

B. "Why do you expect me to finish your work? You must realize that I have my own responsibilities."

C. "It is not fair to expect me to complete your work. If you continue, then I will report your behavior to our supervisor."

D. " when I have to pick up extra work, I feel very overwhelmed. I need to focus on my own responsibilities.

ATI RN Mental Health Nursing Modules Ch. 9 Notes

D:

Disapproving/disagreeing, "why" question, and aggressive/threatening statements can prompt a defensive reaction.

This response demonstrates *assertive communication, which allows the client to state her feelings about the behavior and then promote a change.

ATI RN Mental Health Nursing Modules Ch. 9 Notes

A nurse is providing teaching for a client who is scheduled to receive electroconvulsive therapy (ECT) for the treatment of major depressive disorder. Which of the following client statements indicates understanding of the teaching?

A. "It is common to treat depression with ECT before trying medications."

B. "I can have my depression cured if I receive a series of ECT treatments."

C. "I will have seizures lasting 1 1/2 to 2 minutes during ECT."

D. "I will receive a muscle relaxant to protect me from injury during ECT."

ATI RN Mental Health Nursing Modules Ch. 10 Notes

D:

ECT: for major depressive disorder not responsive to meds, ↓ incidence and relapse of depression, causes seizures of 25-60 seconds.

A muscle relaxant, such as succinylcholine (Anectine), is administered to reduce the risk of injury during induced seizure activity.

ATI RN Mental Health Nursing Modules Ch. 10 Notes

A charge nurse is discussing transcranial magnetic stimulation (TMS) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching?

A. "TMS is indicated for clients whose depression is not relieved by medication."

B. "I will provide postanesthesia care following TMS."

C. "TMS is usually performed as an outpatient procedure."

D. "I will schedule the client for daily TMS treatments for the first several weeks."

ATI RN Mental Health Nursing Modules Ch. 10 Notes

B:

Postanesthesia care is not necessary because the client does not receive anesthesia and is alert during the procedure.

ATI RN Mental Health Nursing Modules Ch. 10 Notes

A nurse is assessing a client immediately following an electroconvulsive therapy (ECT) proceedure. Which of the following are expected findings? (SATA)

A. Hypotension

B. Paralytic ileus

C. Memory loss

D. Nausea

E. Tachycardia

ATI RN Mental Health Nursing Modules Ch. 10 Notes

C, D, E:

BP is expected to be elevated.

ATI RN Mental Health Nursing Modules Ch. 10 Notes

A nurse is leading a peer group discussion about the indications for electroconvulsive therapy (ECT). Which of the following is appropriate to include in the discussion?

A. Borderline personality disorder

B. Acute withdrawal related to substance use disorder

C. Bipolar disorder with rapid cycling

D. Dysthymic disorder

ATI RN Mental Health Nursing Modules Ch. 10 Notes

C:

ECT is indicated for the treatment of bipolar disorder with rapid cycling.

ATI RN Mental Health Nursing Modules Ch. 10 Notes

A nurse is planning care for a client following surgical implantation of a vagus nerve stimlation (VNS) device. The nurse should plan to monitor for which of the following adverse effects? (SATA)

A. Voice changes

B. Seizure activity

C. Disorientation

D. Dysphagia

E. Neck pain

ATI RN Mental Health Nursing Modules Ch. 10 Notes

A, D, E:

All that is associated with the neck area is expected.

ATI RN Mental Health Nursing Modules Ch. 10 Notes

A nurse is caring for a client who has acute stress disorder and is experiencing severe anxiety. Which of the following statements by the nurse is appropriate?

A "Tell me about how you are feeling right now."

B. "You should focus on the positive things in your life to decrease your anxiety."

C. "Why do you believe you are experiencing this anxiety?"

D. "Let's discuss the medications your provider is prescribing to decrease your anxiety."

ATI RN Mental Health Nursing Modules Ch. 11 Notes

A:

Open-ended.

Postpone health teaching until after acute anxiety subsides. Clients experiencing severe anxiety are unable to concentrate or learn.

ATI RN Mental Health Nursing Modules Ch. 11 Notes

A nurse observes a client who has OCD repeatedly applying, removing, and then reapplying makeup. The nurse identifies that repetitive behavior in a client who has OCD is due to which of the following?

A. Narcissitic behavior

B. Fear of rejection from staff

C. Attempt to reduce anxiety

D. Adverse effect of antidepressant medication

ATI RN Mental Health Nursing Modules Ch. 11 Notes

C:

Clients who have OCD demonstrate repetitive behavior in an attempt to suppress persistent thoughts or urges.

ATI RN Mental Health Nursing Modules Ch. 11 Notes

A nurse is caring for a client who is experiencing a panic attack. Which of the following is an appropriate nursing intervention?

A. Discuss new relaxation techniques.

B. Show the client how to change his behavior.

C. Distract the client with a television show.

D. Stay with the client, and remain quiet.

ATI RN Mental Health Nursing Modules Ch. 11 Notes

D:

This promotes safety and reassurance without additional stimuli.

ATI RN Mental Health Nursing Modules Ch. 11 Notes

A nurse observes a client who is pacing and wringing his hands. The client states, "I don't know why, but I've worried every day for over a year that my son will die a horrible death." The nurse identifies that this finding is consistent with which of the following disorders?

A. Generalized anxiety disorder

B. Panic disorder

C. Posttraumatic stress disorder

D. Acute stress disorder.

ATI RN Mental Health Nursing Modules Ch. 11 Notes

A:

Generalized anxiety disorder is characterized by uncontrollable, excessive worry for more than 3 months.

ATI RN Mental Health Nursing Modules Ch. 11 Notes

A nurse working on an acute mental health unit is caring for a client who has posttraumatic stress disorder (PTSD). Which of the following is an expected finding? (SATA)

A. Hallucinations

B. Obsessive need to talk about the traumatic event

C. Exaggerated displays of emotion

D. Recurring nightmares

E. Diminished reflexes

ATI RN Mental Health Nursing Modules Ch. 11 Notes

A, D:

PTSD:

Hallucinations

Avoidance of stimuli associated with event

Inability to show feelings

Recurring nightmares

Increased arousal

ATI RN Mental Health Nursing Modules Ch. 11 Notes

A nurse working in an acute mental health facility is caring for a 35-year-old female client who has clinical findings of depression. The client lives at home with her husband and two young children. She currently smokes and has a history of chronic asthma. The nurse should identify which of the following as risk factors for depression for this client? (SATA)

A. Age of 35 years old

B. Female gender

C. History of chronic asthma

D. Currently smokes

E. Being married

ATI RN Mental Health Nursing Modules Ch. 11 Notes

A, B, C, D:

Depression:

15-40 yo

> females

Chronic medical illness

Substance use disorder

Unmarried

ATI RN Mental Health Nursing Modules Ch. 12 Notes

A nurse working in an outpatient clinic is providing teaching to a client who has a new diagnosis of premenstrual dysphoric disorder (PMDD). Which of the following statements by the client indicates understanding of the teaching?

A. "I can expect my problems with PMDD to be worse when I'm menstruating."

B. "I will use light therapy 30 min a day to prevent further recurrences of PMDD."

C. "I am aware that my PMDD causes me to have rapid mood swings."

D. "I should increase my caloric intake with a nutritional supplement when my PMDD is active."

ATI RN Mental Health Nursing Modules Ch. 12 Notes

C:

Clinical findings:

During luteal phase of menstrual cycle before menses.

Emotional lability

Weight gain

ATI RN Mental Health Nursing Modules Ch. 12 Notes

A charge nurse is discussing the care of a client who has major depressive disorder (MDD) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching?

A. "Care during the continuation phase focuses on treating continued manifestations of MDD."

B. "The goal of treatment during the maintenance phase is prevention of future episodes of MDD."

C. "The client is at greatest risk for suicide during the first weeks of an MDD episode."

D. "Medication and psychotherapy are used to prevent a relapse of MDD."

ATI RN Mental Health Nursing Modules Ch. 12 Notes

A:

The focus for the continuation phase is relapse prevention. Treatment of manifestations occurs during the acute phase of MDD.

ATI RN Mental Health Nursing Modules Ch. 12 Notes

A nurse working on an acute mental health unit is admitting a client who has major depressive disorder and comorbid anxiety disorder. Which of the following is the highest priority action by the nruse?

A. Placing the client on one-to-one observation.

B. Assisting the client to perform ADLs.

C. Encouraging the client to participate in counseling.

D. Teaching the client about medication adverse effects.

ATI RN Mental Health Nursing Modules Ch. 12 Notes

A:

Injury due to self-harm.

ATI RN Mental Health Nursing Modules Ch. 12 Notes

A nurse is interviewing a 25-year-old client who has a new diagnosis of dysthymia. Which of the following findings should the nurse expect?

A. There are wide fluctuations in mood.

B. The report of a minimum of five clinical findings of depression.

C. The presence of manifestations for at least 2 years.

D. There is an inflated sense of self-esteem.

ATI RN Mental Health Nursing Modules Ch. 12 Notes

C:

The manifestations of dysthymic disorder last for at least 2 years in adults.

MDD rather than dysthymic disorder contains a minimum of five clinical findings of depression.

A nurse is planning care for a client who has bipolar disorder and is experiencing a manic episode. Which of the following is appropriate for the nurse to include in the plan of care? (SATA)

A. Provide flexible client behavior expectations.

B. Offer concise explanations.

C. Establish consistent limits.

D. Disregard client complaints.

E. Use a firm approach with communication.

ATI RN Mental Health Nursing Modules Ch. 13 Notes

B, C, E:

Consistent client behavior expectations decrease the risk for client manipulation.

Offering concise explanations improves the client's ability to focus and comprehend the information.

The nurse should respond to valid client complaints to foster a trusting nurse-client relationship.

Using a firm approach with client communication promotes structure and minimizes inappropriate client behaviors.

ATI RN Mental Health Nursing Modules Ch. 13 Notes

A nurse is teaching a newly licensed nurse about the use of electroconvulsive therapy (ECT) for the treatment of bipolar disorder. Which of the following statements by the newly licensed nurse indicates understanding?

A. "ECT is the recommended initial treatment for bipolar disorder."

B. "ECT is contraindicated for clients who have suicidal ideation."

C. "ECT is effective for clients who are experiencing severe mania."

D. "ECT is prescribed to prevent the relapse of bipolar disorder."

ATI RN Mental Health Nursing Modules Ch. 13 Notes

C:

ECT is effective fo clients who have bipolar disorder and suicidal ideation.

ECT is prescribed for clients experiencing an acute episode of bipolar disorder rather than for the prevention of relapse.

ATI RN Mental Health Nursing Modules Ch. 13 Notes

A nurse in an acute mental health facility is caring for a client who is experiencing a mixed episode of bipolar disorder. Which of the following is the priority nursing action?

A. Set consistent limits for expected client behavior.

B. Administer prescribed medications as scheduled.

C. Provide the client with step-by-step instructions during hygiene activities.

D. Monitor the client for escalating behavior.

ATI RN Mental Health Nursing Modules Ch. 13 Notes

D:

Monitoring the client for escalating behavior addresses the client's priority need for safety and is therefore the priority nursing action.

ATI RN Mental Health Nursing Modules Ch. 13 Notes

A nurse is caring for a client who has bipolar disorder. The client states, "I am very rich, and I feel I must give my money to you." Which of the following is an appropriate response by the nurse?

A. "Why do you think you feel the need to give money away?"

B. "I am here to provide care and cannot accept this from you."

C. "I can request that your case manager discuss appropriate charity options with you."

D. "You should know that giving away your money is inappropriate."

B:

This statement is matter-of-fact and concise and is an appropriate response to a client who has bipolar disorder.

ATI RN Mental Health Nursing Modules Ch. 13 Notes

A nurse is discussing relapse prevention with a client who has bipolar disorder. Which of the following should the nurse include in the teaching? (SATA)

A. Use caffeine in moderation to prevent relapse.

B. Difficulty sleeping can indicate a relapse.

C. Begin taking your medications as soon as a relapse begins.

D. Participating in psychotherapy can help prevent a relapse.

E. Anhedonia is a clinical manifestation of a depressive relapse.

ATI RN Mental Health Nursing Modules Ch. 13 Notes

B, D, E:

Caffeine can precipitate a relapse.

Sleep disturbances can indicate a relapse.

ATI RN Mental Health Nursing Modules Ch. 13 Notes

A nurse is caring for a client who has bipolar disorder. The client states, "I am very rich, and I feel I must give my money to you." Which of the following is an appropriate response by the nurse?

A. "Why do you think you feel the need to give money away?"

B. "I am here to provide care and cannot accept this from you."

C. "I can request that your case manager discuss appropriate charity options with you."

D. "You should know that giving away your money is inappropriate."

A nurse is caring for a client who has substance-induced psychotic disorder and is experiencing auditory hallucinations. The client states, "The voices won't leave me alone!" Which of the following statements by the nurse are appropriate? (SATA)

A. "When did you start hearing the voices?"

B. "The voices are not real, or else we would both hear them."

C. "It must be scary to hear voices."

D. "Are the voices telling you to hurt yourself?"

E. "Why are the voices talking to only you?"

ATI RN Mental Health Nursing Modules Ch. 14 Notes

A, C, D:

ATI RN Mental Health Nursing Modules Ch. 14 Notes

A nurse is completing an admission assessment for a client who has schizophrenia. Which of the following findings should the nurse document as positive symptoms? (SATA)

A. Auditory hallucinations

B. Lack of motivation

C. Use of clang associations

D. Delusion of persecution

E. Constantly waving arms

F. Flat affect

ATI RN Mental Health Nursing Modules Ch. 14 Notes

A, C, D, E:

Positive symptoms:

Hallucinations

Alterations in speech

Delusions

Bizarre motor movements

ATI RN Mental Health Nursing Modules Ch. 14 Notes

A nurse is caring for a client who has schizoaffective disorder. Which of the following statements indicates the client is experiencing depersonalization?

A. "I am a superhero and am immortal."

B. "I am no one, and everyone is me."

C. "I feel monsters pinching me all over."

D. "I know that you are stealing my thoughts."

ATI RN Mental Health Nursing Modules Ch. 14 Notes

B:

Loss of identity

ATI RN Mental Health Nursing Modules Ch. 14 Notes

A nurse is speaking with a client who has schizophrenia when he suddenly seems to stop focusing on the nurse's questions and begins looking at the ceiling and talking to himself. Which of the following actions should the nurse take?

A. Stop the interview at this point, and resume later when the client is better able to concentrate.

B. Ask the client, "Are you seeing something on the ceiling?"

C. Tell the client, "You seem to be looking at something on the ceiling. I see something there, too."

D. Continue the interview without comment on the client's behavior.

ATI RN Mental Health Nursing Modules Ch. 14 Notes

B:

The nurse should ask the client directly about the hallucination to identify client needs and assess for a potential risk for injury.

ATI RN Mental Health Nursing Modules Ch. 14 Notes

A nurse is caring for a client on an acute mental health unit. The client reports hearing voices that are telling her to "kill your doctor." Which of the following is the priority action for the nurse to take?

A. Use therapeutic communication to discuss the hallucination with the client.

B. Initiate one-to-one observation of the client.

C. Focus the client on reality.

D. Notify the provider of the client's statement.

ATI RN Mental Health Nursing Modules Ch. 14 Notes

B:

A client who is experiencing a command hallucination is at risk for injury to self or others. Therefore, safety is the priority, and initiating one-to-one observation is the priority action.

ATI RN Mental Health Nursing Modules Ch. 14 Notes

1. A nurse assesses a client at a community mental health facility using the SAD PERSONS tool. The nurse knows that this tool provides which of the following data related to a client?

A.Current anxiety level

B.Problem-solving ability

C.Suicide potential

D.Mood disturbance

C

A.INCORRECT: SAD PERSONS is not a tool to provide data related to the client's current anxiety level.

B.INCORRECT: SAD PERSONS is not a tool to provide data related to a client's ability to problem solve.

C.CORRECT: SAD PERSONS is a tool that provides data related to a client's suicide potential.

D.INCORRECT: SAD PERSONS does not provide data related to a client's mood disturbance.

NCLEX® Connection: Psychosocial Integrity, Crisis Intervention

2. A client says, "I plan to commit suicide." Which of the following should be the nurse's priority assessment?

A.Client's educational and economic background

B.Lethality of the method and availability of means

C.Quality of the client's social support

D.Client's insight into the reasons for the decision

B

A.INCORRECT: This is an appropriate action by the nurse. However, it is not the priority.

B.CORRECT: The greatest risk to the client is self-harm as a result of carrying out a suicide plan. Therefore, the priority assessment is to determine how lethal the method is, how available the method is, and how detailed the plan is.

C.INCORRECT: This is an appropriate action by the nurse. However, it is not the priority.

D.INCORRECT: This is an appropriate action by the nurse. However, it is not the priority.

NCLEX® Connection: Psychosocial Integrity, Crisis Intervention

3. A nurse is assessing a client who is suicidal. Which of the following is appropriate for the nurse to ask the client? (Select all that apply.)

A.Do you have a plan?

B.Have you thought about hurting yourself?

C.Do you feel that life is not worth living?

D.Why do you want to commit suicide?

E.Have you experienced a recent change in your mood?

A, B, C

A.CORRECT: It is important to ask the client if they have a plan.

B.CORRECT: The nurse should ask the client about thoughts of hurting herself.

C.CORRECT: This is an appropriate question for nurse to ask a client who is suicidal.

D.INCORRECT: This is a nontherapeutic response. "Why" questions should be avoided because they may cause the client to be defensive.

E.CORRECT: This is an appropriate question for the nurse to ask a client who is suicidal.

NCLEX® Connection: Psychosocial Integrity, Crisis Intervention

4. A nurse is caring for a client who is on suicide precautions. Which of the following interventions should the nurse include in the plan of care?

A."Assign the client to a private room."

B."Document the client's behavior every hour."

C."Allow the client to keep perfume in her room."

D."Ensure that the client swallows medication."

D

A.INCORRECT: Clients who are suicidal should not be assigned a private room.

B.INCORRECT: Client's behavior should be documented every 15 minutes.

C.INCORRECT: Remove perfume from the client's room.

D.CORRECT: Ensure that the client swallows medication.

NCLEX® Connection: Psychosocial Integrity, Crisis Intervention

5. A nurse is conducting a class for a group of newly licensed nurses on identifying risk factors for suicide. Which of the following individuals should the nurse include as having the highest risk for suicide? (Select all that apply.)

A.Older adult females

B.Adolescents

C.Native Americans

D.Clients who have a depressive disorder

E.Clients who have hypomania

B, C, D

A.INCORRECT: Older adult males are among those individuals who are at the highest risk for suicide.

B.CORRECT: Adolescents are among those individuals who are at the highest risk for suicide.

C.CORRECT: Native Americans are among those individuals who are at the highest risk for suicide.

D.CORRECT: Clients who have a depressive disorder are among those individuals who are at the highest risk for suicide.

E.INCORRECT: Clients who have hypomania are not among those individuals who are at the highest risk for suicide.

NCLEX® Connection: Health Promotion and Maintenance, Health Promotion/Disease Prevention

1. A nurse manager is discussing the care of a client who has a personality disorder with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching?

A."I can promote my client's sense of control by establishing a schedule."

B."Self-assessment will help me cope with emotional reactions to client care."

C."I should practice limit-setting to help prevent client manipulation."

D."Maintaining professional boundaries is a priority of client care."

A

1. A. CoRRECT: Rather than establishing a schedule, the nurse should ask for the client's input and offer realistic choices to promote the client's sense of control.

B. inCorrECt: Caring for a client who has a personality disorder can evoke an intense emotional response by the nurse. Self-assessment assists the nurse to cope with these reactions.

C. inCorrECt: When caring for a client who has a personality disorder, limit-setting is appropriate to help prevent client manipulation.

D. inCorrECt: When caring for a client who has a personality disorder, the nurse should always maintain professional boundaries.

NCLEX® Connection: Psychosocial Integrity, Behavioral Interventions

2. A nurse is caring for a client who has avoidant personality disorder. Which of the following statements is expected from a client who has this type of personality disorder?

A."I'm scared that you're going to leave me."

B. "I'll go to group therapy if you'll let me smoke."

C."I need to feel that everyone admires me."

D."I sometimes feel better if I cut myself."

A

A. CoRRECT: Clients who have avoidant personality disorder often have a fear of abandonment. Therefore, this type of statement is expected.

B. inCorrECt: This statement indicates manipulation, which is not expected from a client who has borderline rather than avoidant personality disorder.

C. inCorrECt: This statement indicates a need for admiration, which is expected from a client who has narcissistic rather than avoidant personality disorder.

D. inCorrECt: This statement indicates a risk for self-injury, which is expected from a client who has borderline rather than avoidant personality disorder.

NCLEX® Connection: Psychosocial Integrity, Mental Health Concepts

3. A charge nurse is preparing a staff education session on personality disorders. Which of the following should be included as personality characteristics associated with all of the personality disorders? (Select all that apply.)

A.Difficulty in getting along with other members of a group

B.Belief in the ability to become invisible during times of stress

C.Display of defense mechanisms when routines are changed

D. Claiming to be more important than other persons

E.Difficulty understanding why it is inappropriate to have a personal relationship with staff

A, C, E

A. CoRRECT: Difficulty with social and professional relationships is a personality characteristic that can be seen with all personality disorder types.

B. inCorrECt: Clients who have schizotypal personality disorder may display magical thinking or delusions; however, this is not associated with all personality disorder types.

C. CoRRECT: Maladaptive response to stress is a personality characteristic that can be seen with all personality disorder types.

D.inCorrECt: Clients who have narcissistic personality disorder may display grandiose thinking; however, this is not associated with all personality disorder types.

E. CoRRECT: Difficulty understanding personal boundaries is a personality characteristic that can be seen with all personality disorder types.

NCLEX® Connection: Psychosocial Integrity, Mental Health Concepts

4. A nurse is caring for a client who has borderline personality disorder. The client says, "The nurse on the evening shift is always nice! You are the meanest nurse ever!" The nurse should recognize the client's statement as an example of which of the following defense mechanisms?

A.Regression

B.Splitting

C.Undoing

D.Identification

B

A. INCORRECT: Regression refers to resorting to an earlier way of functioning, such as having a temper tantrum.

B. CORRECT: Splitting occurs when a person is unable to see both positive and negative qualities at the same time. The client who has borderline personality disorder tends to see a person as all bad one time and all good another time.

C.INCORRECT: Undoing is a behavior that is intended to undo or reverse unacceptable thoughts or acts, such as buying a gift for a spouse after having an extramarital affair.

D.INCORRECT: In identification, the person imitates the behavior of someone admired or feared.

NCLEX® Connection: Psychosocial Integrity, Mental Health Concepts

5. A nurse is assisting with a court-ordered evaluation of a client who has antisocial personality disorder. When assessing this client, which of the following are expected findings? (Select all that apply.)

A.Demonstrates extreme anxiety when placed in a social situation

B.Has difficulty making even simple decisions

C.Attempts to convince other clients to give him their belongings

D.Becomes agitated if his personal area is not neat and orderly

E.Blames others for his past and current problems

C, E

A. INCORRECT: Anxiety in social situations is an expected finding of clients who have avoidant rather than antisocial personality disorder.

B. INCORRECT: Indecisiveness, due to a sensitivity to criticism, is an expected finding of clients who have narcissistic rather than antisocial personality disorder.

C.CORRECT: Exploitation and manipulation of others is an expected finding of antisocial personality disorder.

D. INCORRECT: Perfectionism with a focus on orderliness and control is an expected finding of clients who have obsessive-compulsive rather than antisocial personality disorder.

E.CORRECT: Failure to accept personal responsibility is an expected finding of clients who have antisocial personality disorder.

