Saunders PN Mental Health questions
and answers graded A+
Which data indicate to the nurse that a client is experiencing effective coping following the loss
of a spouse? Select all that apply.
1.Looks at old snapshots of family
2.Constantly neglects personal grooming
3.Visits the spouse's grave once a month
4.Visits the senior citizens' center once a month
5.Prefers to spend time alone and avoids contact with others
134
Rationale: Coping mechanisms are behaviors that are used to decrease stress and anxiety.
Visiting a spouse's grave, visiting the senior citizens' center, and looking at snapshots of the
family are effective coping mechanisms. Neglecting grooming and preferring to spend time
alone and avoiding contact with others are behaviors that identify ineffective coping of the
grieving process.
Which client is most likely at risk to become a victim of elder abuse?
1.A 75-year-old man with moderate hypertension
2.A 68-year-old man with newly diagnosed cataracts
3.A 90-year-old woman with advanced Alzheimer's disease
4.A 70-year-old woman with early diagnosed Lyme disease
A 90-year-old woman with advanced Alzheimer's disease
Rationale:Elder abuse is widespread and occurs among all subgroups of the population. It
includes physical and psychological abuse, the misuse of property, and the violation of rights.
The person at highest risk of abuse is an elder with dementia that occurs with Alzheimer's
disease.
,The nurse is assigned to care for a client experiencing disturbed thought processes. The nurse is
told that the client believes that their food is being poisoned. Which communication technique
should the nurse plan to use to encourage the client to eat?
1.Open-ended questions and silence
2.Focusing on self-disclosure regarding food preferences
3.Stating the reasons that the client may not want to eat
4.Offering opinions about the necessity of adequate nutrition
1. Open-ended questions and silence
Rationale: Open-ended questions and silence are strategies used to encourage clients to discuss
their problem. Options 3 and 4 do not encourage the client to express feelings. The nurse
should not offer opinions and should not state the reasons, but should encourage the client to
identify the reasons for their behavior. Option 2 is not a client-centered intervention
We have an expert-written solution to this problem!
The nurse is assigned to care for a client admitted to the hospital after sustaining an injury from
a house fire. The client attempted to save a neighbor involved in the fire, but despite the client's
efforts, the neighbor died. Which action should the nurse take to enable the client to work
through the meaning of the crisis?
1.Identifying the client's ability to function
2.Identifying the client's potential for self-harm
3.Inquiring about the client's feelings that may affect coping
4.Inquiring about the client's perception of the cause of the neighbor's death
3. Inquiring about the client's feelings that may affect coping
Rationale:The client must first deal with feelings and negative responses before the client is
able to work through the meaning of the crisis. Option 3 pertains directly to the client's feelings.
Options 1, 2, and 4 do not directly address the client's feelings.
We have an expert-written solution to this problem!
,The nurse is assisting with the data collection on a client admitted to the psychiatric unit. After
review of the obtained data, the nurse should identify which as a priority concern?
1.The client's report of not eating or sleeping
2.The presence of bruises on the client's body
3.The client's report of self-destructive thoughts
4.The family member is disapproving of the treatment.
3. The client's report of self-destructive thoughts
Rationale: The client's thoughts are extremely important when verbalized. Self-destructive
thoughts are the highest priority. Options 1, 2, and 4 will all affect the treatment of the client
but are not of greatest importance at this time.
Laboratory work is prescribed for a client who has been experiencing delusions. When the
laboratory technician approaches the client to obtain a specimen of the client's blood, the client
begins to shout, "You're all vampires. Let me out of here!" The nurse present at the time should
respond with which question or statement?
1."The technician is not going to hurt you but is going to help."
2."Are you fearful and think that others may want to hurt you?"
3."What makes you think that the technician wants to hurt you?"
4."The technician will leave and come back later for your blood."
2. "Are you fearful and think that others may want to hurt you?"
Rationale:Option 2 is the only option that recognizes the client's need. This response helps the
client focus on the emotion underlying the delusion but does not argue with it. If the nurse
attempts to change the client's mind, the delusion may, in fact, be even more strongly held.
Options 1, 3, and 4 do not focus on the client's feelings.
