Mental Health and Abusive Behavior Assessment

MULTIPLE CHOICE

1. What function do neurotransmitters have in mental health disorders?
a. Dopamine levels are increased in schizophrenia.
b. Increased levels of gamma aminobutyric acid (GABA) contribute to anxiety.
c. Serotonin is decreased in a state of anxiety.
d. Norepinephrine is increased in depression.
ANS: A

Feedback
A Dopamine levels are increased in schizophrenia.
B Insufficient GABA may contribute to anxiety. GABA is an inhibitory neurotransmitter.
C Serotonin is increased in anxiety states.
D Norepinephrine is decreased in depression.
DIF: Cognitive Level: Remember REF: 66
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Mental Health Concepts

2. A male patient scores 125 on the Holmes Social Readjustment Scale. How does the nurse interpret this score?
a. He is experiencing a great deal of stress in his life and needs hospitalization.
b. At this time he has no stress in his life and is healthy both mentally and physically.
c. He has relatively low stress in his life and use of daily relaxation can be beneficial.
d. He has a moderate chance of developing a stress-related illness and can reduce this by practicing stress management.
ANS: C

Feedback
A A score on the Holmes Social Readjustment Scale greater than 300 is needed for hospitalization.
B This does not apply to this person. The lowest score possible on the Holmes Social Readjustment Scale (less than 150) indicates the amount of stress experienced is a result of normal changes in life and is manageable.
C A score on the Holmes Social Readjustment Scale of below 150 indicates the amount of stress experienced is a result of normal changes in life and is manageable.
D A moderate chance of developing a stress-related illness and reduction through stress management applies to a patient who scores between 150 and 300.
DIF: Cognitive Level: Apply REF: 69
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Mental Health Concepts

3. A 24-year-old male patient tells the nurse he has had no energy for 2 weeks. He has no trouble falling asleep; in fact, he sleeps deeply about 12 hours every night. He states that he has gained 10 lb in the past 2 months and has no friends. The nurse associates these manifestations with which mental health disorder?
a. Depression
b. Schizophrenia
c. Bipolar disorder
d. Anxiety disorder
ANS: A

Feedback
A These are symptoms of depression.
B Clinical manifestations of schizophrenia include apathy and confusion, delusions and hallucinations, and rambling or stylized patterns of speech.
C Characteristics of the manic phase are excessive emotional displays, excitement, euphoria, and hyperactivity. In contrast, characteristics of the depressive phase are marked apathy and feelings of profound sadness, loneliness, guilt, and lowered self-esteem.
D Anxiety is a feeling of uneasiness or discomfort experienced in varying degrees, from mild anxiety to panic. The energy that anxiety provides may mobilize a person to take constructive action such as solving a major problem or filling an unmet need.
DIF: Cognitive Level: Apply REF: 68-69
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Mental Health Concepts

4. A female patient states that she has had problems with depression in the past and thinks she is depressed again. Which response by the nurse is most appropriate?
a. “What do you think is causing your depression this time?”
b. “What therapies have worked for you in the past?”
c. “Did you stop taking your medication?’”
d. “Do you think this is a situational depression?”
ANS: B

Feedback
A This question provides information but does not direct the patient toward identifying a treatment.
B This question is a therapeutic response to determine if the same or similar therapy can be used again for this depression. It is an open-ended question to collect more data. Also treatment is information collected in a symptom analysis that is useful in this situation.
C This question sounds accusatory, and the nurse is guessing the cause of this episode of depression without collecting data from the patient. This is a closed-ended question asking for a “yes” or “no” response.
D This is a closed-ended question and does not collect data to determine if the patient has depression again.
DIF: Cognitive Level: Apply REF: 70
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Mental Health Concepts

5. Which patient may be experiencing severe anxiety?
a. A woman who tells the nurse she is terrified of cats
b. A man who tells the nurse he feels worthless and is always tired
c. A woman who reports that she is sleeping very lightly each night because her child has an ear infection
d. A man who phones the nurse five times asking for instructions about how to take his new medication
ANS: D

Feedback
A Being terrified of cats describes fear or a phobia rather than anxiety. Unlike fear, which is a response to an actual object or event, anxiety is a response to no specific source or actual object.
B Although fatigue is a characteristic of anxiety, in this case, the patient also verbalizes feelings of worthlessness, which suggests depression rather than anxiety.
C Although problems falling and staying asleep are characteristics of anxiety, in this example the patient can identify the cause of the sleeplessness—her ill child—thus anxiety is not the cause of the sleep disturbance.
D A man who phones the nurse five times asking for instructions about how to take his new medication shows characteristics of anxiety, which includes forgetfulness and difficulty concentrating or making decisions.
DIF: Cognitive Level: Apply REF: 70
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Mental Health Concepts

