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NURSING 1950 Mental Health Module 4 Exam (GRADED A)
Questions and Answers Solutions
A patient diagnosed with alcoholism asks, "How will Alcoholics Anonymous (AA) help me?" Select the nurse's best response. "An individual is supported by peers while striving for abstinence one day at a time."
1. A nurse reviews vital signs for a patient admitted with an injury sustained
while intoxicated. The medical record shows these blood pressure and pulse readings at the times listed: 0200: 118/78 mm Hg and 72 beats/min 0400: 126/80 mm Hg and 76 beats/min 0600: 128/82 mm Hg and 72 beats/min 0800: 132/88 mm Hg and 80 beats/min 1000: 148/94 mm Hg and 96 beats/min What is the nurse's priority action? Consult the health care provider
2. A nurse cares for a patient diagnosed with an opioid overdose. Which focused
assessment has the highest priority? Respiratory
3. A patient admitted for injuries sustained while intoxicated has been
hospitalized for 48 hours. The patient is now shaky, irritable, anxious, diaphoretic, and reports nightmares. The pulse rate is 130 beats/min. The patient shouts, "Bugs are crawling on my bed. I've got to get out of here." Select the most accurate assessment of this situation. The patient: has symptoms of alcohol-withdrawal delirium
4. A patient admitted yesterday for injuries sustained while intoxicated believes
bugs are crawling on the bed. The patient is anxious, agitated, and diaphoretic. What is the priority nursing diagnosis? Risk for injury
5. A hospitalized patient diagnosed with an alcohol abuse disorder believes the
window blinds are snakes trying to get in the room. The patient is anxious, agitated, and diaphoretic. The nurse can anticipate the health care provider will prescribe a(n): sedative, such as lorazepam (Ativan) or chlordiazepoxide (Librium)
6. A hospitalized patient diagnosed with an alcohol abuse disorder believes
spiders are spinning entrapping webs in the room. The patient is fearful, agitated, and diaphoretic. Which nursing intervention is indicated? One-on-one supervision
7. A patient diagnosed with an alcohol abuse disorder says, "Drinking helps me
cope with being a single parent." Which therapeutic response by the nurse would help the patient conceptualize the drinking objectively? "Tell me what happened the last time you drank."
8. A patient asks for information about Alcoholics Anonymous. Select the nurse's
best response. "Alcoholics Anonymous is a: “self-help group for which the goal is sobriety."
9. Police bring a patient to the emergency department after an automobile
accident. The patient demonstrates ataxia and slurred speech. The blood alcohol level is 500 mg%. Considering the relationship between the behavior and blood alcohol level, which conclusion is most probable? The patient: has a high tolerance to alcohol
10. A patient admitted to an alcoholism rehabilitation program tells the nurse,
"I'm actually just a social drinker. I usually have a drink at lunch, two in the afternoon, wine with dinner, and a few drinks during the evening." The patient is using which defense mechanism? Denial
11. Which medication to maintain abstinence would most likely be prescribed for
patients with an addiction to either alcohol or opioids? Naltrexone (ReVia)
12. During the third week of treatment, the spouse of a patient in a
rehabilitation program for substance abuse says, "After this treatment program, I think everything will be all right." Which remark by the nurse will be most helpful to the spouse? "While sobriety solves some problems, new ones may emerge as one adjusts to living without drugs and alcohol."
