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MENTAL HEALTH NURSING II
EXAM 1 UNIT 1-4 WITH 100%
CORRECT ANSWERS 2025
A nurse is assessing a client who is experiencing occasional feelings of sadness because of the recent death of a beloved pet. The client's appetite, sleep patterns, and daily routine have not changed. How should the nurse interpret the client's behaviors?
The client's behaviors demonstrate mental illness in the form of depression.
The client's behaviors are extensive, which indicates the presence of mental illness.
The client's behaviors are not congruent with cultural norms.
The client's behaviors demonstrate no functional impairment, indicating no mental illness. correct answers >> 4
The nurse should assess that the client's daily functioning is not impaired. The client who experiences feelings of sadness after the loss of a pet is responding within normal expectations. At what point should the nurse determine that a client is at risk for developing a mental illness?
When thoughts, feelings, and behaviors are not reflective of the DSM- criteria.
When maladaptive responses to stress are coupled with interference in daily functioning.
When a client communicates significant distress.
When a client uses defense mechanisms as ego protection. correct answers >> 2 The nurse should determine that the client is at risk for mental illness when responses to stress are maladaptive and interfere with daily functioning. The DSM-5 indicates that in order to be diagnosed with a mental illness, daily functioning must be significantly impaired. A nurse is assessing a set of 15-year-old identical twins who respond very differently to stress. One twin becomes anxious and irritable, and
A Catholic, black male.
A Protestant, Swedish business executive. correct answers >> 1 The nurse should anticipate that the client of Jewish culture would place a high importance on preventative health care and would consider mental health as equally important to physical health. A psychiatric nurse intern states, "This client's use of defense mechanisms should be eliminated." Which is a correct evaluation of this nurse's statement?
Defense mechanisms can be appropriate responses to stress and need not be eliminated.
Defense mechanisms are a maladaptive attempt of the ego to manage anxiety and should always be eliminated.
Defense mechanisms, used by individuals with weak ego integrity, should be discouraged and not eliminated.
Defense mechanisms cause disintegration of the ego and should be fostered and encouraged. correct answers >> 1
The nurse should determine that defense mechanisms can be appropriate during times of stress. During an intake assessment, a nurse asks both physiological and psychosocial questions. The client angrily responds, "I'm here for my heart, not my head problems." Which is the nurse's best response?
"It is just a routine part of our assessment. All clients are asked these same questions."
"Why are you concerned about these types of questions?"
"Psychological factors, like excessive stress, have been found to affect medical conditions."
"We can skip these questions, if you like. It isn't imperative that we complete this section." correct answers >> 3 The nurse should attempt to educate the client on the negative effects of excessive stress on medical conditions. An employee uses the defense mechanism of displacement when the boss openly disagrees with suggestions. What behavior would be expected from this employee?
The nurse should identify that the boy is using reaction formation as a defense mechanism. Reaction formation is the attempt to prevent undesirable thoughts from being expressed by expressing opposite thoughts or behaviors. Which nursing statement about the concept of neurosis is most accurate?
An individual experiencing neurosis is unaware that he or she is experiencing distress.
An individual experiencing neurosis feels helpless to change his or her situation.
An individual experiencing neurosis is aware of the psychological causes of his or her behavior.
An individual experiencing neurosis has a loss of contact with reality. correct answers >> 2 Which nursing statement regarding the concept of psychosis is most accurate?
Individuals experiencing psychoses are aware that their behaviors are maladaptive.
Individuals experiencing psychoses experience little distress.
Individuals experiencing psychoses are aware of experiencing psychological problems.
Individuals experiencing psychoses are based in reality. correct answers >> 2 The nurse should understand that the client with psychosis experiences little distress owing to his or her lack of awareness of reality. When under stress, a client routinely uses alcohol to excess. Finding her drunk, her husband yells at the client about her chronic alcohol abuse. Which action alerts the nurse to the client's use of the defense mechanism of denial?
The client hides liquor bottles in a closet.
The client yells at her son for slouching in his chair.
The client burns dinner on purpose.
able to focus on the reality of the loss and its meaning in relation to life. A nurse is performing a mental health assessment on an adult client. According to Maslow's hierarchy of needs, which client action would demonstrate the highest achievement in terms of mental health?
Maintaining a long-term, faithful, intimate relationship
Achieving a sense of self-confidence
Possessing a feeling of self-fulfillment and realizing full potential
Developing a sense of purpose and the ability to direct activities correct answers >> 3 The nurse should identify that the client who possesses a feeling of self-fulfillment and realizes his or her full potential has achieved self- actualization, the highest level on Maslow's hierarchy of needs. According to Maslow's hierarchy of needs, which situation on an inpatient psychiatric unit would require priority intervention by a nurse?
