Test Bank Psychiatric Mental Health Nursing Concepts of Care in Evidence-BasedPractice 10th Edition Townsend

Test Bank Psychiatric Mental Health Nursing Concepts of Care in Evidence-BasedPractice 10th Edition TownsendChapter 1. The Concept of Stress Adaptation MULTIPLE CHOICE 1. A client has experienced the death of a close family member and at the same time becomes unemployed. The client’s 6-month score on the Recent Life Changes Questionnaire is 110. The nurse: A. Understands the client is at risk for significant stress-related illness. B. C. D. Determines the client is not at risk for significant stress-related illness. Needs further assessment of the client’s coping skills to determine susceptibility to stress-related illness. Recognizes the client may view the losses as challenges and perceive them as opportunities. ANS: C C Chapter learning objective: Explain the relationship between stress and diseases of adaptation. Page: 5–6 Heading: Stress as an Environmental Event Integrated Processes: Nursing Process: Evaluation Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Stress Difficulty: Moderate Feedback 1 | P a g eA This is incorrect. Assessment is the first step of the nursing process. The nurse should assess the client’s coping skills and available support before determining susceptibility to stress-related physical and psychological illness. The Recent Life Changes Questionnaire is an expanded version of the Schedule of Recent Experiences and the Rahe- Holmes Social Readjustment Rating Scale. A 6-month score of 300 or more, or a year-score total of 500 or more, indicates high stress in a client’s life and susceptibility to stress-related illnesses. B This is incorrect. Assessment is the first step in the nursing process. The nurse should assess the client’s coping skills and available support before determining the client’s perception of the current stresses. A 6-month score of 300 or a year-score of 500 or more on the Recent Life Changes Questionnaire indicates high stress in a client’s life and susceptibility to stress- related physical and psychological illness. C This is correct. Assessment is the first step in the nursing process. The nurse should assess the client’s coping skills and available support before determining susceptibility to stress- related physical and psychological illness. A 6-month score of 300 or a year- score of 500 or more indicates high stress in a client’s life and risk for significant stress- related physical and psychological illness. 2 | P a g eD This is incorrect. Assessment is the first step in the nursing process. The nurse should assess the client’s coping skills and available support before determining susceptibility to stress-related illness. A 6- month score of 300 or a year-score of 500 or more on the Recent Life Changes Questionnaire indicates high stress in a client’s life is susceptible to significant stress-related physical and psychological illness. PTS: 1 2. CON: Stress A physically and emotionally healthy client has just been fired. During a routine office visit, he tells the nurse, “Perhaps this was the best thing to happen. Maybe I’ll consider pursuing an art degree.” The nurse determines the client perceives the stressor of his job loss as: A. Irrelevant. B. C. D. Harm/loss. A threat. A challenge. ANS: D Chapter: Chapter 0, The Concept of Stress Adaptation Chapter learning objective: Discuss adaptive coping strategies in the management of stress. Page: 7 Heading: Individual’s Perception of the Event > Primary Appraisal Integrated Processes: Nursing Process: Assessment Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Stress Difficulty: Easy Feedback A This is incorrect. The client’s statement indicates he perceives the loss of his job as a challenge and an opportunity for growth. 3 | P a g eB This is incorrect. The client’s statement indicates he perceives the loss of his job as a challenge and an opportunity for growth. C D This is incorrect. The client’s statement indicates he perceives the loss of his job as a challenge and an opportunity for growth. This is correct. The client’s statement indicates he perceives the loss of his job as a challenge and an opportunity for growth. PTS: 1 3. CON: Stress Which client statement alerts the nurse that the client may be responding maladaptively to stress? A. “Avoiding contact with others helps me cope.” 4 | P a g eB. “I really enjoy journaling; it’s my private time.” C. D. “I signed up for a yoga class this week.” “I made an appointment to meet with a therapist.” ANS: A Chapter: Chapter 0, The Concept of Stress Adaptation Chapter learning objective: Discuss adaptive coping strategies in the management of stress. Page: 8–9 Heading: Stress Management Integrated Processes: Nursing Process: Evaluation Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Stress Difficulty: Easy Feedback A This is correct. Reliance on social isolation as a coping mechanism is a maladaptive method to relieve stress. It can prevent learning appropriate coping skills and can prevent access to needed support systems. B C D This is incorrect. Journaling is not considered a maladaptive coping method. This is incorrect. Group exercise is not considered a maladaptive coping method. This is incorrect. Seeing a therapist is not considered a maladaptive coping method. PTS: 1 4. CON: Stress A nursing student comes down with a sinus infection toward the end of every semester. Which stage of stress is the student most likely experiencing when this occurs? A. Alarm reaction B. C. D. 5 | P a g e Resistance Exhaustion Fight or flightANS: C Chapter: Chapter 0, The Concept of Stress Adaptation Chapter learning objective: Explain the relationship between stress and diseases of adaptation. Page: 9 Heading: Stress as a Biological Response > Stage of Exhaustion Integrated Processes: Nursing Process: Assessment Client Need: Psychosocial Integrity Cognitive Level: Comprehension [Understanding] Concept: Stress Difficulty: Easy Feedback A This is incorrect. At the alarm reaction stage, physiological responses of the fight- or-flight syndrome are initiated. B This is incorrect. At the stage of resistance, the individual uses the physiological responses of the first stage as a defense in the attempt to adapt to the stressor. Physiological symptoms may disappear. C This is correct. At the stage of exhaustion, the student’s exposure to stress has been prolonged and adaptive energy has been depleted. Diseases of adaptation occur more frequently in this stage. D This is incorrect. The fight-or-flight syndrome occurs during the alarm reaction stage. PTS: 1 5. CON: Stress A school nurse is assessing a female high-school student who is overly concerned about her appearance. The client’s mother states, “That’s not something to be stressed about!” Which response by the nurse is best? A. “Teenagers! They don’t know a thing about real stress.” 