Question 1

Certain psychiatric diagnoses are associated with stereotypes. Which of the following actions ensures that the client's social identity is not discredited?

Accepted Answer

Referring to a client as "X who has a diagnosis of schizophrenia" acknowledges their diagnosis while maintaining their individual identity and avoids the stereotype associated with the label "schizophrenic." Referring to a client as a "paranoid" or "delusional and psychotic" can be stigmatizing and discrediting to their social identity.

Question 2

A client with a diagnosis of bipolar disorder has had several hospitalizations to treat this mental illness and feels that the care he received was not consistent with his best interests. The client's experience is indicative of which of the following needs?

Accepted Answer

A psychiatric advance directive (PAD) is a legal document that allows an individual to specify the mental health treatment they prefer to receive or not receive in the event they are unable to make decisions for themselves. This is particularly important for individuals with mental illnesses, such as bipolar disorder, who may have had negative experiences with past hospitalizations or treatments. By creating a PAD, the client can ensure that their preferences and best interests are being considered and followed, even if they are not able to communicate them at the time.

Question 3

A 40-year-old man is accused of sexual assault and is arrested by law enforcement. The forensic nurse is a sexual assault nurse examiner and is asked to testify in what capacity?

Accepted Answer

As a sexual assault nurse examiner, the forensic nurse has specialized knowledge and experience that makes them qualified to testify as an expert witness in cases involving sexual assault. They can provide expert opinions and interpretations of physical evidence related to the assault. They would not serve as a hostage negotiator, profiler, or fact witness in this case.

Question 4

A nurse observes an acutely psychotic client scratching at his arms with his fingernails until his arms bleed. When asked what is happening, the client states he is trying to let the evil spirits out of his body. He is easily redirected by the nurse, but resumes scratching when the nurse leaves his side. The nurse orders 1:1 supervision of the client to keep him from harming himself. Which principle of bioethics was applied in this situation?

Accepted Answer

The principle of beneficence was applied in this situation, as the nurse took action to prevent harm to the client by ordering 1:1 supervision. The nurse prioritized the client's well-being and safety over other factors, such as the client's autonomy or confidentiality.

Question 5

A nurse is learning how to advocate for populations with mental disorders. Which of the following statements by the nurse would reflect that learning has taken place?

Accepted Answer

This statement reflects an understanding of the role of nursing in monitoring and advocating for the rights and well-being of individuals with mental disorders. The other options either reflect a lack of understanding or inaccurate beliefs about mental disorders and their treatment.

Question 6

The nurse conducts ongoing evaluation of the crisis situation to ensure the client's right to the least restrictive intervention. This means the assessment factor receiving the highest priority is:

Accepted Answer

The nurse's priority in a crisis situation is to ensure the client's safety while also respecting their right to the least restrictive intervention possible. Therefore, the assessment of the client's condition in comparison to the adequacy of the environment designed to prevent injury should receive the highest priority. This will help the nurse determine if any interventions need to be put in place to keep the client safe while also ensuring that those interventions are the least restrictive necessary. The client-staff ratio, comfort level of the environment, and client's mental status are also important factors to consider, but ensuring the client's safety while respecting their autonomy should be the top priority in a crisis situation.

Question 7

Which symptom would indicate that a client is delirious?

Accepted Answer

Illusions or hallucinations are a common symptom of delirium, which is characterized by confusion, disorientation, and a fluctuating level of consciousness. Slurred speech, unsteady gait, and dehydration can also be symptoms of delirium, but they are not specific to this condition and can be present in other medical conditions as well.

Question 8

A client has dementia of the Alzheimer's type. He is no longer able to walk, and he does not recognize family members, even his wife of 52 years, when they visit him. He attempts to communicate with agitated behaviors or with occasional incoherent vocalizations. The client is in which stage of the illness?

Accepted Answer

The client's inability to walk and lack of recognition of family members are indicative of late-stage dementia, where the individual experiences significant cognitive decline and physical impairment. The agitated behavior and incoherent vocalizations are also common in this stage.

Question 9

An 84-year-old woman with a diagnosis of dementia lives with her daughter and son-in-law. The client's daughter tearfully tells the nursing student that she doesn't know what's wrong with her mother, who has begun accusing them of stealing her lingerie and keeping her prisoner. Based on the above, the nursing student identifies the following nursing diagnosis for the client:

Accepted Answer

The client's accusations suggest a disturbance in her thought processes. This may be due to her dementia, but additional assessment and interventions are needed to address her behavior and improve her quality of life. Option A (defensive coping) refers to a person's attempts to protect self-image and deal with emotional conflict, while option B (powerlessness) and option C (ineffective coping) do not fully capture the client's presenting problem.

