Question 1

A patient hospitalized for bipolar disorder is sitting in the corner of the room with the lights off and staring into space. Three hours later, the patient is in the same position. Which statement by the nurse is appropriate?

Accepted Answer

Option B is the most appropriate response as it is non-judgmental, offers support, and gently encourages the patient to engage in social interaction without pressuring them.

Question 2

A patient with schizophrenia is returning from a computerized tomography (CT) scan of the brain followed by an electroencephalogram. Which diagnostic test findings does the nurse identify as supporting this patient's diagnosis? (Select all that apply.)

Accepted Answer

Enlarged ventricles, reduced amount of gray matter, and diminished prefrontal cortex activity are findings that have been associated with schizophrenia in various studies. These changes can reflect the structural and functional abnormalities in the brain that are linked to the disorder. Areas of nerve demyelination are more characteristic of neurological conditions like multiple sclerosis, and aneurysms of the cerebral vessels are vascular issues that are not specifically associated with schizophrenia.

Question 3

The nurse has a coworker who becomes extremely upset when any spider is noticed, regardless of the size or type. Which characteristic of the coworker's phobia is untrue?

Accepted Answer

The coworker's fear being controllable is untrue regarding phobias. Phobias are characterized by an irrational and overwhelming fear that the person cannot control simply through willpower.

Question 4

The nurse is providing care for a patient with symptoms of tardive dyskinesia from major tranquilizers. Which treatment does the nurse anticipate?

Accepted Answer

The answer of The nurse is providing care for a...

Question 5

A patient is self-admitted to a mental health facility for "problems related to military service." The nurse is collecting information for the patient's plan of care. Which behavior will prompt the nurse to immediately notify the RN or HCP?

Accepted Answer

The patient shouting and crying in response to questions may indicate a severe emotional disturbance or crisis, requiring immediate attention from a higher-level healthcare provider.

Question 6

The nurse is making a home visit to an older adult patient who requires a dressing change for a recent surgery. The nurse notices that the patient seems unusually confused and disoriented. Which assessment is most likely to aid the nurse in making a determination for the patient's change in mental status?

Accepted Answer

The answer of The nurse is making a home visit...

Question 7

The nurse is assisting in the preparation of an educational seminar on anxiety disorders. Which anxiety disorders does the nurse make sure are included in this presentation? (Select all that apply.)

Accepted Answer

Phobia, Panic disorder, PTSD (Post-Traumatic Stress Disorder), and OCD (Obsessive-Compulsive Disorder) are all types of anxiety disorders. Schizophrenia, however, is a separate mental health disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions.

Question 8

The spouse of an older patient is concerned because, since retiring, the patient sits around the house, avoids eating, naps, and refuses to participate in sporting activities. Which disorder does the nurse recognize as being associated with these manifestations?

Accepted Answer

The symptoms described, such as lack of interest in activities, changes in eating habits, and increased sleep, are indicative of depression. This is especially common in older adults who may struggle with the transition into retirement and experience feelings of purposelessness or isolation.

Question 9

A patient who experienced injuries from a motor vehicle crash 6 months ago continues to request prescriptions for an opioid analgesic. When assessing this patient for opioid dependency which finding is the nurse least likely to observe?

Accepted Answer

The patient managing to get to work each day is least likely to be observed in someone with opioid dependency, as this indicates a level of functioning that might not be consistent with severe dependency, where daily activities and responsibilities often become neglected.

Question 10

The nurse is assisting with a patient who is newly diagnosed with diabetes mellitus and is prescribed insulin. The patient voices a fear of needles and nearly faints when the insulin needle is uncapped. When the registered nurse (RN) suggests a process of desensitizing, which action does the nurse initiate?

Accepted Answer

Desensitization involves gradual exposure to the feared object or situation to reduce anxiety. Allowing the patient to look at and describe an uncapped syringe is a step in this process, helping the patient become more comfortable with the sight and idea of the needle.