6 | P a g eB. “Psychological or physical stress occur only when there is a loss.” C. D. “Poor physical condition can interfere with psychological well-being.” “A threat to self-esteem can result in psychological stress.” ANS: D Chapter: Chapter 0, The Concept of Stress Adaptation Chapter learning objective: Describe the core concept of stress as an environmental event. Page: 7 Heading: Stress as a Transaction Between the Individual and the Environment Integrated Processes: Nursing Process: Implementation Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Stress Difficulty: Moderate Feedback A B This is incorrect. This response is judgmental and nontherapeutic. This is incorrect. Physical and psychological stress can be precipitated by events other than loss. C This is incorrect. Stress can be physical or psychological in nature. A perceived threat to self-esteem can be as stressful as a physiological change. D This is correct. Determination of an event as stressful depends on the individual’s cognitive appraisal of the situation, which is an individual’s evaluation of the personal significance of the event or occurrence. Stress can be physical or psychological in nature. A perceived threat to self-esteem can be as stressful as a physiological change. PTS: 1 7 | P a g e CON: Stress6. A student confides in the school nurse that he is “stressed out” about deciding whether to go to college or work to provide income the family needs. Which coping strategy is the nurse’s best recommendation? A. Meditation B. C. D. Problem-solving training Relaxation Journaling ANS: B Chapter: Chapter 0, The Concept of Stress Adaptation Chapter learning objective: Discuss adaptive coping strategies in the management of stress. Page: 8 Heading: Stress Management Integrated Processes: Nursing Process: Implementation Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Stress Difficulty: Moderate Feedback A This is incorrect. The student must assess his or her situation and determine which coping strategy is best for him. B This is correct. The student must assess his or her situation and determine which coping strategy is best for him. Problem-solving training, by providing structure and objectivity, can assist in decision-making. C D This is incorrect. The student must assess his or her situation and determine which coping strategy is best for him. This is incorrect. The student must assess his or her situation and determine which coping strategy is best for him. PTS: 1 8 | P a g e CON: Stress7. An unemployed college graduate confides in the clinic nurse that she is experiencing severe anxiety over not finding a teaching position and that she is having difficulty with independent problem-solving. Which nursing intervention is best? A. Encourage her to use other coping mechanisms. B. C. D. Complete the problem-solving process for her. Assist her with the problem-solving process. Encourage her to keep a daily journal of feelings. ANS: C Chapter: Chapter 0, The Concept of Stress Adaptation Chapter learning objective: Discuss adaptive coping strategies in the management of stress. Page: 9 Heading: Stress Management Integrated Processes: Nursing Process: Implementation Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Stress Difficulty: Moderate Feedback A This is incorrect. The nurse should assist the client to problem-solve to determine the best coping strategy for her. B This is incorrect. Completing the client’s problem-solving does not provide the opportunity for her to utilize this coping strategy. C This is correct. Assist the client with problem- solving. During times of high anxiety and stress, clients will need more assistance in problem-solving and decision-making. 9 | P a g eD This is incorrect. The nurse should assist the client to problem solve to determine the best coping strategy for her. PTS: 1 8. CON: Stress The school nurse is assessing a female high school student who is distraught because her parents can’t afford horseback riding lessons. The nurse recognizes the student’s perception is that the problem is: A. Endangering her well-being. B. C. D. Personally relevant. Based on immaturity. Exceeds her capacity to cope. ANS: B Chapter: Chapter 0, The Concept of Stress Adaptation Chapter learning objective: Explain the concept of stress as a transaction between the individual and the environment. Page: 7 Heading: Stress as a Transaction Between the Individual and the Environment Integrated Processes: Nursing Process: Evaluation Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Stress Difficulty: Moderate Feedback A This is incorrect. An event becomes relevant to an individual when the outcome holds personal significance. B This is correct. Determination of an event as stressful depends on the individual’s cognitive appraisal of the situation. An event becomes relevant to an individual when the outcome holds personal significance. C This is incorrect. An event becomes relevant to an individual when the outcome holds 10 | P a g epersonal significance. D This is incorrect. An event becomes relevant to an individual when the outcome holds personal significance. PTS: 1 CON: Stress 9. Meditation has been shown to be an effective stress management technique. Which nursing assessment indicates meditation has been effective? A. An achieved state of relaxation B. C. D. An achieved insight into one’s feelings A demonstration of appropriate role behaviors An enhanced ability to problem-solve ANS: A Chapter: Chapter 0, The Concept of Stress Adaptation Chapter learning objective: Discuss adaptive coping strategies in the management of stress. Page: 8 Heading: Stress Management > Adaptive Coping Strategies Integrated Processes: Nursing Process: Evaluation Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Stress Difficulty: Easy Feedback A This is correct. Meditation produces relaxation by creating a special state of consciousness through focused concentration. 11 | P a g eB This is incorrect. Meditation does not necessarily produce an achieved insight into one’s feelings. C D This is incorrect. Meditation does not help to demonstrate appropriate role behaviors. This is incorrect. Meditation does not necessarily enhance one’s ability to solve problems. PTS: 1 CON: Stress 10. A first-time mother is crying and asks the nurse, “How can I go to work if I can’t afford child care?” Which is the nurse’s initial action to assist the client with problem-solving? A. Determine the risks and benefits for each alternative B. C. D. Formulate goals for resolution of the problem Evaluate the outcome of the implemented alternative Assess the facts of the situation ANS: D Chapter: Chapter 0, The Concept of Stress Adaptation Chapter learning objective: Discuss adaptive coping strategies in the management of stress. Page: 9 Heading: Stress Management >Adaptive Coping Strategies Integrated Processes: Nursing Process: Implementation Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Stress Difficulty: Easy Feedback A This is incorrect. Assessment is the first step of the nursing process. Before any other steps can be taken, accurate information about the situation must be gathered. 12 | P a g eB This is incorrect. Assessment is the first step of the nursing process. Before any other steps can be taken, accurate information about the situation must be gathered. 13 | P a g eC This is incorrect. Assessment is the first step of the nursing process. Before any other steps can be taken, accurate information about the situation must be gathered. D This is correct. Assessment is the first step of the nursing process. Before any other steps can be taken, accurate information about the situation must be gathered. PTS: 1 CON: Stress 11. A nursing instructor asks students when diseases of adaptation are likely to occur. Which student response indicates that teaching is effective? A. “When an individual has limited experience dealing with stress.” B. C. D. “When an individual inherits maladaptive genes.” “When an individual experiences existing conditions that exacerbate stress.” “When an individual’s physiological and psychological resources are depleted.” ANS: D Chapter: Chapter 0, The Concept of Stress Adaptation Chapter learning objective: Explain the relationship between stress and diseases of adaptation. Page: 4 Heading: Stress as a Biological Response Integrated Processes: Nursing Process: Evaluation Client Need: Psychological Integrity Cognitive Level: Comprehension [Understanding] Concept: Stress Difficulty: Easy Feedback 14 | P a g eA This is incorrect. Diseases of adaptation occur when the individual loses the capacity to adapt effectively because physiological and psychological resources have become depleted. This is referred to as the stage of exhaustion. 