6. While assessing a man during a physical examination for work, the nurse suspects alcohol use. Which assessment tool is appropriate in this situation?
a. AUDIT screening tool
b. Rapid eye test
c. Mental status examination
d. Holmes Social Readjustment Rating Scale
ANS: A

Feedback
A AUDIT, an abbreviation for Alcohol Use Disorders Identification Test, is the correct assessment tool in this situation.
B The rapid eye test is used when there is suspicion of drug intoxication.
C Mental status examination is not indicated in this case because there are no data to suggest an alteration in mental status.
D The Holmes Social Readjustment Rating Scale is used to assess stress and predict the occurrence of a serious illness over the next 2 years based on stress alone.
DIF: Cognitive Level: Understand REF: 71-72
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Mental Health Concepts

7. A nurse screens every adult and adolescent patient for alcohol consumption. Which patient drinks more than recommended?
a. The man who reports drinking 3 beers and one shot of whiskey each day
b. The woman who reports drinking 2 glasses of wine and 2 vodka martinis each day
c. The older adult man who reports drinking one glass of sherry before going to bed each night
d. The woman who reports drinking one glass of wine with lunch and dinner each day.
ANS: B

Feedback
A The man who reports drinking 3 beers and one shot of whiskey each day. This amount of alcohol is within the National Institute on Alcohol Abuse and Alcoholism recommendations for men to drink fewer than 5 standard drinks daily.
B The woman who reports drinking 2 glasses of wine and 2 vodka martinis each day. The National Institute on Alcohol Abuse and Alcoholism recommends women drink fewer than 4 standard drinks daily.
C The older adult man who reports drinking one glass of sherry before going to bed each night. This amount of alcohol is within the National Institute on Alcohol Abuse and Alcoholism recommendations for men to drink fewer than 5 standard drinks daily.
D The woman who reports drinking one glass of wine with lunch and dinner each day. This amount of alcohol is within the National Institute on Alcohol Abuse and Alcoholism recommendations for women to drink fewer than 4 standard drinks daily.
DIF: Cognitive Level: Apply REF: 71
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Mental Health Concepts

8. During a sports physical for a 16-year-old girl, the nurse asks which question to collect data about drug use?
a. “Many teenagers have tried street drugs. Have you tried these drugs? ”
b. “Tell me which street drugs your friends have offered to you?”
c. “Do most of your friends drink alcohol or do street drugs?”
d. “Your high school has a reputation for drug use. Do you use drugs?”
ANS: A

Feedback
A This uses a questioning technique called “permission giving” in which the nurse “gives permission” to the patient to discuss drug use. Questions like this help identify a pattern of drug use and screen for drug abuse.
B This is not an appropriate question because the nurse does not need this information to assess the patient.
C This is not an appropriate question because the nurse does not need this information to assess the patient.
D This is not an appropriate question because the nurse is associating the school’s reputation with the patient’s behaviors.
DIF: Cognitive Level: Apply REF: 72
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Mental Health Concepts

9. In contrasting the assessment of mental status from mental health, a nurse recognizes that data for the mental status examination are obtained using which techniques?
a. Asking them about their relatives who have mental health disorders
b. Having them demonstrate their ability to reason and calculate
c. Asking them to recall how they have coped with daily stress
d. Having them describe their mood and emotions
ANS: B

Feedback
A This obtains information from patients for the histories, but does not ask patients to demonstrate mental abilities.
B The mental status examination asks patients to perform calculations and other tasks to show their abilities, rather than asking them about their abilities.
C This obtains information from patients for the histories, but does not ask patients to demonstrate mental abilities.
D Having them describe their mood and emotions does not ask patients to demonstrate mental abilities.
DIF: Cognitive Level: Analyze REF: 70
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Mental Health Concepts

10. A nurse is admitting a new patient. Which statement by the patient suggests a bipolar disorder?
a. “The last time I had blood drawn at the office, I fainted dead away.”
b. “No matter how hard I try, I just can’t get into an elevator of any kind.”
c. “Everyone knows I can control the financial health of this town with a snap of my fingers.”
d. “I worked for Frank Sinatra’s band for several months when I lived in New Jersey years ago.”
ANS: C

