Mental Health Nursing Test III - Set A

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Mental Health Nursing Test III - Set A - Quiz

This test contains 25 items Questions about Mental Health Nursing
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Menta Health Nursing Test III - Set A: Questions with Answers
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Questions and Answers
  • 1. 

    1. Despite the repeated nursing interventions to improve reality orientation, a client insists that he is the savior of the world. What is this adaptation known as?

    • A.

      Confabulation

    • B.

      Hallucination

    • C.

      Delusion

    • D.

      Illusion

    Correct Answer
    C. Delusion
    Explanation
    Delusion refers to a fixed, false belief that is not based on reality and is not influenced by evidence to the contrary. In this scenario, despite the nursing interventions to improve reality orientation, the client continues to believe that he is the savior of the world, which is a clear example of a delusion. Delusions are often seen in psychiatric disorders such as schizophrenia and can significantly impact an individual's perception of reality.

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  • 2. 

    A newly admitted client is apathetic and exhibits an inappropriate affect. A diagnosis of acute schizophrenic reaction is made. Considering the diagnosis, a symptom the nurse would expect to observe in the client’s communication or behavior is:

    • A.

      Autistic magical thinking

    • B.

      Absence of self-criticism

    • C.

      Suicidal preoccupation

    • D.

      Logical deductions

    Correct Answer
    A. Autistic magical thinking
    Explanation
    Autistic magical thinking refers to a symptom commonly observed in individuals with schizophrenia. It involves the belief in unrealistic or fantastical ideas that are not based in reality. This symptom can manifest in the client's communication or behavior, such as having irrational beliefs, difficulty distinguishing between fantasy and reality, or engaging in magical or superstitious thinking. It is characterized by a lack of logical reasoning and a disconnect from reality.

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  • 3. 

    Princess is brought to the psychiatric hospital by her roommate after noticing that she has become increasingly withdrawn and neglectful of her studies and personal hygiene. Detailed assessment reveals a diagnosis of schizophrenia. It is unlikely that Princess will demonstrate:

    • A.

      Effective self-boundaries

    • B.

      A low self-esteem

    • C.

      Concrete thinking

    • D.

      A weak ego

    Correct Answer
    A. Effective self-boundaries
    Explanation
    Princess, who has been diagnosed with schizophrenia, is unlikely to demonstrate effective self-boundaries. Schizophrenia is a mental disorder characterized by a distorted perception of reality and difficulty in distinguishing between what is real and what is not. Individuals with schizophrenia often struggle with maintaining clear boundaries between themselves and others, as their thoughts and perceptions may become fragmented and distorted. This can lead to difficulties in setting personal boundaries and maintaining a sense of self. Therefore, it is unlikely that Princess will demonstrate effective self-boundaries.

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  • 4. 

    A client diagnosed with schizophrenia says to the nurse, “Yes, it’s march. March is Little women. That’s literal you know.” This statement illustrates:

    • A.

      Loosening of associations

    • B.

      Flight of ideas

    • C.

      Neologisms

    • D.

      Echolalia

    Correct Answer
    A. Loosening of associations
    Explanation
    Loosening of associations refers to a disturbance in the thought process where there is a lack of logical connection between thoughts and ideas. In this case, the client's statement about March and Little Women does not make logical sense and does not follow a coherent train of thought. This is indicative of loosening of associations, which is a common symptom in schizophrenia.

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  • 5. 

    The nurse recognizes that client with the diagnosis of an acute schizophrenia reaction has better potential for recovery when history reveals:

    • A.

      Appearance of many poorly defined prepsychotic symptoms

    • B.

      Presence of a family history of schizophrenia

    • C.

      Occurrence of a precipitating event

    • D.

      Insidious onset of illness

    Correct Answer
    C. Occurrence of a precipitating event
    Explanation
    The occurrence of a precipitating event is a better indicator for potential recovery in a client with acute schizophrenia reaction. This suggests that the onset of the illness was sudden and triggered by a specific event, which may allow for a targeted treatment approach. The presence of prepsychotic symptoms, a family history of schizophrenia, or an insidious onset of illness may all contribute to a more chronic and difficult-to-treat condition.

