lOMoARcPSD| 7906827
Essentials of Psychiatric Mental Health Nursing 8th Ed
j j j j j j jj
ition Concepts of Care in Evidence -
j j j j j j
Based Practice 9th Edition Morgan Townsend
j jj j j j j
Chapterj1.jMentaljHealthjandjMentaljI
llnessMultiplejChoice
1. Ajnursejisjassessingjajclientjwhojisjexperiencingjoccasionaljfeelingsjofjsadnessjbecausejofjt
herecentjdeathjofjajbelovedjpet.jThejclientsjappetite,jsleepjpatterns,jandjdailyjroutinejhavejn
otjchanged.jHowjshouldjthejnursejinterpretjthejclientsjbehaviors?
1. Thejclientsjbehaviorsjdemonstratejmentaljillnessjinjthejformjofjdepression.
2. Thejclientsjbehaviorsjarejextensive,jwhichjindicatesjthejpresencejofjmentaljillness.
3. Thejclientsjbehaviorsjarejnotjcongruentjwithjculturaljnorms.
4. Thejclientsjbehaviorsjdemonstratejnojfunctionaljimpairment,jindicatingjnojmentaljill
ness.
ANS:j4
Rationale:jThejnursejshouldjassessjthatjthejclientsjdailyjfunctioningjisjnotjimpaired.jThejcli
entwhojexperiencesjfeelingsjofjsadnessjafterjthejlossjofjajpetjisjrespondingjwithinjnormaljex
pectations.jWithoutjsignificantjimpairment,jthejclientsjdistressjdoesjnotjindicatejajmentalji
llness.
CognitivejLevel:jAnalysisjInteg
ratedjProcess:
Assessment
2. Atjwhatjpointjshouldjthejnursejdeterminejthatjajclientjisjatjriskjforjdevelopingjajme
ntalillness?
1. Whenjthoughts,jfeelings,jandjbehaviorsjarejnotjreflectivejofjthejDSM-5jcriteria.
2. Whenjmaladaptivejresponsesjtojstressjarejcoupledjwithjinterferencejinjdailyjfu
nctioning.
3. Whenjajclientjcommunicatesjsignificantjdistress.
4. Whenjajclientjusesjdefensejmechanismsjasjegojprotection.
ANS:j2
Rationale:jThejnursejshouldjdeterminejthatjthejclientjisjatjriskjforjmentaljillnessjwhen
, lOMoARcPSD| 7906827
responsestojstressjarejmaladaptivejandjinterferejwithjdailyjfunctioning.jThejDSM-
5jindicatesjthatjinjordertojbejdiagnosedjwithjajmentaljillness,jdailyjfunctioningjmustjbejsig
nificantlyjimpaired.jThejclientsjabilityjtojcommunicatejdistressjwouldjbejconsideredjajposi
tivejattribute.
CognitivejLevel:jApplicationjIn
tegratedjProcess:
Assessment
3. Ajnursejisjassessingjajsetjofj15-year-
oldjidenticaljtwinsjwhojrespondjveryjdifferentlyjtojstress.Onejtwinjbecomesjanxiousjandji
rritable,jandjthejotherjwithdrawsjandjcries.jHowjshouldjthejnursejexplainjthesejdifferentj
stressjresponsesjtojthejparents?
1. Reactionsjtojstressjarejrelativejratherjthanjabsolute;jindividualjresponsesjtojstressjvar
y.
2. Itjisjabnormaljforjidenticaljtwinsjtojreactjdifferentlyjtojsimilarjstressors.
3. Identicaljtwinsjshouldjsharejthejsamejtemperamentjandjrespondjsimilarlyjtojstress.
4. Environmentaljinfluencesjtojstressjweighjmorejheavilyjthanjgeneticjinfluences.
, lOMoARcPSD| 7906827
ANS:j1
Rationale:jThejnursejshouldjexplainjtojthejparentsjthat,jalthoughjthejtwinsjhavejidenticalj
DNA,therejarejseveraljotherjfactorsjthatjaffectjreactionsjtojstress.jMentaljhealthjisjajstatejof
beingjthatisjrelativejtojthejindividualjclient.jEnvironmentaljinfluencesjandjtemperamentj
j
canjaffectjstressjreactions.
CognitivejLevel:jApplicationjI
ntegratedjProcess:
Implementation
4. Whichjclientjshouldjthejnursejanticipatejtojbejmostjreceptivejtojpsychiatricjtreatment?
1. AjJewish,jfemalejsocialjworker.
2. AjBaptist,jhomelessjmale.
3. AjCatholic,jblackjmale.
4. AjProtestant,jSwedishjbusinessjexecutive.
ANS:j1
Rationale:jThejnursejshouldjanticipatejthatjthejclientjofjJewishjculturejwouldjplacejajhighj
importancejonjpreventativejhealthjcarejandjwouldjconsiderjmentaljhealthjasjequallyjimpo
rtantjasphysicaljhealth.jWomenjarejalsojmorejlikelyjtojseekjtreatmentjforjmentaljhealthjpr
oblemsjthanjmen.