15 | P a g eB This is incorrect. Diseases of adaptation occur when the individual loses the capacity to adapt effectively because physiological and psychological resources have become depleted. This is referred to as the stage of exhaustion. C This is incorrect. Diseases of adaptation occur when the individual loses the capacity to adapt effectively because physiological and psychological resources have become depleted. This is referred to as the stage of exhaustion. D This is correct. Diseases of adaptation occur when the individual loses the capacity to adapt effectively because physiological and psychological resources have become depleted. This is referred to as the stage of exhaustion. PTS: 1 CON: Stress 12. When an individual’s stress response is sustained over a long period, the nurse anticipates which physiological effect? A. B. C. D. Decreased resistance to disease Increased libido Decreased blood pressure Increased inflammatory response ANS: A Chapter: Chapter 0, The Concept of Stress Adaptation Chapter learning objective: Identify physiological responses to stress. Page: 4 Heading: Stress as a Biological Response Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Comprehension [Understanding] Concept: Stress Difficulty: Moderate Feedback 16 | P a g eA This is correct. Selye’s general adaptation syndrome identified prolonged exposure to stress leads to a decreased immune response and resistance to disease. During the stage of exhaustion, the body’s compensatory mechanisms no longer function effectively and diseases of adaptation occur. B This is incorrect. Selye’s general adaptation syndrome identified prolonged exposure to stress leads to a decreased immune response and resistance to disease. During the stage of exhaustion, the body’s compensatory mechanisms no longer function effectively and diseases of adaptation occur. C This is incorrect. Selye’s general adaptation syndrome identified prolonged exposure to stress leads to a decreased immune response and resistance to disease. During the stage of exhaustion, the body’s compensatory mechanisms no longer function effectively and diseases of adaptation occur. D This is incorrect. Selye’s general adaptation syndrome identified prolonged exposure to stress leads to a decreased immune response and resistance to disease. During the stage of exhaustion, the body’s compensatory mechanisms no longer function effectively and diseases of adaptation occur. PTS: 1 13. flight response? A. B. C. D. 17 | P a g e CON: Stress The nurse identifies which symptom as typical of the fight-or- Decreased heart rate Increased peristalsis Increased salivation Pupil constrictionANS: B Chapter: Chapter 0, The Concept of Stress Adaptation Chapter learning objective: Identify physiological responses to stress. Page: 4 Heading: Stress as a Biological Response Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Comprehension [Understanding] Concept: Stress Difficulty: Easy Feedback A This is incorrect. During the fight-or-flight response, the heart rate increases in response to the release of epinephrine. Pupils dilate to enhance vision. Salivation and peristalsis decrease as the body slows unessential functions. B This is correct. During the fight-or-flight response, the heart rate increases in response to the release of epinephrine. Pupils dilate to enhance vision. Salivation and peristalsis decrease as the body slows unessential functions. C This is incorrect. During the fight-or-flight response, the heart rate increases in response to the release of epinephrine. Pupils dilate to enhance vision. Salivation and peristalsis decrease as the body slows unessential functions. D This is incorrect. During the fight-or-flight response, the heart rate increases in response to the release of epinephrine. Pupils dilate to enhance vision. Salivation and peristalsis decrease as the body slows unessential functions. 18 | P a g ePTS: 1 CON: Stress 14. A nurse is assessing a client’s response to stress. The nurse concludes that the client is performing a secondary appraisal of a stressful event when the client determines: A. The event is benign. B. C. D. The event is irrelevant. Resources are available. The event is pleasurable. ANS: C Chapter: Chapter 0, The Concept of Stress Adaptation Chapter learning objective: Explain the concept of stress as a transaction between the individual and the environment. Page: 7 Heading: Stress as a Transaction Between the Individual and the Environment > Individual’s Perception of the Event Integrated Processes: Nursing Process: Evaluation Client Need: Psychosocial Integrity Cognitive Level: Comprehension [Understanding] Concept: Stress Difficulty: Easy Feedback A This is incorrect. When the individual judges the resources and skills needed to deal with the event, the individual is conducting a secondary appraisal. There are three types of primary appraisals: irrelevant, benign- positive, and stressful. B This is incorrect. When the individual judges the resources and skills needed to deal with the event, the individual is conducting a secondary appraisal. There are three types of primary appraisals: irrelevant, benign- positive, and stressful. 19 | P a g eC This is correct. When the individual judges the resources and skills needed to deal with the event, the individual is conducting a secondary appraisal. There are three types of primary appraisals: irrelevant, benign- positive, and stressful. D This is incorrect. When the individual judges the resources and skills needed to deal with the event, the individual is conducting a secondary appraisal. There are three types of primary appraisals: irrelevant, benign- positive, and stressful. PTS: 1 CON: Stress 15. Miller and Rahe (1997) identified a correlation between the effects of life change and illness. This research led to the development of the Recent Life Changes Questionnaire (RLCQ). Which principle most limits the effectiveness of this tool? 20 | P a g eA. Specific physical and psychological illnesses are not identified. B. C. D. Numerical values associated with specific life events are randomly assigned. Stress is viewed as a solely physiological response. An individual’s personal perception of the event is excluded. ANS: D Chapter: Chapter 0, The Concept of Stress Adaptation Chapter learning objective: Explain the relationship between stress and diseases of adaptation. Page: 5–6 Heading: Stress as an Environmental Event Integrated Processes: Nursing Process: Evaluation Client Need: Psychosocial Integrity Cognitive Level: Comprehension [Understanding] Concept: Stress Difficulty: Easy Feedback A This is incorrect. Individuals differ in response to life events. The RLCQ uses a scale that does not take these differences into consideration. B This is incorrect. Individuals differ in response to life events. The RLCQ uses a scale that does not take these differences into consideration. C This is incorrect. Individuals differ in response to life events. The RLCQ uses a scale that does not take these differences into consideration. D This is correct. Individuals differ in response to life events. The RLCQ uses a scale that does not take these differences into 21 | P a g econsideration. PTS: 1 CON: Stress 16. A client tells the nurse, “I experience stress on a regular basis. Why do I feel this way?” Which is the nurse’s most appropriate response? A. “Genetics has nothing to do with your temperament or feelings.” B. C. D. “Your reactions to past experiences influence your current feelings.” “Your stress level is lower when you are in good physical health.” “You’ll experience less stress if you use appropriate coping skills.” ANS: B Chapter: Chapter 0, The Concept of Stress Adaptation Chapter learning objective: Explain the concept of stress as a transaction between the individual and the environment. Page: 7 Heading: Stress as a Transaction Between the Individual and the Environment > Predisposing Factors Integrated Processes: Nursing Process: Implementation Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Stress Difficulty: Moderate Feedback A This is incorrect. Past experiences are occurrences that result in learned patterns that can influence an individual’s current adaptation response. They include previous exposure to the stressor or other stressors in general, learned coping responses, and degree of adaptation to previous stressors. 22 | P a g eB This is correct. Past experiences are occurrences that result in learned patterns that can influence an individual’s current adaptation response. They include previous exposure to the stressor or other stressors in general, learned coping responses, and degree of adaptation to previous stressors. 23 | P a g eC This is incorrect. Past experiences are occurrences that result in learned patterns that can influence an individual’s current adaptation response. They include previous exposure to the stressor or other stressors in general, learned coping responses, and degree of adaptation to previous stressors. D This is incorrect. Past experiences are occurrences that result in learned patterns that can influence an individual’s current adaptation response. They include previous exposure to the stressor or other stressors in general, learned coping responses, and degree of adaptation to previous stressors. PTS: 1 CON: Stress 17. A nurse is providing education on anxiety and stress management. Which of the following should be identified as the most important initial step in learning how to manage anxiety? A. Diagnostic blood tests B. C. D. Awareness of factors creating stress Relaxation exercises Identification of support systems ANS: B Chapter: Chapter 0, The Core concept of Stress Adaptation Chapter learning objective: Discuss adaptive coping strategies in the management of stress. Page: 8 Heading: Stress Management > Adaptive Coping Strategies Integrated Processes: Teaching/Learning Client Need: Health Promotion and Maintenance Cognitive Level: Comprehension [Understanding] Concept: Stress Difficulty: Easy Feedback 24 | P a g eA This is incorrect. The initial step is awareness that stress is being experienced and awareness of factors that create stress. Diagnostic blood tests, identification of support systems, and relaxation exercises can be implemented after the client becomes aware of factors that create stress. B This is correct. The initial step is awareness that stress is being experienced and awareness of factors that create stress. Diagnostic blood tests, identification of support systems, and relaxation exercises can be implemented after the client becomes aware of factors that create stress. C This is incorrect. The initial step is awareness that stress is being experienced and awareness of factors that create stress. Diagnostic blood tests, identification of support systems, and relaxation exercises can be implemented after the client becomes aware of factors that create stress. D This is incorrect. The initial step is awareness that stress is being experienced and awareness of factors that create stress. Diagnostic blood tests, identification of support systems, and relaxation exercises can be implemented after the client becomes aware of factors that create stress. PTS: 1 CON: Stress 18. A 32-year-old woman is speaking to the office nurse at an initial visit. The nurse asked, “What brings you in today?” The woman replied, “I have been having headaches three to four times a week for the past month or so. I’m not sleeping well and feel tired most of the time. I work 60 hours per week and am going through a divorce.” The nurse determines the client’s symptoms represent which of the following? 25 | P a g eA. B. C. D. Adaptive coping Maladaptive coping Problem-solving Self-awareness ANS: B Chapter: Chapter 0, The Concept of Stress Adaptation Chapter learning objective: Define adaptation and maladaptation. Page: 8 Heading: Core Concepts Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Stress Difficulty: Easy Feedback A This is incorrect. When behavior disrupts the integrity of the individual, it is perceived as maladaptive. Maladaptive responses are considered negative or unhealthy. An adaptive response to stress is a behavior that maintains the integrity of the individual. B This is correct. When behavior disrupts the integrity of the individual, it is perceived as maladaptive. Maladaptive responses are considered negative or unhealthy. C This is incorrect. The client demonstrates a maladaptive response to stress. When behavior disrupts the integrity of the individual, it is perceived as maladaptive. Maladaptive responses are considered to be negative or unhealthy D This is incorrect. When behavior disrupts the integrity of the individual, it is perceived as maladaptive. Maladaptive responses are considered negative or unhealthy. An adaptive response to stress is a behavior that maintains 26 | P a g ethe integrity of the individual. PTS: 1 CON: Stress 19. The emergency department nurse is providing discharge instructions to a 23-year-old man who was injured in a motor vehicle crash. The client stated, “My heart was racing when I saw the car coming through the red light was going to hit me. I didn’t know my heart could go that fast!” Which is the nurse’s best response? A. “Don’t worry, your heart is strong because you are young and in good health.” B. “Everyone gets scared when they realize another car is going to hit them.” 27 | P a g eC. “You had a panic attack when you saw the car that hit you was not going to stop.” D. “Your body responded to the stress of knowing the car was going to hit you.” ANS: D Chapter: Chapter 0, The Concept of Stress Adaptation Chapter learning objective: Identify physiological responses to stress. Page: 3–4 Heading: Stress as a Biological Response Integrated Processes: Teaching/Learning Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Stress Difficulty: Moderate Feedback A B C This is incorrect. The nurse’s response in this example is nontherapeutic. This is incorrect. The nurse’s response does not explain the reason for the client’s rapid heart rate. This is incorrect. The client experienced a physical reaction to the stressor of the impending car crash. A stressor is a biological, psychological, social, or chemical factor that causes physical or emotional tension. The client’s increased heart rate was a physical response during the alarm reaction stage of the fight-or-flight syndrome. D This is correct. The client experienced a physical reaction to the stressor of the impending car crash. A stressor is a biological, psychological, social, or chemical factor that causes physical or emotional tension. The client’s increased heart rate was a physical response during the alarm reaction stage of the fight-or-flight syndrome. 