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  • 6. 

    Lito is admitted to a mental health facility because of inappropriate behavior. He has been hearing voices, responding to imaginary companions, and withdrawing to his room for several days at a time. The nurse is aware that withdrawal is a defense against the client’s fear of:

    • A.

      The lack of power

    • B.

      The unknown

    • C.

      Punishment

    • D.

      Rejection

    Correct Answer
    D. Rejection
    Explanation
    Lito's withdrawal to his room for several days at a time can be seen as a defense mechanism against his fear of rejection. By isolating himself, he is avoiding potential interactions and situations that may lead to rejection from others. This behavior can be a way for Lito to protect himself from the emotional pain that rejection may cause.

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  • 7. 

    The nurse asked the family of a young client with the diagnosis of schizophrenia about the onset of the problem. The nurse should expect that they would state that the client’s difficulties began during:

    • A.

      Early childhood

    • B.

      Late childhood

    • C.

      Adolescence

    • D.

      Puberty

    Correct Answer
    C. Adolescence
    Explanation
    Adolescence is the correct answer because schizophrenia typically emerges during this developmental stage. Schizophrenia is a mental disorder characterized by disturbances in thinking, perception, emotions, and behavior. It often becomes evident during late adolescence or early adulthood, although it can occasionally start earlier. The nurse asked about the onset of the problem to gather information about when the client's difficulties first appeared, which would likely align with the typical age of onset for schizophrenia.

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  • 8. 

    A client with schizophrenia sees a group of visitors sitting together talking. The client tells the nurse, “I know they are talking about me.” Which altered thought process should the nurse identify?

    • A.

      Thought broadcasting

    • B.

      Ideas of reference

    • C.

      Grandiose delusion

    • D.

      Flight of ideas

    Correct Answer
    B. Ideas of reference
    Explanation
    The nurse should identify "Ideas of reference" as the altered thought process in this scenario. Ideas of reference refer to the belief that neutral events or situations have a special and personal significance specifically related to oneself. In this case, the client's belief that the group of visitors is talking about them indicates a distorted perception of reality, commonly seen in individuals with schizophrenia. This symptom is characterized by the tendency to interpret external stimuli as being directed towards oneself, even when there is no evidence to support such beliefs.

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  • 9. 

    When planning care of a young woman admitted with a diagnosis of schizophrenia who is actively hallucinating and delusional, the nurse should be aware that hallucinations are:

    • A.

      Generally related to the client’s thought process

    • B.

      Misinterpretations of environmental stimuli

    • C.

      Usually triggered by unknown factors

    • D.

      Upsetting to the client

    Correct Answer
    A. Generally related to the client’s thought process
    Explanation
    Hallucinations are generally related to the client's thought process. This means that they are a product of the client's own mind and are not based on actual external stimuli. Hallucinations can involve seeing, hearing, smelling, or feeling things that are not actually present. In the case of schizophrenia, hallucinations are often a result of the client's distorted perception of reality. They can be very distressing and disruptive to the client's life. Understanding that hallucinations are related to the client's thought process helps the nurse in planning appropriate care and interventions to manage and alleviate the distress caused by these symptoms.

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  • 10. 

    The nurse understands that a client with schizophrenia who repeatedly says to the nurse, “No moley, jandu!” is exhibiting:

    • A.

      Perseveration

    • B.

      Concretism

    • C.

      Neologisms

    • D.

      Echolalia

    Correct Answer
    C. Neologisms
    Explanation
    Neologisms refer to the use of new or made-up words that have no meaning to others. In this scenario, the client with schizophrenia is repeatedly saying "No moley, jandu!" which does not make sense to the nurse or anyone else. This demonstrates the characteristic of neologisms, as the client is using words that are not part of the normal vocabulary and have no understandable meaning.

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  • 11. 

    Which factor might place young person in a high risk category for substance abuse?

    • A.

      Typical stresses associated with adolescence

    • B.

