Nursing Interventions for Mental Health Clients
Nursing Interventions for Mental Health Clients
YBOA (FINALS)
1. A nurse notices that a client is mistrustful and shows hostile behavior. Which of the following types of
personality disorder is associated with these characteristics?
A. Antisocial
B. Avoidant
C. Borderline
D. Paranoid
2. Which of the following statements is typical for a client diagnosed with a personality disorder?
3. Which of the following types of behavior is expected from a client diagnosed with a paranoid
personality disorder?
A. Eccentric
B. exploitative
C. Hypersensitive
D. Seductive
4. A client is admitted to the mental health unit because of a progressively increasing depression over
the past month. What clinical finding does a nurse expect during the initial assessment of the client?
5. A client who is being admitted to the mental health unit with bipolar disorder is depressed, avoids
eye contact, responds in a very low voice, and is tearful. What is most therapeutic for a nurse to say
during the assessment interview?
A. "You'll find that you'll get better faster if you try to help us to help you."
B. "Hold my hand. I know you are frightened. I will not allow anyone to harm you."
C. "I'm your nurse. I'll take you to the day room as soon as I get some information."
D. "I know this is difficult, but as soon as we are finished, I'll take you to your room."
6. A client who is being admitted to the mental health unit with bipolar disorder is depressed, avoids eye
contact, responds in a very low voice, and is tearful. What is most therapeutic for a nurse to say during
the assessment interview?
A. "You'll find that you'll get better faster if you try to help us to help you."
B. "Hold my hand. I know you are frightened. I will not allow anyone to harm you."
C. "I'm your nurse. I'll take you to the day room as soon as I get some information."
D. "I know this is difficult, but as soon as we are finished, I'll take you to your room."
7. A client is admitted to the mental health unit because of a progressively increasing depression over
the past month. What clinical finding does a nurse expect during the initial assessment of the client?
8. The activity that would be the least therapeutic for severely depressed clients would be:
9. When caring for the extremely depressed client, the staff should set specific goals directed
toward helping the client:
10. When developing a nursing care plan for depressed client, the approach that would be most
therapeutic would be:
A. Allowing time for the client's slowness when planning activities
B. Helping the client focus on family strengths and support systems
C. Encouraging the client to perform menial tasks to meet the need for punishment
D. Repeating again and again that the staff views the client as worthwhile and important
11. The statement that would be most appropriate for the nurse to use in interviewing a newly
admitted, 35-year-old, depressed client whose thoughts focus on feelings of unworthiness and
failure would be:
12. An activity that would be most appropriate for a depressed client during the early part of
hospitalization would be a:
13. A female client is hospitalized because of a severe depression. while at home she refused to
eat, stayed in bed most of the time and did not talk with family members. finally, unable to cope
with the problem, her husband took her to the hospital. here the symptoms persist and she will
not leave her room. the nurse caring for her attempts to talk to her, asking questions but
receiving no answers. finally, in exasperation, the nurse tells the client that if she does not
respond she will be left alone. The nurse:
A. Recognizes that the client has the right to make the decision
B. Attempts to use reward and punishment to motivate the client
C. Is really assaulting the client and should have reframed from this
D. Should get her involved in group therapy rather than attempting one to one therapy
14. The first priority for nursing interventions with georgie upon his admission to the unit would be
15. After Georgie has been taking lithium for 2 weeks, she complains of vomiting, having diarrhea and
slurring her words. Which of the following represents the most appropriate nursing action?
A. Tell Georgie that these symptoms of mild toxicity that will go away as she becomes reaccustomed to
the lithium.
B. Immediately call the physician to inform her of Georgie’s symptoms and hold her next lithium dose.
C. Check to see that her last lithium level was safely between 1 and 2 mEg/L
D. Tell her to lie down, immediately drawing a blood glucose and giving her orange juice.
17. A 35-year-old client with depression lost his job and most of his investments because of his own
unethical business practices. He states his family would be better off without him because of the shame
he has brought to them. How should the nurse respond to this statement?
19. A 25-year-old male client has been in patient treatment for severe depression for 3 weeks. He will be
discharged soon, and the nurse is evaluating the effectiveness if the plan of care. Which outcome is the
most appropriate indicator that the client’s depression is resolving sufficiently for safe discharge?
A. The client has resumed caring for his physical appearance and always appears clean and groomed.
B. The client denies wanting to commit suicide
C. The client expresses a willingness to begin tapering his medication.
D. The client will sit in the public areas and will speak when addressed.
20. Which of the following variables has the most impact on relapse prevention for clients with
depressive or bipolar disorders?
