Essentials of Psychiatric Mental Health
Nursing Chapter 1
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 clients behaviors?
1. The client's behaviors demonstrate mental illness in the form of depression.
2. The clients behaviors are extensive, which indicates the presence of mental illness.
3. The clients behaviors are not congruent with cultural norms.
4. The client's behaviors demonstrate no functional impairment, indicating no mental illness. -
ANS-4. The client's behaviors demonstrate no functional impairment, indicating no mental
illness.
Rationale: 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. Without significant impairment, the clients distress does not indicate a mental
illness
\10. Which nursing statement regarding the concept of psychosis is most accurate?
1. Individuals experiencing psychoses are aware that their behaviors are maladaptive.
2. Individuals experiencing psychoses experience little distress.
3. Individuals experiencing psychoses are aware of experiencing psychological problems.
4. Individuals experiencing psychoses are based in reality - ANS-2. Individuals experiencing
psychoses experience little distress.
The nurse should understand that the client with psychosis experiences little distress owing to
his or her lack of awareness of reality. The client with psychosis is unaware that his or her
behavior is maladaptive or that he or she has a psychological problems
\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
clients use of the defense mechanism of denial?
1. The client hides liquor bottles in a closet.
2. The client yells at her son for slouching in his chair.
3. The client burns dinner on purpose.
4. The client says to the spouse, I dont drink too much! - ANS-4. The client says to the spouse, I
dont drink too much!
, Rationale: The clients statement I dont 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
\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. I am so mad that the children and I had to put up with him as long as we did.
3. Yes, it was a difficult relationship, but I think I have learned from the experience.
4. I still dont have any appetite and continue to lose weight. - ANS-3. Yes, it was a difficult
relationship, but I think I have learned from the experience.
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.
\13. A nurse is performing a mental health assessment on an adult client. According to Maslows
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. - ANS-3. Possessing a
feeling of self-fulfillment and realizing full potential.
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 Maslows hierarchy of
needs.
\14. According to Maslows hierarchy of needs, which situation on an in-patient 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. - ANS-2. A client exhibiting aggressive behavior toward
another client.
The nurse should immediately intervene when a client exhibits aggressive behavior toward
another client. Safety and security are considered lower-level needs according to Maslows
hierarchy of needs and must be fulfilled before other higher-level needs can be met. Clients who
complain, have feelings of failure, or 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.
Nursing Chapter 1
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 clients behaviors?
1. The client's behaviors demonstrate mental illness in the form of depression.
2. The clients behaviors are extensive, which indicates the presence of mental illness.
3. The clients behaviors are not congruent with cultural norms.
4. The client's behaviors demonstrate no functional impairment, indicating no mental illness. -
ANS-4. The client's behaviors demonstrate no functional impairment, indicating no mental
illness.
Rationale: 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. Without significant impairment, the clients distress does not indicate a mental
illness
\10. Which nursing statement regarding the concept of psychosis is most accurate?
1. Individuals experiencing psychoses are aware that their behaviors are maladaptive.
2. Individuals experiencing psychoses experience little distress.
3. Individuals experiencing psychoses are aware of experiencing psychological problems.
4. Individuals experiencing psychoses are based in reality - ANS-2. Individuals experiencing
psychoses experience little distress.
The nurse should understand that the client with psychosis experiences little distress owing to
his or her lack of awareness of reality. The client with psychosis is unaware that his or her
behavior is maladaptive or that he or she has a psychological problems
\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
clients use of the defense mechanism of denial?
1. The client hides liquor bottles in a closet.
2. The client yells at her son for slouching in his chair.
3. The client burns dinner on purpose.
4. The client says to the spouse, I dont drink too much! - ANS-4. The client says to the spouse, I
dont drink too much!
, Rationale: The clients statement I dont 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
\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. I am so mad that the children and I had to put up with him as long as we did.
3. Yes, it was a difficult relationship, but I think I have learned from the experience.
4. I still dont have any appetite and continue to lose weight. - ANS-3. Yes, it was a difficult
relationship, but I think I have learned from the experience.
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.
\13. A nurse is performing a mental health assessment on an adult client. According to Maslows
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. - ANS-3. Possessing a
feeling of self-fulfillment and realizing full potential.
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 Maslows hierarchy of
needs.
\14. According to Maslows hierarchy of needs, which situation on an in-patient 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. - ANS-2. A client exhibiting aggressive behavior toward
another client.
The nurse should immediately intervene when a client exhibits aggressive behavior toward
another client. Safety and security are considered lower-level needs according to Maslows
hierarchy of needs and must be fulfilled before other higher-level needs can be met. Clients who
complain, have feelings of failure, or 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.