Feedback
A This statement does not indicate bipolar disorder and may be a true statement.
B This statement is an example of a phobia.
C Patients in the manic phase of bipolar disorder have delusions of grandeur, which is described in the statement.
D This may be a true statement depending on the age of the patient.
DIF: Cognitive Level: Apply REF: 76
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Mental Health Concepts

11. During conversation, the nurse observes that the patient is talking continuously and excitedly, and is switching rapidly from one topic to another with seemingly no relationship between topics. This behavior is often associated with which disorder?
a. Depression
b. Obsessive-compulsive disorder
c. Schizophrenia
d. Bipolar disorder
ANS: C

Feedback
A This behavior is flight of ideas, which occurs in patients with schizophrenia rather than depression.
B This behavior is flight of ideas, which occurs in patients with schizophrenia rather than obsessive-compulsive disorder.
C This behavior is flight of ideas, which occurs in patients with schizophrenia.
D This behavior is flight of ideas, which occurs in patients with schizophrenia rather than bipolar disorder.
DIF: Cognitive Level: Understand REF: 76
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Mental Health Concepts

12. During a visit to the clinic for an annual gynecologic examination, a patient tells the nurse that she had a bad experience on an airplane, saying, “When I sat down, my heart started racing, I was short of breath and sweaty, and I felt as if I was going to die.” She stated that her husband helped her to calm down after a few minutes. The nurse recognizes that the patient was describing which problem?
a. Bipolar disorder, manic phase
b. Moderate anxiety
c. Panic
d. Delusions
ANS: C

Feedback
A Characteristics of the manic phase are excessive emotional displays, excitement, euphoria, hyperactivity accompanied by elation, boisterousness, impaired ability to concentrate, decreased need for sleep, and limitless energy, often accompanied by delusions of grandeur.
B The moderately anxious person has a narrower field of perception and uses selective inattention to ignore stimuli in the environment to focus on a specific concern.
C Physical manifestations of a panic attack represent sympathetic nervous system stimulation. The person experiences muscle tension, tachycardia, dyspnea, hypertension, increased respiration, and profuse perspiration.
D Delusions are persistent abnormal beliefs or perceptions held by a person despite the evidence that refutes it.
DIF: Cognitive Level: Apply REF: 77
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Mental Health Concepts

13. A patient in the waiting room appears anxious and moves around the room cleaning surfaces with a disinfectant cloth. This behavior is consistent with which disorder?
a. Bipolar disorder
b. Delirium
c. Schizophrenia
d. Obsessive-compulsive disorder
ANS: D

Feedback
A Bipolar disorder is a type of depression characterized by episodes of mania, depression, or mixed moods.
B Delirium has manifestations that include attention deficits, disorganized thinking, confusion, disorientation, restlessness, incoherence, anxiety, and excitement.
C Schizophrenia is characterized by gross distortion of reality, disturbances of language and communication, withdrawal from social interaction, and the disorganization and fragmentation of thought perception and emotional reaction.
D This patient was concerned about contamination. Compulsions are unwanted, repetitive behavior patterns or mental acts that are intended to reduce anxiety. The person recognizes that the behaviors are excessive or unreasonable but continues them because of the relief from the discomfort of anxiety that they provide.
DIF: Cognitive Level: Understand REF: 77
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Mental Health Concepts

14. An elderly patient was admitted with pneumonia and a fever of 104.5° F. At the time of admission he was confused, disoriented, restless, and tried to slap the nurse who started an intravenous line. His daughter stated, “Just yesterday he was perfectly fine, except for a cold. I can’t believe he is acting this way now.” Within a few days, his erratic behavior subsided and his daughter was relieved that he was “back to normal.” The nurse recognizes that this patient was exhibiting signs of which disorder?
a. Dementia
b. Delirium
c. Panic attack
d. Alcohol withdrawal
ANS: B

Feedback
A Dementia is a syndrome of acquired, progressive, intellectual impairment that compromises function, such as memory, language, visual-spatial skills, emotion, personality, and cognition.
B Delirium is characterized by a disturbance of consciousness and a change in cognition that develops rapidly over a short period of time.
C A panic attack is characterized by complete disruption of the perceptual field. The person experiences intense terror and is unable to think logically or make decisions. The person experiences muscle tension, tachycardia, dyspnea, hypertension, increased respiration, and profuse perspiration.
D Early manifestations of alcohol withdrawal include hand tremors, sweating, nausea and vomiting, anxiety, and agitation.
DIF: Cognitive Level: Understand REF: 77
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Mental Health Concepts

