You are on page 1of 17

Silvestri, 3/e, ISBN 1-1460-0052-6

Chapter 062 (edited file)—"Foundations of Psychiatric Mental Health Nursing"


10/14/08, Page 1 of 17, 0 Figure(s), 1 Table(s), 5 Box(es)

62: Foundations of Psychiatric Mental Health Nursing

PRACTICE QUESTIONS

1. A nurse assists in planning care for a client scheduled to be discharged from a mental health
clinic. The nurse understands that the client’s unresolved feelings related to loss may resurface
during which phase of the therapeutic nurse-client relationship?
1. Orientation phase
2. Working phase
3. Termination phase
4. Trusting phase
Answer: 3
Rationale: In the termination phase, the relationship comes to a close. Ending treatment may
sometimes be traumatic for clients who have come to value the relationship and the help.
Because loss is an issue, any unresolved feelings related to loss may resurface during this phase.
Options 1, 2, and 4 are incorrect.
Test-Taking Strategy: Note the key words unresolved and loss in the question. Consider the
phases of the therapeutic nurse-client relationship to direct you to option 3. Review these phases
and the nursing implications if you had difficulty with this question.
Level of Cognitive Ability: Comprehension
Client Needs: Psychosocial Integrity
Integrated Process: Caring
Content Area: Mental Health
Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis:
Mosby, pp. 105-107.

2. A client with depression who has attempted suicide says to the nurse, “I should have died.
I’ve always been a failure. Nothing ever goes right for me.” The nurse makes which therapeutic
response to the client?
1. “I don’t see you as a failure.”
2. “Feeling like this is all part of being ill.”
3. “You’ve been feeling like a failure for a while?”
4. “You have everything to live for.”
Answer: 3
Rationale: Responding to the feelings expressed by a client is an effective therapeutic
communication technique. The correct option is an example of the use of restating. Options 1,
2, and 4 block communication because they minimize the client’s feelings and do not facilitate
exploration of the client’s expressed feelings.
Test-Taking Strategy: Use therapeutic communication techniques. Select the option that directly
addresses the client feelings and concerns. Option 3 is the only option that is stated in the form
of a question and is open-ended; therefore, it will encourage the verbalization of feelings.
Review these techniques if you had difficulty with this question.
Level of Cognitive Ability: Application
Client Needs: Psychosocial Integrity
Silvestri, 3/e, ISBN 1-1460-0052-6
Chapter 062 (edited file)—"Foundations of Psychiatric Mental Health Nursing"
10/14/08, Page 2 of 17, 0 Figure(s), 1 Table(s), 5 Box(es)

Integrated Process: Communication and Documentation


Content Area: Mental Health
Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis:
Mosby, p. 88.

3. A client states to the nurse, “I haven't slept at all the last couple of nights." The nurse makes
which therapeutic response to the client?
1. “Go on......”
2. “Sleeping?”
3. “The last couple of nights?”
4. “You're having difficulty sleeping?”
Answer: 4
Rationale: Option 4 identifies the therapeutic communication technique of restatement. Although it
is a technique that has a prompting component to it, it repeats the client's major theme and addresses
the problem from the client’s perspective. Option 1 allows the client to direct the discussion when it
needs to be more focused at this point. Option 2 uses reflection that simply repeats the client's last
words to prompt further discussion. Option 3 focuses on the number of nights rather than the
specific problem of sleep.
Test-Taking Strategy: Use therapeutic communication techniques. Option 4 identifies restatement
and repeats the client's major theme. Review therapeutic communication techniques if you had
difficulty with this question.
Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Communication and Documentation
Content Area: Mental Health
Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis:
Mosby, p. 88.

4. The nurse is collecting data from a client and is attempting to obtain subjective data regarding
the client’s sexual-reproductive status. The client states, “I don't want to discuss this; it's private
and personal.” Which statement by the nurse indicates a therapeutic response?
1. “I hate being asked these sorts of questions too.”
2. “I am a nurse and as such I'll have you know that all information is kept confidential.”
3. “I know that some of these questions are difficult for you, but as a nurse, I must legally
respect your confidentiality.”
4. “This is difficult for you to speak about, but I am trying to perform a complete data collection
and I need this information.”
Answer: 3
Rationale: Option 3 is the only option that identifies a therapeutic response. In option 1, the nurse’s
feelings are the focus. This response clearly ignores the fact that the issue is about the client and the
client's discomfort, not about the nurse. In option 2, the nurse becomes pompous and a little angry
and supercilious, which is not therapeutic. In option 4, the nurse begins correctly with an empathic
stance but then becomes demanding.
Test-Taking Strategy: Use of the process of elimination and therapeutic communication techniques
will easily direct you to option 3. Review therapeutic communication techniques if you had
Silvestri, 3/e, ISBN 1-1460-0052-6
Chapter 062 (edited file)—"Foundations of Psychiatric Mental Health Nursing"
10/14/08, Page 3 of 17, 0 Figure(s), 1 Table(s), 5 Box(es)

difficulty with this question.


