lOMoARcPSD| 7906827
Essentials of Psychiatric Mental Health Nursing 8th E
v v v v v v vv
dition Concepts of Care in Evidence -
v v v v v v
v Based Practice 9th Edition Morgan Townsend
vv v v v v
Chapterv1.vMentalvHealthvandvMentalv
IllnessMultiplevChoice
1. Avnursevisvassessingvavclientvwhovisvexperiencingvoccasionalvfeelingsvofvsadnessvbecausev
ofvtherecentvdeathvofvavbelovedvpet.vThevclientsvappetite,vsleepvpatterns,vandvdailyvroutinev
havevnotvchanged.vHowvshouldvthevnursevinterpretvthevclientsvbehaviors?
1. Thevclientsvbehaviorsvdemonstratevmentalvillnessvinvthevformvofvdepression.
2. Thevclientsvbehaviorsvarevextensive,vwhichvindicatesvthevpresencevofvmentalvillness.
3. Thevclientsvbehaviorsvarevnotvcongruentvwithvculturalvnorms.
4. Thevclientsvbehaviorsvdemonstratevnovfunctionalvimpairment,vindicatingvnovmentalvi
llness.
ANS:v4
Rationale:vThevnursevshouldvassessvthatvthevclientsvdailyvfunctioningvisvnotvimpaired.vThe
clientwhovexperiencesvfeelingsvofvsadnessvaftervthevlossvofvavpetvisvrespondingvwithinvnor
v
malvexpectations.vWithoutvsignificantvimpairment,vthevclientsvdistressvdoesvnotvindicatev
avmentalvillness.
CognitivevLevel:vAnalysisvInte
gratedvProcess:
Assessment
2. Atvwhatvpointvshouldvthevnursevdeterminevthatvavclientvisvatvriskvforvdevelopingvav
mentalillness?
1. Whenvthoughts,vfeelings,vandvbehaviorsvarevnotvreflectivevofvthevDSM-5vcriteria.
2. Whenvmaladaptivevresponsesvtovstressvarevcoupledvwithvinterferencevinvdailyvf
unctioning.
3. Whenvavclientvcommunicatesvsignificantvdistress.
4. Whenvavclientvusesvdefensevmechanismsvasvegovprotection.
ANS:v2
Rationale:vThevnursevshouldvdeterminevthatvthevclientvisvatvriskvforvmentalvillnessvwhen
, lOMoARcPSD| 7906827
responsestovstressvarevmaladaptivevandvinterferevwithvdailyvfunctioning.vThevDSM-
5vindicatesvthatvinvordertovbevdiagnosedvwithvavmentalvillness,vdailyvfunctioningvmustvbev
significantlyvimpaired.vThevclientsvabilityvtovcommunicatevdistressvwouldvbevconsideredva
v positivevattribute.
CognitivevLevel:vApplicationvI
ntegratedvProcess:
Assessment
3. Avnursevisvassessingvavsetvofv15-year-
oldvidenticalvtwinsvwhovrespondvveryvdifferentlyvtovstress.Onevtwinvbecomesvanxiousvan
dvirritable,vandvthevothervwithdrawsvandvcries.vHowvshouldvthevnursevexplainvthesevdiff
erentvstressvresponsesvtovthevparents?
1. Reactionsvtovstressvarevrelativevrathervthanvabsolute;vindividualvresponsesvtovstressv
vary.
2. Itvisvabnormalvforvidenticalvtwinsvtovreactvdifferentlyvtovsimilarvstressors.
3. Identicalvtwinsvshouldvsharevthevsamevtemperamentvandvrespondvsimilarlyvtovstress.
4. Environmentalvinfluencesvtovstressvweighvmorevheavilyvthanvgeneticvinfluences.
, lOMoARcPSD| 7906827
ANS:v1
Rationale:vThevnursevshouldvexplainvtovthevparentsvthat,valthoughvthevtwinsvhavevidentic
alvDNA,therevarevseveralvothervfactorsvthatvaffectvreactionsvtovstress.vMentalvhealthvisvavst
atevofvbeingvthatisvrelativevtovthevindividualvclient.vEnvironmentalvinfluencesvandvtempe
ramentvcanvaffectvstressvreactions.
CognitivevLevel:vApplicationvI
ntegratedvProcess:
Implementation
4. Whichvclientvshouldvthevnursevanticipatevtovbevmostvreceptivevtovpsychiatricvtreatment?
1. AvJewish,vfemalevsocialvworker.
2. AvBaptist,vhomelessvmale.
3. AvCatholic,vblackvmale.
4. AvProtestant,vSwedishvbusinessvexecutive.
ANS:v1
Rationale:vThevnursevshouldvanticipatevthatvthevclientvofvJewishvculturevwouldvplacevavhi
ghvimportancevonvpreventativevhealthvcarevandvwouldvconsidervmentalvhealthvasvequallyv
importantvasphysicalvhealth.vWomenvarevalsovmorevlikelyvtovseekvtreatmentvforvmentalvh
ealthvproblemsvthanvmen.
