Chapter 1: Foundations of Psych MH Nursing
A client with the inability to work due to relapsing schizophrenia is receiving Social Security Benefits. Which benefit will this provide to the client experiencing serious mental illness?
A. The client will be able to maintain some level of independence financially.
B. The client will have the option to only obtain inpatient treatment.
C. The client will be able to pay all of their bills as well as purchase medication.
D. The client will have the ability to obtain psychiatric service regardless of setting.
Answer: A
Rationale: Federal legislation was passed to provide an income for disabled persons: supplemental security income (SSI) and Social Security disability income (SSDI). This allowed people with severe and persistent mental illness to be more independent financially and to not rely on family for money. This does not prevent the client in acute crisis from a relapse from being admitted to the inpatient setting if they are at risk of harm to self or others. Social security is limited and the client may still have some degree of financial difficulty. The client may be limited to state owned facilities and not be able to seek treatment at a private facility. This does not dictate to the client the level of care offered to the client.
The nurse has completed health teaching about dietary restrictions for a client taking a monoamine oxidase inhibitor. Which statement made by the client indicates that teaching is effective?
A. “I’m glad I can eat pizza since it’s my favorite food.”
B. “I must follow this diet or I will have severe vomiting.”
C. “It will be difficult for me to avoid pepperoni.”
D. “None of the foods that are restricted are part of a regular daily diet.”
Answer: C
Rationale: Pepperoni is one of the foods containing tyramine, so it must be avoided. Particular concern to this client is the potential life-threatening hypertensive crisis if the client ingests food that contains tyramine. For many clients, prohibited foods are components of their usual diet. Hypertension is the most serious adverse effect, not nausea.
A client is being admitted to an inpatient unit for treatment of anorexia nervosa. Of the following assessment data, which will the nurse place as priority in the plan of care?
A. Weight 24% below normal for height
B. Distorted body image
C. Feelings of inadequacy
D. Frequent vomiting after meals
Answer: D
Rationale: Maslow’s hierarchy of needs hypothesizes that the basic needs at the bottom of the pyramid dominate the person’s behavior until those needs are met, at which time the next level of needs would become dominant. Vomiting threatens fluid and electrolyte balance and poses a more acute threat to survival than low weight. Once basic physical needs are met, the higher level needs such as body image and self-esteem can be addressed.
The nurse is caring for a client when the client begins to revert to child-like behavior. Which action by the nurse can continue to nurture the client while establishing and maintaining appropriate boundaries?
A. Retain an easygoing, non-judgmental attitude.
B. Employ an authoritative manner to take charge of the situation.
C. Allow the client’s behavior to continue since it will eventually stop.
D. Stop the interaction with the client and leave, returning at a later time.
Answer: A
Rationale: By retaining an open, easygoing, nonjudgmental attitude, the nurse can continue to nurture the client while establishing boundaries. Employing an authoritative attitude may encourage the client to continue the behaviors and become more resistant to the change. The limits for behavior should be set and not encouraged to continue and reset the limits if needed. The nurse should not leave the client and return later since that will not be effective in maintaining trust in the nurse–client relationship.
A nurse is having a discussion with a client. What may be the reason for the nurse not utilizing active listening skills?
A. The nurse is thinking about issues in their personal life.
B. The nurse is uncomfortable with the client and situation.
C. The nurse is thinking ahead for answers for the client.
D. The nurse is unable to understand cues.
Answer: C
Rationale: Nurses employing the art of therapeutic communication are sometimes mistaken in believing it is necessary to be ready with answers immediately the instant the client stops speaking. They often think ahead and not actively listen to the client. Boredom, discomfort, and an inability to understand cues are all factors that inhibit communication, but none of these factors has a direct effect on the student's ability to exercise active listening.
The nurse working in the ED of an urban hospital notifies the manager that there are several clients with mental health disorders still present in the ED that have been there over 48 hours. Which issue related to this phenomenon does the nurse discuss with the manager?