SABIO QUIZZES
psychosexual
1. When a nurse sees a patient masturbating in his room, she should do one of the following
A. tell the patient to stop doing it.
B. Criticized patient for doing it.
C. Tell the patient you are going to inform the physician about the behavior
D. Quietly leave the room
2. A female client is saying sexually provocative remarks to a male physician in the unit. The nurse
should
A. attempt to understand the meaning of the client’s sexual behavior
B. distract client’s attention by giving her a task to completion
C. Identify client’s need for sexual health education
D. None of the Above
4. Dennis and Yna are newly married couple and are interested to know more about sexuality. “Which of
the following characteristics is indicative that the couple are sexually healthy. The couple
A. Exhibit congruence of the various components of sexual identity
B. Manifest ability to a lasting relationship identity
C. Express their love through sexual intercourse
D. Demonstrate an integration of the somatic, emotional, intellectual, and social aspects of sexual well-
being.
5. Which of the following are physiologic changes during the excitement phase of the male sexual
response cycle?
A. Develops a recurring contractions of the muscles of the penis and deep perineum
B. A high level of sexual tension is maintained.
C. Heart and respiration may double and BP rises 67% above the resting level.
D. Vasocongestion of the penis shaft is diminished
9. The condition of experiencing sexual arousal in response to the extreme pain, suffering or humiliation
of others is termed as?
A. Sexual Sadism
B. Sexual Fetishism
C. Sadomasochism
D. Voyeurism
10. According to DSM V, a confirmatory diagnosis of Paraphilia's can be made only if the behaviour
persists for
a. 3
b. 2
C. 6
d. 9
11. In disorders of sexuality and sexual functioning the term gender identity disorder refers to
A. Problems with sexual fantasies
B. Sexual urges or fantasies involving unusual sources of gratification problems
C. Problems with Sexual Fantasies
D. An individual is dissatisfied with their own biological sex and have a strong desire to be a member of
opposite sex
12. A patient who is being treated at the community health clinic complains of lack of sexual desire and
mentions the problems this is causing in her marriage. Which of the following data is likely related to her
sexual dysfunction?
a. Being an adopted only child
b. Taking an antidepressant medication
c. Growing up in a dysfunctional family
d. Living in an isolated area in the country
3. Which assessment question demonstrates knowledge of possible risk factors for the development of a
paraphilic disorder?
15. Female sexual arousal disorder is defined primarily in terms of a deficiency in a physical or
physiological response and as a result may be caused by a range of physical or physiological factors,
including
a. Hormone imbalances
b. Diabetes
c. Medications
d. All of the above
16. A male client has undergone surgery for the repair of an abdominal aortic aneurysm. Which of the
following responses is most appropriate to the client's wife when she asks if her husband will be
impotent?
a. "Don't worry; he will be all right."
b. "He has other problems to worry about.”
c. "We will cross that bridge when we come to it."
d. "There's a chance of impotence after repair of an abdominal aortic aneurysm."
17. Which of the following discharge instructions would be most accurate to provide to a female client
who has suffered a spinal cord injury at the C4 level?
a. After a spinal cord injury, women usually remain fertile; therefore, you may consider
c. Sexual intercourse shouldn't be different for you.
b. After a spinal cord injury, women are usually unable to conceive a child.
d. After a spinal cord injury, menstruation usually stops.
18. Which of the following permanent complications might the nurse expect to see in a client who has
just undergone a perineal prostatectomy?
a. Bleeding
b. Erectile dysfunction
c. Infection
d. Pneumonia
19. A client is admitted to the hospital for treatment of pedophilia and tells the nurse that he doesn't
want to talk to her about his sexual behaviors. Which of the following responses from the nurse is most
appropriate?
a. "I need to ask you the questions on the database."
b. "It is your right not to answer my questions."
c. "OK, I'll just write 'no comment."
d. "I know this must be difficult for you."
20. Which of the following treatments might be used for a patient with gender identity disorder?
a. Group therapy
b. Surgical sexual reassignment
c. Relaxation techniques
d. Antipsychotic agent
21. A 33-year-old female tells the nurse she has never had an orgasm. She tells the nurse that her
partner is upset that he can't meet her needs. Which of the following nursing interventions is most
appropriate?
a. Ask the client if she desires intercourse.
b. Assess the couple's perception of the problem.
c. Tell the client that most women don't reach orgasm.
d. Refer the client to a therapist because she has sexual aversion disorder.
YBOA (MIDTERM)
38. Mr. Bartowski who is newly diagnosed with rheumatoid arthritis asks the community nurse
how stress can affect his disease. The nurse would explain that:
A, the psychological experience of stress will not affect symptoms of physical disease.
B. psychological stress can cause painful emotions, which are harmful to a person with an
illness.
C, stress can overburden the body's immune system, and therefore one can experience
increased symptoms.