CognitivevLevel:
ApplicationIntegratedvProces
s:vPlanning
5. Avpsychiatricvnursevinternvstates,vThisvclientsvusevofvdefensevmechanismsvshouldvbev
eliminated.Whichvisvavcorrectvevaluationvofvthisvnursesvstatement?
1. Defensevmechanismsvcanvbevappropriatevresponsesvtovstressvandvneedvnotvbev
eliminated.
2. Defensevmechanismsvarevavmaladaptivevattemptvofvthevegovtovmanagevanxiety
andvshouldalwaysvbeveliminated.
3. Defensevmechanisms,vusedvbyvindividualsvwithvweakvegovintegrity,vshouldvbev
discouragedvandnotveliminated.
4. Defensevmechanismsvcausevdisintegrationvofvthevegovandvshouldvbevfosteredvandv
encouraged.
ANS:v1
, lOMoARcPSD| 7906827
ANS:v1
Rationale:vThevnursevshouldvdeterminevthatvdefensevmechanismsvcanvbevappropriatevdu
ringvtimesofvstress.vThevclientvwithvnovdefensevmechanismsvmayvhavevavlowervtolerancevf
orvstress,vthusvleadingvtovanxietyvdisorders.vDefensevmechanismsvshouldvbevconfrontedvw
henvtheyvimpedevthevclientvfromvdevelopingvhealthyvcopingvskills.
CognitivevLevel:
ApplicationvIntegrated
v Process:vEvaluation
6. Duringvanvintakevassessment,vavnursevasksvbothvphysiologicalvandvpsychosocialvqu
estions.vTheclientvangrilyvresponds,vImvherevforvmyvheart,vnotvmyvheadvproblems.vW
hichvisvthevnursesvbestvresponse?
1. Itsvjustvavroutinevpartvofvourvassessment.vAllvclientsvarevaskedvthesevsamevquestions.
2. Whyvarevyouvconcernedvaboutvthesevtypesvofvquestions?
3. Psychologicalvfactors,vlikevexcessivevstress,vhavevbeenvfoundvtovaffectvmedicalv
conditions.
4. Wevcanvskipvthesevquestions,vifvyouvlike.vItvisntvimperativevthatvwevcompletevthisvs
ection.
Essentials of Psychiatric Mental Health Nursing 8th E
v v v v v v vv
dition Concepts of Care in Evidence -
v v v v v v
v Based Practice 9th Edition Morgan Townsend
vv v v v v
Chapterv1.vMentalvHealthvandvMentalv
IllnessMultiplevChoice
1. Avnursevisvassessingvavclientvwhovisvexperiencingvoccasionalvfeelingsvofvsadnessvbecausev
ofvtherecentvdeathvofvavbelovedvpet.vThevclientsvappetite,vsleepvpatterns,vandvdailyvroutinev
havevnotvchanged.vHowvshouldvthevnursevinterpretvthevclientsvbehaviors?
1. Thevclientsvbehaviorsvdemonstratevmentalvillnessvinvthevformvofvdepression.
2. Thevclientsvbehaviorsvarevextensive,vwhichvindicatesvthevpresencevofvmentalvillness.
3. Thevclientsvbehaviorsvarevnotvcongruentvwithvculturalvnorms.
4. Thevclientsvbehaviorsvdemonstratevnovfunctionalvimpairment,vindicatingvnovmentalvi
llness.
ANS:v4
Rationale:vThevnursevshouldvassessvthatvthevclientsvdailyvfunctioningvisvnotvimpaired.vThe
clientwhovexperiencesvfeelingsvofvsadnessvaftervthevlossvofvavpetvisvrespondingvwithinvnor
v
malvexpectations.vWithoutvsignificantvimpairment,vthevclientsvdistressvdoesvnotvindicatev
avmentalvillness.
CognitivevLevel:vAnalysisvInte
gratedvProcess:
Assessment
2. Atvwhatvpointvshouldvthevnursevdeterminevthatvavclientvisvatvriskvforvdevelopingvav
mentalillness?
1. Whenvthoughts,vfeelings,vandvbehaviorsvarevnotvreflectivevofvthevDSM-5vcriteria.
2. Whenvmaladaptivevresponsesvtovstressvarevcoupledvwithvinterferencevinvdailyvf
unctioning.