A. Temporary detaining orders for clients
B. Decision to practice boarding
C. The revolving door for clients
D. The cost of holding clients in the ED for over 48 hours
Answer: B
Rationale: The practice of boarding is frustrating to health care personnel in EDs since it may interfere with the acute care and emergencies that are required in that setting. Clients become dissatisfied with care, and their families feel as though clients are not receiving the care needed to move through the crisis and some believe an increase in suicide. Provision of an adequate number of psychiatric inpatient beds could better meet the needs of clients and might even decrease homelessness, incarceration, and violence. The revolving door phenomenon is the increase in short-stay admissions repeatedly. Having to obtain a temporary detaining order improves the transition into inpatient care. Cost is not the immediate issue of the nurse.
A client prescribed disulfiram experiences facial flushing, a throbbing headache, nausea, and vomiting and states to the nurse that “I only drank one beer.” Which is the best response by the nurse?
A. “This is a mild side effect of the medication, and one beer shouldn’t cause the reaction.”
B. “The reaction that you experienced is an expected response with the ingestion of alcohol.”
C. “This is an idiosyncratic reaction to the medication and is an expected response to treatment.”
D. “You must have a severe allergy to disulfiram that you were not aware of and will need to stop the medication.”
Answer: B
Rationale: Disulfiram is a sensitizing agent that causes an adverse reaction when mixed with alcohol in the body. Five to 10 minutes after a person taking disulfiram ingests alcohol, symptoms begin to appear: facial and body flushing from vasodilation, a throbbing headache, sweating, dry mouth, nausea, vomiting, dizziness, and weakness. These symptoms are not mild side effects because these are very uncomfortable symptoms. These symptoms would not be an idiosyncratic reaction because this is the expected reaction. These symptoms are not indicative of a severe allergy to the medication.
The nurse is admitting a client to the behavioral health unit seeking help voluntarily. Which consideration will have the most influence in the choice of the treatment for the client?
A. The client’s feelings and perceptions about the situation
B. The nurse’s beliefs about the theories of psychosocial development
C. The nurse’s familiarity with the type of treatment
D. Any approach to treatment should work with any client.
Answer: A
Rationale: The client’s feelings and perceptions about the situation are the most influential factors in determining the client’s response to therapeutic interventions, rather than what the nurse believes the client should do. The nurse must examine individual beliefs about the theories of psychosocial development and realize that many treatment approaches are available. Different treatments may work for different clients: no one approach works for everyone. Becoming familiar with the variety of psychosocial approaches for working with clients will increase the nurse’s effectiveness in promoting the client’s health and well-being. However, the treatments with which the nurse is most familiar may not be most effective for the client.
A nurse in the behavioral health unit witnessed another nurse violate the boundaries of the professional relationship with a client. When reporting this to the nurse manager, which role is the nurse acting in for the client?
A. Teacher
B. Parent surrogate
C. Advocate
D. Care giver
Answer: C
Rationale: The role of advocate requires the nurse to be observant of other health care professionals. Nurses must take action by talking to the colleague or a supervisor when they observe boundary violations. This action does not demonstrate teaching and does not constitute the nurse acting as a parent surrogate. Caregiving involves the direct provision of care.
The nurse is attempting to develop empathy for a client but is not completely feeling empathetic. Which factor might be hindering the nurse from developing empathy for this client?
A. Interjecting personal experiences into the interactions
B. Be sure to ask the client to restate statements for clarity
C. Asking leading questions to obtain the most information
D. Focusing on one issue
Answer: A
Rationale: Nurses develop empathy by gathering as much information about an issue as possible directly from the client to avoid interjecting their own personal experiences and interpretations of the situation. Asking for restatement is often beneficial to communication. Leading questions and an excessive focus on one issue can inhibit communication but are less likely to have an effect on empathy.
The nurse is talking with family members of a client with a mental health disorder, and they are relaying their issues with the treatment of their family member in general. Which statement by the nurse to the client’s family will provide them with an explanation for this issue?
