Chapter 8 My Nursing Test Banks

 

Kneisl, Contemporary Psychiatric-Mental Health Nursing, 3/e Test Bank
Chapter 8

Question 1

Type: MCMA

A nurse is responding to a code on the unit which occurs during the nurses scheduled lunch time. Racing to the code, the nurse cuts her hand on a sharp doorframe but continues quickly down the hall and begins the code. The fight-flight response to stress has allowed the nurse to do which of the following things?

Standard Text: Select all that apply.

1. Remember what needed to be done.

2. Not feel hungry during the code.

3. Notice getting cut in the arm in the rush to respond.

4. Resist germs that were trying to get into the cut.

5. Get to the scene quickly.

Correct Answer: 1,2,4,5

Rationale 1: Remember what needed to be done. Heightened memory functions would allow the nurse to do what needed to be done.

Rationale 2: Not feel hungry during the code. A slowed digestive system and increased blood sugar provides energy and curbs the appetite.

Rationale 3: Notice getting cut in the arm in the rush to respond. Lower sensitivity to pain would keep the nurse from noticing the cut.

Rationale 4: Resist germs that were trying to get into the cut. A burst of increased immunity would give some increased protection against germs in the environment.

Rationale 5: Get to the scene quickly. A quick burst of energy would get the nurse to the scene.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Explain how stress affects an individual.

Question 2

Type: MCSA

A client diagnosed with a brain tumor is considering whether or not to have surgery after the physician explains that possible responses might include stroke, facial paralysis, and other mobility-limiting events. A few hours after signing the consent form, the client anxiously calls the nurse to withdraw consent, and then reverses the decision again a few moments later. This behavior continues over the next several hours. How should the nurse understand what is going on with this client?

1. The client is vacillating regarding the decision for surgery.

2. The client does not have adequate information to make a decision.

3. The client is refusing surgery.

4. The client is undergoing stress.

Correct Answer: 1

Rationale 1: The clients frequent change of mind regarding the surgery suggests that the client is in the third stage of conflict and is vacillating, first moving towards one goal and then another. The client has not made a clear choice to refuse surgery (that would be an approach-avoidance conflict). While it is important to recognize that the client is stressed, that in itself does not help explain what the client is experiencing and does not provide direction for a nursing intervention. There is nothing in the scenario to indicate the client does not have adequate information; the consent process would have provided information and the client would have had opportunity to ask for clarification.

Rationale 2: The clients frequent change of mind regarding the surgery suggests that the client is in the third stage of conflict and is vacillating, first moving towards one goal and then another. The client has not made a clear choice to refuse surgery (that would be an approach-avoidance conflict). While it is important to recognize that the client is stressed, that in itself does not help explain what the client is experiencing and does not provide direction for a nursing intervention. There is nothing in the scenario to indicate the client does not have adequate information; the consent process would have provided information and the client would have had opportunity to ask for clarification.

Rationale 3: The clients frequent change of mind regarding the surgery suggests that the client is in the third stage of conflict and is vacillating, first moving towards one goal and then another. The client has not made a clear choice to refuse surgery (that would be an approach-avoidance conflict). While it is important to recognize that the client is stressed, that in itself does not help explain what the client is experiencing and does not provide direction for a nursing intervention. There is nothing in the scenario to indicate the client does not have adequate information; the consent process would have provided information and the client would have had opportunity to ask for clarification.

Rationale 4: The clients frequent change of mind regarding the surgery suggests that the client is in the third stage of conflict and is vacillating, first moving towards one goal and then another. The client has not made a clear choice to refuse surgery (that would be an approach-avoidance conflict). While it is important to recognize that the client is stressed, that in itself does not help explain what the client is experiencing and does not provide direction for a nursing intervention. There is nothing in the scenario to indicate the client does not have adequate information; the consent process would have provided information and the client would have had opportunity to ask for clarification.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Explain how stress affects an individual.

Question 3

Type: MCMA

A nurse is talking with the wife of a client who has terminal cancer. The wife is explaining what an ordeal it has been over the last six months. She states her diabetes is out of control and she feels tired and exhausted all the time. What risks does chronic stress present for the wife?

Standard Text: Select all that apply.

1. Risk for mental illness

2. Risk for fracture

3. Risk for stroke or heart attack

4. Risk for infection

5. Risk for an auto accident

Correct Answer: 2,3,4,5

Rationale 1: Risk for mental illness. Risk factors for mental illness are associated with family history. Though stress is a trigger for many symptoms in those who have existing mental illness, there is no indication that the wife has a mental illness.

Rationale 2: Risk for fracture. Higher and more prolonged levels of cortisol in the bloodstream (like those associated with chronic stress) have been shown to have negative effects, such as decreased bone density (risk for fracture).

Rationale 3: Risk for stroke or heart attack. Higher and more prolonged levels of cortisol in the bloodstream (like those associated with chronic stress) have been shown to have negative effects, such as higher blood pressure (risk for stroke or heart attack).

Rationale 4: Risk for infection. Higher and more prolonged levels of cortisol in the bloodstream (like those associated with chronic stress) have been shown to have negative effects, such as lowered immunity and hyperglycemia (risk for infection).

Rationale 5: Risk for an auto accident. Higher and more prolonged levels of cortisol in the bloodstream (like those associated with chronic stress) have been shown to have negative effects, such as impaired cognitive performance (risk for accident).

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Explain how stress affects an individual.

Question 4

Type: MCMA

A client requests vanilla pudding after a day of diagnostic tests and talking to doctors. The client remembers the clients mother always made vanilla pudding when the client was sick. Which types of coping mechanism is the client describing?

Standard Text: Select all that apply.

1. Using symbolic substitutes

2. Privately thinking it through

3. Seeking comfort

4. Engaging in self-healing mind-body practices

5. Talking it out

Correct Answer: 1,2,3

Rationale 1: Using symbolic substitutes. The fact that the client associates the vanilla pudding with feeling better gives it a symbolic quality beyond the actual meaning of eating pudding.

Rationale 2: Privately thinking it through. The client appears to have engaged in introspection and emerged with an effective tension reliever.

Rationale 3: Seeking comfort. Coping mechanisms in the seeking comfort category are associated with nurturing behaviorsin this case, the clients mothers nurturing.

Rationale 4: Engaging in self-healing mind-body practices. Engaging in self-healing mind-body practices includes such things as yoga, meditation, or relaxation.

Rationale 5: Talking it out. Talking it out would involve an interaction with the nurse. In the scenario, only a request is made.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Explain how stress affects an individual.

Question 5

Type: MCSA

The client is a homeless veteran who has been staying at a shelter since discharge after serving in Iraq. The client has become increasingly irritable over the last two weeks and might be evicted from the shelter if the clients behavior does not improve. The nurse learns that the client has not had more than a few hours of sleep in the last two days. Which diagnosis would be most appropriate for this client at this time?