Level of Cognitive Ability: Analysis
Client Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Content Area: Mental Health
References: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis:
Mosby, p. 88.
Varcarolis, E. (2002). Foundations of psychiatric mental health nursing (4th ed.). Philadelphia:
W.B. Saunders, p. 258.

5. A nurse is caring for a client who says, “I don't want you to touch me. I'll take care of
myself!” The nurse makes which therapeutic response to the client?
1. “I will respect your feelings. I'll just leave this cup for you to collect your urine in. After
breakfast, I will take more blood from you.”
2. “If you didn't want our care, why did you come here?”
3. “Why are you being so difficult? I only want to help you.”
4. “Sounds like you're feeling pretty troubled by all of us. Let's work together so you can do
everything for yourself as you request.”
Answer: 4
Rationale: The therapeutic response is the one that reflects the client's feelings and offers the client
control of care. In option 1, the nurse uses avoidance and gives information. Option 2 is an
aggressive and nontherapeutic communication technique. Option 3 is social and nontherapeutic,
because it labels the client's behavior and is likely to provoke anger from the client.
Test-Taking Strategy: Focus on the client’s statement and use therapeutic communication
techniques. Option 4 is the only option that addresses the client’s statement. Review these cultural
issues if you had difficulty with this question.
Level of Cognitive Ability: Application
Client Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Content Area: Mental Health
References: Jarvis, C. (2004). Physical examination and health assessment (4th ed.).
Philadelphia: W.B. Saunders, pp. 40, 47-49.
Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis: Mosby, p.
88.

6. A nurse is assigned to care for a client who is experiencing disturbed thought processes. The
nurse is told that the client believes that the food is being poisoned. Which communication
technique does the nurse plan to use to encourage the client to eat?
1. Open-ended questions and silence
2. Offering opinions about the necessity of adequate nutrition
3. Identifying the reasons that the client may not want to eat
4. Focusing on self-disclosure regarding food preferences
Answer: 1
Rationale: Open-ended questions and silence are strategies used to encourage clients to discuss
their problem. Options 2 and 3 do not encouraging the client to express feelings. The nurse
Silvestri, 3/e, ISBN 1-1460-0052-6
Chapter 062 (edited file)—"Foundations of Psychiatric Mental Health Nursing"
10/14/08, Page 4 of 17, 0 Figure(s), 1 Table(s), 5 Box(es)

should not offer opinions and should encourage the client to identify the reasons for the behavior.
Option 4 is not a client-centered intervention.
Test-Taking Strategy: Use the process of elimination. Eliminate options 2 and 3 first, because
they do not support client expression of feelings. Eliminate option 4 next, because it is not a
client-centered intervention. Focusing on the client’s feelings will direct you to option 1.
Review therapeutic communication techniques if you had difficulty with this question.
Level of Cognitive Ability: Application
Client Needs: Psychosocial Integrity
Integrated Process: Caring
Content Area: Mental Health
Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th
ed.). St. Louis: Mosby, pp. 30-35.

7. A nurse is assigned to care for a client admitted to the hospital after sustaining an injury from
a house fire. The client attempted to save a neighbor involved in the fire but, in spite of the
client’s efforts, the neighbor died. Which action would the nurse be engaged in with the client
during the working phase of the nurse-client relationship?
1. Identifying the client’s potential for self-harm
2. Identifying the client’s ability to function
3. Inquiring about the client’s perception of the neighbor’s death
4. Inquiring about the client’s feelings that may affect coping
Answer: 4
Rationale: The client must first deal with feelings and negative responses before the client is
able to work through the meaning of the crisis. Option 4 pertains directly to the client’s feelings.
Options 1, 2, and 3 do not directly address the client’s feelings.
Test-Taking Strategy: Use the process of elimination. Focusing on the feelings of the client will
direct you to option 4. Review the phases of the nurse-client relationship if you had difficulty
with this question.
Level of Cognitive Ability: Application
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Mental Health
Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis:
Mosby, pp. 23, 90-91.

8. A client who has just been sexually assaulted is very quiet and calm. The nurse identifies this
behavior as indicative of which defense mechanism?
1. Denial
2. Projection
3. Rationalization
4. Intellectualization
Answer: 1
Rationale: Denial is a common response by a victim of sexual abuse. It is described as an
adaptive and protective reaction. Projection is blaming or "scapegoating." Rationalization is
justifying the unacceptable attributes about him or herself. Intellectualization is the excessive
Silvestri, 3/e, ISBN 1-1460-0052-6
Chapter 062 (edited file)—"Foundations of Psychiatric Mental Health Nursing"
10/14/08, Page 5 of 17, 0 Figure(s), 1 Table(s), 5 Box(es)

use of abstract thinking or generalizations to decrease painful thinking.


