Focus on Mental Health Exam
Questions & Answers 100% Verified
A nurse overhears a hospitalized client with mania telling another client, "I'm actually
a journalist writing an article for a magazine — I'm just posing as a person with
mental illness." How should the nurse respond? - ANSWER-Presenting the client
with the actual situation
Rationale: When dealing with a delusional client, it is important for the nurse to state
clearly that the nurse does not share the client's perceptions. All three of the other
options — ignoring the delusion, taking the client to a quiet room, and supporting the
client's denial of illness — do not focus on reality, and they ignore the issue.
Presenting the client with the actual situation helps orient the client to reality.
A client who is hallucinating fearfully says to the nurse, "Please tell that demon to get
out." How should the nurse respond to the client? - ANSWER-"I know you must be
very upset by this, but I don't see a demon."
Rationale: If the client hallucinates, it is best to provide reality-based perceptions and
not negate the client's experience, because this may lead to a regressive struggle
with the client. Giving advice or false reassurance is incorrect because such
techniques indicate that demons actually are present, which feeds into the client's
hallucination and reinforces the client's behavior.
The mother of a 3-year-old says, "My child hit his teddy bear after being scolded for
picking the neighbors' flowers." Which defense mechanism was the child using? -
ANSWER-Displacement
Rationale: The defense mechanism of displacement involves the discharge of
intense feelings for one person onto a less threatening substitute person or object to
satisfy an impulse. Projection involves attributing an attitude, behavior, or impulse to
someone else, such as that which occurs in blaming or scapegoating. Sublimation is
rechanneling an impulse into a more socially acceptable object. Identification
involves modeling behavior after someone else's.
A client says to the nurse, "Even though my husband and I keep telling them we
don't want to have children, our parents are pressuring us to 'start a family.' What
should we say to them?" Which of the following responses by the nurse is
therapeutic? - ANSWER-"This must be very difficult for both of you."
Rationale: Childless families may elect not to have children or to postpone having
them until they have established themselves occupationally or financially. Telling the
client to tell the parents that the couple can't have children is incorrect because the
client is being encouraged to lie about life decisions rather than helping the parents
understand the couple's choices. Asking how they usually cope with such
,interference is incorrect because it indicates that the nurse is judgmental and has
decided that the parents are interfering with the client and spouse. Saying, "Tell them
to have more children if they want them so badly," is incorrect because it is sarcastic
and ridicules the situation over which the client has expressed concerns.
A young adult client says, "I just can't seem to stop snapping at my parents. I know
they work hard to support me, but what do I do when they're so overbearing?" Which
responses by the nurse is therapeutic? - ANSWER-"Have you talked to your parents
about your frustrations?"
Rationale: The correct response is focused on the client's concerns and encourages
the therapeutic technique of formulating a plan of action. "It's important not to be
rude to your parents" and "You need to be more patient with your parents" are both
nontherapeutic, judgmental responses that do not encourage the client to further
explore her feelings and problem-solve. "Snapping at your parents is childish. How
could you?" is incorrect because it is sarcastic and condescending, which is
nontherapeutic.
A client says, "I have so much trouble caring for my husband's child from his first
marriage. I resent the money we have to pay for child support because we have to
deprive my own child of things. How can I stop feeling this way?" Which response by
the nurse is therapeutic? - ANSWER-"Have you shared your feelings with your
husband?"
Rationale: Remarried individuals often encounter problems as a result of the
stressors they bring into a marriage without prior discussion with the new partner.
Bonding sometimes does always occur when a child is not one's biological offspring.
The correct answer is focused on the client's feelings. "Your child benefits from
having a sibling" is not facilitative. "I wonder why you married him, knowing that he
wouldn't desert his biological child" is incorrect because it prejudges the client. "You
need to take a second job to give your child what you think she deserves" is not
open ended, does not facilitate feelings, and gives advice.
A client says to the nurse, "My wife retired last year from a lucrative law practice, and
I'm really discouraged. I'll be working until I die, even though I helped pay for her
education." Which response by the nurse is supportive? - ANSWER-"You sound very
troubled by this."
Rationale: Saying that the situation is unfair is judgmental and does not encourage
the client to express his feelings; nor does "That's such a tough break for you."
Suggesting that the husband approach the spouse for help is incorrect because it
prematurely gives advice, a nontherapeutic communication technique. The correct
option is focused on the client's feelings.
A gay man is brought to the emergency department by the police. The client tells the
nurse, "I was beaten up. I guess I just have to expect this kind of treatment for the
rest of my life." Which statement by the nurse is therapeutic? - ANSWER-"You feel
that being beaten up goes along with being gay?"
