Scottsdale Community College Psych/Mental Health HESI
Questions With Complete Solutions
A client admitted to a mental health unit for treatment of
psychotic behavior spends hours at the locked exit door
shouting, "Let me out. There's nothing wrong with me. I don't
belong here." What defense mechanism is the client
implementing?
1. Denial
2. Projection
3. Regression
4. Rationalization Correct Answer 1. Denial
Rationale:
Denial is refusal to admit to a painful reality, which is treated as
if it does not exist. In projection, a person unconsciously rejects
emotionally unacceptable features and attributes them to other
persons, objects, or situations. Regression allows the client to
return to an earlier, more comforting, although less mature, way
of behaving. Rationalization is justifying illogical or
unreasonable ideas, actions, or feelings by developing
acceptable explanations that satisfy the teller and the listener.
A client being seen in the emergency department immediately
after being sexually assaulted appears calm and controlled. The
nurse analyzes this behavior as indicating which defense
mechanism?
1. Denial
2. Projection
,3. Rationalization
4. Intellectualization Correct Answer 1. Denial
Rational:
Denial is refusal to admit to a painful reality and may be a
response by a victim of sexual abuse. In this case the client is
not acknowledging the trauma of the assault either verbally or
nonverbally. Projection is transferring one's internal feelings,
thoughts, and unacceptable ideas and traits to someone else.
Rationalization is justifying the unacceptable attributes about
oneself. Intellectualization is the excessive use of abstract
thinking or generalizations to decrease painful thinking.
A client comes to the emergency department after an assault and
is extremely agitated, trembling, and hyperventilating. What is
the priority nursing action for this client?
1. Begin to teach relaxation techniques.
2. Encourage the client to discuss the assault.
3. Remain with the client until the anxiety decreases.
4. Place the client in a quiet room alone to decrease stimulation.
Correct Answer 3. Remain with the client until the anxiety
decreases.
Rationale:
This client is in a severe state of anxiety. When a client is in a
severe or panic state of anxiety, it is crucial for the nurse to
remain with the client. The client in a severe state of anxiety
would be unable to learn relaxation techniques. Discussing the
assault at this point would increase the client's level of anxiety
,further. Placing the client in a quiet room alone may also
increase the anxiety level.
A client diagnosed with delirium becomes disoriented and
confused at night. Which intervention should the nurse
implement initially?
1. Move the client next to the nurse's station.
2. Use an indirect light source and turn off the television.
3. Keep the television and a soft light on during the night.
4. Play soft music during the night, and maintain a well-lit room.
Correct Answer 2. Use an indirect light source and turn off the
television.
Rationale:
Provision of a consistent daily routine and a low stimulating
environment is important when a client is disoriented. Noise,
including radio and television, may add to the confusion and
disorientation. Moving the client next to the nurses' station may
become necessary but is not the initial action.
A client diagnosed with terminal cancer says to the nurse, "I'm
going to die, and I wish my family would stop hoping for a cure!
I get so angry when they carry on like this. After all, I'm the one
who's dying." Which response by the nurse is therapeutic?
1. "Have you shared your feelings with your family?"
2. "I think we should talk more about your anger with your
family."
3. "You're feeling angry that your family continues to hope for
you to be cured?"
, 4. "You are probably very depressed, which is understandable
with such a diagnosis." Correct Answer 3. "You're feeling
angry that your family continues to hope for you to be cured?"
Rationale:
Restating is a therapeutic communication technique in which the
nurse repeats what the client says to show understanding and to
review what was said. While it is appropriate for the nurse to
attempt to assess the client's ability to discuss feelings openly
with family members, it does not help the client discuss the
feelings causing the anger. The nurse's attempt to focus on the
central issue of anger is premature. The nurse would never make
a judgment regarding the reason for the client's feeling; this is
nontherapeutic in the one-to-one relationship.
A client experiencing a great deal of stress and anxiety is being
taught to use self-control therapy. Which statement by the client
indicates a need for further teaching about the therapy?
1. "This form of therapy can be applied to new situations."
2. "An advantage of this technique is that change is likely to
last."
3. "Talking to oneself is a basic component of this form of
therapy."
4. "This form of therapy provides a negative reinforcement
when the stimulus is produced." Correct Answer 4. "This
form of therapy provides a negative reinforcement when the
stimulus is produced."