      Loss of a parent through death or separation

    • C.

      Occasional periods of depression

    • D.

      Curiosity with a daring attitude

    Correct Answer
    B. Loss of a parent through death or separation
    Explanation
    Experiencing the loss of a parent through death or separation can be a traumatic and emotionally challenging event for a young person. This significant loss can lead to feelings of sadness, confusion, and loneliness, which may increase the risk of turning to substance abuse as a coping mechanism. The absence of a parent figure can also result in a lack of guidance and support, making the individual more vulnerable to peer pressure and negative influences. Therefore, the loss of a parent through death or separation can be a contributing factor that places a young person in a high-risk category for substance abuse.

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  • 12. 

    A 22-year old TV stunt man falls from a roof and incurs fractures in the right femur and left tibia after a TV series shooting. The client reveals a history of substance abuse. A primary consideration for the nurse who is caring for this client would be to:

    • A.

      Realize that this client will need more pain medication than a non-abuse

    • B.

      Avoid upsetting the client by calling attention to the drug abuse

    • C.

      Communicate in the same speech pattern that the client uses

    • D.

      Confront the client about substance abuse

    Correct Answer
    A. Realize that this client will need more pain medication than a non-abuse
    Explanation
    Based on the information provided, the client has a history of substance abuse and has incurred fractures in the right femur and left tibia. Substance abuse can affect an individual's tolerance to pain medication, meaning that they may require higher doses to achieve the same level of pain relief as someone without a history of substance abuse. Therefore, the primary consideration for the nurse would be to realize that this client will need more pain medication than a non-abuser.

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  • 13. 

    The nurse is aware that the defense mechanism commonly used by clients who are alcoholics is:

    • A.

      Compensation

    • B.

      Displacement

    • C.

      Projection

    • D.

      Denial

    Correct Answer
    D. Denial
    Explanation
    Denial is a defense mechanism commonly used by clients who are alcoholics. It involves refusing to acknowledge or accept the reality of their addiction. By denying their alcoholism, these individuals can avoid facing the consequences and continue their destructive behavior. Denial allows them to maintain a false sense of control and avoid the discomfort of admitting their problem. This defense mechanism can be a significant barrier to seeking help and starting the recovery process.

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  • 14. 

    Arturo is diagnosed with alcoholism. He explains to the nurse that alcohol has a calming saying, “I function better when I’m drinking than when I’m sober.” The nurse recognizes that the client is using the defense mechanism of:

    • A.

      Compensation

    • B.

      Rationalization

    • C.

      Suppression

    • D.

      Sublimation

    Correct Answer
    B. Rationalization
    Explanation
    Rationalization is a defense mechanism where an individual provides a logical or socially acceptable explanation for their behavior or feelings, in order to avoid facing the true underlying reasons. In this case, Arturo is rationalizing his alcoholism by stating that alcohol has a calming effect on him and helps him function better. He is justifying his excessive drinking by attributing positive qualities to it, rather than acknowledging the negative consequences of his addiction.

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  • 15. 

    The nurse should assess a client within a few hours of alcohol withdrawal for the presence of:

    • A.

      Fever and profuse diaphoresis

    • B.

      Disorientation and paranoia

    • C.

      Yawning and convulsions

    • D.

      Irritability and tremors

    Correct Answer
    D. Irritability and tremors
    Explanation
    During alcohol withdrawal, the body experiences a sudden cessation of alcohol intake, leading to various physical and psychological symptoms. Irritability and tremors are common manifestations of alcohol withdrawal syndrome. Irritability is often caused by the brain's attempt to readjust to functioning without alcohol, while tremors result from the overactivity of the central nervous system. Assessing for irritability and tremors is crucial as it helps the nurse monitor the severity of withdrawal symptoms and determine the appropriate interventions to manage the client's condition effectively.

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  • 16. 

    On the fourth day of admission of a client in an alcohol rehabilitation center, the nurse noticed a strong odor of alcohol on the client’s breath. Which is the nurse first action?

    • A.

      Notify the physician that the client has been drinking

    • B.