13. The treatment team discusses the plan of care for a patient diagnosed with
schizophrenia and daily cannabis abuse who is having increased hallucinations and
Residential program
22. Select the priority nursing intervention when caring for a patient after an
overdose of amphetamines. Monitor vital signs
23. Symptoms of withdrawal from opioids for which the nurse should assess
include: nausea, vomiting, diaphoresis, anxiety, and hyperreflexia
24. A patient has smoked two packs of cigarettes daily for many years. When the
patient tries to reduce smoking, anxiety, craving, poor concentration, and headache occur. This scenario describes: substance addiction
25. Which assessment findings are likely for an individual who recently injected
heroin? Drowsiness, constricted pupils, slurred speech
26. An adult in the emergency department states, "Everything I see appears to
be waving. I am outside my body looking at myself. I think I'm losing my mind." Vital signs are slightly elevated. The nurse should suspect: hallucinogen ingestion
27. A nurse wants to research epidemiology, assessment techniques, and best
practices regarding persons with addictions. Which resource will provide the most comprehensive information? Substance Abuse and Mental Health Services Administration (SAMHSA)
28. A patient is thin, tense, jittery, and has dilated pupils. The patient says, "My
heart is pounding in my chest. I need help." The patient allows vital signs to be taken but then becomes suspicious and says, "You could be trying to kill me." The patient refuses further examination. Abuse of which substance is most likely? Amphetamines
29. Select the priority outcome for a patient completing the fourth alcohol-
detoxification program in the past year. Prior to discharge, the patient will:
state, "I know I need long-term treatment."
30. A nurse prepares for an initial interaction with a patient with a long history
of methamphetamine abuse. Which is the nurse's best first action? Self-assess personal attitude, values, and beliefs about this health problem
31. A patient undergoing alcohol rehabilitation decides to begin disulfiram
(Antabuse) therapy. Patient teaching should include the need to: (select all that apply)
**- avoid alcohol-based skin products
- read labels of all liquid medications
- avoid breathing fumes of paints, stains, and stripping compounds**
32. The nurse can assist a patient to prevent substance abuse relapse by:
(select all that apply)
**- rehearsing techniques to handle anticipated stressful situations
- assisting the patient to identify life skills needed for effective coping
- informing the patient of physical changes to expect as the body adapts to functioning without substances**
33. A patient took a large quantity of bath salts. Priority nursing and medical
measures include: (select all that apply)
**- management of heart rate
34. A new patient beginning an alcoholism rehabilitation program says, "I'm just
a social drinker. I usually have one drink at lunch, two in the afternoon, wine at dinner, and a few drinks during the evening." Select the nurse's most therapeutic responses. Select all that apply.
**- "Social drinkers have one or two drinks, once or twice a week."
- "You describe drinking steadily throughout the day and evening."**
35. Which of the following statements most accurately describes the concept of
tolerance? A person needs increasing amounts of a substance to achieve a desired effect
45. What is the ethical obligation of the nurse who has seen a peer divert a
narcotic compared with the ethical obligation when the nurse observes a peer to be under the influence of alcohol? Supervisory staff should be informed as soon as possible in both cases
46. Which drug is most apt to have been ingested by a young woman who comes
to the emergency department with the report that although she has no recollection of the incident, she believes she was sexually assaulted at a party? GHB
47. While helping an addicted individual plan for ongoing treatment, which of
the following interventions is the first priority for a safe recovery? The client strives to maintain abstinence
48. Symptoms that would signal opioid withdrawal include
lacrimation, rhinorrhea, dilated pupils, and muscle aches
49. Which of the drugs used by a polysubstance abuser is most likely to be
responsible for withdrawal symptoms requiring both medical intervention and nursing support? Barbiturates
50. Nursing assessment of an alcohol-dependent client 6 to 12 hours after the
last drink would most likely reveal the presence of tremors
51. A client has been using cocaine intranasally for 4 years. Two months ago she
started freebasing. For the past week she has locked herself in her apartment and has used $8000 worth of cocaine. When brought to the hospital she was unconscious. Nursing measures should include observation for hyperpyrexia and seizures
52. An unconscious client is admitted to the emergency department. The
admitting diagnosis is "rule out opiate overdose." Which item of assessment data would be most consistent with opiate overdose? Blood pressure, 80/40 mm Hg; pulse, 120 beats/min; respirations, 10 breaths/min
53. Cocaine exerts which of the following effects on a client?
Stimulation and anesthetic effects
54. An appropriate long-term goal/outcome for a recovering substance abuser
would be that the client will abstain from the use of mood-altering substances
55. A client was in an automobile accident. Although he has the odor of alcohol
on his breath, his speech is clear and he is alert and answers questions posed to him. The law enforcement officer requests that the emergency department staff draw a blood sample for blood alcohol level determination. The level is determined to be 0.30 mg%. What conclusion can be drawn? The client has a high tolerance to alcohol
56. A client brought to the emergency department at the university hospital
after PCP ingestion tries to run up and down the hallway. The nursing intervention that would be most therapeutic is obtaining an order for seclusion and close observation
57. A teaching need is revealed when a client taking disulfiram states
"Most over-the-counter cough syrups are OK for me to use."
58. The most helpful message to transmit about relapse to the recovering
alcoholic client is that lapses result from lack of good situational support
59. All of the following substances are considered central nervous system
stimulants, except methadone
60. An adult outpatient diagnosed with major depression has a history of several
suicide attempts by overdose. Given this patient's history and diagnosis, which antidepressant medication would the nurse expect to be prescribed? Fluoxetine (Prozac), a selective serotonin reuptake inhibitor
69. Select the most critical question for the nurse to ask an adolescent who has
threatened to take an overdose of pills. "Do you have access to medications?"
70. It has been 5 days since a suicidal patient was hospitalized and prescribed
an antidepressant medication. The patient is now more talkative and shows increased energy. Select the highest priority nursing intervention. Supervise the patient 24 hours a day
71. A nurse and patient construct a no-suicide contract. Select the preferable
wording. "For the next 24 hours, I will not in any way attempt to harm or kill myself."
72. A tearful, anxious patient at the outpatient clinic reports, "I should be dead."
The initial task of the nurse conducting the assessment interview is to: establish rapport with the patient
73. A nurse interacts with an outpatient who has a history of multiple suicide
attempts. Select the most helpful response for a nurse to make when the patient states, "I am considering committing suicide." "Bringing up these feelings is a very positive action on your part."
74. Which intervention will the nurse recommend for the distressed family and
friends of someone who has committed suicide? Attending a self-help group for survivors
75. Which statement provides the best rationale for closely monitoring a
severely depressed patient during antidepressant medication therapy? As depression lifts, physical energy becomes available to carry out suicide
76. A nurse assesses a patient who reports a 3 - week history of depression and
periods of uncontrolled crying. The patient says, "My business is bankrupt, and I was served with divorce papers." Which subsequent statement by the patient alerts the nurse to a concealed suicidal message? "I have a plan that will fix everything."
77. A depressed patient says, "Nothing matters anymore." What is the most
appropriate response by the nurse? "Are you having thoughts of suicide?"
78. A nurse counsels a patient with recent suicidal ideation. Which is the nurse's
most therapeutic comment? "Let's consider which problems are very important and which are less important."
79. When assessing a patient's plan for suicide, what aspect has priority?
Availability of means and lethality of method
80. The feeling experienced by a patient that should be assessed by the nurse as
most predictive of elevated suicide risk is hopelessness
81. Which statement by a depressed patient will alert the nurse to the patient's
need for immediate, active intervention? "I have no one to turn to for help or support."
82. A patient hospitalized for 2 weeks committed suicide during the night. Which
initial nursing measure will be most important regarding this event? Hold a staff meeting to express feelings and plan care for the other patients
83. After one of their identical twin daughters commits suicide, the parents
express concern that the other twin may also have suicidal tendencies. Which reply should the nurse provide? "Genetics are associated with suicide risk. Monitoring and support are important."
84. Which individual in the emergency department should be considered at
highest risk for completing suicide? A 79 - year-old single, white male diagnosed recently with terminal cancer of the prostate
91. An adolescent comes to the crisis clinic and reports sexual abuse by an
uncle. The adolescent told both parents about the uncle's behavior, but the parents did not believe the adolescent. What type of crisis exists? Adventitious
92. While conducting the initial interview with a patient in crisis, the nurse
should: speak in short, concise sentences
93. An adult seeks counseling after the spouse was murdered. The adult angrily
says, "I hate the beast that did this. It has ruined my life. During the trial, I don't know what I'll do if the jury doesn't return a guilty verdict." What is the nurse's highest priority response? "Are you having thoughts of hurting yourself or others?"
94. Six months ago, a woman had a prophylactic double mastectomy because of
a family history of breast cancer. One week ago, this woman learned her husband was involved in an extramarital affair. The woman tearfully says to the nurse, "What else can happen?" What type of crisis is this person experiencing? Situational
95. A woman said, "I can't take anymore! Last year my husband had an affair,
and now we don't communicate. Three months ago, I found a lump in my breast. Yesterday my daughter said she's quitting college." What is the nurse's priority assessment? Clarify what the patient means by "I can't take anymore."
96. Six months ago, a woman had a prophylactic double mastectomy because of
a family history of breast cancer. One week ago, this woman learned her husband was involved in an extramarital affair. The woman tearfully, "What else can happen?" If the woman's immediate family is unable to provide sufficient support, the nurse should: ask what other relatives or friends are available for support
97. A woman says, "I can't take anymore. Last year my husband had an affair,
and now we do not communicate. Three months ago, I found a lump in my breast. Yesterday my daughter said she's quitting college and moving in with her boyfriend." Which issue should the nurse focus on during crisis intervention?
Coping with the reaction to the daughter's events
98. A patient who is visiting the crisis clinic for the first time asks, "How long
will I be coming here?" The nurse's reply should consider that the usual duration of crisis intervention is: 4 to 8 weeks
99. A student falsely accused a college professor of sexual intimidation. The
professor tells the nurse, "I cannot teach nor do any research. My mind is totally preoccupied with these false accusations." What is the priority nursing diagnosis? Ineffective role performance related to distress from false accusations
100. Which communication technique will the nurse use more in crisis
intervention than traditional counseling? Giving direction
101. Which situation demonstrates use of primary care related to crisis
intervention? Teaching stress reduction techniques to a first-year college student
102. A victim of spousal violence comes to the crisis center seeking help. Crisis
intervention strategies the nurse uses will focus on: supporting emotional security and reestablishing equilibrium
103. After celebrating the fortieth birthday, an individual becomes concerned
with the loss of youthful appearance. What type of crisis has occurred? Maturational
104. Which scenario is an example of an adventitious crisis?
A riot at a rock concert
105. Which agency provides coordination in the event of a terrorist attack?
National Incident Management System (NIMS)
106. During the initial interview at the crisis center, a patient says, "I've been
served with divorce papers. I'm so upset and anxious that I can't think clearly."
113. Which health care worker should be referred for critical incident stress
debriefing? An emergency medical technician (EMT) who treated victims of a car bombing at a mall
114. A nurse driving home after work comes upon a serious automobile
accident. The driver gets out of the car with no apparent physical injuries. Which assessment findings would the nurse expect from the driver immediately after this event? Select all that apply.
**- Difficulty using a cell phone
115. A team of nurses report to the community after a category 5 hurricane
devastates many homes and businesses. The nurses provide emergency supplies of insulin to persons with diabetes and help transfer patients in skilled nursing facilities to sites that have electrical power. Which aspects of disaster management have these nurses fulfilled? Select all that apply.
**- Mitigation
116. Emergency response workers arrive in a community after a large-scale
natural disaster. What is the workers' first action? Report to the incident command system (ICS) center.
