NR-326 Mental Health Nursing - Set 2 - Part 1

Correct Answer: Anergia limiting basic self care

Anergia is the loss of physical energy that turns routine self care into an exhausting effort. It is one of the vegetative signs nurses track, and it often improves before mood does. Option a is incorrect because anhedonia means pleasure has drained out of activities that once mattered. This client is not describing lost enjoyment; she is describing a body that will not move. Option b is incorrect because hypersomnia refers to sleeping far more than usual, a sleep disturbance seen with atypical features. Nothing in her statement concerns how many hours she sleeps. Option d is incorrect because rumination is the cognitive symptom of circling repeatedly over the same negative thoughts. Her complaint is about effort and stamina, which the record should capture in different words.

Correct Answer: Stay with him and reduce environmental stimuli

Severe anxiety calls for presence and a quieter environment before anything else. The nurse stays, lowers stimulation, and speaks in short repeated phrases, which contains the client and keeps him safe while the anxiety settles. Option b is incorrect because teaching requires a perceptual field wide enough to take information in. At the severe level this client cannot learn or problem solve, so a breathing lesson now simply will not register. Option c is incorrect because group is a high stimulus, high demand setting suited to clients at mild or moderate levels. Sending him there adds noise and social pressure to an already overloaded nervous system. Option d is incorrect because leaving to make a phone call abandons the client at the moment presence matters most. Medication may follow once safety is established, but it does not come before staying with him.

Correct Answer: Sit quietly beside the client without demanding conversation

Sitting with a withdrawn client communicates worth without demanding a performance. Presence is a complete intervention, and the nurse who stays for a stated period builds trust that later makes conversation possible. Option a is incorrect because waiting for initiation abandons a client whose illness has stripped away energy and motivation. Withdrawal is the symptom, not a preference, so the nurse must make the approach. Option b is incorrect because peer contact arranged by staff adds social demand this client cannot yet meet. Group involvement comes later, after one to one presence has established a tolerable relationship. Option d is incorrect because why questions demand insight and self justification that depressed thinking cannot supply. The wording also carries blame, and clients typically respond with silence or a shrug.

Correct Answer: Offer small high calorie snacks at frequent intervals

Small frequent high calorie and high protein offerings match the limited appetite and energy of severe depression. Finger foods and a milkshake handed over directly get calories in when a full tray overwhelms. Option b is incorrect because hunger cues are blunted in depression and waiting for them means three more days without food. Intake has to be structured and supervised rather than left to appetite. Option c is incorrect because warning a hopeless client about consequences often confirms his belief that he is failing. Information does not create appetite, and guilt is already a prominent feature of this illness. Option d is incorrect because an open ended question hands decision making back to a client who has just shown he cannot manage it. Indecisiveness is a symptom, so narrow the choice instead.

Correct Answer: Bipolar one disorder, given the single manic episode

One manic episode ever fixes the diagnosis as bipolar one, whatever the depressive count. Hospitalization and delusions both mark that week as manic, and the label does not revert with later depressions. Option a is incorrect because bipolar two requires that a full manic episode has never occurred. This client had one, so the diagnosis moved permanently to bipolar one on that admission and stays there. Option b is incorrect because cyclothymia describes years of subthreshold highs and lows that never reach full episode criteria. Severe depressions and a hospitalized manic week are far beyond that milder chronic pattern. Option d is incorrect because unipolar depression cannot account for a week of elevated mood and grandiosity. Missing that history is the classic error, and it leads to antidepressant treatment that can trigger another switch.

Correct Answer: Persistent depressive disorder, formerly called dysthymia

Persistent depressive disorder requires depressed mood on most days for at least two years in adults, with symptoms milder than a major episode and never absent for more than two months at a time. Option b is incorrect because a major episode is defined by a distinct two week change from previous functioning with five or more symptoms. This woman describes an unbroken low grade state, not discrete episodes. Option c is incorrect because a seasonal pattern means episodes appear and remit at characteristic times of year, usually worsening in autumn and winter. Nothing about her account varies with the calendar. Option d is incorrect because disruptive mood dysregulation disorder is a childhood diagnosis of chronic irritability with frequent explosive outbursts, identified before age ten and never applied to adults.

Correct Answer: A specific plan with available means

Risk climbs as ideation becomes concrete. A worked-out plan paired with ready access to the means signals intent that can be acted on quickly, which calls for constant observation and provider notification. Option a is incorrect because ideation without structure sits at the lower end of the acuity range. It still requires assessment and documentation, but it lacks the specificity that converts thought into action. Option b is incorrect because a wish for relief describes passive ideation, the mildest form on the continuum. Nurses take it seriously and keep asking, though it does not by itself demand constant observation. Option c is incorrect because a remote plan the client discarded describes history rather than present intent. Past ideation belongs in the record and shapes the long view, not tonight's level of supervision.