A. Substance use disorder is effectively treated with brief hospitalization.
B. Financial resources are reallocated from state hospitals to community programs and support.
C. Only one in four people needing mental health services are receiving those services.
D. Emergency department visits by persons who are acutely disturbed are declining.
Answer: C
Rationale: Only one in four adults needing mental health care receives the needed services. Substance use disorders cannot be dealt within 3 to 5 days typical for admissions in the current managed care environment. Money saved by states when state hospitals were closed has not been transferred to community programs and support. Although people with severe and persistent mental illness have shorter hospital stays, they are admitted to hospitals more frequently. In some cities, emergency department visits for acutely disturbed persons have increased by 400% to 500%.
A client is seen for frequent exacerbation of schizophrenia due to nonadherence to medication regimen. The nurse will assess for which common contributor to nonadherence?
A. The client is symptom-free and therefore does not need to adhere to the medication regimen.
B. The client cannot clearly see the instructions written on the prescription bottle.
C. The client dislikes the weight gain associated with antipsychotic therapy.
D. The client sells the antipsychotics to addicts in the neighborhood.
Answer: C
Rationale: Clients with schizophrenia are less likely to exercise or eat low-fat nutritionally balanced diets; this pattern decreases the likelihood that they can minimize potential weight gain or lose excess weight. Antipsychotics should be taken regularly and not omitted when free of symptoms. Antipsychotics do not adversely affect vision, nor do they have addictive potential.
The nurse is planning the care for a client experiencing negative thinking. Which approach to therapy is most effective for this client?
A. Behavior modification
B. Client-centered therapy
C. Cognitive therapy
D. Reality therapy
Answer: C
Rationale: Cognitive therapy focuses on changing the client’s thinking first, in the belief that then feelings and behavior can change as well. Behavior modification is a method of attempting to strengthen a desired behavior or response by reinforcement, either positive or negative; this does not directly address thinking patterns. Client-centered therapy focuses on the role of the client, rather than the therapist, as the key to the healing process. This focus is not specific to patterns of negative thinking. Reality therapy focuses on the person’s behavior and how that behavior keeps the person from achieving life goals.
The client is getting ready to be discharged from the psychiatry unit. The nurse provides education regarding the client’s take-home medications. Which role does the nurse exemplify during this intervention?
A. Advocate
B. Caregiver
C. Teacher
D. Parent surrogate
Answer: C
Rationale: During the working phase of the nurse–client relationship, the nurse may teach the client about the medication regimen and available community resources. The caregiver role is used when the nurse helps the client meet psychosocial or physical needs. When functioning as an advocate, the nurse is acting on the client’s behalf when they cannot do so. Nurses may need to assume a parental role when the client needs nurturing or limit setting, but this is not demonstrated by providing medication teaching.
A nurse is developing a therapeutic relationship with a client from a cultural background different from the nurse. Which will occur if the nurse does not show this cultural competence?
A. Frustration for the client
B. Longer rehabilitation
C. Leads to mental health relapse
D. Eroding trust
Answer: D
Rationale: As the therapeutic relationship develops, the nurse must be aware of and respect the client's religious and spiritual beliefs. Ignoring or being judgmental will quickly erode trust and could stall the relationship. The client's responses may be varied, not just limited to frustration. This may or may not cause the client to require longer rehabilitation or to relapse.
A client diagnosed with a mild anxiety disorder has been referred to treatment in a community mental health center. Which treatment will be most beneficial that the client will receive in this setting?
A. Medical management of symptoms
B. Daily psychotherapy
C. Constant staff supervision
D. Psychological stabilization
Answer: A
Rationale: Community mental health centers focus on rehabilitation, vocational needs, education, and socialization, as well as on management of symptoms and medication. Daily therapies, constant supervision, and stabilization require a more acute care inpatient setting.
The nurse is assessing a client weaning from a selective serotonin reuptake inhibitor (SSRI) to a monoamine oxidase inhibitor (MAOI) with a heart rate of 104, profuse diaphoresis, temperature 102°F (38.9°C), BP 98/58 mm Hg, and hyperreflexia. Which condition will the nurse educate the client regarding after stabilization of the current acute phase?