      Convey the staff’s disappointment in this behavior

    • C.

      Ask directly where the client got the alcohol

    • D.

      Locate and remove the alcoholic substance

    Correct Answer
    D. Locate and remove the alcoholic substance
    Explanation
    The nurse's first action should be to locate and remove the alcoholic substance. This is important to ensure the safety of the client and prevent any further consumption of alcohol. It is not appropriate for the nurse to notify the physician without taking immediate action to remove the alcohol. Conveying disappointment or asking where the client got the alcohol may be addressed later, but the priority is to remove the substance.

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  • 17. 

    Tonyo who has a long history of alcohol abuse seeks help with the problem in one of the local hospitals The nurse understands that the major underlying factor for success in an alcohol treatment program will be the client’s:

    • A.

      Self-esteem

    • B.

      Psychiatrist

    • C.

      Motivation

    • D.

      Family

    Correct Answer
    C. Motivation
    Explanation
    Motivation is the major underlying factor for success in an alcohol treatment program. Without motivation, the client may not be willing to actively participate in the program or make the necessary changes to overcome their alcohol abuse. Motivation is what drives individuals to seek help, set goals, and stay committed to the treatment process. It is essential for the client to have a strong desire and determination to change their behavior and achieve sobriety. Self-esteem, a psychiatrist, and family support can all be beneficial in the treatment process, but without motivation, these factors may not have a significant impact on the client's success.

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  • 18. 

    Mang Pandoy is admitted to a mental health facility and is diagnosed with substance induce persisting dementia resulting from chronic alcoholism. During admitting interview, the nurse finds out that the client is using confabulation. The nurse recognizes that this is caused by the client’s:

    • A.

      Difficulty in accepting the diagnosis

    • B.

      Need to get attention from others

    • C.

      Marked memory loss

    • D.

      Ideas of grandeur

    Correct Answer
    C. Marked memory loss
    Explanation
    The client's use of confabulation is caused by their marked memory loss. Confabulation is a symptom commonly seen in individuals with memory impairments, where they create false or distorted memories to fill in the gaps in their recollection. In this case, the client's chronic alcoholism has resulted in substance-induced persisting dementia, which is characterized by significant memory loss. This memory loss is likely leading the client to confabulate as a way to make sense of their experiences and memories.

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  • 19. 

    In planning care for a client with substance- induced persisting dementia resulting from chronic alcohol ingestion, the nurse considers that the disorder is thought to be caused by:

    • A.

      The deficiency of thiamine in the diet

    • B.

      The malabsorption of riboflavin

    • C.

      A reduction in iron intake

    • D.

      An increase in serotonin

    Correct Answer
    A. The deficiency of thiamine in the diet
    Explanation
    Substance-induced persisting dementia resulting from chronic alcohol ingestion is commonly associated with a deficiency of thiamine in the diet. Thiamine, also known as vitamin B1, is essential for brain function and alcohol interferes with its absorption and utilization in the body. This deficiency can lead to a condition called Wernicke-Korsakoff syndrome, which is characterized by memory loss, confusion, and other cognitive impairments. Therefore, the correct answer is the deficiency of thiamine in the diet.

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  • 20. 

    The nurse understands that for individuals who are alcoholics, alcohol is a substance that is used to:

    • A.

      Stimulate the central nervous system

    • B.

      Promote social interaction

    • C.

      Precipitate euphoria

    • D.

      Blunt reality

    Correct Answer
    D. Blunt reality
    Explanation
    Alcoholics use alcohol to blunt reality. This means that they consume alcohol in order to escape from or numb themselves to the difficulties and challenges of their everyday life. By drinking alcohol, they can temporarily avoid facing their problems and emotions, creating a sense of detachment from reality.

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  • 21. 

    A client with the diagnosis of major depressive disorder has been taking herbal medications. The physician orders venlafaxine (Effexor). When discussing this medication with the client, the nurse should determine if the client has been taking:

    • A.

      St. John’s wort

    • B.

      Kava-kava

    • C.

      Valerian

    • D.