Test-Taking Strategy: Use the process of elimination and knowledge regarding defense
mechanisms. Note the key words, calm and quiet. These behaviors are indicative of denial in a
sexually abused victim. If you had difficulty with this question, review content related to the
sexually abused victim and defense mechanisms.
Level of Cognitive Ability: Comprehension
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Mental Health
Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis:
Mosby, p. 273.

9. A nurse is assisting with the data collection on a client admitted to the psychiatric unit. The
nurse reviews the data obtained and identifies which of the following as a priority concern?
1. The presence of bruises on the client's body
2. The client’s report of not eating or sleeping
3. The client’s report of suicidal thoughts
4. The significant other disapproving of the treatment
Answer: 3
Rationale: The client's thoughts are extremely important when verbalized. Suicidal thoughts are
the highest priority. Options 1, 2, and 4 will all affect the treatment of the client but are not of
greatest importance at this time.
Test -Taking Strategy: The client is the focus of the question; therefore, eliminate option 4.
Focus on the key words, priority concern, and use prioritizing skills. Remember, if the client
verbalizes suicidal thoughts, it is a priority concern. Review data collection techniques related to
the suicidal client if you had difficulty with this question.
Level of Cognitive Ability: Analysis
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Mental Health
Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis:
Mosby, pp. 283, 287.

10. Laboratory work is prescribed for a client who has been experiencing delusions. When the
laboratory technician approaches the client to obtain a specimen of the client’s blood, the client
begins to shout “You're all vampires. Let me out of here!” The nurse who is present at the time
would respond by stating which of the following?
1. "The technician is not going to hurt you, but is going to help you!"
2. "What makes you think that the technician is a vampire?"
3. "The technician will leave and come back later for your blood."
4. "It must be fearful to think others want to hurt you."
Answer: 4
Rationale: Option 4 is the only option that recognizes the client’s need. This response helps the
client focus on the emotion underlying the delusion, but does not argue with it. If the nurse
attempts to change the client's mind, the delusion may, in fact, be even more strongly held.
Silvestri, 3/e, ISBN 1-1460-0052-6
Chapter 062 (edited file)—"Foundations of Psychiatric Mental Health Nursing"
10/14/08, Page 6 of 17, 0 Figure(s), 1 Table(s), 5 Box(es)

Options 1, 2, and 3 do not focus on the client’s feelings.


Test-Taking Strategy: Use therapeutic communication techniques and knowledge regarding the
dynamics of delusions and how delusions meet the client 's underlying needs. This will direct
you to option 4. Additionally, option 4 focuses on the client’s feelings. Review therapeutic
communication techniques if you had difficulty with this question.
Level of Cognitive Ability: Application
Client Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Content Area: Mental Health
Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis:
Mosby, p. 328.
Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed.). St.
Louis: Mosby, pp. 30-35.

11. An inebriated client is brought to the emergency room by the local police. The client is told
that the physician will be in to see the client in about 30 minutes. The client becomes very loud
and offensive and wants to be seen by the physician immediately. The nurse assisting to care for
the client would plan for which appropriate nursing intervention?
1. Attempt to talk with the client to de-escalate the behavior.
2. Watch the behavior escalate before intervening.
3. Inform the client that he or she will be asked to leave if the behavior continues.
4. Offer to take the client to an examination room until he or she can be treated.
Answer: 4
Rationale: Safety of the client, other clients, and staff is of prime concern. When dealing with
an impaired individual, trying to talk may be out of the question. Waiting to intervene could
cause the client to become even more agitated and a threat to others. Option 3 would only
further aggravate an already agitated individual. Option 4 is in effect an isolation technique that
allows for separation from others and provides a less stimulating environment, where the client
can maintain dignity.
Test-Taking Strategy: Focus on the issue of the question and use the process of elimination.
Noting that the client is inebriated will assist in directing you to option 4. Option 4 most directly
addresses the situation and the behavior and feelings of the client. Review nursing interventions
for a client who is inebriated if you had difficulty with this question.
Level of Cognitive Ability: Application
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Planning
Content Area: Mental Health
Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis:
Mosby, pp. 71, 116.