28 | P a g ePTS: 1 CON: Stress 20. The nurse in the intensive care unit (ICU) is giving report to the nurse on the cardiac step-down unit. The nurse states, “The patient is a 48-year-old woman admitted 3 days ago for chest pain and a stent placement. Vital signs are stable, but I am worried about her stress level. She said she just moved here due to a job transfer and her husband stayed behind to sell the house. She told me they have a high insurance deductible and she is worried about the hospital bill.” Which factor has the most significant influence on the client’s health? A. Coping skills B. C. D. Existing conditions Individual vulnerability Perceived threat ANS: B Chapter: Chapter 0, The Concept of Stress Adaptation Chapter learning objective: Identify physiological responses to stress. Page: 7 Heading: Stress as a Transaction between the Individual and the Environment > Predisposing Factors Integrated Processes: Nursing Process: Assessment Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Stress Difficulty: Moderate Feedback A This is incorrect. Predisposing factors influence how an individual responds to a stressful event. Existing conditions incorporate vulnerabilities that influence the adequacy of an individual’s resources to deal with adaptive demands. Existing stressors are the recent move, loss of the support system, and financial concerns. 29 | P a g eB This is correct. Predisposing factors influence how an individual responds to a stressful event. Existing conditions incorporate vulnerabilities that influence the adequacy of an individual’s resources to deal with adaptive demands. Existing stressors are the recent move, loss of the support system, and financial concerns. 30 | P a g eC This is incorrect. Predisposing factors influence how an individual responds to a stressful event. Existing conditions incorporate vulnerabilities that influence the adequacy of an individual’s resources to deal with adaptive demands. Existing stressors are the recent move, loss of the support system, and financial concerns. D This is incorrect. Predisposing factors influence how an individual responds to a stressful event. Existing conditions incorporate vulnerabilities that influence the adequacy of an individual’s resources to deal with adaptive demands. Existing stressors are the recent move, loss of the support system, and financial concerns. PTS: 1 CON: Stress MULTIPLE RESPONSE 21. A nurse is interviewing a distressed client who reports being fired after 15 years of loyal employment. Which of the following questions best assists the nurse to determine the client’s appraisal of the situation? Select all that apply. A. “What resources have you used previously in stressful situations?” B. C. D. E. “Have you ever experienced a similar stressful situation?” “Who do you think is to blame for this situation?” “Why do you think you were fired from your job?” “What skills do you possess that might lead to gainful employment?” ANS: A, B, E Chapter: Chapter 0, The Concept of Stress Adaptation Chapter learning objective: Explain the concept of stress as a transaction 31 | P a g ebetween the individual and the environment. Page: 7–8 Heading: Stress as a Transaction Between the Individual and the Environment > Individual’s Perception of the Event Integrated Processes: Nursing Process: Assessment Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Stress Difficulty: Moderate Feedback 1. 2. 3. 4. This is correct. This question specifically addresses the client’s coping resources. This is correct. This question encourages the client to apply learning from past experiences. This is incorrect. Asking who is to blame does not assess coping abilities, but rather, encourages maladaptive behavior. This is incorrect. This question does not assess coping abilities. Requesting an explanation is a nontherapeutic block to communication. 5. This is correct. This question focuses on coping strategies and alternative methods for dealing with stress. PTS: 1 CON: Stress 22. A nurse is working with a client who has recently been under a great deal of stress. Which nursing recommendations would be most helpful to assist the client to cope with stress? Select all that apply. A. “Enjoy a pet.” B. C. D. E. ANS: A, B, C, D 32 | P a g e “Spend time with a loved one.” “Listen to music.” “Focus on the stressors.” “Journal your feelings.”Chapter: Chapter 0, The Concept of Stress Adaptation Chapter learning objective: Discuss adaptive coping strategies in the management of stress. Page: 8–9 Heading: Stress Management > Adaptive Coping Strategies Integrated Processes: Nursing Process: Implementation Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Stress Difficulty: Moderate Feedback 1. 2. 3. 4. 5. This is correct. Pets have been shown to decrease stress. This is correct. Healthy relationships have been shown to decrease stress. This is correct. Music has been shown to decrease stress. This is incorrect. Focusing on the stressors is more likely to increase stress. This is correct. Journaling feelings has been shown to decrease stress. PTS: 1 CON: Stress 23. A patient presents in the emergency department immediately following a shooting incident in a school where she has been teaching. There is no evidence of physical injury, but she appears very hyperactive and talkative. Which are common initial biological responses to stress? Select all that apply. A. Constricted pupils B. C. D. E. Watery eyes Unusual food cravings Increased heart rate Increased respirations ANS: B, D, E Chapter: Chapter 0, The Concept of Stress Adaptation Chapter learning objective: Identify physiological responses to stress. Page: 3–4 Heading: Stress as a Biological Response Integrated Processes: Nursing Process: 33 | P a g eAssessment Client Need: Physiological Integrity Cognitive Level: Analysis [Analyzing] Concept: Stress Difficulty: Moderate Feedback 1. This is incorrect. Dilated pupils, rather than constricted pupils, are related to the fight- or- flight syndrome. 34 | P a g e2. This is correct. Increased lacrimal secretions, increased heart rate, and increased respirations are identified as initial biological responses to stress. 3. This is incorrect. Unusual food cravings have not been identified as a typical biological response to stress. 4. This is correct. Increased lacrimal secretions, increased heart rate, and increased respirations are identified as initial biological responses to stress. 