3. Whenvavclientvcommunicatesvsignificantvdistress.
4. Whenvavclientvusesvdefensevmechanismsvasvegovprotection.
ANS:v2
Rationale:vThevnursevshouldvdeterminevthatvthevclientvisvatvriskvforvmentalvillnessvwhen
, lOMoARcPSD| 7906827
responsestovstressvarevmaladaptivevandvinterferevwithvdailyvfunctioning.vThevDSM-
5vindicatesvthatvinvordertovbevdiagnosedvwithvavmentalvillness,vdailyvfunctioningvmustvbev
significantlyvimpaired.vThevclientsvabilityvtovcommunicatevdistressvwouldvbevconsideredva
v positivevattribute.
CognitivevLevel:vApplicationvI
ntegratedvProcess:
Assessment
3. Avnursevisvassessingvavsetvofv15-year-
oldvidenticalvtwinsvwhovrespondvveryvdifferentlyvtovstress.Onevtwinvbecomesvanxiousvan
dvirritable,vandvthevothervwithdrawsvandvcries.vHowvshouldvthevnursevexplainvthesevdiff
erentvstressvresponsesvtovthevparents?
1. Reactionsvtovstressvarevrelativevrathervthanvabsolute;vindividualvresponsesvtovstressv
vary.
2. Itvisvabnormalvforvidenticalvtwinsvtovreactvdifferentlyvtovsimilarvstressors.
3. Identicalvtwinsvshouldvsharevthevsamevtemperamentvandvrespondvsimilarlyvtovstress.
4. Environmentalvinfluencesvtovstressvweighvmorevheavilyvthanvgeneticvinfluences.
, lOMoARcPSD| 7906827
ANS:v1
Rationale:vThevnursevshouldvexplainvtovthevparentsvthat,valthoughvthevtwinsvhavevidentic
alvDNA,therevarevseveralvothervfactorsvthatvaffectvreactionsvtovstress.vMentalvhealthvisvavst
atevofvbeingvthatisvrelativevtovthevindividualvclient.vEnvironmentalvinfluencesvandvtempe
ramentvcanvaffectvstressvreactions.
CognitivevLevel:vApplicationvI
ntegratedvProcess:
Implementation
4. Whichvclientvshouldvthevnursevanticipatevtovbevmostvreceptivevtovpsychiatricvtreatment?
1. AvJewish,vfemalevsocialvworker.
2. AvBaptist,vhomelessvmale.
3. AvCatholic,vblackvmale.
4. AvProtestant,vSwedishvbusinessvexecutive.
ANS:v1
Rationale:vThevnursevshouldvanticipatevthatvthevclientvofvJewishvculturevwouldvplacevavhi
ghvimportancevonvpreventativevhealthvcarevandvwouldvconsidervmentalvhealthvasvequallyv
importantvasphysicalvhealth.vWomenvarevalsovmorevlikelyvtovseekvtreatmentvforvmentalvh
ealthvproblemsvthanvmen.
CognitivevLevel:
ApplicationIntegratedvProces
s:vPlanning
5. Avpsychiatricvnursevinternvstates,vThisvclientsvusevofvdefensevmechanismsvshouldvbev
eliminated.Whichvisvavcorrectvevaluationvofvthisvnursesvstatement?
1. Defensevmechanismsvcanvbevappropriatevresponsesvtovstressvandvneedvnotvbev
eliminated.
2. Defensevmechanismsvarevavmaladaptivevattemptvofvthevegovtovmanagevanxiety
andvshouldalwaysvbeveliminated.
3. Defensevmechanisms,vusedvbyvindividualsvwithvweakvegovintegrity,vshouldvbev
discouragedvandnotveliminated.
4. Defensevmechanismsvcausevdisintegrationvofvthevegovandvshouldvbevfosteredvandv
encouraged.
ANS:v1
, lOMoARcPSD| 7906827
ANS:v1
Rationale:vThevnursevshouldvdeterminevthatvdefensevmechanismsvcanvbevappropriatevdu
ringvtimesofvstress.vThevclientvwithvnovdefensevmechanismsvmayvhavevavlowervtolerancevf
orvstress,vthusvleadingvtovanxietyvdisorders.vDefensevmechanismsvshouldvbevconfrontedvw
henvtheyvimpedevthevclientvfromvdevelopingvhealthyvcopingvskills.
CognitivevLevel:
ApplicationvIntegrated
v Process:vEvaluation
6. Duringvanvintakevassessment,vavnursevasksvbothvphysiologicalvandvpsychosocialvqu
estions.vTheclientvangrilyvresponds,vImvherevforvmyvheart,vnotvmyvheadvproblems.vW
hichvisvthevnursesvbestvresponse?
1. Itsvjustvavroutinevpartvofvourvassessment.vAllvclientsvarevaskedvthesevsamevquestions.
2. Whyvarevyouvconcernedvaboutvthesevtypesvofvquestions?
3. Psychologicalvfactors,vlikevexcessivevstress,vhavevbeenvfoundvtovaffectvmedicalv
conditions.
4. Wevcanvskipvthesevquestions,vifvyouvlike.vItvisntvimperativevthatvwevcompletevthisvs
ection.