12. A client is admitted to a psychiatric unit for treatment of psychotic behavior. The client is at
the locked exit door, and is shouting, “Let me out. There's nothing wrong with me. I don't
belong here.” The nurse identifies this behavior as:
1. Projection
2. Denial
Silvestri, 3/e, ISBN 1-1460-0052-6
Chapter 062 (edited file)—"Foundations of Psychiatric Mental Health Nursing"
10/14/08, Page 7 of 17, 0 Figure(s), 1 Table(s), 5 Box(es)

3. Regression
4. Rationalization
Answer: 2
Rationale: Denial is refusal to admit to a painful reality and is treated as if it does not exist. In
projection, a person unconsciously rejects emotionally unacceptable features and attributes them
to other people, objects, or situations. In regression, the client returns to an earlier, more
comforting, although less mature way of behaving. Rationalization is justifying the unacceptable
attributes about oneself.
Test-Taking Strategy: Use the process of elimination. Note the key words, “There's nothing
wrong with me.” Select the option that recognizes the client’s attempt to avoid looking at the
reality of the situation. If you had difficulty with this question, review defense mechanisms.
Level of Cognitive Ability: Comprehension
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Mental Health
Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis:
Mosby, p. 70.

13. A client says to the nurse, “I’m going to die, and I wish my family would stop hoping for a
‘cure’! I get so angry when they carry on like this! After all, I’m the one who's dying.” The
most therapeutic response by the nurse is:
1. "You're feeling angry that your family continues to hope for you to be ‘cured’?"
2. "I think we should talk more about your anger with your family."
3. "Well, it sounds like you're being pretty pessimistic. After all, years ago people died of
pneumonia."
4. "Have you shared your feelings with your family?"
Answer: 1
Rationale: Reflection is the therapeutic communication technique that redirects the client's feelings
back to validate what the client is saying. In option 2, the nurse attempts to use focusing but the
attempt to discuss central issues seems premature. In option 3, the nurse makes a judgment and is
nontherapeutic in the one-on-one relationship. In option 4, the nurse is attempting to assess the
client's ability to openly discuss feelings with family members. Although this may be appropriate,
the timing is somewhat premature and closes off facilitation of the client's feelings.
Test-Taking Strategy: Use therapeutic communication techniques. Note that option 1 uses the
therapeutic technique of reflection and also focuses on the client’s feelings. Options 2, 3, and 4 are
nontherapeutic at this time. Review therapeutic communication techniques if you had difficulty
with this question.
Level of Cognitive Ability: Application
Client Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Content Area: Mental Health
References: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis:
Mosby, p. 88.
Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed.). St.
Louis: Mosby, pp. 30-35.
Silvestri, 3/e, ISBN 1-1460-0052-6
Chapter 062 (edited file)—"Foundations of Psychiatric Mental Health Nursing"
10/14/08, Page 8 of 17, 0 Figure(s), 1 Table(s), 5 Box(es)

14. A nurse employed in a psychiatric unit is assigned to care for a client admitted to the unit 2
days ago. On review of the client’s record, the nurse notes that the admission was an informal
voluntary admission. Based on this type of admission, the nurse would expect which of the
following?
1. The client will be very resistant to treatment measures.
2. The client’s family will be very resistant to treatment measures.
3. The client will be angry and will refuse care.
4. The client will participate in the treatment plan.
Answer: 4
Rationale: Generally, voluntary admission is sought by the client or client’s guardian. If the
client seeks voluntary admission, the most likely expectation is that the client will participate in
the treatment program.
Test-Taking Strategy: Use the process of elimination. Note the key words, informal voluntary
admission. This will direct you to option 4. Additionally, note that options 1, 2, and 3 are
similar. Review the various types of hospital admission processes if you had difficulty with this
question.
Level of Cognitive Ability: Comprehension
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Planning
Content Area: Mental Health
Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis:
Mosby, p. 23.

15. A licensed practical nurse (LPN) enters a client’s room, and the client is demanding release
from the hospital. The LPN reviews the client’s record and notes that the client was admitted 2
days ago for treatment of an anxiety disorder, and that the admission was a voluntary admission.
The LPN reports the findings to the registered nurse (RN) and expects that the RN will take
which of the following actions?
1. Tell the client that discharge is not possible at this time.
2. Call the client’s family.
3. Contact the physician.
4. Persuade the client to stay a few more days.
Answer: 3
Rationale: Generally, voluntary admission is sought by the client or client’s guardian. Voluntary
clients have the right to demand and obtain release. The best nursing action is to contact the
physician.
Test-Taking Strategy: Use the process of elimination. Noting the type of hospital admission will
assist in eliminating option 1. It is inappropriate to “persuade” a client to stay in the hospital.
Option 2 should be eliminated based simply on the issue of client rights and the issue of
confidentiality. Review the various types of hospital admission and discharge processes if you
had difficulty with this question.
Level of Cognitive Ability: Application
Client Needs: Safe, Effective Care Environment
Integrated Process: Nursing Process/Implementation
Silvestri, 3/e, ISBN 1-1460-0052-6
Chapter 062 (edited file)—"Foundations of Psychiatric Mental Health Nursing"
10/14/08, Page 9 of 17, 0 Figure(s), 1 Table(s), 5 Box(es)

Content Area: Mental Health


Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis:
Mosby, p. 23.
Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed.). St.
Louis: Mosby, p. 150.

