Chapter 1: Foundations of Psychiatric-Mental Health Nursing
A nurse is discussing the "revolving door" effect with a group of nursing students. Which factor should the nurse identify as a primary contributor to this phenomenon?
A. The development of psychotropic medications in the 1950s.
B. Shorter hospital stays without adequate stabilization or community support.
C. The implementation of the Mental Health Parity Act in 1996.
D. Increased funding for community-based psychosocial rehabilitation services.
Answer: B. The "revolving door" effect refers to the cycle where clients with severe mental illness have shorter hospital stays but are admitted more frequently because they are discharged before being stabilized and lack community coping skills.
A nurse is teaching a client who has been prescribed a Selective Serotonin Reuptake Inhibitor (SSRI). Which instruction should the nurse include regarding the timing of the dose?
A. Take the medication only when feeling depressed.
B. Take the medication immediately before bedtime.
C. Take the medication first thing in the morning.
D. Take the medication with a high-tyramine snack.
C. Take the medication first thing in the morning.
SRIs can cause insomnia or agitation, so taking them in the morning is generally recommended unless they cause significant sedation.
A client diagnosed with terminal cancer tells the nurse, "I'm not worried about the diagnosis; I feel perfectly fine and plan to run a marathon next month." The nurse identifies that the client is utilizing which defense mechanism?
A. Reaction formation
B. Denial
C. Displacement
D. Projection
Correct Answer: B. Denial
Rationale: Denial is the refusal to accept the reality of a situation to protect the self from emotionally painful thoughts or events. Reaction formation involves exhibiting behavior that is the opposite of what one truly feels.
A nurse observes a physician attempting to examine a client in a semi-private room without pulling the curtain. The nurse intervenes by closing the curtain and draping the client. Which therapeutic role is the nurse demonstrating?
A. Teacher
B. Caregiver
C. Parent surrogate
D. Advocate
D. Advocacy involves acting on the client's behalf to ensure privacy, dignity, and safety when the client cannot do so themselves.
A nurse is conducting an admission interview with a client who has a history of sexual abuse. The client is visibly trembling and tearful. Which action by the nurse is most appropriate?
A. Reach out and hold the client's hand to provide comfort.
B. Sit 12 to 18 inches away from the client to show empathy.
C. Ask the client's permission before performing a physical assessment.
D. Tell the client, "Everything will work out, you are safe here now."
C. Nurses should ask permission before invading the intimate or personal zone (0–36 in). For clients with a history of abuse, touch may be interpreted as harmful or hurtful
A client is being assessed for factors influencing their mental health. Which of the following would the nurse categorize as an "interpersonal" factor?
A. The client's biological makeup and genetic predisposition.
B. The client's sense of community and access to food security.
C. The client's ability to maintain a balance of separateness and connectedness.
D. The client's level of self-esteem and capacity for personal growth.
Answer: C. Interpersonal factors relate to relationships and include effective communication, intimacy, and the balance of separateness and connectedness. Biological makeup and self-esteem are individual factors , while food security is a social determinant.
A client with bipolar disorder is taking Lithium. The nurse notes the client has a coarse hand tremor, is confused, and is complaining of nausea and dizziness. What is the priority nursing action?
A. Encourage the client to rest and re-evaluate in 4 hours.
B. Request a stat white blood cell count.
C. Administer the next scheduled dose of Lithium.
D. Withhold the medication and notify the healthcare provider.
D. Withhold the medication and notify the healthcare provider.
Coarse tremors, confusion, and GI distress are signs of toxicity; the priority is to stop the drug and seek medical assessment.
A nurse is assessing a client who is pacing the hallway, has a heart rate of 110 bpm, and is complaining of chest pain. The client is unable to follow instructions and states, "I think I’m having a heart attack!" Which level of anxiety is the client most likely experiencing?
A. Mild
B. Moderate
C. Severe
D. Panic
Correct Answer: C. Severe
Rationale: Severe anxiety involves feelings of dread, physiological symptoms like tachycardia and chest pain, and an inability to be redirected to tasks. Panic anxiety would involve a more complete loss of rational thought or physical immobility.