A client rudely complaining about limited visiting hours
A client exhibiting aggressive behavior toward another client
A client stating that no one cares
A client verbalizing feelings of failure correct answers >> 2 The nurse should immediately intervene when a client exhibits aggressive behavior toward another client. Safety and security are considered lower-level needs according to Maslow's hierarchy of needs and must be fulfilled before other higher-level needs can be met. How would a nurse best complete the new DSM-5 definition of a mental disorder? "A health condition characterized by significant dysfunction in an individual's cognitions, or behaviors that reflect a disturbance in ..." which of the following?
Psychosocial, biological, or developmental process underlying mental functioning
Psychological, cognitive, or developmental process underlying mental functioning
Psychological, biological, or developmental process underlying mental functioning
_______________________ is a diffuse apprehension that is vague in nature and is associated with feelings of uncertainty and helplessness. correct answers >> Anxiety The definition of anxiety is a diffuse apprehension that is vague in nature and is associated with feelings of uncertainty and helplessness _______________________ is a subjective state of emotional, physical, and social responses to the loss of a valued entity. correct answers >> Grief The definition of grief is a subjective state of emotional, physical, and social responses to the loss of a valued entity In response to a student's question regarding choosing a psychiatric specialty, a charge nurse states, "Mentally ill clients need special care. If I were in that position, I'd want a caring nurse also." From which ethical framework is the charge nurse operating?
Kantianism
Christian ethics
Ethical egoism
Utilitarianism correct answers >> 2 The charge nurse is operating from a Christian ethics framework. The imperative demand of Christian ethics is that all decisions about right and wrong should be centered in love for God and in treating others with the same respect and dignity with which we would expect to be treated. during a hiring interview, which response by a nursing applicant should indicate that the applicant operates from an ethical egoism framework?
"I would want to be treated in a caring manner if I were mentally ill."
"This job will pay the bills, and the workload is light enough for me."
"I will be happy caring for the mentally ill. Working in med/surg kills my back."
"It is my duty in life to be a psychiatric nurse. It is the right thing to do." correct answers >> 2 The applicant's comment reflects the ethical egoism framework. This framework promotes the idea that decisions are made based on what is good for the individual and may not take the needs of others into account.
Justice
Autonomy
Veracity
Beneficence correct answers >> 2 The unit manager's policy regarding voluntary client participation in group therapy preserves the ethical principle of autonomy. The principle of autonomy presumes that individuals are capable of making independent decisions for themselves and that health-care workers must respect these decisions. Which is an example of an intentional tort?
A nurse fails to assess a client's obvious symptoms of neuroleptic malignant syndrome.
A nurse physically places an irritating client in four-point restraints.
A nurse makes a medication error and does not report the incident.
A nurse gives patient information to an unauthorized person. correct answers >> 2 A tort, which can be intentional or unintentional, is a violation of civil law in which an individual has been wronged. A nurse who intentionally physically places an irritating client in restraints has touched the client without consent and has committed an intentional tort. An involuntarily committed client is verbally abusive to the staff, repeatedly threatening to sue. The client records the full names and phone numbers of the staff. Which nursing action is most appropriate to decrease the possibility of a lawsuit?
Verbally redirect the client, and then refuse one-on-one interaction.
Involve the hospital's security division as soon as possible.
Notify the client that documenting personal staff information is against hospital policy.
Continue professional attempts to establish a positive working relationship with the client. correct answers >> 4 The most appropriate nursing action is to continue professional attempts to establish a positive working relationship with the client.
The client threatening to commit suicide
The client who never bathes and wears a wool hat in the summer
The client who eats waste out of a garbage can correct answers >> 2 The nurse should identify the client threatening to commit suicide as eligible for involuntary commitment. The suicidal client who refuses treatments is in danger and needs emergency treatment. A client diagnosed with schizophrenia refuses to take medication, citing the right of autonomy. Under which circumstance would a nurse have the right to medicate the client against the client's wishes?
A client makes inappropriate sexual innuendos to a staff member.
A client constantly demands attention from the nurse by begging, "Help me get better."
A client physically attacks another client after being confronted in group therapy.
A client refuses to bathe or perform hygienic activities. correct answers >> 3
The nurse would have the right to medicate a client against his or her wishes if the client physically attacks another client. This client poses a significant risk to safety and is incapable of making informed choices. The client's refusal to accept treatment can be challenged, because the client is endangering the safety of others. A psychiatric nurse working on an inpatient unit receives a call asking if an individual has been a client in the facility. Which nursing response reflects appropriate legal and ethical obligations?
The nurse refuses to give any information to the caller, citing rules of confidentiality.
The nurse hangs up on the caller.
The nurse confirms that the person has been at the facility but adds no additional information.
The nurse suggests that the caller speak to the client's therapist. correct answers >> 1 The most appropriate action by the nurse is to refuse to give any information to the caller.
