f6
lOMoARc PSD|7906827
Essentialsf6off6Psychiatricf6Mentalf6Healthf6Nursingf68thf6Editionf6Conce
ptsf6off6f6Caref6inf6Evidencef6-
f6 Basedf6Practicef68thf6Editionf6Morganf6Townsend
Chapterf61.f6Mentalf6Healthf6andf6Men
talf6IllnessMultiplef6Choice
1. Af6nursef6isf6assessingf6af6clientf6whof6isf6experiencingf6occasionalf6feelingsf6off6sadnessf6
becausef6off6therecentf6deathf6off6af6belovedf6pet.f6Thef6clientsf6appetite,f6sleepf6patterns,f6a
ndf6dailyf6routinef6havef6notf6changed.f6Howf6shouldf6thef6nursef6interpretf6thef6clientsf6be
haviors?
1. Thef6clientsf6behaviorsf6demonstratef6mentalf6illnessf6inf6thef6formf6off6depression.
2. Thef6clientsf6behaviorsf6aref6extensive,f6whichf6indicatesf6thef6presencef6off6mentalf6illness.
3. Thef6clientsf6behaviorsf6aref6notf6congruentf6withf6culturalf6norms.
4. Thef6clientsf6behaviorsf6demonstratef6nof6functionalf6impairment,f6indicatingf6nof6m
entalf6illness.
,ANS:f64
Rationale:f6Thef6nursef6shouldf6assessf6thatf6thef6clientsf6dailyf6functioningf6isf6notf6impa
ired.f6Thef6clientwhof6experiencesf6feelingsf6off6sadnessf6afterf6thef6lossf6off6af6petf6isf6resp
ondingf6within
, f6
normalf6expectations.f6Withoutf6significantf6im p airment,f6thef6clientsf6distressf6doesf6no
l O M o A R c P S D | 7 9 0 6 8 2 7
tf6indicatef6af6mentalf6illness.
Cognitivef6Level:f6Analysisf6I
ntegratedf6Process:
Assessment
2. Atf6whatf6pointf6shouldf6thef6nursef6determinef6thatf6af6clientf6isf6atf6riskf6forf6deve
lopingf6af6mentalillness?
1. Whenf6thoughts,f6feelings,f6andf6behaviorsf6aref6notf6reflectivef6off6thef6DSM-5f6criteria.
2. Whenf6maladaptivef6responsesf6tof6stressf6aref6coupledf6withf6interferencef6inf
6dailyf6functioning.
3. Whenf6af6clientf6communicatesf6significantf6distress.
4. Whenf6af6clientf6usesf6defensef6mechanismsf6asf6egof6protection.
ANS:f62
Rationale:f6Thef6nursef6shouldf6determinef6thatf6thef6clientf6isf6atf6riskf6forf6mentalf6illnessf6wh
en
, f6
responsestof6stressf6aref6maladaptivef6andf6inte r f eref6withf6dailyf6functioning.f6Thef6DS
l O M o A R c PSD | 7 9 0 6 8 27
M-
5f6indicatesf6thatf6inf6ordertof6bef6diagnosedf6withf6af6mentalf6illness,f6dailyf6functioningf
6 mustf6bef6significantlyf6impaired.f6Thef6clientsf6abilityf6tof6communicatef6distressf6would
f6 bef6consideredf6af6positivef6attribute.
Cognitivef6Level:f6Applicatio
nf6Integratedf6Process:
Assessment
3. Af6nursef6isf6assessingf6af6setf6off615-year-
oldf6identicalf6twinsf6whof6respondf6veryf6differentlyf6tof6stress.Onef6twinf6becomesf6an
xiousf6andf6irritable,f6andf6thef6otherf6withdrawsf6andf6cries.f6Howf6shouldf6thef6nursef6
explainf6thesef6differentf6stressf6responsesf6tof6thef6parents?
1. Reactionsf6tof6stressf6aref6relativef6ratherf6thanf6absolute;f6individualf6responsesf6tof6
stressf6vary.