16. A client is admitted to the psychiatric nursing unit. When collecting data from the client, the
nurse notes that the client was admitted by involuntary status. Based on this type of admission,
the nurse most likely expects that the client:
1. Presents a harm to self
2. Requested the admission
3. Consented to the admission
4. Provided written application to the facility for admission
Answer: 1
Rationale: Involuntary admission is made without the client’s consent. Involuntary admission is
necessary when a person is a danger to self or others or is in need of psychiatric treatment or
physical care. Options 2, 3, and 4 describe the process of voluntary admission.
Test-Taking Strategy: Use the process of elimination. Note the key words, involuntary status.
This should direct you to option 1. Also, note that options 2, 3, and 4 are similar. Review the
process of involuntary admission if you had difficulty with this question.
Level of Cognitive Ability: Comprehension
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Planning
Content Area: Mental Health
Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th
ed.). St. Louis: Mosby, 150.

17. A nurse is caring for a client who is scheduled for electroconvulsive therapy (ECT). The
nurse notes that an informed consent has not been obtained for the procedure. On review of the
record, the nurse notes that the admission was an involuntary hospitalization. Based on this
information, the nurse determines that:
1. An informed consent does not need to be obtained.
2. An informed consent should be obtained from the family.
3. An informed consent needs to be obtained from the client.
4. The physician will obtain the informed consent.
Answer: 3
Rationale: Clients who are involuntarily admitted do not lose their right to informed consent.
The informed consent needs to be obtained from the client. Options 1, 2, and 4 are incorrect.
Test-Taking Strategy: Use the process of elimination and knowledge regarding the hospital
admission processes and client’s rights to answer this question. Focusing on the issue of client’s
rights will direct you to option 3. Review client’s rights if you had difficulty with this question.
Level of Cognitive Ability: Comprehension
Client Needs: Safe, Effective Care Environment
Integrated Process: Nursing Process/Planning
Content Area: Mental Health
Silvestri, 3/e, ISBN 1-1460-0052-6
Chapter 062 (edited file)—"Foundations of Psychiatric Mental Health Nursing"
10/14/08, Page 10 of 17, 0 Figure(s), 1 Table(s), 5 Box(es)

Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis:
Mosby, p. 218.

18. Following a group therapy session, a client approaches the licensed practical nurse (LPN)
and verbalizes a need for seclusion because of uncontrollable feelings. The LPN reports the
findings to the registered nurse (RN) and expects that the RN will take which of the following
actions?
1. Inform the client that seclusion has not been prescribed.
2. Obtain an informed consent.
3. Call the client’s family.
4. Place the client in seclusion immediately.
Answer: 2
Rationale: A client may request to be secluded or restrained. Federal laws require the consent of
the client, unless an emergency situation exists in which an immediate risk to the client or others
can be documented. The use of seclusion and restraint is permitted only on the written order of a
physician, which must be reviewed and renewed every 24 hours; it also must specify the type of
restraint to be used.
Test-Taking Strategy: Use the process of elimination. There is no reason to call the family at
this time; therefore, eliminate option 3. Knowing that a physician’s written order is necessary in
this situation will assist in eliminating option 4. Option 1 is not the best choice because this
information, if given to a client experiencing uncontrollable feelings, may cause escalation of the
feelings. Review the procedures for seclusion if you had difficulty with this question.
Level of Cognitive Ability: Application
Client Needs: Safe, Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Mental Health
Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis:
Mosby, pp. 25, 262-263.

19. A nurse is providing care to a client admitted to the hospital with a diagnosis of anxiety
disorder. The nurse is talking with the client and the client says, “I have a secret that I want to
tell you. You won’t tell anyone about it, will you?” The appropriate nursing response is which
of the following?
1. “No, I won’t tell anyone.”
2. “I cannot promise to keep a secret.”
3. “If you tell me the secret, I will tell it to your doctor.”
4. “If you tell me the secret, I will need to document it in your record.”
Answer: 2
Rationale: The nurse should never promise to keep a secret. Secrets are appropriate in a social
relationship, but not in a therapeutic one. The nurse needs to be honest with the client and tell
the client that a promise cannot be made to keep the secret.
Test-Taking Strategy: Use the process of elimination and therapeutic communication techniques.
Option 1 can be eliminated because it is inappropriate. Also, options 3 and 4 are not only
inappropriate, but are to an extent threatening and may even block further communication.
Review the principles related to a therapeutic nurse-client relationship if you had difficulty with
Silvestri, 3/e, ISBN 1-1460-0052-6
Chapter 062 (edited file)—"Foundations of Psychiatric Mental Health Nursing"
10/14/08, Page 11 of 17, 0 Figure(s), 1 Table(s), 5 Box(es)

this question.
Level of Cognitive Ability: Application
Client Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Content Area: Mental Health
References: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis:
Mosby, p. 88.
Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th ed.). St.
Louis: Mosby, pp. 30-35.