5. This is correct. Increased lacrimal secretions, increased heart rate, and increased respirations are identified as initial biological responses to stress. PTS: 1 24. CON: Stress Which concepts are included in Hobfoll’s Conservation of Resources theory? Select all that apply. A. B. C. D. E. Availability of resources Disequilibrium Genetics Past experiences Resilience ANS: A, C, D Chapter: Chapter 0, The Concept of Stress Adaptation Chapter learning objective: Explain the concept of stress as a transaction between the individual and the environment. Page: 7–8 Heading: Stress as a Transaction Between the Individual and the Environment Integrated Processes: Nursing Process: Assessment Client Need: Psychosocial Integrity Cognitive Level: Comprehension [Understanding] Concept: Stress 35 | P a g eDifficulty: Easy Feedback 36 | P a g e1. This is correct. Hobfoll’s Conservation of Resources theory asserts a variety of elements influence an individual’s perception and response to a stressful event. Predisposing factors strongly influence whether the response is adaptive or maladaptive. These include genetic influences, past experiences, and existing conditions. Available resources also affect an individual’s perception of adaptive capabilities. An individual who experiences stress in the present becomes more vulnerable to future stress when there is a loss or lack of resources. 2. 3. This is incorrect. Disequilibrium is not included as part of Hobfoll’s theory. This is correct. Hobfoll’s Conservation of Resources theory asserts a variety of elements influence an individual’s perception and response to a stressful event. Predisposing factors strongly influence whether the response is adaptive or maladaptive. These include genetic influences, past experiences, and existing conditions. Available resources also affect an individual’s perception of adaptive capabilities. An individual who experiences stress in the present becomes more vulnerable to future stress when there is a loss or lack of resources. 4. This is correct. Hobfoll’s Conservation of Resources theory asserts a variety of elements influence an individual’s perception and response to a stressful event. Predisposing factors strongly influence whether the response is adaptive or maladaptive. These include genetic influences, past experiences, and existing conditions. Available resources also affect an individual’s perception of adaptive capabilities. An individual who experiences stress in the present becomes more 37 | P a g evulnerable to future stress when there is a loss or lack of resources. 5. This is incorrect. Resilience is not included as part of Hobfoll’s theory. PTS: 1 CON: Stress ORDERED RESPONSE 25. Place the selected steps of the problem-solving process in the correct order. 1. Determine risks and benefits of each option. 2. Formulate goals to resolve the stressful situation. 3. Implement a second alternative. 4. Study the alternatives for dealing with the situation. ANS: The correct order is 2, 4, 1, 3 Chapter: Chapter 0, The Concept of Stress Adaptation Chapter learning objective: Discuss adaptive coping strategies in the management of stress. Page: 9 Heading: Stress Management > Adaptive Coping Strategies Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Comprehension [Understanding] Concept: Stress Difficulty: Easy Feedback: Problem-solving is an adaptive coping strategy in which an individual views the situation objectively and applies a decision-making model. The steps of the problem- solving process are: (1) Assessing the facts of the situation; (2) 38 | P a g eformulating goals for resolution of the stressful situation; (3) studying the alternatives for dealing with the situation; (4) determining the risks and benefits of each alternative; (5) selecting an alternative; (6) implementing the selected alternative; (7) evaluating the outcome of the alternative implemented; and (8) if the first choice is ineffective, selecting and implementing a second option. PTS: 1 CON: Stress Chapter 2. Mental Health and Mental Illness: Historical and Theoretical Concepts Multiple Choice Identify the choice that best completes the statement or answers the question. 1. A nurse is assessing a client who is experiencing occasional feelings of sadness because of the recent death of a beloved pet. The client’s appetite, sleep patterns, and daily routine have not changed. How should the nurse interpret the client’s behaviors? 39 | P a g e1. 2. 3. 4. The client’s behaviors demonstrate mental illness in the form of depression. The client’s behaviors are extensive, which indicates the presence of mental illness. The client’s behaviors are not congruent with cultural norms. The client’s behaviors demonstrate no functional impairment, indicating no mental illness. 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. 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. 3. 4. It is abnormal for identical twins to react differently to similar stressors. Identical twins should share the same temperament and respond similarly to stress. Environmental influences to stress weigh more heavily than genetic influences. 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. 5. A psychiatric nurse intern states, “This client’s use of defense mechanisms should be eliminated.” Which is a correct evaluation of this nurse’s statement? 1. Defense mechanisms can be appropriate responses to stress and need not be eliminated. 40 | P a g e2. 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. 41 | P a g e4. Defense mechanisms cause disintegration of the ego and should be fostered and encouraged. 6. During an intake assessment, a nurse asks both physiological and psychosocial questions. The client angrily responds, “I’m here for my heart, not my head problems.” Which is the nurse’s best response? 1. “It is just a routine part of our assessment. All clients are asked these same questions.” 2. 3. 4. “Why are you concerned about these types of questions?” “Psychological factors, like excessive stress, have been found to affect medical conditions.” “We can skip these questions, if you like. It isn’t imperative that we complete this section.” 7. An employee uses the defense mechanism of displacement when the boss openly disagrees with suggestions. What behavior would be expected from this employee? 1. The employee assertively confronts the boss. 2. 3. 4. The employee leaves the staff meeting to work out in the gym. The employee criticizes a coworker. The employee takes the boss out to lunch. 8. A fourth-grade boy teases and makes jokes about a cute girl in his class. This behavior should be identified by a nurse as indicative of which defense mechanism? 1. Displacement 2. Projection 3. 4. Reaction formation Sublimation 9. Which nursing statement about the concept of neurosis is most accurate? 1. 2. 3. 4. An individual experiencing neurosis is unaware that he or she is experiencing distress. An individual experiencing neurosis feels helpless to change his or her situation. An individual experiencing neurosis is aware of the psychological causes of his or her behavior. An individual experiencing neurosis has a loss of contact with reality. 10. Which nursing statement regarding the concept of psychosis is most accurate? 1. Individuals experiencing psychoses are aware that their behaviors are 42 | P a g emaladaptive. 43 | P a g e2. 3. 4. Individuals experiencing psychoses experience little distress. Individuals experiencing psychoses are aware of experiencing psychological problems. Individuals experiencing psychoses are based in reality. 11. When under stress, a client routinely uses alcohol to excess. Finding her drunk, her husband yells at the client about her chronic alcohol abuse. Which action alerts the nurse to the client’s use of the defense mechanism of denial? 1. The client hides liquor bottles in a closet. 2. 3. 4. The client yells at her son for slouching in his chair. The client burns dinner on purpose. The client says to the spouse, “I don’t drink too much!” 12. Devastated by a divorce from an abusive husband, a wife completes grief counseling. Which statement by the wife should indicate to a nurse that the client is in the acceptance stage of grief? 1. “If only we could have tried again, things might have worked out.” 2. 3. 4. “I am so mad that the children and I had to put up with him as long as we did.” “Yes, it was a difficult relationship, but I think I have learned from the experience.” “I still don’t have any appetite and continue to lose weight.” 13. A nurse is performing a mental health assessment on an adult client. According to Maslow’s hierarchy of needs, which client action would demonstrate the highest achievement in terms of mental health? 1. Maintaining a long-term, faithful, intimate relationship 2. Achieving a sense of self-confidence 3. Possessing a feeling of self-fulfillment and realizing full potential 4. Developing a sense of purpose and the ability to direct activities 14. According to Maslow’s hierarchy of needs, which situation on an inpatient psychiatric unit would require priority intervention by a nurse? 1. A client rudely complaining about limited visiting hours 2. A client exhibiting aggressive behavior toward another client 3. A client stating that no one cares 4. A client verbalizing feelings of failure 15. How would a nurse best complete the new DSM-5 definition of a mental disorder? “A health condition characterized by significant dysfunction in an individual’s 44 | P a g ecognitions, or behaviors that reflect a disturbance in …” which of the following? 1. Psychosocial, biological, or developmental process underlying mental functioning 2. 3. 4. Psychological, cognitive, or developmental process underlying mental functioning Psychological, biological, or developmental process underlying mental functioning Psychological, biological, or psychosocial process underlying mental functioning Multiple Response Identify one or more choices that best complete the statement or answer the question. 16. A nurse is assessing a client who appears to be experiencing some anxiety during questioning. Which symptoms might the client demonstrate that would indicate anxiety? (Select all that apply.) 1. Fidgeting 2. 3. 4. 5. Laughing inappropriately Palpitations Nail biting Limited attention span Completion Complete each statement. 17. is a diffuse apprehension that is vague in nature and is associated with feelings of uncertainty and helplessness. 18. is a subjective state of emotional, physical, and social responses to the loss of a valued entity. Chapter 0: Mental Health and Mental Illness Answer Section MULTIPLE CHOICE 1. ANS: 4 Chapter: Chapter 0, Mental Health and Mental Illness Objective: Discuss cultural elements that influence attitudes toward mental health and mental illness. Page: 9 Heading: Grief Integrated Processes: Nursing 45 | P a g eProcess Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Grief and Loss Difficulty: Easy 46 | P a g eFeedback 1 2 3 4 The client’s behaviors are to be expected in a time of grief. The client’s behaviors are not presented as being extensive. The client’s behaviors are to be expected after a loss. The nurse should assess that the client’s daily functioning is not impaired. The client who experiences feelings of sadness after the loss of a pet is responding within normal expectations. PTS: 1 2. CON: Grief and Loss ANS: 2 Chapter: Chapter 0, Mental Health and Mental Illness Objective: Define mental health and mental illness. Page: 3 Heading: Mental Illness Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Stress Difficulty: Easy Feedback 1 2 The client with a mental illness would have symptoms that reflect the DSM-5. 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. 3 4 The client’s ability to communicate distress would be considered a positive attribute. The use of defense mechanisms does not indicate that the client is at risk for mental illness. PTS: 1 3. CON: Stress ANS: 1 Chapter: Chapter 0, Mental Health and Mental Illness Objective: Identify physiological responses to stress. Page: 7 Heading: Physical and Psychological Responses to Stress > Mild Anxiety Integrated Processes: Nursing Process 47 | P a g eClient Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Growth and Development Difficulty: Easy Feedback 1 2 3 4 PTS: 1 4. The nurse should explain to the parents that, although the twins have identical DNA, there are several other factors that affect reactions to stress. It is considered normal for twins to react differently to stress. Identical twins do not necessarily respond similarly to stress, due to differences in temperament and personality. Environmental influences and temperament can affect stress reactions. CON: Growth and Development ANS: 1 Chapter: Chapter 0, Mental Health and Mental Illness Objective: Discuss cultural elements that influence attitudes toward mental health and mental illness. Page: 4 Heading: Box 1-1 Cultural Aspects of Mental Illness Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Culture Difficulty: Easy Feedback 1 2 3 4 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 to physical health. The homeless client may have difficulty accessing health care and may not place a high emphasis on mental health treatment. Women are more likely to seek treatment for mental health problems than men. This client is not typically as receptive to psychiatric treatment as the client of Jewish culture. PTS: 1 5. 48 | P a g e CON: Culture ANS: 1Chapter: Chapter 0, Mental Health and Mental Illness Objective: Identify physiological responses to stress. Page: 7 Heading: Physical and Psychological Responses to Stress > Mild Anxiety Cognitive Level: Application [Applying] Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Concept: Stress Difficulty: Moderate Feedback 1 2 3 4 The nurse should determine that defense mechanisms can be appropriate during times of stress. Defense mechanisms are not maladaptive attempts of the ego to manage anxiety. Defense mechanisms are a normal part of coping with stress. They are not used by individuals with weak ego integrity. They should not be discouraged and eliminated. Defense mechanisms are normal and are used by all individuals in some way during times of stress; they do not cause disintegration of the ego. PTS: 1 6. CON: Stress ANS: 3 Chapter: Chapter 0, Mental Health and Mental Illness Objective: Identify physiological responses to stress. Page: 9 Heading: Physical and Psychological Responses to Stress > Severe Anxiety Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Stress Difficulty: Easy Feedback 1 2 3 4 This statement is not therapeutic to the client. This statement is not therapeutic and may anger the client further. The nurse should attempt to educate the client on the negative effects of excessive stress on medical conditions. It is not appropriate to skip physiological and psychosocial questions, as this would lead to an inaccurate assessment. 