An intoxicated client is brought to the emergency department by local police. The client is told
that the primary health care provider (PHCP) will be in to see the client in about 30 minutes.
The client becomes very loud and offensive and wants to be seen by the PHCP immediately. The
nurse assisting to care for the client should take which appropriate nursing intervention?
1.Watch the behavior escalate before intervening.
2.Attempt to talk with the client to de-escalate the behavior.
, 3.Offer to take the client to an examination room until he or she can be treated.
4.Inform the client that he or she will be asked to leave if the behavior continues
3. Offer to take the client to an examination room until he or she can be treated.
Rationale: Safety of the client, other clients, and staff is of prime concern. Option 3 is in effect
an isolation technique that allows for separation from others and provides for a less stimulating
environment where the client can maintain dignity. When dealing with an impaired individual,
trying to talk may be out of the question. Waiting to intervene could cause the client to become
even more agitated and a threat to others. Option 4 would only further aggravate an already
agitated individual.
A client is admitted to a psychiatric unit for treatment of a psychotic disorder. The client is at the
locked exit door and is shouting, "Let me out! There's nothing wrong with me! I don't belong
here!" The nurse identifies this behavior as which defense mechanism?
1.Denial
2.Projection
3.Regression
4.Rationalization
1. Denial
Rationale: Denial is the refusal to admit to a painful reality and is treated as if it does not exist.
In projection, a person unconsciously rejects emotionally unacceptable features and attributes
them to other people, objects, or situations. In regression, the client returns to an earlier, more
comforting, although less mature, way of behaving. Rationalization is justifying the
unacceptable attributes about oneself.
A client says to the nurse, "I'm going to die, and I wish my family would stop hoping for a 'cure'!
I get so angry when they carry on like this! After all, I'm the one who's dying." Which
therapeutic response should the nurse make to the client?
1."Have you shared your feelings with your family?"
2."I think we should talk more about your anger with your family."
3."You're feeling angry that your family continues to hope for you to be ‘cured'?"
4."Well, it sounds like you're being pretty pessimistic. After all, years ago people died of
pneumonia."
3. "You're feeling angry that your family continues to hope for you to be 'cured'?"
and answers graded A+
Which data indicate to the nurse that a client is experiencing effective coping following the loss
of a spouse? Select all that apply.
1.Looks at old snapshots of family
2.Constantly neglects personal grooming
3.Visits the spouse's grave once a month
4.Visits the senior citizens' center once a month
5.Prefers to spend time alone and avoids contact with others
134
Rationale: Coping mechanisms are behaviors that are used to decrease stress and anxiety.
Visiting a spouse's grave, visiting the senior citizens' center, and looking at snapshots of the
family are effective coping mechanisms. Neglecting grooming and preferring to spend time
alone and avoiding contact with others are behaviors that identify ineffective coping of the
grieving process.
Which client is most likely at risk to become a victim of elder abuse?
1.A 75-year-old man with moderate hypertension
2.A 68-year-old man with newly diagnosed cataracts
3.A 90-year-old woman with advanced Alzheimer's disease
4.A 70-year-old woman with early diagnosed Lyme disease
A 90-year-old woman with advanced Alzheimer's disease
Rationale:Elder abuse is widespread and occurs among all subgroups of the population. It
includes physical and psychological abuse, the misuse of property, and the violation of rights.
The person at highest risk of abuse is an elder with dementia that occurs with Alzheimer's
disease.
,The nurse is assigned to care for a client experiencing disturbed thought processes. The nurse is
told that the client believes that their food is being poisoned. Which communication technique
should the nurse plan to use to encourage the client to eat?
1.Open-ended questions and silence
2.Focusing on self-disclosure regarding food preferences
3.Stating the reasons that the client may not want to eat
4.Offering opinions about the necessity of adequate nutrition
1. Open-ended questions and silence
Rationale: Open-ended questions and silence are strategies used to encourage clients to discuss
their problem. Options 3 and 4 do not encourage the client to express feelings. The nurse
should not offer opinions and should not state the reasons, but should encourage the client to
identify the reasons for their behavior. Option 2 is not a client-centered intervention
We have an expert-written solution to this problem!