Correct Answer: "Are you still having thoughts of suicide right now?"

Regret at surviving signals that intent may be unchanged, so the nurse asks plainly and without judgment. A direct question keeps the conversation open and produces the information the team needs for the safety plan. Option b is incorrect because raising the family's suffering moralizes at a client already burdened by guilt. Lecturing about consequences reliably ends disclosure, and the nurse loses the chance to measure present intent. Option c is incorrect because generalizing to other people minimizes what this client just said. Reassurance drawn from the experience of strangers dismisses the stated wish and answers a question nobody asked. Option d is incorrect because steering toward a cheerful subject is avoidance dressed as encouragement. Changing the topic tells the client that this material is unwelcome, and the assessment ends before it has begun.

Correct Answer: Remain with her and protect her from injury

Panic distorts perception and destroys the ability to follow direction, so the client cannot keep herself safe. The nurse never leaves her alone, keeps stimulation low, and prevents injury until the surge passes. Option a is incorrect because trigger exploration belongs to the recovery phase after anxiety comes down. Someone in panic cannot analyze what happened beforehand, and the questioning itself adds demand she has no capacity to meet. Option b is incorrect because a client screaming and unable to answer her name has lost the words for description. Asking for a detailed account of feelings requires organized thought that panic has already dismantled. Option c is incorrect because charting is a task that waits. Recording the episode matters for the record, yet turning to the computer while a client flails near a wall leaves real danger unaddressed.

Correct Answer: Hold the items and involve the family and team

Restricting money, cards, and phones while judgment is impaired protects the client from consequences that will fuel the later depression. The team documents the clinical reason and lifts the restriction as judgment returns. Option a is incorrect because rights are balanced against a documented clinical justification when judgment is temporarily gone. Handing back the cards invites debt and legal trouble the client will face once the episode lifts. Option b is incorrect because affordability is not the question. Major financial decisions are deferred during mania regardless of the balance in the account, since the reasoning driving the purchase is itself part of the illness. Option d is incorrect because insight oriented discussion fails while grandiosity is at its peak. The conversation becomes an argument, the wallet is still in play, and nothing has actually been secured.

Correct Answer: "My daughter still depends on me to care for her."

Responsibility toward a dependent child is one of the strongest protective factors and gives the client a concrete reason for living. The nurse names it aloud and builds it into the safety plan. Option a is incorrect because living alone after a marital breakup combines isolation with recent loss. Both appear on the risk side of the assessment and argue for closer follow-up rather than reassurance. Option c is incorrect because withdrawal from a faith community removes a protective factor rather than supplying one. Religious or cultural belief protects only while the client remains connected to that community. Option d is incorrect because escalating alcohol use lowers inhibition and appears on every standard risk framework. Increased substance use is counted as an acute warning sign, never as something that steadies a client.

Correct Answer: With peripartum onset

The peripartum specifier covers onset during pregnancy or within four weeks after delivery. Guilt about mothering and difficulty bonding are characteristic, and the Edinburgh Postnatal Depression Scale screens for it. Option b is incorrect because a seasonal pattern requires episodes that recur and remit at characteristic times of year for at least two years. A single postpartum episode carries no such history. Option c is incorrect because catatonia is marked by stupor, mutism, posturing, negativism, and waxy flexibility. This mother is tearful and talking, showing none of those motor and behavioural features. Option d is incorrect because atypical features mean mood brightens with good news, along with oversleeping, increased appetite, and leaden heaviness in the limbs. Her sleeplessness points the opposite way.

Correct Answer: Intellectualization that holds the fear away

Intellectualization keeps threatening emotion at a distance by staying with facts, data, and abstract reasoning. She discusses the disease fluently while never touching the fear that the diagnosis has stirred up in her. Option a is incorrect because denial would have her reject the diagnosis outright or refuse to discuss it. She engages with the illness in detail, which is the opposite of blocking the reality from awareness. Option b is incorrect because regression means falling back on behavior from an earlier developmental stage, such as an adult who curls up and stops speaking. Detailed technical talk points in the other direction entirely. Option d is incorrect because displacement would send her anger toward a safer target such as a nurse or a family member. She is not discharging feeling at anyone; she is avoiding feeling altogether.

Correct Answer: "Do you have a plan for how you would do it?"

After ideation is confirmed, the next step is plan specificity, followed by access to the means and intent. That sequence turns a vague report into an acuity level the team can use. Option a is incorrect because psychosocial context matters but belongs after acuity has been established. Opening the conversation outward at this point delays the specific information that determines tonight's level of observation. Option b is incorrect because duration of low mood describes the depressive episode rather than the immediacy of danger. Chronicity shapes the treatment plan, while plan and access shape the safety decision. Option c is incorrect because family awareness is useful for discharge planning and support, not for grading acute risk. Asking it now tells the nurse nothing about how close this client is to acting.

Correct Answer: The expressed hopelessness predicts risk better than severity

Hopelessness predicts suicide more reliably than the measured severity of depressive symptoms, so the statement outweighs the score. The nurse asks directly about suicidal thinking, a plan, and access to means. Option a is incorrect because a mid-range score cannot cancel out a statement of total futility. Reading the number alone would send home a client whose own words place him in the high-risk category. Option b is incorrect because screening instruments quantify severity and track change, and they were never designed to override clinical findings. What the client says in the room carries more weight than the total. Option d is incorrect because no screening tool makes a diagnosis. Scores quantify severity and monitor response, while diagnosis rests on a full clinical interview against established criteria and a review of medical causes.

Correct Answer: "Tell me more about what you are carrying."

Survivor guilt needs room to be spoken. An open invitation lets the client say more, keeps the nurse present with the feeling, and opens the door to a direct safety assessment as the conversation continues. Option b is incorrect because a premature verdict on blame is dismissive and shuts the topic down. Guilt after surviving is not argued away, and telling her to release it adds a demand she cannot meet. Option c is incorrect because calling survival luck reframes a devastating loss as good fortune. The client hears that her grief is misplaced, and the nurse has minimized exactly what she was trying to describe. Option d is incorrect because generalizing to everyone erases what is particular about her experience. Universal statements sound like comfort but function as a change of subject, leaving the guilt unexplored and the client alone with it.

Correct Answer: Verify documented competency and give explicit instructions

Observation may be assigned only to staff with documented competency, and the nurse gives clear instructions about what to watch for and when to call. Accountability for the assessment stays with the nurse. Option a is incorrect because staffing decisions inside the unit are not consented to by relatives. Family involvement matters for means restriction and discharge teaching, but it has no bearing on who watches the client. Option c is incorrect because assessment cannot be handed to assistive personnel under any circumstance. The aide may observe and report, while judgments about risk level and any change remain a licensed function. Option d is incorrect because the ordered frequency is not something staffing convenience can alter. Stretching intervals to an hour downgrades the level without a provider order and widens the gaps between checks.

Correct Answer: Note her effort aloud, then help her finish

Naming the small gain reinforces it, and finishing together keeps the task from ending in failure. Assistance is reduced step by step as capacity returns, which is how independence is rebuilt. Option a is incorrect because taking over the whole bath erases the first independent act she has managed all week. Doing for a client what she can partly do herself deepens helplessness. Option b is incorrect because waiting for full independence leaves her unwashed and confirms that she cannot manage. Graded assistance now bridges the gap between what she started and what she needs. Option c is incorrect because appealing to adult standards shames a client whose self esteem is already at the floor. Comparisons like this invite guilt and make the next attempt less likely.

Correct Answer: This behavior is a recognized suicide warning sign

Giving away prized possessions is a classic warning sign that a client may be preparing for death. The nurse reassesses risk immediately, asks directly about suicidal thinking, and notifies the treatment team. Option b is incorrect because reading this as generosity mistakes a farewell gesture for social growth. Genuine engagement shows up as participation in groups and conversation, not as the surrender of valued property. Option c is incorrect because discharge planning depends on documented safety, stable mood, and a workable follow-up plan. Nothing in the described behavior meets those conditions, and acting on it would remove supervision prematurely. Option d is incorrect because adjustment to a psychiatric admission usually looks like uncertainty, questions about routine, or homesickness. Parting with treasured items falls outside that range and demands a fresh risk assessment.

Correct Answer: A client's hands are cracked and bleeding

Allowing time for a ritual stops where physical harm begins. Broken bleeding skin means infection risk and tissue damage, so the nurse intervenes now with skin care and a limit rather than waiting for gradual change. Option a is incorrect because lateness is expected when rituals cannot be finished quickly. The nursing response is to build extra time into the schedule, not to treat a missed group as an emergency. Option c is incorrect because silent counting is a mental ritual that harms no tissue. It deserves assessment and eventual work in therapy, yet nothing about it threatens the client's body during this shift. Option d is incorrect because reassurance seeking feeds the disorder slowly rather than injuring anyone. Staff and family are taught to stop answering the question, which is important long term work but not an urgent physical problem.