CognitivejLevel:
ApplicationIntegratedjProcess
:jPlanning
5. Ajpsychiatricjnursejinternjstates,jThisjclientsjusejofjdefensejmechanismsjshouldjbejeli
minated.Whichjisjajcorrectjevaluationjofjthisjnursesjstatement?
1. Defensejmechanismsjcanjbejappropriatejresponsesjtojstressjandjneedjnotjbejeli
minated.
2. Defensejmechanismsjarejajmaladaptivejattemptjofjthejegojtojmanagejanxiety
andjshouldalwaysjbejeliminated.
3. Defensejmechanisms,jusedjbyjindividualsjwithjweakjegojintegrity,jshouldjbejdi
scouragedjandnotjeliminated.
4. Defensejmechanismsjcausejdisintegrationjofjthejegojandjshouldjbejfosteredjandjen
couraged.
ANS:j1
, lOMoARcPSD| 7906827
ANS:j1
Rationale:jThejnursejshouldjdeterminejthatjdefensejmechanismsjcanjbejappropriatejduri
ngjtimesofjstress.jThejclientjwithjnojdefensejmechanismsjmayjhavejajlowerjtolerancejforjst
ress,jthusjleadingjtojanxietyjdisorders.jDefensejmechanismsjshouldjbejconfrontedjwhenjth
eyjimpedejthejclientjfromjdevelopingjhealthyjcopingjskills.
CognitivejLevel:
ApplicationjIntegratedj
Process:jEvaluation
6. Duringjanjintakejassessment,jajnursejasksjbothjphysiologicaljandjpsychosocialjques
tions.jTheclientjangrilyjresponds,jImjherejforjmyjheart,jnotjmyjheadjproblems.jWhichji
sjthejnursesjbestjresponse?
1. Itsjjustjajroutinejpartjofjourjassessment.jAlljclientsjarejaskedjthesejsamejquestions.
2. Whyjarejyoujconcernedjaboutjthesejtypesjofjquestions?
3. Psychologicaljfactors,jlikejexcessivejstress,jhavejbeenjfoundjtojaffectjmedicaljco
nditions.
4. Wejcanjskipjthesejquestions,jifjyoujlike.jItjisntjimperativejthatjwejcompletejthisjsect
ion.
Essentials of Psychiatric Mental Health Nursing 8th Ed
j j j j j j jj
ition Concepts of Care in Evidence -
j j j j j j
Based Practice 9th Edition Morgan Townsend
j jj j j j j
Chapterj1.jMentaljHealthjandjMentaljI
llnessMultiplejChoice
1. Ajnursejisjassessingjajclientjwhojisjexperiencingjoccasionaljfeelingsjofjsadnessjbecausejofjt
herecentjdeathjofjajbelovedjpet.jThejclientsjappetite,jsleepjpatterns,jandjdailyjroutinejhavejn
otjchanged.jHowjshouldjthejnursejinterpretjthejclientsjbehaviors?
1. Thejclientsjbehaviorsjdemonstratejmentaljillnessjinjthejformjofjdepression.
2. Thejclientsjbehaviorsjarejextensive,jwhichjindicatesjthejpresencejofjmentaljillness.
3. Thejclientsjbehaviorsjarejnotjcongruentjwithjculturaljnorms.
4. Thejclientsjbehaviorsjdemonstratejnojfunctionaljimpairment,jindicatingjnojmentaljill
ness.
ANS:j4
Rationale:jThejnursejshouldjassessjthatjthejclientsjdailyjfunctioningjisjnotjimpaired.jThejcli
entwhojexperiencesjfeelingsjofjsadnessjafterjthejlossjofjajpetjisjrespondingjwithinjnormaljex
pectations.jWithoutjsignificantjimpairment,jthejclientsjdistressjdoesjnotjindicatejajmentalji
llness.
CognitivejLevel:jAnalysisjInteg
ratedjProcess:
Assessment
2. Atjwhatjpointjshouldjthejnursejdeterminejthatjajclientjisjatjriskjforjdevelopingjajme
ntalillness?
1. Whenjthoughts,jfeelings,jandjbehaviorsjarejnotjreflectivejofjthejDSM-5jcriteria.
2. Whenjmaladaptivejresponsesjtojstressjarejcoupledjwithjinterferencejinjdailyjfu
nctioning.