49 | P a g ePTS: 1 CON: Stress 7. ANS: 3 Chapter: Chapter 0, Mental Health and Mental Illness Objective: Identify physiological responses to stress. Page: 7 Heading: Table 1-1 Ego Defense Mechanisms > Displacement Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Stress Difficulty: Easy Feedback 1 2 3 4 PTS: 1 8. Confronting others is not a behavior consistent with displacement. Leaving the staff meeting is not a behavior consistent with displacement. The nurse should expect that the client using the defense mechanism displacement would criticize a coworker after being confronted by the boss. Taking the boss out to lunch is not a behavior consistent with displacement. CON: Stress ANS: 3 Chapter: Chapter 0, Mental Health and Mental Illness Objective: Identify physiological responses to stress. Page: 7 Heading: Table 1-1 Ego Defense Mechanisms > Reaction Formation Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Stress Difficulty: Easy Feedback 1 2 3 Displacement refers to transferring feelings from one target to another. Projection refers to the attribution of unacceptable feelings or behaviors to another person. The nurse should identify that the boy is using reaction formation as a defense mechanism. Reaction formation is the attempt to prevent undesirable thoughts 50 | P a g efrom being expressed by expressing opposite thoughts or behaviors. 4 Sublimation refers to channeling unacceptable drives or impulses into more constructive, acceptable activities. PTS: 1 9. CON: Stress ANS: 2 Chapter: Chapter 0, Mental Health and Mental Illness Objective: Identify physiological responses to stress. Page: 9 Heading: Physical and Psychological Responses to Stress > Severe Anxiety Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Stress Difficulty: Easy Feedback 1 2 3 4 PTS: 1 10. The client is aware that he or she is experiencing distress. The client feels helpless to change his or her situation. The client is unaware of the psychological causes of the distress. The client experiences no loss of contact with reality. CON: Stress ANS: 2 Chapter: Chapter 0, Mental Health and Mental Illness Objective: Identify physiological responses to stress. Page: 6 Heading: Physical and Physiological Responses to Stress > Anxiety Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Stress Difficulty: Easy Feedback 1 2 The client with psychosis is unaware that his or her behavior is maladaptive. The nurse should understand that the client with psychosis experiences little distress owing to his or her lack of awareness of reality. 51 | P a g e3 4 PTS: 1 11. The client with psychosis is unaware he or she has a psychological problem. The client experiencing psychosis has a lack of awareness of reality. CON: Stress ANS: 4 Chapter: Chapter 0, Mental Health and Mental Illness Objective: Identify physiological responses to stress. Page: 7 Heading: Table 1-1 Ego Defense Mechanisms > Denial Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Addiction and Behaviors Difficulty: Easy Feedback 52 | P a g e1 2 3 4 This behavior does not indicate denial. Yelling at family members does not indicate denial. Burning dinner on purpose is not an action that indicates denial. The client’s statement “I don’t drink too much!” alerts the nurse to the use of the defense mechanism of denial. The client is refusing to acknowledge the existence of a real situation and the feelings associated with it. PTS: 1 12. CON: Addiction and Behaviors ANS: 3 Chapter: Chapter 0, Mental Health and Mental Illness Objective: Discuss the concepts of anxiety and grief as psychological responses to stress. Page: 10 Heading: Stages of Grief Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Analysis [Analyzing] Concept: Grief and Loss Difficulty: Easy Feedback 1 2 3 This statement indicates denial. This statement indicates anger. 4 PTS: 1 13. The nurse should evaluate that the client is in the acceptance stage of grief because during this stage of the grief process, the client would be able to focus on the reality of the loss and its meaning in relation to life. This statement indicates prolonged grieving. CON: Grief and Loss ANS: 3 Chapter: Chapter 0, Mental Health and Mental Illness Objective: Define mental health and mental illness. Page: 3 Heading: Mental Health Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Self 53 | P a g eDifficulty: Easy Feedback 1 This option is not the highest level on Maslow’s hierarchy of needs. 54 | P a g e2 3 While this option is important, it is not the highest level on Maslow’s hierarchy of needs. The nurse should identify that the client who possesses a feeling of self- fulfillment and realizes his or her full potential has achieved self-actualization, the highest level on Maslow’s hierarchy of needs. 4 This option is important for the development of the client, but is not the most important on Maslow’s hierarchy of needs. PTS: 1 14. CON: Self ANS: 2 Chapter: Chapter 0, Mental Health and Mental Illness Objective: Define mental health and mental illness. Page: 3 Heading: Mental Health Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Analysis [Analyzing] Concept: Stress Difficulty: Easy Feedback 1 2 Clients who complain are struggling with higher-level needs, such as the need for love and belonging or the need for self-esteem. The nurse should immediately intervene when a client exhibits aggressive behavior toward another client. Safety and security are considered lower-level needs according to Maslow’s hierarchy of needs and must be fulfilled before other higher-level needs can be met. 3 4 Clients who state that no one cares are struggling with higher-level needs such as the need for love and belonging or the need for self-esteem. Clients who have feelings of failure are struggling with higher-level needs, such as the need for love and belonging or the need for self-esteem. PTS: 1 55 | P a g e CON: Stress15. ANS: 3 Chapter: Chapter 0, Mental Health and Mental Illness Objective: Define mental health and mental illness. Page: 4 Heading: Mental Illness Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Patient-Centered Care Difficulty: Easy Feedback 1 2 3 This option in not part of the DSM-5 definition of a mental disorder. This option does not define the DSM-5’s mental disorder definition. The new DSM-5 definition of a mental disorder is “A health condition characterized by significant dysfunction in an individual’s cognitions, or behaviors that reflect a disturbance in the psychological, biological, or developmental process underlying mental functioning.” 4 This option is incorrect, because it does not meet the definition set by the DSM- 5 for mental health disorders. PTS: 1 CON: Patient-Centered Care MULTIPLE RESPONSE 16. ANS: 1, 2, 4 Chapter: Chapter 0, Mental Health and Mental Illness Objective: Discuss the concepts of anxiety and grief as psychological responses to stress. Page: 7 Heading: Physical and Physiological Responses to Stress > Mild Anxiety Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Stress Difficulty: Easy Feedback 1. 2. 3. 56 | P a g e This symptom is a sign of anxiety. This is a symptom that the nurse would expect in a client experiencing anxiety. The nurse would not expect the client to have palpitations.4. 5. PTS: 1 COMPLETION 17. This option indicates anxiety. Limited attention span does not indicate anxiety. CON: Stress ANS: Anxiety Chapter: Chapter 0, Mental Health and Mental Illness Objective: Discuss the concepts of anxiety and grief as psychological responses to stress. Page: 6 Heading: Core Concept > Anxiety Integrated Processes: Teaching and Learning Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Stress Difficulty: Easy Feedback: The definition of anxiety is a diffuse apprehension that is vague in nature and is associated with feelings of uncertainty and helplessness. Townsend considers this a core concept. PTS: 1 18. Grief Chapter: Chapter 0, Mental Health and Mental Illness Objective: Discuss the concepts of anxiety and grief as psychological responses to stress. Page: 9 Heading: Physical and Psychological Responses to Stress > Psychological Responses Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Appli