1. Sleep pattern disturbance related to anticipation of threat to basic needs and security

2. Alteration in self-concept related to survivor guilt

3. Potential for self-harm related to irritability secondary to sleeplessness

4. Posttraumatic stress disorder related to combat experiences

Correct Answer: 1

Rationale 1: The client appears to be experiencing sleep pattern disturbance related to the stress of the threatened loss of shelter. The client may or may not be experiencing survivor guilt or posttraumatic stress disorder, but that is not the priority diagnosis at this time. There is no indication the client is having thoughts of self-harm.

Rationale 2: The client appears to be experiencing sleep pattern disturbance related to the stress of the threatened loss of shelter. The client may or may not be experiencing survivor guilt or posttraumatic stress disorder, but that is not the priority diagnosis at this time. There is no indication the client is having thoughts of self-harm.

Rationale 3: The client appears to be experiencing sleep pattern disturbance related to the stress of the threatened loss of shelter. The client may or may not be experiencing survivor guilt or posttraumatic stress disorder, but that is not the priority diagnosis at this time. There is no indication the client is having thoughts of self-harm.

Rationale 4: The client appears to be experiencing sleep pattern disturbance related to the stress of the threatened loss of shelter. The client may or may not be experiencing survivor guilt or posttraumatic stress disorder, but that is not the priority diagnosis at this time. There is no indication the client is having thoughts of self-harm.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: Explain how stress affects an individual.

Question 6

Type: MCSA

A nurse is caring for a client slated for a cardiac procedure in the morning. Which behavior exhibited by the client would indicate the client is experiencing severe anxiety?

1. The client thinks the hospital is a prison and says the jailers have taken the clients clothes.

2. The client is reading todays newspaper and makes small talk about a current event.

3. The client cannot remember what has been taught about post-operative breathing.

4. The client keeps asking about blood clots despite the nurses repeated answers.

Correct Answer: 4

Rationale 1: During severe anxiety, people focus on small or scattered details. In this case, the client cannot organize the responses the nurse gives to attain a clear picture of the treatment risks. The client reading the newspaper is showing little or minimal anxiety by reading the newspaper and engaging in what is happening in the world. Moderate anxiety leads to selective inattention wherein the client may not remember what the nurse taught about post-operative breathing. During panic, the perceptual field is disrupted and the client may be disoriented and confused which may explain the reference to prison and jailers.

Rationale 2: During severe anxiety, people focus on small or scattered details. In this case, the client cannot organize the responses the nurse gives to attain a clear picture of the treatment risks. The client reading the newspaper is showing little or minimal anxiety by reading the newspaper and engaging in what is happening in the world. Moderate anxiety leads to selective inattention wherein the client may not remember what the nurse taught about post-operative breathing. During panic, the perceptual field is disrupted and the client may be disoriented and confused which may explain the reference to prison and jailers.

Rationale 3: During severe anxiety, people focus on small or scattered details. In this case, the client cannot organize the responses the nurse gives to attain a clear picture of the treatment risks. The client reading the newspaper is showing little or minimal anxiety by reading the newspaper and engaging in what is happening in the world. Moderate anxiety leads to selective inattention wherein the client may not remember what the nurse taught about post-operative breathing. During panic, the perceptual field is disrupted and the client may be disoriented and confused which may explain the reference to prison and jailers.

Rationale 4: During severe anxiety, people focus on small or scattered details. In this case, the client cannot organize the responses the nurse gives to attain a clear picture of the treatment risks. The client reading the newspaper is showing little or minimal anxiety by reading the newspaper and engaging in what is happening in the world. Moderate anxiety leads to selective inattention wherein the client may not remember what the nurse taught about post-operative breathing. During panic, the perceptual field is disrupted and the client may be disoriented and confused which may explain the reference to prison and jailers.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Identify the sources of anxiety.

Question 7

Type: MCSA

A teen comes to the school nurse to get help with anxiety about singing in front of the school. The teen states, I just know everyone is going to laugh. What if I sing off-key? What does the nurse recognize as the teens source of anxiety?

1. Unmet expectations important to self-integrity

2. Inability to gain or reinforce self-respect from others

3. Discrepancies between self-view and actual behavior

4. Anticipated disapproval by significant others

Correct Answer: 4

Rationale 1: The teen is anticipating disapproval by significant others/peers, which is of developmental importance to teenagers. The event has not yet occurred, so it cannot be a discrepancy between the self-view and actual behavior. Gaining or reinforcing respect is not the teens issue. There is no failure to accomplish a goal.

Rationale 2: The teen is anticipating disapproval by significant others/peers, which is of developmental importance to teenagers. The event has not yet occurred, so it cannot be a discrepancy between the self-view and actual behavior. Gaining or reinforcing respect is not the teens issue. There is no failure to accomplish a goal.

Rationale 3: The teen is anticipating disapproval by significant others/peers, which is of developmental importance to teenagers. The event has not yet occurred, so it cannot be a discrepancy between the self-view and actual behavior. Gaining or reinforcing respect is not the teens issue. There is no failure to accomplish a goal.

Rationale 4: The teen is anticipating disapproval by significant others/peers, which is of developmental importance to teenagers. The event has not yet occurred, so it cannot be a discrepancy between the self-view and actual behavior. Gaining or reinforcing respect is not the teens issue. There is no failure to accomplish a goal.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Identify the sources of anxiety.

Question 8

Type: MCSA

A nurse wants to assess a clients level of anxiety in order to determine how much of an anti-anxiety drug to administer prior to performing a painful dressing change for a deep tissue burn. Which question would give the nurse the most accurate assessment of the clients level of anxiety?

1. Are you ready for this change of dressing?

2. Did you find the medication helpful that you received before the dressing change yesterday?

3. How are you feeling today?

4. On a scale of one to five, with one being none and five being panic, can you rate your level of anxiety right now?

Correct Answer: 4

Rationale 1: Asking the client to rate the level of anxiety allows the client to give a concrete response about a subjective phenomenon on which the nurse can base the decision about the dose of anti-anxiety agent medication to administer. Asking how the client is feeling today is too general to elicit the information necessary to determine dosing. Asking if the client is ready for the change of dressing will not elicit the information necessary to determine dosing. While asking about yesterdays response to medication may be an important assessment, todays anxiety might be substantially different (in either direction) than yesterdays.

Rationale 2: Asking the client to rate the level of anxiety allows the client to give a concrete response about a subjective phenomenon on which the nurse can base the decision about the dose of anti-anxiety agent medication to administer. Asking how the client is feeling today is too general to elicit the information necessary to determine dosing. Asking if the client is ready for the change of dressing will not elicit the information necessary to determine dosing. While asking about yesterdays response to medication may be an important assessment, todays anxiety might be substantially different (in either direction) than yesterdays.