A. Tardive dyskinesia
B. Allergic reaction to the MAOI
C. Malignant hyperthermia
D. Serotonin syndrome
Answer: D
Rationale: Serotonin syndrome can result from taking an MAOI and an SSRI at the same time. It can also occur if the client takes one of these drugs too close to the end of therapy with the other. In other words, one drug must clear the person’s system before initiation of therapy with the other. Symptoms include agitation, sweating, fever, tachycardia, hypotension, rigidity, hyperreflexia, and, in extreme reactions, even coma and death. Tardive dyskinesia generally occurs with the administration of antipsychotic medications and not SSRIs. There is no indication that the client is allergic to the medications nor experiencing anaphylaxis since there is no respiratory involvement in the symptoms. Malignant hyperthermia is a genetic predisposition to the administration of an anesthetic agent that causes elevated temperature and death.
A client asks the nurse about the use of complementary and alternative therapies. Which of these therapies will the nurse educate the client regarding? Select all that apply.
A. Massage and osteopathic therapy
B. Support group therapy
C. Aromatherapy
D. Self-help therapy
E. Music and art therapy
Answer: A, C, E
Rationale: Alternative therapies include body-based therapies such as massage therapy and osteopathic manipulation. Biologic-based therapies include aromatherapy as well as medicinal teas. Mind–body interventions include music, dance, and art therapy. Support groups and self-help therapy are specific interventions that are not classified as being alternative or complementary.
The nurse has developed a therapeutic relationship with a client in the outpatient behavioral health clinic. Which situation is considered a breach of professional boundaries?
A. Client asking a nurse for the nurse’s phone number
B. The nurse refuses a gift from a client.
C. The nurse changes the subject in response to a client’s compliment.
D. The nurse has a lengthy social conversation with a client on the phone.
Answer: D
Rationale: Having a lengthy social conversation with a client would violate professional boundaries. Nurses need to be aware of professional boundaries to avoid exploitation of the client. In a friendship, there is a two-way sharing of personal information and feelings, but in a nurse–client relationship, the focus is on the client’s needs, and the nurse generally does not share personal information or attempt to meet their own needs through the relationship. Indicators that the relationship may be moving outside the professional boundaries are gift giving on either party’s part, spending more time than usual with a particular client, strenuously defending or explaining the client’s behavior in team meetings, the nurse’s feeling that they are the only one who truly understands the client, keeping secrets, or frequently thinking about the client outside of the work situation. Asking the nurse for their phone number would not violate professional boundaries, however, if the nurse responded and gave the client the number, then professional boundaries would be violated.
A nurse has been waiting for over an hour for the laboratory to draw blood on a client with bipolar disorder in the ED. Which response is an example of assertive communication from the nurse to the laboratory personnel?
A. "So nice of you to join us, it's about time."
B. "When you are late to draw blood the family gets upset, and I don't like having to repeat that you are on your way."
C. "When you work, we never get blood drawn on time."
D. "It's about time, we were beginning to think I would have to do your job and mine too."
Answer: B
Rationale: With assertive communication, the nurse communicates feelings about the specific situation in a calm manner and focuses on "I" statements with no accusation or inflammatory comments. Passive-aggressive communication is inappropriate and is demonstrated by saying "So nice of you to join us, it's about time." Saying "It's about time" or "we never get blood drawn on time" are aggressive responses that are likely to cause conflict and hinder communication.
The geriatric psychiatry nurse reviews the DSM-5-TR for the specific criteria associated with a client’s diagnosis. Which purpose does the nurse identify will be obtained from reviewing this data? Select all that apply.
