Essentials of Psychiatric Mental Health Nursing 8th Edition Concepts of Care in Evidence- Based Practice 8th Edition Morgan Townsend Test Bank

2. At what point should the nurse determine that a client is at risk for developing a mental illness? 1.When thoughts, feelings, and behaviors are not reflective of the DSM-5 criteria. 2.When maladaptive responses to stress are coupled with interference in daily functioning. 3.When a client communicates significant distress. 4.When a client uses defense mechanisms as ego protection. ANS: 2 Rationale: The nurse should determine that the client is at risk for mental illness when responses to stress are maladaptive and interfere with daily functioning. The DSM-5 indicates that in order to be diagnosed with a mental illness, daily functioning must be significantly impaired. The clients ability to communicate distress would be considered a positive attribute. Cognitive Level: Application Integrated Process: Assessment 3. A nurse is assessing a set of 15-year-old identical twins who respond very differently to stress. One twin becomes anxious and irritable, and the other withdraws and cries. How should the nurse explain these different stress responses to the parents? 1.Reactions to stress are relative rather than absolute; individual responses to stress vary. 2.It is abnormal for identical twins to react differently to similar stressors. 3.Identical twins should share the same temperament and respond similarly to stress. 4.Environmental influences to stress weigh more heavily than genetic influences. ANS: 1 Rationale: The nurse should explain to the parents that, although the twins have identical DNA, there are several other factors that affect reactions to stress. Mental health is a state of being that is relative to the individual client. Environmental influences and temperament can affect stress reactions. Cognitive Level: Application Integrated Process: Implementation 4. Which client should the nurse anticipate to be most receptive to psychiatric treatment? 1.A Jewish, female social worker. 2.A Baptist, homeless male. 3.A Catholic, black male. 4.A Protestant, Swedish business executive. ANS: 1 Rationale: The nurse should anticipate that the client of Jewish culture would place a high importance on preventative health care and would consider mental health as equally important as physical health. Women are also more likely to seek treatment for mental health problems than men. Cognitive Level: Application Integrated Process: Planning 5.A psychiatric nurse intern states, This clients use of defense mechanisms should be eliminated. Which is a correct evaluation of this nurses statement? 1.Defense mechanisms can be appropriate responses to stress and need not be eliminated. 2.Defense mechanisms are a maladaptive attempt of the ego to manage anxiety and should always be eliminated. 3.Defense mechanisms, used by individuals with weak ego integrity, should be discouraged and not eliminated. ANS: 1 4.Defense mechanisms cause disintegration of the ego and should be fostered and encouraged. ANS: 1 Rationale: The nurse should determine that defense mechanisms can be appropriate during times of stress. The client with no defense mechanisms may have a lower tolerance for stress, thus leading to anxiety disorders. Defense mechanisms should be confronted when they impede the client from developing healthy coping skills. Cognitive Level: Application Integrated