Rationale:
Questions With Complete Solutions
A client admitted to a mental health unit for treatment of
psychotic behavior spends hours at the locked exit door
shouting, "Let me out. There's nothing wrong with me. I don't
belong here." What defense mechanism is the client
implementing?
1. Denial
2. Projection
3. Regression
4. Rationalization Correct Answer 1. Denial
Rationale:
Denial is refusal to admit to a painful reality, which is treated as
if it does not exist. In projection, a person unconsciously rejects
emotionally unacceptable features and attributes them to other
persons, objects, or situations. Regression allows the client to
return to an earlier, more comforting, although less mature, way
of behaving. Rationalization is justifying illogical or
unreasonable ideas, actions, or feelings by developing
acceptable explanations that satisfy the teller and the listener.
A client being seen in the emergency department immediately
after being sexually assaulted appears calm and controlled. The
nurse analyzes this behavior as indicating which defense
mechanism?
1. Denial
2. Projection
,3. Rationalization
4. Intellectualization Correct Answer 1. Denial
Rational:
Denial is refusal to admit to a painful reality and may be a
response by a victim of sexual abuse. In this case the client is
not acknowledging the trauma of the assault either verbally or
nonverbally. Projection is transferring one's internal feelings,
thoughts, and unacceptable ideas and traits to someone else.
Rationalization is justifying the unacceptable attributes about
oneself. Intellectualization is the excessive use of abstract
thinking or generalizations to decrease painful thinking.
A client comes to the emergency department after an assault and
is extremely agitated, trembling, and hyperventilating. What is
the priority nursing action for this client?
1. Begin to teach relaxation techniques.
2. Encourage the client to discuss the assault.
3. Remain with the client until the anxiety decreases.
4. Place the client in a quiet room alone to decrease stimulation.
Correct Answer 3. Remain with the client until the anxiety
decreases.
Rationale:
This client is in a severe state of anxiety. When a client is in a
severe or panic state of anxiety, it is crucial for the nurse to
remain with the client. The client in a severe state of anxiety
would be unable to learn relaxation techniques. Discussing the
assault at this point would increase the client's level of anxiety
,further. Placing the client in a quiet room alone may also
increase the anxiety level.
A client diagnosed with delirium becomes disoriented and
confused at night. Which intervention should the nurse
implement initially?
1. Move the client next to the nurse's station.
2. Use an indirect light source and turn off the television.
3. Keep the television and a soft light on during the night.
4. Play soft music during the night, and maintain a well-lit room.
Correct Answer 2. Use an indirect light source and turn off the
television.
Rationale:
Provision of a consistent daily routine and a low stimulating
environment is important when a client is disoriented. Noise,
including radio and television, may add to the confusion and
disorientation. Moving the client next to the nurses' station may
become necessary but is not the initial action.
A client diagnosed with terminal cancer says to the nurse, "I'm
going to die, and I wish my family would stop hoping for a cure!
I get so angry when they carry on like this. After all, I'm the one
who's dying." Which response by the nurse is therapeutic?
1. "Have you shared your feelings with your family?"
2. "I think we should talk more about your anger with your
family."
3. "You're feeling angry that your family continues to hope for
you to be cured?"
, 4. "You are probably very depressed, which is understandable
with such a diagnosis." Correct Answer 3. "You're feeling
angry that your family continues to hope for you to be cured?"
Rationale:
Restating is a therapeutic communication technique in which the
nurse repeats what the client says to show understanding and to
review what was said. While it is appropriate for the nurse to
attempt to assess the client's ability to discuss feelings openly
with family members, it does not help the client discuss the
feelings causing the anger. The nurse's attempt to focus on the
central issue of anger is premature. The nurse would never make
a judgment regarding the reason for the client's feeling; this is
nontherapeutic in the one-to-one relationship.
A client experiencing a great deal of stress and anxiety is being
taught to use self-control therapy. Which statement by the client
indicates a need for further teaching about the therapy?
1. "This form of therapy can be applied to new situations."
2. "An advantage of this technique is that change is likely to
last."
3. "Talking to oneself is a basic component of this form of
therapy."
4. "This form of therapy provides a negative reinforcement
when the stimulus is produced." Correct Answer 4. "This
form of therapy provides a negative reinforcement when the
stimulus is produced."
Rationale:
