Question 1

The nurse has been caring for a client with a diagnosis of depression. The client says to the nurse, "I wish you would just be my friend." The appropriate response by the nurse is:

Accepted Answer

The appropriate response is to clarify the professional nature of the relationship, emphasizing that it is therapeutic and aimed at helping the client. This maintains professional boundaries while still offering support.

Question 2

The nurse is developing a care plan that will include goals that will help the client achieve an optimal level of functioning and appropriate resource utilization. When the nurse enters the client's room,the client asks the nurse, "Could you ask the physician to let me have a pass for the weekend?" The nursing response that assists the client in achieving these goals is:

Accepted Answer

Option B is the most appropriate response as it encourages communication between the client and the physician, promoting client involvement in care decisions and optimal use of resources without making assumptions about the physician's decision.

Question 3

In preparing for the orientation phase of the therapeutic relationship, the nurse suggests addressing which of the following subjects?

Accepted Answer

During the orientation phase of the therapeutic relationship, it's crucial to establish the parameters of the relationship, including roles, confidentiality, and the goals of the interaction. This sets a clear framework for the therapeutic process.

Question 4

The nurse who is reviewing the record of a client admitted to the mental health unit notes that the client was admitted by voluntary status, which indicates that:

Accepted Answer

Voluntary status means the client admitted themselves to the mental health unit under their own will, indicating they have the right to request and be released, unlike involuntary admissions where release is not solely at the patient's discretion.

Question 5

The nurse is collecting data on a client diagnosed with mild depression. The client says to the nurse, "I haven't had an appetite at all for the last few weeks." Which of the following responses by the nurse would be best?

Accepted Answer

Option B, "You haven't had an appetite at all?" is the best response as it uses therapeutic communication techniques by reflecting the client's statement, encouraging them to elaborate more on their experience. This approach fosters a supportive environment and promotes further discussion about their feelings and symptoms.

Question 6

A nurse in the emergency department is preparing to care for a female client who has just been sexually assaulted. Which of the following client behaviors would demonstrate denial?

Accepted Answer

Denial is a defense mechanism where an individual refuses to accept reality or facts, acting as if a painful event, thought, or feeling did not exist. A client who is calm and quiet after a traumatic event like sexual assault may be demonstrating denial by not acknowledging the severity or reality of the situation.

Question 7

The day nurses in a psychiatric unit are receiving report from the night shift. While this is occurring, a client approaches the nurses' station, becomes very loud and offensive, and demands to be seen by the physician immediately. The appropriate nursing intervention is which of the following?

Accepted Answer

Offering to assist the client to an examination room until the physician is notified is the most therapeutic intervention. It addresses the client's immediate need for attention in a manner that is both respectful and practical, without reinforcing the disruptive behavior or ignoring the client's distress.

Question 8

The nurse is assisting in developing a plan of care for a client with a psychotic disorder who is experiencing altered thought processes that include the belief that the food is being poisoned. The nurse develops strategies that will encourage the client to discuss feelings and plans to:

Accepted Answer

Using open-ended questions and silence encourages the client to express thoughts and feelings, which is therapeutic for clients experiencing altered thought processes. It helps in understanding the client's perspective without directly confronting or challenging their beliefs, which can be counterproductive in the context of psychotic disorders.

Question 9

The mental health nurse has been meeting with a client on a weekly basis and, over the past several weeks, the client has been consistently 15 minutes late. Which of the following nursing actions is appropriate regarding the client's lateness for the scheduled meetings?

Accepted Answer

Asking the client if something is going on that they may have difficulty handling is appropriate because it addresses the behavior in a non-judgmental way, opens up a dialogue for potential issues affecting the client's punctuality, and maintains the therapeutic relationship. Ignoring the behavior, threatening to terminate meetings, or adjusting the nurse's arrival time do not address the underlying issue or support the client's needs.

Question 10

A mental health nurse who has been meeting with a client with a diagnosis of post-traumatic stress disorder is in the termination phase of the nurse-client relationship. The nurse notes that the client has been quiet and withdrawn and interprets the client's behavior as:

Accepted Answer

Termination is a phase in the therapeutic relationship where feelings of loss can manifest as withdrawal or quietness. This is a normal part of the process as the client adjusts to the end of the relationship.

Question 11

The nurse is preparing for the arrival of a new client at a drug abusers' residential treatment center and prepares to explain to the client that the emphasis of the center is on group and social interaction, and that rules and expectations are mediated by peer pressure. The most likely focus of therapy of this residential center is:

Accepted Answer

Milieu therapy focuses on creating a therapeutic community environment where the social structure and group dynamics are utilized to promote individual change and positive peer interactions. This approach emphasizes group and social interaction, with rules and expectations often mediated by peer pressure, aligning with the description provided.

Question 12

A client with a phobia will be treated for the condition using a behavior modification technique known as systematic desensitization. The nurse describes the components of this form of therapy to the client and instructs the client that:

Accepted Answer

Systematic desensitization involves gradually exposing the client to the phobic object or situation while they are in a relaxed state to reduce the fear response over time.

Question 13

The nurse is conducting a group therapy session when a female client, who has shared with the group at a previous session that she isolates herself when she feels depressed, suddenly gets up to leave. The appropriate nursing action is which of the following?

Accepted Answer

Encouraging the client to stay and asking what she is feeling is the most therapeutic response. It respects the client's autonomy while also showing concern for her well-being and encouraging communication about her feelings, which is crucial in a therapeutic setting.

Question 14

The nurse is helping to conduct a group therapy session. During the session, a male client threatens to act out physically and states that he will punch another member of the group. Which of the following is the appropriate initial nursing action?

Accepted Answer

The appropriate initial nursing action is to set boundaries and remind the client that while it is acceptable to talk about feelings of anger, acting on these feelings with violence is not permitted during the group session. This approach maintains a therapeutic environment and encourages verbal expression of emotions rather than physical actions.

Question 15

The nurse is preparing a plan of care for a client with an autistic disorder. A behavior modification approach (operant conditioning) is being used to improve communication. Which of the following would be appropriate for the nurse to include in the plan of care?

Accepted Answer

Rewarding the client when a desired behavior is performed is a key component of behavior modification approaches like operant conditioning. It helps in reinforcing the desired behavior.

Question 16

A nursing student is conducting a clinical conference and is describing the characteristics associated with milieu therapy. Which of the following statements, if made by the student, indicates an understanding of the focus of this form of therapy?

Accepted Answer

Milieu therapy focuses on using the patient's immediate environment to create a therapeutic community where the environment itself becomes a part of the treatment. It emphasizes the importance of the social environment and interactions within it to facilitate healing and learning. Choices A, C, and D suggest cognitive and behavioral approaches, which are distinct from the environmental and community focus of milieu therapy.

Question 17

A nurse working in an urgent care center is interviewing a woman with vague somatic complaints. When the nurse is alone with the client, however, the client states that she was raped a few weeks ago but still feels "as if it just happened to me." The nurse should make which therapeutic re sponse to the client?

Accepted Answer

Option C is the correct choice because it encourages the client to express her feelings and thoughts about the traumatic event in a supportive and non-judgmental manner. This approach is therapeutic as it validates the client's feelings and helps in the healing process by allowing her to discuss her experiences openly.

Question 18

The nurse is developing a plan of care for a client admitted to the psychiatric unit at high risk for suicide. The focus of the plan is to promote a safe and therapeutic environment. Which of the following interventions would the nurse include in the plan of care?

Accepted Answer

Establishing a therapeutic relationship is crucial in managing clients at high risk for suicide. It helps in building trust, understanding the client's feelings, and providing emotional support, which are essential in a safe and therapeutic environment.

Question 19

A client admitted to the mental health unit with depression states to the nurse, "My life has been such a failure; nothing I do turns out right." Which of the following responses by the nurse would be therapeutic?

Accepted Answer

Option D is therapeutic because it acknowledges the client's feelings of discouragement and encourages the client to explore their own experiences and perceptions, which can help in identifying positive aspects of their life and challenge their negative thoughts.

Question 20

A client is admitted to the psychiatric unit with a diagnosis of bipolar affective disorder and mania. The nurse would prioritize that which of the following symptoms or behaviors requires immediate intervention?

Accepted Answer

Constant physical activity combined with poor oral intake can lead to physical health complications such as dehydration and malnutrition, requiring immediate intervention to prevent further health decline.

Quiz 5: Mental Health