20. A psychiatric nurse is greeted by a neighbor in a local grocery store. The neighbor says to
the nurse, “How is Carol doing? She is my best friend and is seen at your clinic every week.”
The appropriate nursing response is which of the following?
1. “I’m not suppose to discuss this, but since you are my neighbor, I can tell you that she is
doing great!”
2. “I’m not suppose to discuss this, but since you are my neighbor, I can tell you that she really
has some problems!”
3. “If you want to know about Carol, you need to ask her yourself.”
4. “I cannot discuss any client situation with you.”
Answer: 4
Rationale: A nurse is required to maintain confidentiality regarding clients and their care.
Confidentiality is basic to the therapeutic relationship and is a client’s right. Option 3 is correct
in a sense; however, it is a rather blunt statement. Both options 1 and 2 identify statements that
do not maintain client confidentiality.
Test-Taking Strategy: Use the process of elimination. Focus on the issue of the question,
maintaining confidentiality. This should assist in eliminating options 1 and 2. From the
remaining options, select option 4 over option 3 because it is most direct and correct. Option 3 is
a rather blunt and somewhat rude statement. Review confidentiality issues if you had difficulty
with this question.
Level of Cognitive Ability: Application
Client Needs: Safe, Effective Care Environment
Integrated Process: Communication and Documentation
Content Area: Mental Health
Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis:
Mosby, p. 21.

21. A client was involuntarily admitted to the psychiatric unit because of episodes of extremely
violent behavior. The client is demanding to be discharged from the hospital. The licensed
practical nurse (LPN) reports the information to the registered nurse (RN), and the RN does not
allow the client to leave. The LPN understands that which of the following represents the legal
ramifications associated with the RN’s behavior?
1. The RN will be charged with imprisonment.
2. The RN will be charged with assault.
3. The RN will be charged with slander.
4. No charge will be made against the RN because the RN’s actions are reasonable.
Silvestri, 3/e, ISBN 1-1460-0052-6
Chapter 062 (edited file)—"Foundations of Psychiatric Mental Health Nursing"
10/14/08, Page 12 of 17, 0 Figure(s), 1 Table(s), 5 Box(es)

Answer: 4
Rationale: False imprisonment is an act with the intent to confine a person to a specific area. A
nurse can be charged with false imprisonment if the nurse prohibits a client from leaving the
hospital if the client was voluntarily admitted and if there are no agency or legal policies for
detaining the client. On the other hand, if the client has been involuntarily admitted or has
agreed to an evaluation before discharge, the nurse’s actions are reasonable.
Test-Taking Strategy: Use the process of elimination. Noting the key words, involuntarily
admitted, will assist to eliminate option 1 and direct you to option 4. Options 2 and 3 are
unrelated to the issue of the question and can be easily eliminated. Review the issues related to
false imprisonment and hospital admissions if you had difficulty with this question.
Level of Cognitive Ability: Comprehension
Client Needs: Safe, Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Mental Health
Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis:
Mosby, pp. 24-25.

22. A nurse is preparing a client for the termination phase of the nurse-client relationship.
Which nursing task would the nurse appropriately plan for this phase?
1. Identify expected outcomes.
2. Plan short-term goals.
3. Assist in making appropriate referrals.
4. Assist in developing realistic solutions.
Answer: 3
Rationale: Tasks of the termination phase include evaluating client performance, evaluating
achievement of expected outcomes, evaluating future needs, making appropriate referrals, and
dealing with the common behaviors associated with termination. Options 1, 2, and 4 identify the
tasks of the working phase of the relationship.
Test-Taking Strategy: Noting the key words, termination phase, should direct you to option 3. If
you are unfamiliar with the appropriate tasks of the phases of the nurse-client relationship,
review this content.
Level of Cognitive Ability: Application
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Planning
Content Area: Mental Health
Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis:
Mosby, pp. 106-107.

23. During the termination phase of the nurse-client relationship, the clinic nurse observes that
the client continuously demonstrates bursts of anger. The appropriate interpretation of the
behavior is that the client:
1. Requires further treatment and is not ready to be discharged
2. Is displaying typical behaviors that can occur during termination
3. Needs to be admitted to the hospital
4. Needs to be referred to the psychiatrist as soon as possible
Silvestri, 3/e, ISBN 1-1460-0052-6
Chapter 062 (edited file)—"Foundations of Psychiatric Mental Health Nursing"
10/14/08, Page 13 of 17, 0 Figure(s), 1 Table(s), 5 Box(es)

Answer: 2
Rationale: In the termination phase of a relationship, it is normal for a client to demonstrate a
number of regressive behaviors. Typical behaviors include return of symptoms, anger,
withdrawal, and minimizing the relationship. The anger that the client is experiencing is a
normal behavior during the termination phase and does not necessarily indicate the need for
hospitalization or treatment.
Test-Taking Strategy: Use the process of elimination. Note the key words, termination phase.
This alone may assist in directing you to option 2. Additionally, note the similarity among
options 1, 3, and 4. These options address the need for further supervised treatment. If you are
unfamiliar with the client behaviors associated with the termination phase, review this content.
Level of Cognitive Ability: Analysis
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Mental Health
Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis:
Mosby, p. 107.