NCLEX® Connection: Psychosocial Integrity, Mental Health Concepts

1. A nurse is assisting the parents of a school-age child who has oppositional defiant disorder in identifying strategies to promote positive behavior. Which of the following is an appropriate strategy for the nurse to recommend? (Select all that apply.)

A.Allow the child to choose consequences for negative behavior.

B.Use role playing to act out unacceptable behavior.

C.Develop a reward system for acceptable behavior.

D.Encourage the child to participate in school sports.

E.Be consistent when addressing unacceptable behavior.

C, D, E

A.IncOrrEct: The parents should set clear limits on unacceptable behavior.

B.IncOrrEct: The parents should focus on acceptable behavior and should demonstrate this through modeling.

C.CORRECT: The parents should have a method to reward the child for acceptable behavior.

D.CORRECT: The parents should encourage physical activity through which the child can use energy and obtain success.

E.CORRECT: The parents should set clear limits on unacceptable behavior and should be consistent.

NCLEX® Connection: Psychosocial Integrity, Behavioral Interventions

2. A nurse is performing an admission assessment on an adolescent client who has depression. Which of the following is an expected finding? (Select all that apply.)

A.Fear of being alone

B.Substance use

C.Weight gain

D.Irritability

E.Aggressiveness

B, D, E

A.IncOrrEct: Solitary play or work, rather than the fear of being alone, is an expected finding associated with depression.

B.CORRECT: Substance use is an expected finding associated with depression.

C.IncOrrEct: Loss of appetite and weight loss, not weight gain, are expected findings associated with depression.

D.CORRECT: Irritability is an expected finding associated with depression.

E.CORRECT: Aggressiveness is an expected finding associated with depression.

NCLEX® Connection: Psychosocial Integrity, Mental Health Concepts

3. A nurse working in a pediatric clinic is caring for a preschool-age child who has a new diagnosis of ADHD. When teaching the parent about this disorder, which of the following statements should the nurse include in the teaching?

A."Behaviors associated with ADHD must be present prior to age 3."

B."This disorder is characterized by argumentativeness."

C."Below-average intellectual functioning is associated with ADHD."

D."Because of this disorder, your child is at an increased risk for injury."

D

A.IncOrrEct: Behaviors associated with ADHD must be present before the age of 12.

B.IncOrrEct: Argumentativeness is associated with oppositional defiant disorder rather than ADHD.

C.IncOrrEct: Below-average intellectual functioning is associated with intellectual developmental disorder rather than ADHD.

D.CORRECT: Inattentive or impulsive behavior increases the risk for injury in a child who has ADHD.

NCLEX® Connection: Safety and Infection Control, Accident/Error/Injury Prevention

4. A nurse is obtaining a health history from the parents of a 12-year-old client who has conduct disorder. Which of the following are expected findings? (Select all that apply.)

A.Bullying of others

B.Threats of suicide

C.Law-breaking activities

D.Narcissistic behavior

E.Flat affect

A, B, C

A.CORRECT: Bullying behavior is an expected finding of conduct disorder.

B.CORRECT: Suicidal ideation is an expected finding of conduct disorder.

C.CORRECT: Law and/or rule-breaking behavior is an expected finding of conduct disorder.

D.IncOrrEct: Low self-esteem, rather than narcissism, is an expected finding of conduct disorder.

E.IncOrrEct: Irritability and temper outbursts, rather than a flat affect, are expected findings of conduct disorder.

NCLEX® Connection: Psychosocial Integrity, Mental Health Concepts

5. A nurse is assessing a 4-year-old child for indications of autism spectrum disorder. For which of the following indications should the nurse assess?

A.Impulsive behavior

B.Repetitive counting

C.Destructiveness

D.Somatic problems

B

A.IncOrrEct: Impulsive behavior is an indication of ADHD rather than autism spectrum disorder.

B.CORRECT: Repetitive actions and strict routines are an indication of autism spectrum disorder.

C.IncOrrEct: Destructiveness is an indication of conduct disorder rather than autism spectrum disorder.

D.IncOrrEct: Somatic problems are an indication of posttraumatic stress disorder rather than autism spectrum disorder.

NCLEX® Connection: Psychosocial Integrity, Mental Health Concepts