Focus on Mental Health.
1.ID: 9476853992
A nurse overhears a hospitalized client with mania telling another
client, “I’m actually a journalist writing an article for a magazine —
I’m just posing as a
person with mental illness.” How should the nurse respond?
A. Ignoring the delusion
B. Taking the client to a quiet room
C. Supporting the client’s denial of illness
D. Presenting the client with the actual situation Correct
Rationale: When dealing with a delusional client, it is important for the
nurse to state clearly that the nurse does not share the client’s
perceptions. All three of the other options — ignoring the delusion,
taking the client to a quiet room, and supporting the client’s denial of
illness — do not focus on reality, and they ignore the issue.
Presenting the client with the actual situation helps orient the
client to reality.
Test-Taking Strategy: Use the process of elimination and your knowledge
that reality orientation is the priority. The correct option illustrates a
means of helping orient the client to reality. Review care of the client
experiencing delusions if you
had difficulty with this
question. Level of Cognitive
Ability: Applying Client Needs:
Psychosocial integrity
Integrated Process: Nursing Process/Implementation
Content Area: Mental Health
Giddens Concepts: Communication, Psychosis
HESI Concepts: Cognition – Psychosis, Stress and Coping – Caregiving
Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health
Nursing: A communication approach to evidence-based care. (revised reprint))
(2nd ed. pp. 305, 318-320). St. Louis:
Saunders. Awarded 1.0 points out of 1.0
possible points.
2.ID: 9476861052
A client who is hallucinating fearfully says to the nurse, “Please tell
that demon
to get out.” How should the nurse respond to the client?
A. “If you tell the demon to go away, it will.”
B. “I’ll stay here with you until the demon leaves your room.”
C. “If you return to bed, you will find that the demon will
leave.”
D. “I know you must be very upset by this, but I don’t see a
demon.”
Correct
Rationale: If the client hallucinates, it is best to provide reality-based
,Focus on Mental Health.
perceptions and not negate the client’s experience, because this may
lead to a regressive struggle with the client. Giving advice or false
reassurance is incorrect because such techniques indicate that
demons actually are present,
which feeds into the client’s hallucination and reinforces the client’s
behavior.
Test-Taking Strategy: Use your knowledge of therapeutic communication
techniques, noting that the client is hallucinating. Remember that it is
most
,Focus on Mental Health.
important to maintain reality with the client. This will direct you to the
correct option. Review communication techniques for the client who is
hallucinating if
you had difficulty with this
question. Level of Cognitive
Ability: Applying Client Needs:
Psychosocial Integrity
Integrated Process: Communication and Documentation
Content Area: Mental Health
Giddens Concepts: Communication, Psychosis
HESI Concepts: Cognition – Psychosis, Communication
References: Stuart, G. (2013). Principles & practice of psychiatric nursing
(10th
ed., pp. 25-29). St. Louis: Mosby.
Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A
communication approach to evidence-based care. (revised reprint)) (2nd ed.
p. 320). St. Louis: Saunders.
Awarded 1.0 points out of 1.0 possible points.
3.ID: 9476835369
The mother of a 3-year-old says, “My child hit his teddy bear after
being scolded
for picking the neighbors’ flowers.” Which defense mechanism was
the child using?
A. Projection
B. Sublimation
C. Displacement Correct
D. Identification
Rationale: The defense mechanism of displacement involves the
discharge of intense feelings for one person onto a less threatening
substitute person or object to satisfy an impulse. Projection involves
attributing an attitude, behavior, or impulse to someone else, such as
that which occurs in blaming or scapegoating. Sublimation is
rechanneling an impulse into a more socially acceptable object.
Identification involves modeling behavior after someone
else's.
Test-Taking Strategy: Use the process of elimination and your
knowledge regarding defense mechanisms. Focusing on the child’s
behavior will direct you to the correct option. Review these defense
mechanisms if you had difficulty
with this question.
Level of Cognitive Ability: Understanding
Client Needs: Psychosocial Integrity
Integrated Process: Nursing
Process/Analysis Content Area: Mental
Health
Giddens Concepts: Development, Coping
, Focus on Mental Health.
HESI Concepts: Developmental, Stress and Coping
Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health
Nursing: A communication approach to evidence-based care. (revised reprint))
(2nd ed. pp. 171, 173). St. Louis:
Saunders. Awarded 1.0 points out of
1.0 possible points.