The nurse is assigned to care for a client admitted to the hospital after sustaining an injury from
a house fire. The client attempted to save a neighbor involved in the fire, but despite the client's
efforts, the neighbor died. Which action should the nurse take to enable the client to work
through the meaning of the crisis?
1.Identifying the client's ability to function
2.Identifying the client's potential for self-harm
3.Inquiring about the client's feelings that may affect coping
4.Inquiring about the client's perception of the cause of the neighbor's death
3. Inquiring about the client's feelings that may affect coping
Rationale:The client must first deal with feelings and negative responses before the client is
able to work through the meaning of the crisis. Option 3 pertains directly to the client's feelings.
Options 1, 2, and 4 do not directly address the client's feelings.
We have an expert-written solution to this problem!
,The nurse is assisting with the data collection on a client admitted to the psychiatric unit. After
review of the obtained data, the nurse should identify which as a priority concern?
1.The client's report of not eating or sleeping
2.The presence of bruises on the client's body
3.The client's report of self-destructive thoughts
4.The family member is disapproving of the treatment.
3. The client's report of self-destructive thoughts
Rationale: The client's thoughts are extremely important when verbalized. Self-destructive
thoughts are the highest priority. Options 1, 2, and 4 will all affect the treatment of the client
but are not of greatest importance at this time.
Laboratory work is prescribed for a client who has been experiencing delusions. When the
laboratory technician approaches the client to obtain a specimen of the client's blood, the client
begins to shout, "You're all vampires. Let me out of here!" The nurse present at the time should
respond with which question or statement?
1."The technician is not going to hurt you but is going to help."
2."Are you fearful and think that others may want to hurt you?"
3."What makes you think that the technician wants to hurt you?"
4."The technician will leave and come back later for your blood."
2. "Are you fearful and think that others may want to hurt you?"
Rationale:Option 2 is the only option that recognizes the client's need. This response helps the
client focus on the emotion underlying the delusion but does not argue with it. If the nurse
attempts to change the client's mind, the delusion may, in fact, be even more strongly held.
Options 1, 3, and 4 do not focus on the client's feelings.
An intoxicated client is brought to the emergency department by local police. The client is told
that the primary health care provider (PHCP) will be in to see the client in about 30 minutes.
The client becomes very loud and offensive and wants to be seen by the PHCP immediately. The
nurse assisting to care for the client should take which appropriate nursing intervention?
1.Watch the behavior escalate before intervening.
2.Attempt to talk with the client to de-escalate the behavior.
, 3.Offer to take the client to an examination room until he or she can be treated.
4.Inform the client that he or she will be asked to leave if the behavior continues
3. Offer to take the client to an examination room until he or she can be treated.
Rationale: Safety of the client, other clients, and staff is of prime concern. Option 3 is in effect
an isolation technique that allows for separation from others and provides for a less stimulating
environment where the client can maintain dignity. When dealing with an impaired individual,
trying to talk may be out of the question. Waiting to intervene could cause the client to become
even more agitated and a threat to others. Option 4 would only further aggravate an already
agitated individual.
A client is admitted to a psychiatric unit for treatment of a psychotic disorder. The client is at the
locked exit door and is shouting, "Let me out! There's nothing wrong with me! I don't belong
here!" The nurse identifies this behavior as which defense mechanism?
1.Denial
2.Projection
3.Regression
4.Rationalization
1. Denial
Rationale: Denial is the refusal to admit to a painful reality and is treated as if it does not exist.
In projection, a person unconsciously rejects emotionally unacceptable features and attributes
them to other people, objects, or situations. In regression, the client returns to an earlier, more
comforting, although less mature, way of behaving. Rationalization is justifying the
unacceptable attributes about oneself.
A client says to the nurse, "I'm going to die, and I wish my family would stop hoping for a 'cure'!
I get so angry when they carry on like this! After all, I'm the one who's dying." Which
therapeutic response should the nurse make to the client?
1."Have you shared your feelings with your family?"
2."I think we should talk more about your anger with your family."
3."You're feeling angry that your family continues to hope for you to be ‘cured'?"
4."Well, it sounds like you're being pretty pessimistic. After all, years ago people died of
pneumonia."
3. "You're feeling angry that your family continues to hope for you to be 'cured'?"