Question 11

The nurse is assisting at a health fair being held in a community center for older adults. Screenings are being performed for suicide risk. Which participant does the nurse identify as being at highest risk for suicide?

Accepted Answer

A widower who recently bought a new gun but does not hunt may indicate a risk for suicide, especially if there's no other known purpose for the purchase. This scenario lacks a clear, healthy reason for acquiring a firearm and could suggest suicidal ideation, making it a significant risk factor to be addressed.

Question 12

A patient who is withdrawing from alcohol is restless and reports seeing snakes on the ceiling. Vital signs are blood pressure 180/100 mm Hg, pulse 92 beats/min, and respirations 22 breaths/min. Which action does the nurse perform first?

Accepted Answer

The answer of A patient who is withdrawing from alcohol...

Question 13

The nurse is assisting with data collection on a patient newly diagnosed with schizophrenia. Which observations does the nurse consider as being positive symptoms of schizophrenia? (Select all that apply.)

Accepted Answer

Positive symptoms of schizophrenia include those that add to normal behavior, such as delusions (C) and hallucinations (D). These symptoms represent an excess or distortion of normal functions. Alogia, apathy, and social isolation are considered negative symptoms, which reflect a diminution or loss of normal functions.

Question 14

The nurse works on a mental health unit and is assisting with data collection from a patient just admitted through the court system with a diagnosis of personality disorder. Which comment by the patient is unexpected in regard to the diagnosis?

Accepted Answer

Personality disorders often involve a lack of insight into one's own behaviors and conditions. A statement expressing shock and a desire for self-control, like option C, is unexpected because individuals with personality disorders typically do not recognize their behavior as problematic or express a desire to change.

Question 15

The nurse is collecting data from a patient in an HCP's office. The patient was recently diagnosed with a chronic respiratory disorder and states, "I just cannot seem to enjoy any activity anymore." The patient's clothes are baggy and wrinkled, and the patient reports an inability to sleep. Which question does the nurse need to ask first?

Accepted Answer

The patient's statement about not enjoying any activity anymore, along with the observation of baggy and wrinkled clothes and reported inability to sleep, suggests possible depression. The most immediate concern is the patient's safety, so the nurse should first ask about thoughts of self-harm, which is addressed by asking, "Do you think about hurting yourself?" This question directly assesses the risk of suicide, which is a priority.

Question 16

The nurse is reviewing potential patient teaching needs. For which prescribed medications does the nurse plan to reinforce instructions to follow a tyramine-free diet? (Select all that apply.)

Accepted Answer

Phenelzine and isocarboxazid are both monoamine oxidase inhibitors (MAOIs) that require a tyramine-free diet to prevent hypertensive crisis.

Question 17

The nurse is assisting in the care of a patient admitted to a special unit for patients with eating disorders. Which nursing intervention is aimed at successful treatment?

Accepted Answer

The answer of The nurse is assisting in the care...

Question 18

A patient with schizophrenia calls the nurse into the room and says, "Help me! The books are on fire!" Which response by the nurse is best?

Accepted Answer

The best response is to acknowledge the patient's reality without reinforcing the hallucination, then redirecting the patient's attention to a real-world activity. Saying "I don't see any fire. Let's go to dinner now." does this effectively.

Question 19

The nurse is working with a patient diagnosed with obsessive-compulsive disorder (OCD) manifested by frequent handwashing. The nurse notes the patient's hands are severely dried and chapped. Which action by the nurse is contraindicated with this patient?

Accepted Answer

The answer of The nurse is working with a patient...

Question 20

A patient who just completed an alcohol treatment program is prescribed disulfiram to help maintain sobriety. Which teaching is most important for the nurse to review with the patient?

Accepted Answer

Disulfiram works by causing unpleasant reactions when alcohol is consumed. It is crucial for the patient to understand these reactions to avoid consuming alcohol and risking severe adverse effects.

Quiz 57: Nursing Care of Patients With Mental Health Disorders