Essentials of Psychiatric Mental Health Nursing 8th Edition Concepts of Care in Evidence - Based Practice 8th Edition Morgan Townsend

A nurse is assessing a client who is experiencing occasional feelings of sadness because of therecent death of a beloved pet. The clients appetite, sleep patterns, and daily routine have not changed. How should the nurse interpret the clients behaviors? 1. The clients behaviors demonstrate mental illness in the form of depression. 2. The clients behaviors are extensive, which indicates the presence of mental illness. 3. The clients behaviors are not congruent with cultural norms. 4. The clients behaviors demonstrate no functional impairment, indicating no mental illness. ANS: 4 Rationale: The nurse should assess that the clients daily functioning is not impaired. The clientwho experiences feelings of sadness after the loss of a pet is responding within normal expectations. Without significant impairment, the clients distress does not indicate a mental illness. Cognitive Level: Analysis Integrated Process: Assessment 2. At what point should the nurse determine that a client is at risk for developing a mentalillness? 1. When thoughts, feelings, and behaviors are not reflective of the DSM-5 criteria. 2. When maladaptive responses to stress are coupled with interference in daily functioning. 3. When a client communicates significant distress. 4. When a client uses defense mechanisms as ego protection. ANS: 2 Rationale: The nurse should determine that the client is at risk for mental illness when lOMoARcPSD| responsesto stress are maladaptive and interfere with daily functioning. The DSM-5 indicates that in orderto be diagnosed with a mental illness, daily functioning must be significantly impaired. The clients ability to communicate distress would be considered a positive attribute. Cognitive Level: Application Integrated Process: Assessment 3. A nurse is assessing a set of 15-year-old identical twins who respond very differently to stress.One twin becomes anxious and irritable, and the other withdraws and cries. How should the nurse explain these different stress responses to the parents? 1. Reactions to stress are relative rather than absolute; individual responses to stress vary. 2. It is abnormal for identical twins to react differently to similar stressors. 3. Identical twins should share the same temperament and respond similarly to stress. 4. Environmental influences to stress weigh more heavily than genetic influences. lOMoARcPSD| ANS: 1 Rationale: The nurse should explain to the parents that, although the twins have identical DNA,there are several other factors that affect reactions to stress. Mental health is a state of being thatis relative to the individual client. Environmental influences and temperament can affect stress reactions. Cognitive Level: Application Integrated Process: Implementation 4. Which client should the nurse anticipate to be most receptive to psychiatric treatment? 1. A Jewish, female social worker. 2. A Baptist, homeless male. 3. A Catholic, black male. 4. A Protestant, Swedish business executive. ANS: 1 Rationale: The nurse should anticipate that the client of Jewish culture would place a high importance on preventative health care and would consider mental health as equally important asphysical health. Women are also more likely to seek treatment for mental health problems than men. Cognitive Level: ApplicationIntegrated Process: Planning 5. A psychiatric nurse intern states, This clients use of defense mechanisms should be eliminated.Which is a correct evaluation of this nurses statement? 1. Defense mechanisms can be appropriate responses to stress and need not be eliminated. 2. Defense mechanisms are a maladaptive attempt of the ego to manage anxiety and shouldalways be eliminated. 3. Defense mechanisms, used by individuals with weak ego integrity, should be discouraged andnot eliminated. 4. Defense mechanisms cause disintegration of the ego and should be fostered and encouraged. ANS: 1 lOMoARcPSD| ANS: 1 Rationale: The nurse should determine that defense mechanisms can be appropriate during timesof stress. The client with no defense mechanisms may have a lower tolerance for stress, thus leading to anxiety disorders. Defense mechanisms should be confronted when they impede the client from developing healthy coping skills. Cognitive Level: Application Integrated Process: Evaluation 6. During an intake assessment, a nurse asks both physiological and psychosocial questions. Theclient angrily responds, Im here for my heart, not my head problems. Which is the nurses best response? 1. Its just a routine part of our assessment. All clients are asked these same questions. 2. Why are you concerned about these types of questions? 3. Psychological factors, like excessive stress, have been found to affect medical conditions. 4. We can skip these questions, if you like. It isnt imperative that we complete this section. lOMoARcPSD| ANS: 3 Rationale: The nurse should attempt to educate the client on the negative effects of excessivestress on medical conditions. It is not appropriate to skip physiological and psychosocial questions, as this would lead to an inaccurate assessment. Cognitive Level: Application Integrated Process: Implementation