24. An 18-year-old woman is admitted to an inpatient psychiatric unit with the diagnosis of
anorexia nervosa. A behavior therapy approach is used as part of her treatment plan. The nurse
understands that the purpose of this approach is to:
1. Help the client identify and examine dysfunctional thoughts and beliefs.
2. Emphasize social interaction with clients who withdraw.
3. Provide a supportive environment.
4. Examine conflicts and past issues.
Answer: 1
Rationale: Behavior therapy is used to help clients identify and examine dysfunctional thoughts
as well as identify and examine values and beliefs that maintain these thoughts. Options 2, 3,
and 4 are incorrect.
Test-Taking Strategy: Use the process of elimination and note the key word, behavior. Focusing
on this key word should direct you to option 1. If you are unfamiliar with this type of therapy
and its purpose, review this content.
Level of Cognitive Ability: Comprehension
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Mental Health
Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis:
Mosby, pp. 40-42.

25. Milieu therapy is prescribed for a client. The nurse understands that this type of therapy can
best be described as which of the following?
1. A form of behavior modification therapy
2. A cognitive approach to changing behavior
3. The client is involved in setting goals
4. A behavioral approach to changing behavior
Answer: 3
Silvestri, 3/e, ISBN 1-1460-0052-6
Chapter 062 (edited file)—"Foundations of Psychiatric Mental Health Nursing"
10/14/08, Page 14 of 17, 0 Figure(s), 1 Table(s), 5 Box(es)

Rationale: Milieu therapy provides a safe environment that is adapted to the individual client’s
needs and also provides greater comfort and freedom of expression than has been experienced in
the past by the client. All members contribute to the planning and functioning of the setting.
Options 1, 2, and 4 are not characteristics of milieu therapy.
Test-Taking Strategy: Use the process of elimination. Note that options 1, 2, and 4 are similar
and that option 3 identifies the umbrella (global) description. Review this model of care if you
had difficulty with this question.
Level of Cognitive Ability: Comprehension
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Mental Health
Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th
ed.). St. Louis: Mosby, pp. 700-701.

26. Disulfiram (Antabuse) is prescribed for a client with a problem related to alcohol. The nurse
understands that this medication works on the principle of which of the following therapies?
1. Desensitization
2. Self-control therapy
3. Milieu therapy
4. Aversion therapy
Answer: 4
Rationale: Aversion therapy, also known as aversion conditioning or negative reinforcement, is a
technique used to change behavior. In this therapy, a stimulus (alcohol) attractive to the client is
paired with an unpleasant event in hopes of associating the stimulus with negative properties.
Desensitization is the reduction of intense reactions to a stimulus by repeated exposure to the
stimulus in a weaker and milder form. Milieu therapy provides positive environmental
manipulation, both physical and social, to effect a positive change in the client. Self-control
therapy combines cognitive and behavioral approaches and is useful to deal with stress.
Test-Taking Strategy: Focus on the information in the question. Recalling that aversion therapy
is a form of negative reinforcement will direct you to the correct option. If you had difficulty
with this question, review this form of therapy.
Level of Cognitive Ability: Comprehension
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Mental Health
Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis:
Mosby, p. 300.

27. A nurse informs a client with an eating disorder about group meetings with Overeaters
Anonymous. Which statement by the client indicates the need for additional information about
this self-help group?
1. “In this self-help group, people who have a similar problem are able to help others.”
2. “This self-help group is designed to serve people who have a common problem.”
3. “The members of this self-help group provide support to each other.”
4. “The leader of this self-help group is a nurse or psychiatrist.”
Silvestri, 3/e, ISBN 1-1460-0052-6
Chapter 062 (edited file)—"Foundations of Psychiatric Mental Health Nursing"
10/14/08, Page 15 of 17, 0 Figure(s), 1 Table(s), 5 Box(es)

Answer: 4
Rationale: The sponsor of a self-help group is an experienced member of the group. A nurse or
psychiatrist may be asked by the group to serve as a resource but would not be the leader of the
group. Options 1, 2, and 3 are characteristics of a self-help group.
Test-Taking Strategy: Use the process of elimination and note the key words, need for
additional information, in the stem of the question. Note that options 1, 2, and 3 are similar.
This should direct you to option 4. Review the characteristics of a self-help group if you had
difficulty with this question.
Level of Cognitive Ability: Comprehension
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Mental Health
Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis:
Mosby, p. 49.