A nurse is in the working phase of a relationship with a client who has depression. The client states, "My family doesn't care about me. They never visit." The nurse guides the client to look at how their own habit of complaining may affect family visits. This is an example of which subphase?
A. Orientation
B. Problem identification
C. Exploitation (Exploration)
D. Termination
C. During exploitation (or exploration), the nurse guides the client to examine feelings and responses and develop better coping skills and behavior changes.
A client tells the nurse, "I'm so glad I'm finally getting help," while sitting with clenched fists, a rigid posture, and a frowning expression. How should the nurse interpret this communication?
A. The message is congruent because the client is expressing a need for help.
B. The message is incongruent because the nonverbal behavior invalidates the verbal content.
C. The client is using an abstract message to describe their emotional state.
D. The client is using a "social-polite" touch to initiate a relationship.
B. An incongruent message occurs when the speaker's words and behavior do not agree. Nonverbal process (clenched fists/rigid posture) usually represents a more accurate message than verbal content.
The nurse understands that the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, Text Revision (DSM-5-TR) serves which primary purpose?
A. To provide a list of legal definitions for mental insanity.
B. To mandate specific nursing interventions for psychiatric clients.
C. To provide a standardized nomenclature and language for mental health professionals.
D. To determine the financial eligibility of clients for Medicaid benefits.
Answer: C. The DSM-5-TR provides a standardized language, defines characteristics that differentiate diagnoses, and assists in identifying underlying causes.
The nurse is reviewing the 'black box warning' for a client's atypical antipsychotic medication. What specific risk is highlighted for older adults with dementia-related psychosis?
A. Increased risk of death from cardiovascular or infectious causes
B. Increased risk for suicidal ideation
C. Permanent loss of vision
D. Rapid onset of liver failure
A. Increased risk of death from cardiovascular or infectious causes
The FDA requires a black box warning stating that older clients with dementia-related psychosis have an increased risk of death when treated with these drugs.
An 80-year-old client expresses regret about their life, stating, "I've wasted my time and didn't achieve anything of value." According to Erikson’s psychosocial stages, this client is struggling with which developmental task?
A. Integrity vs. Despair
B. Generativity vs. Stagnation
C. Industry vs. Inferiority
D. Identity vs. Role Confusion
Correct Answer: A. Integrity vs. Despair
Rationale: This stage occurs in late adulthood (65 years to death), where the task is to achieve a sense of integrity and wisdom by looking back on life with satisfaction rather than regret (despair).
Which behavior by the nurse best demonstrates the concept of "congruence"?
A. Telling a client they are interested in their story while checking the clock.
B. Feeling pity for a client's situation and sharing a similar personal struggle.
C. Telling a client they will return at 1:00 p.m. and arriving exactly at 1:00 p.m.
D. Referring to a client by their room number to maintain professional distance.
C. Congruence occurs when words and actions match. Returning when promised is a prime example of congruent behavior that builds trust.
A nurse is working with a client who is experiencing high levels of anxiety. Which statement by the nurse demonstrates the use of a concrete message?
A. "How did you get here today?"
B. "Your clinical performance has to improve."
C. "What health symptoms caused you to come to the hospital today?"
D. "Get the stuff from him before we begin the session."
C. Concrete messages use explicit words and nouns instead of pronouns (e.g., "health symptoms" instead of "stuff"). Abstract messages like "How did you get here?" can be confusing to anxious clients.
A student nurse is concerned about "saying the wrong thing" during their first clinical rotation in a psychiatric unit. Which response by the instructor is most appropriate?
A. "As long as you follow the script provided, you cannot make a mistake."
B. "No single statement will significantly worsen a client’s condition; focus on listening and caring".
C. "You should remain silent and only observe the staff until you are more experienced."
D. "If you say something wrong, you should immediately end the interaction to prevent further harm."
Answer: B. There is no "magic phrase," and students are encouraged to show genuine interest. If a statement is awkward, the nurse can simply restate it.
A client is experiencing akathisia after starting an antipsychotic. How should the nurse expect the client to describe this feeling?
A. 'I feel like I have to keep moving; I can't sit still.'
B. 'My hands are shaking, and I'm drooling more than usual.'
C. 'My muscles are so stiff I can't move my neck.'
D. 'I feel like I'm moving in slow motion and have no energy.'
A. 'I feel like I have to keep moving; I can't sit still.'
Akathisia is characterized by an intense need to move and a feeling of internal restlessness.