Question 10

Which of the following statements would be most important for staff to consider when planning delirium management for a client?

Accepted Answer

Sensory deprivation and overstimulation can both worsen symptoms of delirium. Therefore, it is important for staff to carefully manage the client's environment and level of stimulation to promote optimal functioning and reduce agitation or confusion. Providing education to family members, decreasing stimulation in the client's room, and involving the client in conversations and interactions may also be important strategies for managing delirium, but they are not as critical as addressing sensory deprivation and overstimulation.

Question 11

An older adult client is observed as having several cognitive problems, including memory and attention deficits and fluctuating levels of orientation. The nurse confirms that the client's symptoms developed over a 3-day period. The client's symptoms are most characteristic of:

Accepted Answer

The symptoms of memory and attention deficits and fluctuating levels of orientation developing over a short period of time are typical of delirium. Depression, dementia, and DAT (Alzheimer's disease) may also affect cognition, but their onset is typically more gradual and less fluctuating.

Question 12

Which questions would assist the nurse in developing self-awareness when working with clients who have cognitive disorders?
Select all that apply.

Accepted Answer

Asking about personal feelings and potential frustrations can help the nurse become more self-aware and better able to address their own biases and barriers towards working with clients who have cognitive disorders. Questions about how to assist the client and how they feel about working with the nurse are important, but they do not pertain to self-awareness. Similarly, asking what the clients like about working with the nurse is important for improving care, but it does not necessarily lead to improved self-awareness.

Question 13

A client brought to the emergency room after a motor vehicle accident tells the nurse that she attended a party and drank four drinks over the last hour. Her blood alcohol level is 0.15g/dl. She states she is "buzzed." What conclusions can the nurse draw?

Accepted Answer

A blood alcohol level of 0.15g/dl indicates that the client is legally intoxicated, regardless of whether she feels "buzzed." The fact that she consumed four drinks in one hour also suggests that she may have a problem with excessive alcohol consumption. However, the information provided does not allow the nurse to definitively conclude that the client has alcohol dependence. The blood alcohol level is higher than the legal limit for driving, indicating that it is dangerously high.

Question 14

A college student tells the nurse that he sometimes cannot recall conversations or events during times when he was drinking heavily. The nurse teaches the client that this experience is indicative of which of the following symptoms?

Accepted Answer

The experience described by the college student is indicative of a blackout, which is a temporary disruption in memory formation that can occur during heavy alcohol consumption. Confabulation involves the construction of false memories, delusions involve false beliefs about reality, and addiction involves compulsive drug-seeking behavior.

Question 15

Since chemical dependency is a family disease, it is important to help non-abusing family members change over-responsible behaviors such as:

Accepted Answer

Covering up for the client's problems is an over-responsible behavior that non-abusing family members often engage in, which can inadvertently enable the client's chemical dependency. It prevents the client from facing the natural consequences of their actions, which is crucial for their recovery process.

Question 16

The nurse is learning how to reduce the stigma associated with substance abuse. Which of the following statements by the nurse would reflect that learning has taken place?

Accepted Answer

Using person-first language and avoiding derogatory terms, such as "druggie," helps reduce the stigma associated with substance abuse. Option B uses person-first language and focuses on the reason for admission rather than the substance or behavior.

Question 17

What treatment approach would be most appropriate for a client who has had multiple substance abuse treatments and has relapsed?

Accepted Answer

The answer of What treatment approach would be most appropriate...

Question 18

When focusing on relapse prevention, what is most important for the client?

Accepted Answer

Identifying high-risk situations is crucial in preventing relapse as it allows the client to be aware of triggers and plan ahead for how to cope with them. While the other options may also be important, they are not as essential as identifying high-risk situations.

Question 19

A client who presents in the psychiatric unit tells the admitting nurse that she is very depressed and is having a hard time staying clean and sober. Which of the following is true regarding mental illness in a client with identified substance abuse?

Accepted Answer

Depression or other untreated mental illness can contribute to relapse. It is common for individuals with substance abuse disorders to also have co-occurring mental health disorders. Treating only the substance abuse without addressing the underlying mental health issues can contribute to relapse. It is important to address both issues simultaneously in order to increase the likelihood of success in recovery.

Question 20

A client was brought to the hospital at 2 a.m. She had been drinking and she fell, fracturing her femur. If the client is going to experience withdrawal symptoms, the nurse should be alert for them to peak around which time?

Accepted Answer

Withdrawal symptoms for someone who has been drinking heavily can typically begin to peak around 24 to 48 hours after the last drink. This is when symptoms such as tremors, agitation, and other withdrawal effects can become most intense.

Quiz 2: Psychiatric-Mental Health Nursing Processes, and Clients With Mental Disorders