Rationale 3: Asking the client to rate the level of anxiety allows the client to give a concrete response about a subjective phenomenon on which the nurse can base the decision about the dose of anti-anxiety agent medication to administer. Asking how the client is feeling today is too general to elicit the information necessary to determine dosing. Asking if the client is ready for the change of dressing will not elicit the information necessary to determine dosing. While asking about yesterdays response to medication may be an important assessment, todays anxiety might be substantially different (in either direction) than yesterdays.

Rationale 4: Asking the client to rate the level of anxiety allows the client to give a concrete response about a subjective phenomenon on which the nurse can base the decision about the dose of anti-anxiety agent medication to administer. Asking how the client is feeling today is too general to elicit the information necessary to determine dosing. Asking if the client is ready for the change of dressing will not elicit the information necessary to determine dosing. While asking about yesterdays response to medication may be an important assessment, todays anxiety might be substantially different (in either direction) than yesterdays.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Identify the sources of anxiety.

Question 9

Type: MCSA

A nurse has been working with a client who witnessed a traumatic event and is now experiencing panic-level anxiety. The desired outcome is:

1. Stated improvement of self-esteem.

2. Absence of anxiety.

3. Hope for the future.

4. Anxiety is maintained at a manageable level.

Correct Answer: 4

Rationale 1: The desired outcome is for the client to maintain anxiety at a manageable level. Anxiety is the result of adaptation to a changing world; its absence would be impossible. There is no data to suggest the client is not hopeful for the future. During panic-level anxiety, it is not reasonable for the client to state improvement of self-esteem.

Rationale 2: The desired outcome is for the client to maintain anxiety at a manageable level. Anxiety is the result of adaptation to a changing world; its absence would be impossible. There is no data to suggest the client is not hopeful for the future. During panic-level anxiety, it is not reasonable for the client to state improvement of self-esteem.

Rationale 3: The desired outcome is for the client to maintain anxiety at a manageable level. Anxiety is the result of adaptation to a changing world; its absence would be impossible. There is no data to suggest the client is not hopeful for the future. During panic-level anxiety, it is not reasonable for the client to state improvement of self-esteem.

Rationale 4: The desired outcome is for the client to maintain anxiety at a manageable level. Anxiety is the result of adaptation to a changing world; its absence would be impossible. There is no data to suggest the client is not hopeful for the future. During panic-level anxiety, it is not reasonable for the client to state improvement of self-esteem.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Identify the sources of anxiety.

Question 10

Type: MCSA

A community health nurse meets with a 15-year-old single mother to teach a tube-feeding technique to her infant. The teens mother is present. The nurse notes that the young mother is hesitant to try the feeding technique and does not ask questions. During the feeding, the teen mother almost drops the feeding tube and is scolded by her mother for being clumsy. Based on this initial information, which nursing diagnosis is most appropriate?

1. Anxiety related to lack of knowledge and inexperience

2. Ineffective Family Coping related to conflicted daughterparent relationship and dysfunctional communication

3. Social Interaction Impaired related to paternal interference

4. Self-Esteem (Low) Situational, related to lack of experience, criticism, and role uncertainty

Correct Answer: 4

Rationale 1: When people feel confident to deal with stress and the situation, their behavior is task-oriented. This young mother lacks the confidence to deal with a new experience. She is unprepared to accept a new role as a mother and has little emotional support from her own parent. While the teen attempts to take on the task of nurturing her newborn, other factors in the environment pose obstacles to her success. The diagnosis of Anxiety related to lack of knowledge and inexperience does not capture the obstacles to role performance in the teens environment. There is no data to support a diagnosis of Impaired Social Interaction, Ineffective Family Coping, or Ongoing Dysfunctional Communication.

Rationale 2: When people feel confident to deal with stress and the situation, their behavior is task-oriented. This young mother lacks the confidence to deal with a new experience. She is unprepared to accept a new role as a mother and has little emotional support from her own parent. While the teen attempts to take on the task of nurturing her newborn, other factors in the environment pose obstacles to her success. The diagnosis of Anxiety related to lack of knowledge and inexperience does not capture the obstacles to role performance in the teens environment. There is no data to support a diagnosis of Impaired Social Interaction, Ineffective Family Coping, or Ongoing Dysfunctional Communication.

Rationale 3: When people feel confident to deal with stress and the situation, their behavior is task-oriented. This young mother lacks the confidence to deal with a new experience. She is unprepared to accept a new role as a mother and has little emotional support from her own parent. While the teen attempts to take on the task of nurturing her newborn, other factors in the environment pose obstacles to her success. The diagnosis of Anxiety related to lack of knowledge and inexperience does not capture the obstacles to role performance in the teens environment. There is no data to support a diagnosis of Impaired Social Interaction, Ineffective Family Coping, or Ongoing Dysfunctional Communication.

Rationale 4: When people feel confident to deal with stress and the situation, their behavior is task-oriented. This young mother lacks the confidence to deal with a new experience. She is unprepared to accept a new role as a mother and has little emotional support from her own parent. While the teen attempts to take on the task of nurturing her newborn, other factors in the environment pose obstacles to her success. The diagnosis of Anxiety related to lack of knowledge and inexperience does not capture the obstacles to role performance in the teens environment. There is no data to support a diagnosis of Impaired Social Interaction, Ineffective Family Coping, or Ongoing Dysfunctional Communication.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: Identify the sources of anxiety.

Question 11

Type: MCSA

A client with diabetes checks blood sugar levels daily and carefully administers insulin, but has not been following a diabetic diet. After discussion with the nurse about the importance of diet, the client states intentions to eat regular meals, get sugar substitute and fresh vegetables, throw out potato chips and cookies, and buy a new nonstick frying pan. The clients behavior is an example of:

1. Reappraisal.

2. Secondary appraisal.

3. Coping.

4. Primary appraisal.

Correct Answer: 1

Rationale 1: Reappraisal involves an ongoing reinterpretation based on new information; the client is rethinking the mistaken idea that diet was not important. Primary appraisal involves assessing benefit or harm. Secondary appraisal involves evaluating ones coping resources and options. The person exhibiting coping skills applies the resources and options.

Rationale 2: Reappraisal involves an ongoing reinterpretation based on new information; the client is rethinking the mistaken idea that diet was not important. Primary appraisal involves assessing benefit or harm. Secondary appraisal involves evaluating ones coping resources and options. The person exhibiting coping skills applies the resources and options.

Rationale 3: Reappraisal involves an ongoing reinterpretation based on new information; the client is rethinking the mistaken idea that diet was not important. Primary appraisal involves assessing benefit or harm. Secondary appraisal involves evaluating ones coping resources and options. The person exhibiting coping skills applies the resources and options.

Rationale 4: Reappraisal involves an ongoing reinterpretation based on new information; the client is rethinking the mistaken idea that diet was not important. Primary appraisal involves assessing benefit or harm. Secondary appraisal involves evaluating ones coping resources and options. The person exhibiting coping skills applies the resources and options.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Describe the everyday methods people use to cope with stress and anxiety.

Question 12

Type: MCMA

A female client comes to the nursing clinic for a routine physical. When asked how she has been doing, she reports that she has been feeling very low since her youngest child left to attend dental school. She indicates that she has told herself to just get over it and find something to do. She has been telling herself that feeling so low is foolish since she is happy her daughter got into a good school. Which coping methods does the nurse recognize in the clients statements?

Standard Text: Select all that apply.

1. Talking it out

2. Privately thinking it through

3. Seeking comfort

4. Using symbolic substitutes

5. Relying on self-discipline

Correct Answer: 2,5

Rationale 1: Talking it out. The client does not indicate she has been talking with others.

Rationale 2: Privately thinking it through. The client is dwelling on the life change and thinking it through to relieve tension.

Rationale 3: Seeking comfort. The client is not turning inward for soothing comfort and protection.

Rationale 4: Using symbolic substitutes. The client does not that she is using objects as symbolic substitutes to reduce tension.

Rationale 5: Relying on self-discipline. The client indicates that she is using self-discipline to tell herself to get over it.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Describe the everyday methods people use to cope with stress and anxiety.

Question 13

Type: MCSA

A nurse is caring for a client with a terminal illness. The client asks if the nurse will pray with the client for the remission of the cancer. The nurse does not practice the same religion and does not believe that a remission is possible at this stage of the disease. The nurse should:

1. Gently confront the client about unrealistic expectations that the cancer is going to regress.

2. Encourage the client to go ahead, but leave the room while the client prays.

3. Call the chaplain and set up a referral for the clients spiritual distress.

4. Stand silently for a few moments while the client prays.

Correct Answer: 4

Rationale 1: Silence and respect do not indicate that the nurse agrees or supports the clients religion, but that the nurse accepts and understands the importance of coping mechanisms. Leaving the room is not supportive of the clients preferred coping mechanism and the client may feel offended by the nurses actions. While there is no evidence that the client is experiencing spiritual distress, a referral to the chaplain can be made. Confronting the client about unrealistic expectations does not address the clients coping mechanisms.

Rationale 2: Silence and respect do not indicate that the nurse agrees or supports the clients religion, but that the nurse accepts and understands the importance of coping mechanisms. Leaving the room is not supportive of the clients preferred coping mechanism and the client may feel offended by the nurses actions. While there is no evidence that the client is experiencing spiritual distress, a referral to the chaplain can be made. Confronting the client about unrealistic expectations does not address the clients coping mechanisms.

Rationale 3: Silence and respect do not indicate that the nurse agrees or supports the clients religion, but that the nurse accepts and understands the importance of coping mechanisms. Leaving the room is not supportive of the clients preferred coping mechanism and the client may feel offended by the nurses actions. While there is no evidence that the client is experiencing spiritual distress, a referral to the chaplain can be made. Confronting the client about unrealistic expectations does not address the clients coping mechanisms.

Rationale 4: Silence and respect do not indicate that the nurse agrees or supports the clients religion, but that the nurse accepts and understands the importance of coping mechanisms. Leaving the room is not supportive of the clients preferred coping mechanism and the client may feel offended by the nurses actions. While there is no evidence that the client is experiencing spiritual distress, a referral to the chaplain can be made. Confronting the client about unrealistic expectations does not address the clients coping mechanisms.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Describe the everyday methods people use to cope with stress and anxiety.

Question 14

Type: MCSA

Knowing that there is a high rate of smoking in the local community, a nurse decides to lead a community health promotion group and seeks the hospitals backing. The nurse decides to organize the curriculum around the Lazarus Model of Stress. How does this model motivate smoking cessation?

1. By helping participants understand the nature of stress as a conflict

2. By helping participants understand stressors in their own lives

3. By encouraging the exploration of the pros and cons of smoking

4. By understanding the negative effects of stress on the body

Correct Answer: 3

Rationale 1: The Lazarus model helps individuals understand their readiness for change and make good cost/benefit decisions. The general adaptation syndrome (GAS) of understanding the effect of stress on the body is too broad a theory to connect to smoking cessation. Life change theory helps participants learn about life stressors associated with life events and situations. Conflict theory explains movement toward goals; it would help smokers understand their behavior but would not be the most effective method to help them make a decision about smoking cessation.

Rationale 2: The Lazarus model helps individuals understand their readiness for change and make good cost/benefit decisions. The general adaptation syndrome (GAS) of understanding the effect of stress on the body is too broad a theory to connect to smoking cessation. Life change theory helps participants learn about life stressors associated with life events and situations. Conflict theory explains movement toward goals; it would help smokers understand their behavior but would not be the most effective method to help them make a decision about smoking cessation.

Rationale 3: The Lazarus model helps individuals understand their readiness for change and make good cost/benefit decisions. The general adaptation syndrome (GAS) of understanding the effect of stress on the body is too broad a theory to connect to smoking cessation. Life change theory helps participants learn about life stressors associated with life events and situations. Conflict theory explains movement toward goals; it would help smokers understand their behavior but would not be the most effective method to help them make a decision about smoking cessation.

Rationale 4: The Lazarus model helps individuals understand their readiness for change and make good cost/benefit decisions. The general adaptation syndrome (GAS) of understanding the effect of stress on the body is too broad a theory to connect to smoking cessation. Life change theory helps participants learn about life stressors associated with life events and situations. Conflict theory explains movement toward goals; it would help smokers understand their behavior but would not be the most effective method to help them make a decision about smoking cessation.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Describe the everyday methods people use to cope with stress and anxiety.

Question 15

Type: MCSA

A client with newly diagnosed breast cancer states that her fate is in Gods hands and that she will accept whatever the future holds. The nurse is aware that a sense of coherence helps people cope successfully with lifes challenges, but the nurse is concerned about the womans continuation with medical treatment. What might the nurse think is lacking in this clients coping?

1. She does not appear to be demonstrating motivation or feeling about investing time and energy in life.

2. She does not seem to have a basic trust that things will work out.

3. She seems to have lost hope.

4. She is expressing that she does not have the resources to meet the demands of her illness.

Correct Answer: 1

Rationale 1: The clients statement does not demonstrate an intention to invest time and energy in life; compliance with treatment requires energy and commitment to living. There is no information about lacking resources or trust; in fact, her faith is a helpful resource. The client does not exhibit a lack of hope; she gives her fate over to God.

Rationale 2: The clients statement does not demonstrate an intention to invest time and energy in life; compliance with treatment requires energy and commitment to living. There is no information about lacking resources or trust; in fact, her faith is a helpful resource. The client does not exhibit a lack of hope; she gives her fate over to God.

Rationale 3: The clients statement does not demonstrate an intention to invest time and energy in life; compliance with treatment requires energy and commitment to living. There is no information about lacking resources or trust; in fact, her faith is a helpful resource. The client does not exhibit a lack of hope; she gives her fate over to God.

Rationale 4: The clients statement does not demonstrate an intention to invest time and energy in life; compliance with treatment requires energy and commitment to living. There is no information about lacking resources or trust; in fact, her faith is a helpful resource. The client does not exhibit a lack of hope; she gives her fate over to God.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Describe the everyday methods people use to cope with stress and anxiety.

Question 16

Type: MCSA

A clients progress notes read, states he does not want to sit or talk with others; they frighten him; stays in room alone unless strongly encouraged to come out; no group involvement; at times listens to group from a distance but does not engage in conversation; some hypervigilance and scanning noted. The nurse decides that the clients behavior is defensive and plans care accordingly. Which strategy should the nurse employ?

1. Help the client gradually accept realistic goals.

2. Help the client identify his fears regarding participating in the group.

3. Help the client develop motivation and a plan for group involvement.

4. Help the client see that there is a possibility for change.

Correct Answer: 2

Rationale 1: This client appears to be using projection. Identifying his fears would help the client understand he is attributing to others hostile motives that do not actually exist. Helping the client accept realistic goals would benefit a client who uses fantasy as a coping defense. Helping the client see possibility for change benefits a client who copes by rationalization. Helping the client develop a plan would benefit a client who uses intellectualization to cope with anxiety.

Rationale 2: This client appears to be using projection. Identifying his fears would help the client understand he is attributing to others hostile motives that do not actually exist. Helping the client accept realistic goals would benefit a client who uses fantasy as a coping defense. Helping the client see possibility for change benefits a client who copes by rationalization. Helping the client develop a plan would benefit a client who uses intellectualization to cope with anxiety.

Rationale 3: This client appears to be using projection. Identifying his fears would help the client understand he is attributing to others hostile motives that do not actually exist. Helping the client accept realistic goals would benefit a client who uses fantasy as a coping defense. Helping the client see possibility for change benefits a client who copes by rationalization. Helping the client develop a plan would benefit a client who uses intellectualization to cope with anxiety.

Rationale 4: This client appears to be using projection. Identifying his fears would help the client understand he is attributing to others hostile motives that do not actually exist. Helping the client accept realistic goals would benefit a client who uses fantasy as a coping defense. Helping the client see possibility for change benefits a client who copes by rationalization. Helping the client develop a plan would benefit a client who uses intellectualization to cope with anxiety.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Compare and contrast the common defense-oriented behaviors (defense mechanisms) people use to cope with stress and anxiety.

Question 17

Type: MCSA

During a peer group support session, a teenager shares that her little sister destroyed a valued collection of glass animals. Another member of the group says, I would have killed her. The teenager quickly denies angry feelings towards the little sister and states, She didnt do it on purpose. This is an example of the defense mechanism of:

1. Identification.

2. Projection.

3. Intellectualization.

4. Reaction formation.

Correct Answer: 4

Rationale 1: This is a reaction formation; the teen is unable to express anger toward her little sister. Projection involves internal feelings which are attributed to an outside source. Identification involves an unconscious attempt to be like someone else. Intellectualization involves a disconnect between thoughts and emotions.

Rationale 2: This is a reaction formation; the teen is unable to express anger toward her little sister. Projection involves internal feelings which are attributed to an outside source. Identification involves an unconscious attempt to be like someone else. Intellectualization involves a disconnect between thoughts and emotions.

Rationale 3: This is a reaction formation; the teen is unable to express anger toward her little sister. Projection involves internal feelings which are attributed to an outside source. Identification involves an unconscious attempt to be like someone else. Intellectualization involves a disconnect between thoughts and emotions.

Rationale 4: This is a reaction formation; the teen is unable to express anger toward her little sister. Projection involves internal feelings which are attributed to an outside source. Identification involves an unconscious attempt to be like someone else. Intellectualization involves a disconnect between thoughts and emotions.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Compare and contrast the common defense-oriented behaviors (defense mechanisms) people use to cope with stress and anxiety.

Question 18

Type: MCSA

A nurse is leading a support group for girls who were sexually abused by their stepfathers. Each girl made a statement to the group about the experience. The nurse recognizes intellectualization in one of the girls remarks. Which statement did the girl make?

1. If my mother hadnt married him, it never would have happened.

2. I cant remember much of the details.

3. Sexual abuse happens all of the time in families with stepfathers.

4. I dont think my stepfather meant me any harm.

Correct Answer: 3

Rationale 1: Stating that sexual abuse happens frequently in families with stepfathers is an example of intellectualization, the separation of an emotion from an idea or thought because it is too painful to be acknowledged. Stating that the stepfather meant no harm is an example of rationalization. Stating that it would not have happened if her mother had not married him is an example of projection. Stating that details are vague is an example of repression.

Rationale 2: Stating that sexual abuse happens frequently in families with stepfathers is an example of intellectualization, the separation of an emotion from an idea or thought because it is too painful to be acknowledged. Stating that the stepfather meant no harm is an example of rationalization. Stating that it would not have happened if her mother had not married him is an example of projection. Stating that details are vague is an example of repression.

Rationale 3: Stating that sexual abuse happens frequently in families with stepfathers is an example of intellectualization, the separation of an emotion from an idea or thought because it is too painful to be acknowledged. Stating that the stepfather meant no harm is an example of rationalization. Stating that it would not have happened if her mother had not married him is an example of projection. Stating that details are vague is an example of repression.

Rationale 4: Stating that sexual abuse happens frequently in families with stepfathers is an example of intellectualization, the separation of an emotion from an idea or thought because it is too painful to be acknowledged. Stating that the stepfather meant no harm is an example of rationalization. Stating that it would not have happened if her mother had not married him is an example of projection. Stating that details are vague is an example of repression.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Compare and contrast the common defense-oriented behaviors (defense mechanisms) people use to cope with stress and anxiety.

Question 19

Type: MCSA

A client who abuses alcohol was brought to the hospital as a police hold after a fight with his wife. When the client is sober, the nurse recognizes that the client is using a defensive behavior called rationalization. Which statement did the client make?

1. I dont remember doing any of those things.

2. The police are always out to get me; I bet they were watching my house.

3. I just needed my space. If she had just left me alone, I wouldnt have hit her.

4. When my wife comes in, tell her to take the money I left in the hospital safe.

Correct Answer: 3

Rationale 1: Rationalization is a falsification of experience through construction of a social or local explanation. The client not remembering could be repression. Feeling that the police are out to get the client sounds like projection. Suggesting that the wife should retrieve the money from the safe does not indicate a defensive behavior.

Rationale 2: Rationalization is a falsification of experience through construction of a social or local explanation. The client not remembering could be repression. Feeling that the police are out to get the client sounds like projection. Suggesting that the wife should retrieve the money from the safe does not indicate a defensive behavior.

Rationale 3: Rationalization is a falsification of experience through construction of a social or local explanation. The client not remembering could be repression. Feeling that the police are out to get the client sounds like projection. Suggesting that the wife should retrieve the money from the safe does not indicate a defensive behavior.