28. A client is attending a Gamblers Anonymous meeting for the first time. The model used by
this group is the 12-step program developed by Alcoholics Anonymous. The nurse understands
that the first step in the 12-step program is which of the following?
1. Stating that the gambling will be stopped
2. Discontinuing relationships with friends who are gamblers
3. Substituting gambling for other activities
4. Admitting to having a problem
Answer: 4
Rationale: The first step in the 12-step program is to admit that a problem exists. Options 1 and
2 are unrealistic as a first step in the process to recovery. Although option 3 may be a strategy, it
is not the first step.
Test-Taking Strategy: Note the key words, first step, in the question. This will assist in directing
you to option 4. If you are unfamiliar with the 12-step program, review this content.
Level of Cognitive Ability: Comprehension
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Mental Health
Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th
ed.). St. Louis: Mosby, pp. 506-507.

29. A nurse is assisting in conducting a group therapy session and a client with a manic disorder
is monopolizing the group. The appropriate nursing action is which of the following?
1. Suggest that the client stop talking and try listening to others.
2. Ask the client to leave.
3. Tell the client to stop monopolizing the group.
4. Refer the client to another group.
Answer: 1
Rationale: If a client is monopolizing the group, it is important that the nurse be direct and
decisive. The best action is to suggest that the client stop talking and try listening to others.
Although option 3 may be a direct response, option 1 is the most therapeutic direct statement.
Silvestri, 3/e, ISBN 1-1460-0052-6
Chapter 062 (edited file)—"Foundations of Psychiatric Mental Health Nursing"
10/14/08, Page 16 of 17, 0 Figure(s), 1 Table(s), 5 Box(es)

Options 2 and 4 are inappropriate.


Test-Taking Strategy: Use the process of elimination. Eliminate options 2 and 4 first because
they are similar. Use therapeutic communication techniques to assist in directing you to option
1. If you had difficulty with this question, review therapeutic communication techniques.
Level of Cognitive Ability: Application
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Mental Health
Reference: Morrison-Valfre, M. (2005). Foundations of mental health care (3rd ed.). St. Louis:
Mosby, p. 88.

30. A nurse is assisting in monitoring a group therapy session. During this session, the members
are identifying tasks and boundaries. The nurse understands that these activities are
characteristic of which stage of group development?
1. Forming
2. Storming
3. Norming
4. Performing
Answer: 1
Rationale: In the forming or initial stage, the members are identifying tasks and boundaries.
Storming involves responding emotionally to tasks. In the norming stage, members express
intimate personal opinions and feelings around personal tasks. In the performing stage, members
direct group energy toward the completion of tasks.
Test-Taking Strategy: Use the process of elimination. Note the key word, identifying, in the
question. This key word should assist in directing you to option 1. If you had difficulty with this
question, review the stages of group development.
Level of Cognitive Ability: Comprehension
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Mental Health
Reference: Stuart, G., & Laraia, M. (2005). Principles and practice of psychiatric nursing (8th
ed.). St. Louis: Mosby, p. 672.

<AQ>31. The nurse in the mental health unit reviews the therapeutic and nontherapeutic
communication techniques with a nursing student. Select all therapeutic communication
techniques.
____Making value judgments
____Listening
____ Giving advice or approval or disapproval
____Maintaining neutral responses
____Providing false reassurance
____Restating
____Asking the client "Why?"
____Providing acknowledgment and feedback
Answers:
Silvestri, 3/e, ISBN 1-1460-0052-6
Chapter 062 (edited file)—"Foundations of Psychiatric Mental Health Nursing"
10/14/08, Page 17 of 17, 0 Figure(s), 1 Table(s), 5 Box(es)

Listening
Maintaining neutral responses
Restating
Providing acknowledgment and feedback
Rationale: Some therapeutic communication techniques include listening, maintaining silence,
maintaining neutral responses, using broad openings and open-ended questions, focusing and
refocusing, restating, clarifying and validating, sharing perceptions, reflecting, providing
acknowledgment and feedback, giving information and presenting reality, encouraging
formulation of a plan of action, providing nonverbal encouragement, and summarizing.
Test-Taking Strategy: Focus on the issue, therapeutic communication techniques. This will
assist in selecting the correct answers. Review therapeutic and nontherapeutic techniques if you
had difficulty with this question.
Level of Cognitive Ability: Comprehension
Client Needs: Psychosocial Integrity
Integrated Process: Teaching/Learning
Content Area: Mental Health
Reference: Harkreader, H., & Hogan, M.A. (2004) Fundamentals of nursing: Caring and
clinical judgment (2nd ed.). Philadelphia: W.B. Saunders, pp. 251-252.