A. To provide the practitioner with standards of care for all clients
B. To provide a standardized nomenclature and language for all mental health professionals
C. To provide standards for hospital and community-based institutions
D. To present defining characteristics or symptoms that differentiate specific diagnoses
E. To assist in identifying the underlying causes of disorders
Answer: B, D, E
Rationale: The DSM-5-TR has three purposes: (1) to provide a standardized nomenclature and language for all mental health professionals; (2) to present defining characteristics or symptoms that differentiate specific diagnoses; and (3) to assist in identifying the underlying causes of disorders. The DSM-5-TR was not designed to provide the practitioner with standards of care for all clients nor to provide standards for hospital and community-based institutions.
The nurse is educating a client with anxiety that is prescribed alprazolam by the health care provider. Which statement made by the client indicates that further education is required? Select all that apply.
A. “Taking this medication will alleviate the problems associated with the anxiety.”
B. “I can still have one or two alcoholic beverages while I am taking this medication.”
C. “When I am feeling better in a few months, I can stop taking this medication.”
D. “I may have slower response time while driving or operating heavy machinery.”
E. “Withdrawing from this medication requires a health care provider’s supervision.”
Answer: A, B, C
Rationale: Clients need to know that antianxiety agents are aimed at relieving symptoms such as anxiety or insomnia but do not treat the underlying problems that cause the anxiety. Benzodiazepines strongly potentiate the effects of alcohol; one drink while on a benzodiazepine may have the effect of three drinks. Therefore, clients should not drink alcohol while taking benzodiazepines. Clients should be aware of decreased response time, slower reflexes, and possible sedative effects of these drugs when attempting activities such as driving or going to work.
Benzodiazepine withdrawal can be fatal. After the client has started a course of therapy, they should never discontinue benzodiazepines abruptly or without the supervision of the provider.
A nurse is participating in a therapy session along with several clients. Which client(s) does the nurse identify as experiencing moderate anxiety? Select all that apply.
A. A client exhibiting profuse diaphoresis
B. A client that states, “I am feeling a little nausea right now.”
C. A client responding to questions in a higher pitched voice
D. A client that states that they are experiencing a rapid heart rate.
E. A client that is unable to communicate verbally
Answer: A, C, D
Rationale: Moderate anxiety is expressed with diaphoresis, dry mouth, pounding pulse, higher pitched voice, gastric upset, etc. Severe anxiety is expressed by nausea, vomiting and diarrhea, inability to complete tasks, trembling, vertigo, paleness, etc. Those experiencing panic cannot communicate, have distorted perceptions, and cannot process environmental stimuli.
The nurse manager suspects a nurse of violating the professional boundaries of the nurse–client relationship. Which behaviors identified with the nurse would correlate with the manager’s suspicions? Select all that apply.
A. The nurse makes exceptions of the rules for the client.
B. The nurse is not sharing information about the client with other team members.
C. The nurse is talking to team members about the client.
D. The nurse is having inappropriate social conversations.
E. The nurse brings the client small gifts that other clients are not receiving.
Answer: A, B, D, E
Rationale: Nurses should never make exceptions for clients, keep secrets, or have inappropriate conversations. These can be detrimental to the therapeutic relationship. It is appropriate to talk to team members regarding clients and their plan of care to maintain continuity of care. Inappropriate social conversations that may be sexual in nature should never occur since it makes the nurse–client relationship ineffective and is detrimental to client outcomes. Gift giving is inappropriate if all of the clients are not receiving them such as snacks, baked goods, etc.
The nurse is talking with a client that is having a difficult time solving a personal problem regarding staying together with a partner. Place in order the problem-solving process to assist the client in making a decision. All options must be used.
A. Evaluate the situation.
B. Implement the selected alternative.
C. Brainstorm all possible solutions.
D. Identify the problem.
E. If dissatisfied with the results, select another alternative and continue the process.
F. Select the best alternative
Answer: D, C, F, B, A, E
Rationale: Identifying the problem involves engaging the client in therapeutic communication. The client tells the nurse the problem and what they have tried to do to solve it. Brainstorming all possible solutions will allow the options to be reviewed to choose which may be the best one. Selection of the best alternative will narrow the options down to one. Implementation is the next step in the process to be able to determine how it works. Evaluation to determine if the intervention worked or if another option would be better.