A child with ADHD is given a sticker every time they complete their homework. After collecting ten stickers, the child is allowed to choose a small toy. This behavioral technique is an example of:
A. Systematic desensitization
B. Classical conditioning
C. Reality therapy
D. A token economy
Correct Answer: D. A token economy
Rationale: A token economy is a method of reinforcement where desired behaviors are rewarded with tokens (like stars or stickers) that can later be exchanged for prizes or privileges.
During the orientation phase of the therapeutic relationship, a client asks the nurse, "Can you keep a secret? I want to tell you something, but you have to promise not to tell anyone else." Which response by the nurse is most appropriate?
A. "I promise. As your nurse, I am here to protect your privacy."
B. "I cannot make that promise because I may need to share information with the team for your safety."
C. "It depends on what the secret is. Why don't you tell me first?"
D. "I am required by law to report everything you tell me to your family."
B. The nurse must avoid promising to keep secrets, as the information may involve the client's safety or the safety of others. The nurse should be honest about the limits of confidentiality.
A client says, "Life is hard. I want it to be done. There is no rest. Sleep... sleep is good... forever." Which response by the nurse is the priority?
A. "I hear you saying things seem hopeless. I wonder if you are planning to kill yourself."
B. "You seem very tired today. Would you like to take a nap?"
C. "Everyone feels that way sometimes when they are overwhelmed."
D. "Tell me more about what you mean by 'life is hard'."
A. When a nurse suspects suicidal ideation (a covert cue like "sleep forever"), they should use a direct yes-or-no question to elicit a clear response and ensure safety.
The nurse is aware that "mental health parity" refers to which of the following?
A. The equal distribution of psychiatric beds across all states.
B. Equality in insurance coverage provided for both physical and mental illnesses.
C. The requirement that all nurses have equal experience in medical and psychiatric units.
D. A standardized salary scale for all mental health clinicians.
Answer: B. Mental health parity refers to equality in insurance coverage for both physical and mental health treatments, aiming to eliminate spending caps that were historically placed on mental health care.
A client is prescribed a Monoamine Oxidase Inhibitor (MAOI) for depression. Which food item must the nurse instruct the client to avoid to prevent a life-threatening hypertensive crisis?
A. Aged cheddar cheese
B. Fresh cottage cheese
C. Grilled chicken breast
D. Steamed green beans
A. Aged cheddar cheese
Aged or fermented foods contain high levels of tyramine, which can lead to a hypertensive crisis when combined with MAOIs.
During which phase of Peplau’s therapeutic nurse-patient relationship does the patient begin to work interdependently with the nurse and express feelings?
A. Orientation phase
B. Identification phase
C. Exploitation phase
D. Resolution phase
Correct Answer: B. Identification phase
Rationale: In the identification phase, the patient works interdependently with the nurse, begins to feel stronger, and expresses feelings. The orientation phase is for initial engagement , while the exploitation phase is when the patient fully uses available services.
A nurse is working with a client who has a history of violence. The nurse realizes that their own father was violent, causing the nurse to feel tense and anxious. Which action should the nurse take first?
A. Request that the client be reassigned to another nurse immediately.
B. Perform a self-assessment to determine if these memories will interfere with care.
C. Tell the client about their childhood to build a bond of empathy.
D. Suppress the feelings and continue with the orientation phase as planned.
B. Before meeting a client, the nurse must perform self-assessment to identify personal strengths and limitations and ensure personal experiences do not interfere with the relationship.
During a shift report, a nurse is consistently 10 minutes late, disrupting the flow of information. Which response by a coworker demonstrates assertive communication?
A. "So nice of her to join us! Aren’t we lucky?"
B. "When you are late, report is disrupted, and I don’t like having to repeat information."
C. (To another nurse later) "She’s always late. I had to tell her what she missed."
D. "You’re always late! That is so rude! Why can't you be on time like everyone else?"
B. Assertive communication uses "I" statements and specific, factual comments without being accusatory or inflammatory. Option A is passive-aggressive, C is passive, and D is aggressive.