Rationale 4: Rationalization is a falsification of experience through construction of a social or local explanation. The client not remembering could be repression. Feeling that the police are out to get the client sounds like projection. Suggesting that the wife should retrieve the money from the safe does not indicate a defensive behavior.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Compare and contrast the common defense-oriented behaviors (defense mechanisms) people use to cope with stress and anxiety.

Question 20

Type: MCSA

A team meeting is scheduled to teach nurses about communicating with clients who are using defense mechanisms. The instructor understands that more teaching is needed when a nurse says which of the following?

1. Defense mechanisms are not helpful and must be challenged.

2. People use defense mechanisms every day, though they are not aware of it.

3. Defense mechanisms are used when you feel threatened or anxious.

4. Primitive and early-formed defenses would be stronger and more difficult to change.

Correct Answer: 1

Rationale 1: Defense mechanisms are helpful ways of reducing anxiety; challenging them would be more threatening to the client and would increase anxiety. Defense mechanisms are unconscious processes and protect people from feelings of anxiety. Habitual patterns of use can develop over time, making defensive behavior difficult to change.

Rationale 2: Defense mechanisms are helpful ways of reducing anxiety; challenging them would be more threatening to the client and would increase anxiety. Defense mechanisms are unconscious processes and protect people from feelings of anxiety. Habitual patterns of use can develop over time, making defensive behavior difficult to change.

Rationale 3: Defense mechanisms are helpful ways of reducing anxiety; challenging them would be more threatening to the client and would increase anxiety. Defense mechanisms are unconscious processes and protect people from feelings of anxiety. Habitual patterns of use can develop over time, making defensive behavior difficult to change.

Rationale 4: Defense mechanisms are helpful ways of reducing anxiety; challenging them would be more threatening to the client and would increase anxiety. Defense mechanisms are unconscious processes and protect people from feelings of anxiety. Habitual patterns of use can develop over time, making defensive behavior difficult to change.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: Compare and contrast the common defense-oriented behaviors (defense mechanisms) people use to cope with stress and anxiety.

Question 21

Type: MCSA

A client who abuses alcohol states that the client drinks because the clients job is so stressful. Recognizing this as rationalization, the nurse makes a response to the client. The nurse would know treatment was effective when the client says which of the following?

1. Maybe my just needing a little drink to do my job has gotten way out of hand.

2. If I took a less stressful job, I wouldnt have to drink.

3. I can quit drinking whenever I want.

4. Listen, Im not a drunk, and I dont have a problem with alcohol.

Correct Answer: 1

Rationale 1: The clients statement that the drinking has become uncontrolled suggests that the client is beginning to become more realistic about alcohol abuse. The statement that a less stressful job would remove the need to drink is a re-escalation of the clients rationalization. Stating that the client does not have a problem with alcohol demonstrates increased anxiety and denial. Expressing that the client can quit drinking whenever the client wants is fantasy, a satisfaction of wishes through non-rational thought.

Rationale 2: The clients statement that the drinking has become uncontrolled suggests that the client is beginning to become more realistic about alcohol abuse. The statement that a less stressful job would remove the need to drink is a re-escalation of the clients rationalization. Stating that the client does not have a problem with alcohol demonstrates increased anxiety and denial. Expressing that the client can quit drinking whenever the client wants is fantasy, a satisfaction of wishes through non-rational thought.

Rationale 3: The clients statement that the drinking has become uncontrolled suggests that the client is beginning to become more realistic about alcohol abuse. The statement that a less stressful job would remove the need to drink is a re-escalation of the clients rationalization. Stating that the client does not have a problem with alcohol demonstrates increased anxiety and denial. Expressing that the client can quit drinking whenever the client wants is fantasy, a satisfaction of wishes through non-rational thought.

Rationale 4: The clients statement that the drinking has become uncontrolled suggests that the client is beginning to become more realistic about alcohol abuse. The statement that a less stressful job would remove the need to drink is a re-escalation of the clients rationalization. Stating that the client does not have a problem with alcohol demonstrates increased anxiety and denial. Expressing that the client can quit drinking whenever the client wants is fantasy, a satisfaction of wishes through non-rational thought.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Implement nursing intervention strategies specific to each defense-oriented behavior listed.

Question 22

Type: MCMA

A home care nurse is teaching an older client about colostomy care. The clients wife is taking charge of the irrigations. Both are very anxious. During the procedure, the wife continually watches the nurse, asking Is this correct? and waits for approval before continuing. Both the client and his wife express how glad they are that the nurse is coming and that they dont know what they will do without the help. Knowing that the goal of care is to promote independence, how will the nurse address these behaviors?

Standard Text: Select all that apply.

1. Remind the couple that there are only a few visits left.

2. Tell the husband he has to do the irrigation.

3. Reinforce the wifes competency and the strength of coping as a team.

4. Gradually encourage them to do the procedure on their own, while continuing to provide support.

5. Recognize this passive behavior and take a firm stand against it.

Correct Answer: 3,4

Rationale 1: Remind the couple that there are only a few visits left. Reminding them that there are few visits left will increase their anxiety.

Rationale 2: Tell the husband he has to do the irrigation. The couple is using a successful coping approach by working together; demanding that the client do it by himself would increase their anxiety.

Rationale 3: Reinforce the wifes competency and their strengths of coping as a team. Helping them feel more confident and capable is an important strategy in addressing identification.

Rationale 4: Gradually encourage them to do the procedure on their own, while continuing to provide support. Providing a bridge of support until they reach independence is an important strategy in addressing identification.

Rationale 5: Recognize this passive behavior and take a firm stand against it. Telling the couple that their behavior is inappropriate would increase their anxiety.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Implement nursing intervention strategies specific to each defense-oriented behavior listed.

Question 23

Type: MCSA

A nurse manager is mentoring a junior nurse. The junior nurse models everything after the manager, and even dresses like the manager. How would the manager address the junior nurses identification?

1. You can just have a copy of my plans.

2. I appreciate you wanting my help, but these plans have to represent your personal desires and goals.

3. Youre becoming too dependent on me. Cant you just think for yourself?

4. Ill be glad to look over your work after you come up with some of your own ideas.

Correct Answer: 4

Rationale 1: Offering to look at the junior nurses work after it is written is the best approach because it encourages initiative without entirely stripping away the junior nurses sense of security. Suggesting the junior nurse is too dependent and cannot think for him or herself is a harsh confrontation of identification which will increase the junior nurses anxiety. Suggesting that the junior nurse needs to develop a personal plan helps clarify expectations but does not offer initial support. Offering a copy of plans does not do anything to address identification and may be threatening to the junior nurse as it could sound critical.