3. Whenjajclientjcommunicatesjsignificantjdistress.
4. Whenjajclientjusesjdefensejmechanismsjasjegojprotection.
ANS:j2
Rationale:jThejnursejshouldjdeterminejthatjthejclientjisjatjriskjforjmentaljillnessjwhen
, lOMoARcPSD| 7906827
responsestojstressjarejmaladaptivejandjinterferejwithjdailyjfunctioning.jThejDSM-
5jindicatesjthatjinjordertojbejdiagnosedjwithjajmentaljillness,jdailyjfunctioningjmustjbejsig
nificantlyjimpaired.jThejclientsjabilityjtojcommunicatejdistressjwouldjbejconsideredjajposi
tivejattribute.
CognitivejLevel:jApplicationjIn
tegratedjProcess:
Assessment
3. Ajnursejisjassessingjajsetjofj15-year-
oldjidenticaljtwinsjwhojrespondjveryjdifferentlyjtojstress.Onejtwinjbecomesjanxiousjandji
rritable,jandjthejotherjwithdrawsjandjcries.jHowjshouldjthejnursejexplainjthesejdifferentj
stressjresponsesjtojthejparents?
1. Reactionsjtojstressjarejrelativejratherjthanjabsolute;jindividualjresponsesjtojstressjvar
y.
2. Itjisjabnormaljforjidenticaljtwinsjtojreactjdifferentlyjtojsimilarjstressors.
3. Identicaljtwinsjshouldjsharejthejsamejtemperamentjandjrespondjsimilarlyjtojstress.
4. Environmentaljinfluencesjtojstressjweighjmorejheavilyjthanjgeneticjinfluences.
, lOMoARcPSD| 7906827
ANS:j1
Rationale:jThejnursejshouldjexplainjtojthejparentsjthat,jalthoughjthejtwinsjhavejidenticalj
DNA,therejarejseveraljotherjfactorsjthatjaffectjreactionsjtojstress.jMentaljhealthjisjajstatejof
beingjthatisjrelativejtojthejindividualjclient.jEnvironmentaljinfluencesjandjtemperamentj
j
canjaffectjstressjreactions.
CognitivejLevel:jApplicationjI
ntegratedjProcess:
Implementation
4. Whichjclientjshouldjthejnursejanticipatejtojbejmostjreceptivejtojpsychiatricjtreatment?
1. AjJewish,jfemalejsocialjworker.
2. AjBaptist,jhomelessjmale.
3. AjCatholic,jblackjmale.
4. AjProtestant,jSwedishjbusinessjexecutive.
ANS:j1
Rationale:jThejnursejshouldjanticipatejthatjthejclientjofjJewishjculturejwouldjplacejajhighj
importancejonjpreventativejhealthjcarejandjwouldjconsiderjmentaljhealthjasjequallyjimpo
rtantjasphysicaljhealth.jWomenjarejalsojmorejlikelyjtojseekjtreatmentjforjmentaljhealthjpr
oblemsjthanjmen.
CognitivejLevel:
ApplicationIntegratedjProcess
:jPlanning
5. Ajpsychiatricjnursejinternjstates,jThisjclientsjusejofjdefensejmechanismsjshouldjbejeli
minated.Whichjisjajcorrectjevaluationjofjthisjnursesjstatement?
1. Defensejmechanismsjcanjbejappropriatejresponsesjtojstressjandjneedjnotjbejeli
minated.
2. Defensejmechanismsjarejajmaladaptivejattemptjofjthejegojtojmanagejanxiety
andjshouldalwaysjbejeliminated.
3. Defensejmechanisms,jusedjbyjindividualsjwithjweakjegojintegrity,jshouldjbejdi
scouragedjandnotjeliminated.
4. Defensejmechanismsjcausejdisintegrationjofjthejegojandjshouldjbejfosteredjandjen
couraged.
ANS:j1
, lOMoARcPSD| 7906827
ANS:j1
Rationale:jThejnursejshouldjdeterminejthatjdefensejmechanismsjcanjbejappropriatejduri
ngjtimesofjstress.jThejclientjwithjnojdefensejmechanismsjmayjhavejajlowerjtolerancejforjst
ress,jthusjleadingjtojanxietyjdisorders.jDefensejmechanismsjshouldjbejconfrontedjwhenjth
eyjimpedejthejclientjfromjdevelopingjhealthyjcopingjskills.
CognitivejLevel:
ApplicationjIntegratedj
Process:jEvaluation
6. Duringjanjintakejassessment,jajnursejasksjbothjphysiologicaljandjpsychosocialjques
tions.jTheclientjangrilyjresponds,jImjherejforjmyjheart,jnotjmyjheadjproblems.jWhichji
sjthejnursesjbestjresponse?
1. Itsjjustjajroutinejpartjofjourjassessment.jAlljclientsjarejaskedjthesejsamejquestions.
2. Whyjarejyoujconcernedjaboutjthesejtypesjofjquestions?
3. Psychologicaljfactors,jlikejexcessivejstress,jhavejbeenjfoundjtojaffectjmedicaljco
nditions.
4. Wejcanjskipjthesejquestions,jifjyoujlike.jItjisntjimperativejthatjwejcompletejthisjsect
ion.