15. During a report, a nurse hears about a patient who was admitted at 8 PM after an automobile accident. He had a blood alcohol level of 100 mg/dl at the time of admission. During the 8 AM assessment, the nurse notes that the patient is having hand tremors, is sweaty, is slightly agitated, and complains of nausea. The nurse recognizes that the patient may be exhibiting signs of which disorder?
a. Alcohol withdrawal syndrome
b. Delirium tremens
c. Panic
d. Delirium
ANS: A

Feedback
A The history and laboratory data reflect alcohol withdrawal syndrome. Early manifestations of alcohol withdrawal include hand tremors, sweating, nausea and vomiting, anxiety, and agitation. These manifestations begin 6 to 24 hours after the patient’s last drink, peak in 24 to 36 hours, and end after 48 hours of abstinence.
B The time sequence is not consistent with delirium tremens. During delirium tremens, a patient experiences cardiac dysrhythmias, hypertension, increased respirations, profuse sweating, delusion, and hallucinations.
C The history is not consistent with panic disorder. In the panic level of anxiety, a person experiences manifestations of anxiety that represent sympathetic nervous system stimulation, as well as muscle tension, tachycardia, dyspnea, hypertension, increased respiration, and profuse perspiration.
D Manifestations of delirium include attention deficits, disorganized thinking, confusion, disorientation, restlessness, incoherence, anxiety, excitement, and, at times, illusions.
DIF: Cognitive Level: Understand REF: 77
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Mental Health Concepts

MULTIPLE RESPONSE

1. Which neurotransmitters are decreased in patients with depression? Select all that apply.
a. Acetylcholine (Ach)
b. Histamine
c. Norepinephrine (NE)
d. Dopamine (DA)
e. Gamma aminobutyric acid (GABA)
f. Serotonin (5 HT)
ANS: B, C, D, F
Correct: Histamine, norepinephrine (NE), dopamine (DA), and serotonin (5 HT) are neurotransmitters that are decreased in depression. Drugs prescribed for people with depression may provide therapy by increasing these neurotransmitters.
Incorrect: Acetylcholine (Ach) is increased in depression. Gamma aminobutyric acid (GABA) is decreased in schizophrenia and anxiety states.

DIF: Cognitive Level: Understand REF: 66
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Mental Health Concepts

2. During a mental health history, the nurse suspects altered mental status for a patient. Which questions are appropriate to ask when assessing mental status? Select all that apply.
a. “Do you have difficulty making decisions?”
b. “Do you know where you are?”
c. “Are there times when you wanted to escape?”
d. “If you bought a hat for $5.75 and gave the sales person $10.00, how much change do you expect back?”
e. “What would you do if a fire started in your home?”
f. “What does this phrase ‘A rolling stone gathers no moss’ mean?”
ANS: B, D, E, F
Correct: “Do you know where you are?” assesses orientation. “If you bought a hat for $5.75 and gave the sales person $10.00, how much change do you expect back?” assesses calculation ability. “What would you do if a fire started in your home?” assesses judgment. “What does this phrase ‘A rolling stone gathers no moss’ mean?” assesses abstract reasoning.
Incorrect: For the nurse to assess mental status, the patient needs to demonstrate abilities such as calculation, judgment, and abstract reasoning.

DIF: Cognitive Level: Apply REF: 70-71
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Mental Health Concepts

3. While conducting a health history, the nurse asks which questions to assess for risk factors associated with depression? Select all that apply.
a. “Has anyone in your family ever been diagnosed with depression?”
b. “Have you noticed a change in how much energy you have?”
c. “Do you have crying spells?”
d. “Do your muscles seem tense?”
e. “Do you feel that something bad is about to happen to you?”
f. “Do you have difficulty making decisions?”
ANS: A, B, C, F
Correct: These questions are related to risk factors for depression.
Incorrect: Tense muscles are associated with stress and anxiety rather than depression.
Feeling that something bad is about to happen relates to paranoia rather than depression.

DIF: Cognitive Level: Apply REF: 68-70| 76
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Mental Health Concepts

COMPLETION

1. Researchers have found that it is the ______ of a recent life event that determines a person’s emotional or psychological reaction to it.

ANS:
Perceptions
Each culture influences how a stressful event is perceived and the acceptable ways that people of that culture are expected to respond.

DIF: Cognitive Level: Remember REF: 67
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Psychosocial Integrity: Mental Health Concepts