117. Anger can best be defined as
a normal response to a perceived threat
118. The factor most likely to contribute to a client's escalating anger is
a staff member telling him that he is inappropriate
119. Which assessment finding is the best predictor of violence in a newly
admitted client? A recent assault on a drinking companion
120. Which nursing diagnosis is the priority when planning care for a client who
displays considerable anger and occasional aggression? Risk for other-directed violence
121. Which neurotransmitter imbalance has been shown to be related to
impulsive aggression? Low levels of serotonin
122. When working with an angry client, it is best to
help the client reframe the anger-producing situation
123. Nurses coping with angry clients may find it helpful to remember that
anger and aggression begin as feelings of vulnerability
124. Which would be the most appropriate response by the nurse to help a
client who is demonstrating escalating anger? Walk the client to his room and help him practice stress-reduction techniques, such as deep breathing or muscle relaxation
125. The more a nurse's intervention is prompted by emotion
the less likely it is to be therapeutic
126. The most restrictive method for dealing with an aggressive client who is
out of control is seclusion
127. The client at highest risk for violence directed at others is one who
has delusions of persecution
128. A client experiencing manic hyperactivity stands up, glares challengingly
at clients and staff, and shouts, "This food is garbage! I'll fight anyone who says it's not!" The nurse's most relevant assessment is that the client has a high potential for other-directed violence
providing for nutrition and hydration
137. Peter, a 21-year-old patient, asks you, "What's wrong with my brain that I
have such a problem with aggression?" Your response is based on the knowledge that: the limbic system, the prefrontal cortex, and neurotransmitters have been implicated in playing a part in aggression
138. One older concept that is being used currently that may help in violence
reduction in patients is: trauma-informed care
139. You are working in the emergency department. You notice Matt, your
patient's husband, pacing in the hallway, muttering to himself, and looking angrily around the emergency department. Which of the following statements to Matt may help prevent escalation and/or violence? "You appear upset. Can I help you with anything?"
140. You are working on an adolescent psychiatric unit. Katy, aged 16 years, has
been angry all day because her boyfriend was not allowed to visit last night. Katy is in the hallway and begins yelling, "It's not fair! You all hate me! I hate this place!" She begins pounding her fists on the wall. To deal with the situation and prevent further escalation, your best response would be to say: "Katy, I will help you calm down. Do you want to go to your room and talk or go to the quiet room?"
141. When you approach Katy, what considerations should you take?
Have other staff as backup, and stand far enough away to avoid injury
142. An elderly patient is being cared for in a nursing home. The patient shouts
that she wants to go home as her children are waiting for her. The patient says the children are very young and need to be fed. What is the most appropriate response by the nurse? "You miss your children. Can you tell me something more about them?"
143. The nurse receives a patient with an injury and provides first aid to the
patient. Another patient who had been present in the treatment room suddenly becomes aggressive and shouts at the nurse. The patient threatens the nurse with
a pair of scissors to get the nurse to attend to them first. What should be the most appropriate response of the nurse? "Would you please tell me your problem?"
144. A patient has been placed in seclusion to control aggressive behavior. Care
while the patient is secluded should include Providing for nutrition and hydration
145. The nurse is assigned to care for an aggressive patient who is holding a
sharp object. What nursing action is most appropriate for this patient? Making firm eye contact with the patient while speaking
146. The parent of a hospitalized adolescent enters the inpatient unit yelling,
"What is wrong with you people? My daughter cut herself and you let it to happen. I thought my child would be safe here." Select the nurse's appropriate response. "I can't understand you when your voice is so loud. Let's go to a private area and talk about it."
147. Which comment by the nurse would best support relationship building with
a survivor of intimate partner abuse? "You are feeling violated because you thought you could trust your partner."
148. An 11 - year-old reluctantly tells the nurse, "My parents don't like me. They
said they wish I was never born." Which type of abuse is likely? Emotional
149. What feelings are most commonly experienced by nurses working with
abusive families? Helplessness regarding the victim and anger toward the abuser
150. Which rationale best explains why a nurse should be aware of personal
feelings while working with a family experiencing family violence? Strong negative feelings interfere with assessment and judgment
151. The parents of a 15 - year-old seek to have this teen declared a delinquent
because of excessive drinking, habitually running away, and prostitution. The nurse interviewing the patient should recognize these behaviors often occur in