2. Itf6isf6abnormalf6forf6identicalf6twinsf6tof6reactf6differentlyf6tof6similarf6stressors.
3. Identicalf6twinsf6shouldf6sharef6thef6samef6temperamentf6andf6respondf6similarlyf6tof6stress.
4. Environmentalf6influencesf6tof6stressf6weighf6moref6heavilyf6thanf6geneticf6influences.
lOMoARc PSD|7906827
Essentialsf6off6Psychiatricf6Mentalf6Healthf6Nursingf68thf6Editionf6Conce
ptsf6off6f6Caref6inf6Evidencef6-
f6 Basedf6Practicef68thf6Editionf6Morganf6Townsend
Chapterf61.f6Mentalf6Healthf6andf6Men
talf6IllnessMultiplef6Choice
1. Af6nursef6isf6assessingf6af6clientf6whof6isf6experiencingf6occasionalf6feelingsf6off6sadnessf6
becausef6off6therecentf6deathf6off6af6belovedf6pet.f6Thef6clientsf6appetite,f6sleepf6patterns,f6a
ndf6dailyf6routinef6havef6notf6changed.f6Howf6shouldf6thef6nursef6interpretf6thef6clientsf6be
haviors?
1. Thef6clientsf6behaviorsf6demonstratef6mentalf6illnessf6inf6thef6formf6off6depression.
2. Thef6clientsf6behaviorsf6aref6extensive,f6whichf6indicatesf6thef6presencef6off6mentalf6illness.
3. Thef6clientsf6behaviorsf6aref6notf6congruentf6withf6culturalf6norms.
4. Thef6clientsf6behaviorsf6demonstratef6nof6functionalf6impairment,f6indicatingf6nof6m
entalf6illness.
,ANS:f64
Rationale:f6Thef6nursef6shouldf6assessf6thatf6thef6clientsf6dailyf6functioningf6isf6notf6impa
ired.f6Thef6clientwhof6experiencesf6feelingsf6off6sadnessf6afterf6thef6lossf6off6af6petf6isf6resp
ondingf6within
, f6
normalf6expectations.f6Withoutf6significantf6im p airment,f6thef6clientsf6distressf6doesf6no
l O M o A R c P S D | 7 9 0 6 8 2 7
tf6indicatef6af6mentalf6illness.
Cognitivef6Level:f6Analysisf6I
ntegratedf6Process:
Assessment
2. Atf6whatf6pointf6shouldf6thef6nursef6determinef6thatf6af6clientf6isf6atf6riskf6forf6deve
lopingf6af6mentalillness?
1. Whenf6thoughts,f6feelings,f6andf6behaviorsf6aref6notf6reflectivef6off6thef6DSM-5f6criteria.
2. Whenf6maladaptivef6responsesf6tof6stressf6aref6coupledf6withf6interferencef6inf
6dailyf6functioning.
3. Whenf6af6clientf6communicatesf6significantf6distress.
4. Whenf6af6clientf6usesf6defensef6mechanismsf6asf6egof6protection.
ANS:f62
Rationale:f6Thef6nursef6shouldf6determinef6thatf6thef6clientf6isf6atf6riskf6forf6mentalf6illnessf6wh
en
, f6
responsestof6stressf6aref6maladaptivef6andf6inte r f eref6withf6dailyf6functioning.f6Thef6DS
l O M o A R c PSD | 7 9 0 6 8 27
M-
5f6indicatesf6thatf6inf6ordertof6bef6diagnosedf6withf6af6mentalf6illness,f6dailyf6functioningf
6 mustf6bef6significantlyf6impaired.f6Thef6clientsf6abilityf6tof6communicatef6distressf6would
f6 bef6consideredf6af6positivef6attribute.
Cognitivef6Level:f6Applicatio
nf6Integratedf6Process:
Assessment
3. Af6nursef6isf6assessingf6af6setf6off615-year-
oldf6identicalf6twinsf6whof6respondf6veryf6differentlyf6tof6stress.Onef6twinf6becomesf6an
xiousf6andf6irritable,f6andf6thef6otherf6withdrawsf6andf6cries.f6Howf6shouldf6thef6nursef6
explainf6thesef6differentf6stressf6responsesf6tof6thef6parents?
1. Reactionsf6tof6stressf6aref6relativef6ratherf6thanf6absolute;f6individualf6responsesf6tof6
stressf6vary.
2. Itf6isf6abnormalf6forf6identicalf6twinsf6tof6reactf6differentlyf6tof6similarf6stressors.
3. Identicalf6twinsf6shouldf6sharef6thef6samef6temperamentf6andf6respondf6similarlyf6tof6stress.
4. Environmentalf6influencesf6tof6stressf6weighf6moref6heavilyf6thanf6geneticf6influences.