D. the body's stress response is stimulated when there are major disruptions in one's life.
39. David is preoccupied with numerous bodily complaints even after a careful diagnostic workup
reveals no physiologic problems. Which nursing intervention would be therapeutic for him?
A. Acknowledge that the complaints are real to the client, and refocus the client on other concerns and
problems.
B. Challenge the physical complaints by confronting the client with the normal diagnostic findings.
C. Ignore the client's complaints, but request that the client keep a list of all symptoms.
D. Listen to the client's complaints carefully, and question him about specific symptoms.
40. A middle-aged woman's father has passed away, and her mother requires physical and emotional
help due to disabilities. The woman is married and raising two children, along with working full time. All
of the factors described are
a) Stressors
b) Demands
c) Illnesses
d) Stimuli
41. An adolescent entering high school voices anxiety over changing schools. Stating anxiety is an act of
a) Valuation
b) Adaptation
c) Evaluation
42. You are the nurse caring for a 72-year-old female who is recovering from abdominal surgery on the
Medical Surgical unit. The surgery was very stressful and prolonged and you note on the chart that her
blood sugars are elevated yet she in not been diagnosed with diabetes. To what do you attribute this
elevation in blood sugars?
43. You walk into your patients' room and find her sobbing uncontrollably. When you ask what the
problem is your patient responds "I am so scared. I have never known anyone who goes into a hospital
and comes out alive." On this patient's care plan you note a nursing diagnosis of "Ineffective coping
related to stress". What is the best outcome you can expect for this patient?
44. A nurse is caring for a client who is grieving the loss of a spouse. The nurse understands that grief is
a combination of various factors including all except:
a. Moral
b. Psychological
c. Biological
d. Behavioral
45. A nurse is conducting a grief and loss assessment interview and understands that the current loss,
the history of previous losses, and lifestyle are all a part of this assessment. What question will the nurse
ask the client to assess the current loss?
a. "Do you drink on a regular basis?"
b. "Are you having trouble carrying on with your normal activities?"
c. "What types of coping mechanisms have you employed to work through your grief?
d. "Do you have an active support system?"
46. The concept system for classifying and diagnosing mental disorders was established by the
a. American Nurses Association
b. Professional Regulation Commission
c. American Psychiatric Association
d. American Mental Health Association
47. A client is admitted for surgery. Although not physically distressed, the client appears apprehensive
and withdrawn. What is the nurse's best action?
1. Orient the client to the unit environment.
2. Have a copy of hospital regulations available.
3. Explain that there is no reason to be concerned.
4. Reassure the client that the staff is available to answer questions.
48. An acutely ill client with the diagnosis of schizophrenia has just been admitted to the mental health
unit. When working with this client initially, the nurse's most therapeutic action should be to:
1. Spend time with the client to build trust and demonstrate acceptance
2. Involve the client in occupational therapy and use diversional activity
3. Delay one-to-one interactions until medications reduce psychiatric symptoms
4. Involve the client in multiple small-group discussions to distract attention from the fantasy world
49. The statement that best describes the practice of psychiatric nursing is:
a. Helps people with present or potential mental health problems
b. Ensures clients' legal and ethical rights by acting as a client advocate
c. Focuses interpersonal skills on people with physical or emotional problems
d. Acts in a therapeutic way with people who are diagnosed as having a mental disorder
50. A nurse asks the supervisor, “What coping strategy could I develop to prevent over-responding to
stress in the future?” The supervisor could best respond
a. Monitor your problem solving skills
b. Improve your time management skills
c. Ignore situations that you can change
d. Develop a wide variety of coping strategies
SABIO (MIDTERM)
1. An 18-year old college student, Glady's has lost 35 lbs. for five weeks. Her parents brought
her to take hospital for medical evaluation. The working diagnosis: Anorexia nervosa. Upon
admission, Gladys says to the nurse, "Why am I here. I am not sick. I don't have any health
problem." This statement exemplifies a common defense mechanism used by anorectic client
known as one of the following
a. Conversion
b. Denial
c. Regression
d. Suppression
2. A behavior modification program is to be carried out for Gladys. An appropriate nursing
intervention would be one of the following:
3. In caring for client with anorexia nervosa, the appropriate attitudes of the nurse is one of the
following:
4. Clients with anorexia nervosa usually manifest one of the following behaviors:
a. Low self-esteem
b. Assertiveness
c. Hostility
d. Impulsiveness
a. Telling you she will report to the physician if she does not
b. Allow her time to eat
a. Ethnic background
b. Life experiences
a. Ethnic background
b. Life experiences
c. Socio-economic level
d. Educational background
8. Which of the following best describes a crisis state which will help the nurse develop a plan
of care for the client?
a. A crisis state may indicate that the client is suffering from emotional disturbance
b. A crisis state is a good indicator that the client is suffering from a mental illness
c. A person responds to crisis differently
d. All persons experiencing crisis present similar
11. Nurse Maureen is developing a plan of care for a female client with anorexia nervosa.
Which action should the nurse include in the plan?