      Ginseng

    Correct Answer
    A. St. John’s wort
    Explanation
    St. John's wort is an herbal medication commonly used for the treatment of depression. However, it can interact with venlafaxine, an antidepressant medication, leading to a potentially dangerous condition called serotonin syndrome. Therefore, it is important for the nurse to determine if the client has been taking St. John's wort before starting venlafaxine to avoid any potential drug interactions and ensure the client's safety.

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  • 22. 

    Methylphenidate (Ritalin) is used in the treatment of Attention-deficit-hyperactivity disorder (ADHD) in children for it’s:

    • A.

      Hypotensive effect

    • B.

      Synergistic effect

    • C.

      Paradoxical effect

    • D.

      Diuretic effect

    Correct Answer
    C. Paradoxical effect
    Explanation
    Methylphenidate (Ritalin) is used in the treatment of ADHD in children for its paradoxical effect. This means that instead of causing hyperactivity or increased arousal, which is the typical response in individuals without ADHD, it actually helps to calm and focus the child with ADHD. This paradoxical effect is thought to be due to the way methylphenidate affects the balance of neurotransmitters in the brain, specifically by increasing the availability of dopamine and norepinephrine. This helps to improve attention, reduce impulsivity, and control hyperactivity in children with ADHD.

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  • 23. 

    Which common side effect the nurse should assess for clients with anxiety and physical symptoms related to work pressures receiving alprazolam (Xanax) 0.25 mg PO three times a day?

    • A.

      Tardive dyskinesia

    • B.

      Agranulocytosis

    • C.

      Drowsiness

    • D.

      Bradycardia

    Correct Answer
    C. Drowsiness
    Explanation
    Clients who are taking alprazolam (Xanax) may experience drowsiness as a common side effect. Alprazolam is a benzodiazepine medication that is commonly prescribed for anxiety and can cause sedation and drowsiness. It is important for the nurse to assess for drowsiness in clients taking alprazolam, as it can affect their ability to perform tasks that require alertness, such as driving or operating machinery. The nurse should educate the client about this potential side effect and advise them to avoid activities that may be dangerous if they are feeling excessively drowsy.

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  • 24. 

    The nurse understands that after administering alpraxolam (Xanax) it is important to assess the client for side effects. Initially the nurse should:

    • A.

      Check the size of the pupils frequently

    • B.

      Monitor the blood pressure

    • C.

      Assess for blood pressure

    • D.

      Measure urinary output

    Correct Answer
    B. Monitor the blood pressure
    Explanation
    After administering alprazolam (Xanax), it is important to monitor the client's blood pressure as one of the possible side effects of this medication is a decrease in blood pressure. By monitoring the blood pressure, the nurse can assess if the client is experiencing any hypotensive effects. This allows for early detection and intervention if necessary. Checking the size of the pupils frequently may be important for assessing other medications or conditions, but it is not specifically related to alprazolam administration. Assessing for blood pressure and measuring urinary output are redundant options as they both involve monitoring blood pressure.

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  • 25. 

    When asked by a client’s family about the treatment of schizophrenia, the nurse recalls that:

    • A.

      Drug therapy, although not eliminating the underlying problem, reduces the symptoms of acute aschzophrenia

    • B.

      Insight therapy has proven to be highly successful in the treatment of client’s with schizophrenia

    • C.

      Family therapy has not proven to be effective in the treatment of clients with schizophrenia

    • D.

      Electroconvulsive therapy is more effective in treating schizophrenia than mood disorders

    Correct Answer
    A. Drug therapy, although not eliminating the underlying problem, reduces the symptoms of acute aschzophrenia
    Explanation
    Drug therapy is a commonly used treatment for schizophrenia. While it does not completely eliminate the underlying problem, it is effective in reducing the symptoms of acute schizophrenia. This means that medication can help manage hallucinations, delusions, and other symptoms associated with the disorder. However, it is important to note that drug therapy is not a cure for schizophrenia and may need to be combined with other forms of therapy, such as counseling or support groups, for optimal results.

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