4.ID: 9476840153
1.ID: 9476853992
A nurse overhears a hospitalized client with mania telling another
client, “I’m actually a journalist writing an article for a magazine —
I’m just posing as a
person with mental illness.” How should the nurse respond?
A. Ignoring the delusion
B. Taking the client to a quiet room
C. Supporting the client’s denial of illness
D. Presenting the client with the actual situation Correct
Rationale: When dealing with a delusional client, it is important for the
nurse to state clearly that the nurse does not share the client’s
perceptions. All three of the other options — ignoring the delusion,
taking the client to a quiet room, and supporting the client’s denial of
illness — do not focus on reality, and they ignore the issue.
Presenting the client with the actual situation helps orient the
client to reality.
Test-Taking Strategy: Use the process of elimination and your knowledge
that reality orientation is the priority. The correct option illustrates a
means of helping orient the client to reality. Review care of the client
experiencing delusions if you
had difficulty with this
question. Level of Cognitive
Ability: Applying Client Needs:
Psychosocial integrity
Integrated Process: Nursing Process/Implementation
Content Area: Mental Health
Giddens Concepts: Communication, Psychosis
HESI Concepts: Cognition – Psychosis, Stress and Coping – Caregiving
Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health
Nursing: A communication approach to evidence-based care. (revised reprint))
(2nd ed. pp. 305, 318-320). St. Louis:
Saunders. Awarded 1.0 points out of 1.0
possible points.
2.ID: 9476861052
A client who is hallucinating fearfully says to the nurse, “Please tell
that demon
to get out.” How should the nurse respond to the client?
A. “If you tell the demon to go away, it will.”
B. “I’ll stay here with you until the demon leaves your room.”
C. “If you return to bed, you will find that the demon will
leave.”
D. “I know you must be very upset by this, but I don’t see a
demon.”
Correct
Rationale: If the client hallucinates, it is best to provide reality-based
,Focus on Mental Health.
perceptions and not negate the client’s experience, because this may
lead to a regressive struggle with the client. Giving advice or false
reassurance is incorrect because such techniques indicate that
demons actually are present,
which feeds into the client’s hallucination and reinforces the client’s
behavior.
Test-Taking Strategy: Use your knowledge of therapeutic communication
techniques, noting that the client is hallucinating. Remember that it is
most
,Focus on Mental Health.
important to maintain reality with the client. This will direct you to the
correct option. Review communication techniques for the client who is
hallucinating if
you had difficulty with this
question. Level of Cognitive
Ability: Applying Client Needs:
Psychosocial Integrity
Integrated Process: Communication and Documentation
Content Area: Mental Health
Giddens Concepts: Communication, Psychosis
HESI Concepts: Cognition – Psychosis, Communication
References: Stuart, G. (2013). Principles & practice of psychiatric nursing
(10th
ed., pp. 25-29). St. Louis: Mosby.
Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A
communication approach to evidence-based care. (revised reprint)) (2nd ed.
p. 320). St. Louis: Saunders.
Awarded 1.0 points out of 1.0 possible points.
3.ID: 9476835369
The mother of a 3-year-old says, “My child hit his teddy bear after
being scolded
for picking the neighbors’ flowers.” Which defense mechanism was
the child using?
A. Projection
B. Sublimation
C. Displacement Correct
D. Identification
Rationale: The defense mechanism of displacement involves the
discharge of intense feelings for one person onto a less threatening
substitute person or object to satisfy an impulse. Projection involves
attributing an attitude, behavior, or impulse to someone else, such as
that which occurs in blaming or scapegoating. Sublimation is
rechanneling an impulse into a more socially acceptable object.
Identification involves modeling behavior after someone
else's.
Test-Taking Strategy: Use the process of elimination and your
knowledge regarding defense mechanisms. Focusing on the child’s
behavior will direct you to the correct option. Review these defense
mechanisms if you had difficulty
with this question.
Level of Cognitive Ability: Understanding
Client Needs: Psychosocial Integrity
Integrated Process: Nursing
Process/Analysis Content Area: Mental
Health
Giddens Concepts: Development, Coping
, Focus on Mental Health.
HESI Concepts: Developmental, Stress and Coping
Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health
Nursing: A communication approach to evidence-based care. (revised reprint))
(2nd ed. pp. 171, 173). St. Louis:
Saunders. Awarded 1.0 points out of
1.0 possible points.
4.ID: 9476840153