12. A client is experiencing anxiety attack. The most appropriate nursing intervention should
include?
13. Nurse Claire is caring for a client diagnosed with bulimia! The most appropriate initial goal
for a client diagnosed with bulimia is?
14. To establish open and trusting relationship with a female client who has been hospitalized
nurse in charge should?
15. Linda is pacing the floor and appears extremely anxious. The duty nurse approaches in an
attempt to alleviate Linda's anxiety. The most therapeutic question by the nurse would be?
16. Nurse Penny is aware that the symptoms that distinguish post-traumatic stress disorder
from other anxiety disorder would be:
17. A characteristic that would suggest to Nurse Anne that an adolescent may have bulimia
would be
19. Nurse Cardo is caring for a client diagnosed with bulimia. The most appropriate initial goal
for a client diagnosed with bulimia is to:
20. Lovie a nursing student is anxious about the upcoming board examination but is able to
study intently and does not become distracted by a roommate's talking and loud music. The
student's ability to ignore distractions and to focus on studying demonstrates:
a. Mild-level anxiety
b. Panic-level anxiety
c. Severe-level anxiety
d. Moderate-level anxiety
21. Anxiety is
a. An abnormal response to everyday stress
b. A sense of psychological distress
c. A physiological response to stress
e. A normal response to everyday stress
24. A Client comes to the mental health clinic saying she has been “on edge” lately. She states
she has been preoccupied with work, is making mistakes because she can’t concentrate, and is
forgetting important meetings. She says she thinks she’s going crazy. These symptoms of
anxiety are
a. affective
b. physiologic
c. cognitive
d. behavior
25. A client with generalized anxiety disorders states she is worried about her finances. She has
substantial savings that are managed by reputable financial company. She says she is afraid the
company will go bankrupt and she will lose her money. Which response by the nurse is most
therapeutic?
26. A 40- year old man with a history of panic attacks complains that his attacks are becoming
more frequent. He is a good and health and exercises regularly. He states he occasionally drinks
wine with dinner. Which of the following interventions should the nurse discussed with the
client?
a. Desensitization
b. Lifestyle challenges
c. Problem-solving strategies
d. Controlled breathing techniques
27. A nurse is discussing treatment options with client has intense fear of snakes. The nurse
correctly describes the treatment approach when she makes which of the following?
a. “You will meet weekly with a psychiatrist who will discuss childhood issues with you”
b. “You will be treated with medications; antidepressants that affect serotonin levels are the
treatment of choice for phobias”
c. “You will be gradually exposed to the object you fear until you become desensitized to it”
d. “You will be taught a problem-solving technique that will help you manage everyday stress,
which is contributing to your phobic response”
28. A nurse is developing a care plan for a female client with post-traumatic stress disorder.
Which of the following would she do initially?
29. The psychiatric nurse uses cognitive-behavioral techniques when working with a client who
experiences panic attacks. Which of the following techniques are common to this theoretical
framework? (Select all that apply.)
31. Mandy, a nurse who works at Nurseslabs Rehabilitation Center is assessing a client for
recent stressful life events. She recognizes that stressful life events are both:
32. During a community visit, volunteer nurses teach stress management to the participants.
The nurses will most likely advocate which belief as a method of coping with stressful life
events?
33. Genevieve only attends social events when a family member is also present. She exhibits
behavior typical of which anxiety disorder?
a. Agoraphobia
b. Generalized Anxiety disorder
c. Obsessive Compulsive behavior
d. Post-traumatic stress disorder
34. When assessing a client with anxiety, the nurse’s questions should be:
35. During the assessment, the client tells the nurse that she cannot stop worrying about her
appearance and
that she often removes "old" makeup and applies fresh makeup every hour or two throughout
the day. The nurse identifies this behavior as indicative of a
34. When assessing a client with anxiety, the nurse’s questions should be:
35. During the assessment, the client tells the nurse that she cannot stop worrying about her
appearance and
that she often removes "old" makeup and applies fresh makeup every hour or two throughout
the day. The nurse identifies this behavior as indicative of a
36. The best goal for a client learning a relaxation technique is that the client will
37. The nurse observes a client who is becoming increasingly upset. He is rapidly pacing,
hyperventilating, clenching his jaw, wringing his hands, and trembling. His speech is high
pitched and random; he seems preoccupied with his thoughts. He is pounding his fist into his
other hand. The nurse identifies his anxiety level as
a. Mild
b. Moderate
c. Severe
d. Panic