Rationale 2: Offering to look at the junior nurses work after it is written is the best approach because it encourages initiative without entirely stripping away the junior nurses sense of security. Suggesting the junior nurse is too dependent and cannot think for him or herself is a harsh confrontation of identification which will increase the junior nurses anxiety. Suggesting that the junior nurse needs to develop a personal plan helps clarify expectations but does not offer initial support. Offering a copy of plans does not do anything to address identification and may be threatening to the junior nurse as it could sound critical.

Rationale 3: Offering to look at the junior nurses work after it is written is the best approach because it encourages initiative without entirely stripping away the junior nurses sense of security. Suggesting the junior nurse is too dependent and cannot think for him or herself is a harsh confrontation of identification which will increase the junior nurses anxiety. Suggesting that the junior nurse needs to develop a personal plan helps clarify expectations but does not offer initial support. Offering a copy of plans does not do anything to address identification and may be threatening to the junior nurse as it could sound critical.

Rationale 4: Offering to look at the junior nurses work after it is written is the best approach because it encourages initiative without entirely stripping away the junior nurses sense of security. Suggesting the junior nurse is too dependent and cannot think for him or herself is a harsh confrontation of identification, which will increase the junior nurses anxiety. Suggesting that the junior nurse needs to develop a personal plan helps clarify expectations but does not offer initial support. Offering a copy of plans does not do anything to address identification and may be threatening to the junior nurse as it could sound critical.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Implement nursing intervention strategies specific to each defense-oriented behavior listed.

Question 24

Type: MCSA

A 22-year-old delivers a baby at home and calls the police who bring her to the psychiatric unit for an evaluation. The nurse learns that the mother is unwilling to accept the pregnancy and denies that she ever delivered a baby. The nurse continues to work with the client and establishes a trusting relationship. How should the nurse proceed in order to help the client?

1. Avoid talking about babies or deliveries in the clients presence.

2. Explore the protective functions of this behavior.

3. Discuss adoption proceedings.

4. Take the client to the nursery and show her the baby.

Correct Answer: 2

Rationale 1: Denial must be approached carefully as it serves to protect the client from overwhelming anxiety. Exploring the functions of denial will help the nurse understand the clients needs. Taking the client to the nursery would increase the clients anxiety as it is a direct challenge to her perception of reality. Avoiding talking about babies or deliveries would strengthen the clients pattern of denial. Discussion of adoption is inappropriate as the clients anxiety level is too high to make reasonable decisions that will affect her and her childs future.

Rationale 2: Denial must be approached carefully as it serves to protect the client from overwhelming anxiety. Exploring the functions of denial will help the nurse understand the clients needs. Taking the client to the nursery would increase the clients anxiety as it is a direct challenge to her perception of reality. Avoiding talking about babies or deliveries would strengthen the clients pattern of denial. Discussion of adoption is inappropriate as the clients anxiety level is too high to make reasonable decisions that will affect her and her childs future.

Rationale 3: Denial must be approached carefully as it serves to protect the client from overwhelming anxiety. Exploring the functions of denial will help the nurse understand the clients needs. Taking the client to the nursery would increase the clients anxiety as it is a direct challenge to her perception of reality. Avoiding talking about babies or deliveries would strengthen the clients pattern of denial. Discussion of adoption is inappropriate as the clients anxiety level is too high to make reasonable decisions that will affect her and her childs future.

Rationale 4: Denial must be approached carefully as it serves to protect the client from overwhelming anxiety. Exploring the functions of denial will help the nurse understand the clients needs. Taking the client to the nursery would increase the clients anxiety as it is a direct challenge to her perception of reality. Avoiding talking about babies or deliveries would strengthen the clients pattern of denial. Discussion of adoption is inappropriate as the clients anxiety level is too high to make reasonable decisions that will affect her and her childs future.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Implement nursing intervention strategies specific to each defense-oriented behavior listed.

Question 25

Type: MCSA

A client has received some bad news about a prognosis from the physician. When the nurse comes in with medications, the client states in an angry tone, Youre late; I was just about to call the hospital administrator to complain. The nurse is aware that the client received a disappointing prognosis and understands the behavior as displacement. The nurse is silent for a few moments to let the client collect some thoughts and control any feelings. Which response should the nurse make next?

1. You are really angry at your physician; why dont you tell the physician how you feel.

2. You must be really angry at me.

3. Im not late if I get this medication to you within thirty minutes of the scheduled time.

4. I know you heard some bad news today. I wonder if that could be bothering you.

Correct Answer: 4

Rationale 1: Acknowledging the clients prognosis will help the client examine thoughts and feelings more realistically and opens up the possibility for a discussion of anger. Stating that the client must be angry with the nurse, or defending the medication timetable, is self-focusing and does not recognize displacement. Suggesting that the client express anger to the physician shows a misunderstanding of the purpose of displacement and fails to focus on the clients thoughts and feelings.

Rationale 2: Acknowledging the clients prognosis will help the client examine thoughts and feelings more realistically and opens up the possibility for a discussion of anger. Stating that the client must be angry with the nurse, or defending the medication timetable, is self-focusing and does not recognize displacement. Suggesting that the client express anger to the physician shows a misunderstanding of the purpose of displacement and fails to focus on the clients thoughts and feelings.

Rationale 3: Acknowledging the clients prognosis will help the client examine thoughts and feelings more realistically and opens up the possibility for a discussion of anger. Stating that the client must be angry with the nurse, or defending the medication timetable, is self-focusing and does not recognize displacement. Suggesting that the client express anger to the physician shows a misunderstanding of the purpose of displacement and fails to focus on the clients thoughts and feelings.

Rationale 4: Acknowledging the clients prognosis will help the client examine thoughts and feelings more realistically and opens up the possibility for a discussion of anger. Stating that the client must be angry with the nurse, or defending the medication timetable, is self-focusing and does not recognize displacement. Suggesting that the client express anger to the physician shows a misunderstanding of the purpose of displacement and fails to focus on the clients thoughts and feelings.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Implement nursing intervention strategies specific to each defense-oriented behavior listed.

Question 26

Type: MCMA

A client reporting respiratory discomfort, dizziness, and becoming easily fatigued is given a diagnosis of cardiac neurosis. Which interventions would the nurse expect to be used with this client?

Standard Text: Select all that apply.

1. Psychiatric treatment

2. Weight control

3. Relaxation training

4. Biofeedback

5. Stress management

Correct Answer: 2,3,4,5

Rationale 1: Psychiatric treatment. Cardiac neurosis requires multifaceted treatment. Medical or surgical treatment can be used. There is no indication of the need for psychiatric treatment at this time.

Rationale 2: Weight control. Cardiac neurosis requires multifaceted treatment. Weight control can be used to control myriad related symptoms.

Rationale 3: Relaxation training. Cardiac neurosis requires multifaceted treatment. Relaxation training can be used.

Rationale 4: Biofeedback. Cardiac neurosis requires multifaceted treatment. Biofeedback can be used.

Rationale 5: Stress management. Cardiac neurosis requires multifaceted treatment. Stress management can be used.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Discuss common medical conditions with an onset or a course influenced by psychological and behavioral factors.

Question 27

Type: MCSA

A child with asthma was admitted to the hospital during an attack. The mother says, This is all my fault, if only I hadnt smoked when I was pregnant. Which response would be helpful to the mother?

1. Tell her not to worry because her smoking did not cause the childs asthma.

2. Explain that asthma involves a host of biological factors, of which heredity plays a large role.

3. Tell the mother that she should feel guilty, and find out if shes still smoking.

4. Ask why she believes that she caused the childs admission.

Correct Answer: 2

Rationale 1: Explaining that asthma is caused by many factors provides information that may allow the mother to relinquish some of her feelings of guilt. Telling the mother she did not cause the asthma is false reassurance. Asking the mother for a justification of her feelings is not helpful to her. Telling the mother she should feel guilty is blaming and shaming.

Rationale 2: Explaining that asthma is caused by many factors provides information that may allow the mother to relinquish some of her feelings of guilt. Telling the mother she did not cause the asthma is false reassurance. Asking the mother for a justification of her feelings is not helpful to her. Telling the mother she should feel guilty is blaming and shaming.

Rationale 3: Explaining that asthma is caused by many factors provides information that may allow the mother to relinquish some of her feelings of guilt. Telling the mother she did not cause the asthma is false reassurance. Asking the mother for a justification of her feelings is not helpful to her. Telling the mother she should feel guilty is blaming and shaming.

Rationale 4: Explaining that asthma is caused by many factors provides information that may allow the mother to relinquish some of her feelings of guilt. Telling the mother she did not cause the asthma is false reassurance. Asking the mother for a justification of her feelings is not helpful to her. Telling the mother she should feel guilty is blaming and shaming.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: Discuss common medical conditions with an onset or a course influenced by psychological and behavioral factors.

Question 28

Type: MCMA

A client with Crohns disease is seen in the nursing clinic following a recent flare-up. The client describes herself as married with no children and a hard-working elementary school teacher. Which questions asked by the nurse are an important part of this clients assessment?

Standard Text: Select all that apply.

1. What sort of coping mechanisms do you usually use?

2. Do you consider yourself to be hard-driving, ambitious, and competitive?

3. How are things at work for you at present?

4. What can you tell me about your relationship with your husband?

5. How do you feel about yourself in general?

Correct Answer: 1,3,4,5

Rationale 1: What sort of coping mechanisms do you usually use? Crohns disease is an inflammatory bowel disorder thought to be influenced by psychological factors. Assessment should focus on psychological factors such as the use of coping mechanisms that might contribute to the disorder. Some coping mechanisms might help feelings but aggravate the disorder.

Rationale 2: Do you consider yourself to be hard-driving, ambitious, and competitive? These described Type A traits are associated with cardiovascular disorders, not inflammatory bowel disease (IBD). Controversy exists regarding the relationship between personality traits and IBD.

Rationale 3: How are things at work for you at present? Crohns disease is an inflammatory bowel disorder thought to be influenced by psychological factors. Assessment should focus on psychological factors such as stress that might contribute to the disorder.

Rationale 4: What can you tell me about your relationship with your husband? Crohns disease is an inflammatory bowel disorder thought to be influenced by psychological factors. Assessment should focus on psychological factors such as interpersonal relationships that might contribute to the disorder.

Rationale 5: How do you feel about yourself in general? Crohns disease is an inflammatory bowel disorder thought to be influenced by psychological factors. Assessment should focus on psychological factors such as self-esteem that might contribute to the disorder.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Discuss common medical conditions with an onset or a course influenced by psychological and behavioral factors.

Question 29

Type: MCSA

The visiting nurse cares for an older client with rheumatoid arthritis. During a nurses visit to supervise the home health aide, the client reports a flare-up in symptoms and the pain medication is not helping. To plan continuing care for the client, it would be important to focus on:

1. Emotional issues and depression.

2. Environmental conditions, temperature, and humidity.

3. Medication tolerance and addiction.

4. Dietary changes.

Correct Answer: 1

Rationale 1: There is a strong connection between emotional life and rheumatoid arthritis. Stressors and depression are associated with flare-ups. This creates a cyclic experience in which depression, flare-ups, and loss of mobility compound and exacerbate. Dietary changes, environmental conditions, and medication issues are not the primary focus.

Rationale 2: There is a strong connection between emotional life and rheumatoid arthritis. Stressors and depression are associated with flare-ups. This creates a cyclic experience in which depression, flare-ups, and loss of mobility compound and exacerbate. Dietary changes, environmental conditions, and medication issues are not the primary focus.

Rationale 3: There is a strong connection between emotional life and rheumatoid arthritis. Stressors and depression are associated with flare-ups. This creates a cyclic experience in which depression, flare-ups, and loss of mobility compound and exacerbate. Dietary changes, environmental conditions, and medication issues are not the primary focus.

Rationale 4: There is a strong connection between emotional life and rheumatoid arthritis. Stressors and depression are associated with flare-ups. This creates a cyclic experience in which depression, flare-ups, and loss of mobility compound and exacerbate. Dietary changes, environmental conditions, and medication issues are not the primary focus.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: Discuss common medical conditions with an onset or a course influenced by psychological and behavioral factors.

Question 30

Type: MCSA

A nurse reviews the chart of a client seen at the nursing clinic for treatment of tension headache. Which client complaint did the nurse enter into the nursing record?

1. When the music plays so loud, my head starts to pound.

2. My whole cheek hurts, and it feels like I have bruising under my eye.

3. Usually there is just this steady pressure around my entire head.

4. I can tell its coming on; sometimes I vomit before it hits.

Correct Answer: 3

Rationale 1: Steady pressure in the head expresses the classic symptom of tension headache. Vomiting prior to the onset of the headache is more typical of a migraine. Facial pain could be expressing a disease-related headache. A headache after hearing loud music is more typical of a conversion headache.

Rationale 2: Steady pressure in the head expresses the classic symptom of tension headache. Vomiting prior to the onset of the headache is more typical of a migraine. Facial pain could be expressing a disease-related headache. A headache after hearing loud music is more typical of a conversion headache.

Rationale 3: Steady pressure in the head expresses the classic symptom of tension headache. Vomiting prior to the onset of the headache is more typical of a migraine. Facial pain could be expressing a disease-related headache. A headache after hearing loud music is more typical of a conversion headache.

Rationale 4: Steady pressure in the head expresses the classic symptom of tension headache. Vomiting prior to the onset of the headache is more typical of a migraine. Facial pain could be expressing a disease-related headache. A headache after hearing loud music is more typical of a conversion headache.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: Discuss common medical conditions with an onset or a course influenced by psychological and behavioral factors.

Kneisl, Contemporary Psychiatric-Mental Health Nursing, 3/e Test Bank

Copyright 2012 by Pearson Education, Inc.

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