, Rationale: Many lesbians and gays encounter harassment or violence in the course
of their lives. "I think you should take some self-defense classes" is incorrect
because it advises the client, and giving advice is not therapeutic. "Maybe you
should be more discreet when you're in public" also gives advice and presumes that
the client has been indiscreet. "Why not try counseling to change your sexual
orientation?" is incorrect because it assumes that sexual orientation can or should be
changed. The correct option indicates reflection and is focused on the client's
feelings.
A client whose spouse recently died is experiencing dysfunctional grieving. Which
intervention has priority in the plan of care? - ANSWER-Assessing the client's risk for
violence toward self and others
Rationale: The priority intervention for a client with dysfunctional grieving is
assessment of the client's risk for violence toward self and others. Although the
nurse will assist the client in resolving the grief and monitor the client's sleep pattern,
these are not the priority interventions of the options given. Obtaining a prescription
for an antidepressant is not a priority.
A nurse develops a plan of care for a client in whom AIDS was recently diagnosed.
The client is experiencing difficulty adjusting to the illness. Which interventions are
appropriate for this client? Select all that apply. - ANSWER-Assisting the client in
verbalizing fears
Helping the client identify sources of hope
Monitoring the client for signs of self-harm
Assisting the client with problem-solving and decision-making
Rationale: Assisting the client with problem-solving and decision-making, helping the
client verbalize fears, helping the client identify sources of hope, and monitoring the
client for signs of self-harm are all appropriate interventions. In planning care for a
client having difficulty adjusting to an illness, the nurse develops interventions to
promote social networking that will provide needed support and information to the
client.
An emergency department nurse is caring for an older client who is a victim of
physical abuse. List in order of priority the following nursing actions, with number 1
representing the first action and number 4 the last. - ANSWER-1. Checking the client
for physical injuries
2. Contacting the appropriate state officials to report the abuse
3. Contacting a social worker to assist in planning care for the client
4. Calling a member of the clergy to address the client's spiritual needs
Rationale: The priority intervention in the event of physical abuse is to check the
client for physical injuries. The nurse should then fulfill the legal obligation of
reporting suspected elder abuse. The next action is to contact the social worker to
obtain assistance in planning care for the client. The client may need the social
worker's help with housing as well. Last, a referral to a member of the clergy is an
appropriate intervention if the client desires it.
Questions & Answers 100% Verified
A nurse overhears a hospitalized client with mania telling another client, "I'm actually
a journalist writing an article for a magazine — I'm just posing as a person with
mental illness." How should the nurse respond? - ANSWER-Presenting the client
with the actual situation
Rationale: When dealing with a delusional client, it is important for the nurse to state
clearly that the nurse does not share the client's perceptions. All three of the other
options — ignoring the delusion, taking the client to a quiet room, and supporting the
client's denial of illness — do not focus on reality, and they ignore the issue.
Presenting the client with the actual situation helps orient the client to reality.
A client who is hallucinating fearfully says to the nurse, "Please tell that demon to get
out." How should the nurse respond to the client? - ANSWER-"I know you must be
very upset by this, but I don't see a demon."
Rationale: If the client hallucinates, it is best to provide reality-based perceptions and
not negate the client's experience, because this may lead to a regressive struggle
with the client. Giving advice or false reassurance is incorrect because such
techniques indicate that demons actually are present, which feeds into the client's
hallucination and reinforces the client's behavior.
The mother of a 3-year-old says, "My child hit his teddy bear after being scolded for
picking the neighbors' flowers." Which defense mechanism was the child using? -
ANSWER-Displacement
Rationale: The defense mechanism of displacement involves the discharge of
intense feelings for one person onto a less threatening substitute person or object to
satisfy an impulse. Projection involves attributing an attitude, behavior, or impulse to
someone else, such as that which occurs in blaming or scapegoating. Sublimation is
rechanneling an impulse into a more socially acceptable object. Identification
involves modeling behavior after someone else's.
A client says to the nurse, "Even though my husband and I keep telling them we
don't want to have children, our parents are pressuring us to 'start a family.' What
should we say to them?" Which of the following responses by the nurse is
therapeutic? - ANSWER-"This must be very difficult for both of you."
Rationale: Childless families may elect not to have children or to postpone having
them until they have established themselves occupationally or financially. Telling the
client to tell the parents that the couple can't have children is incorrect because the
client is being encouraged to lie about life decisions rather than helping the parents
understand the couple's choices. Asking how they usually cope with such
,interference is incorrect because it indicates that the nurse is judgmental and has
decided that the parents are interfering with the client and spouse. Saying, "Tell them
to have more children if they want them so badly," is incorrect because it is sarcastic
and ridicules the situation over which the client has expressed concerns.
A young adult client says, "I just can't seem to stop snapping at my parents. I know
they work hard to support me, but what do I do when they're so overbearing?" Which
responses by the nurse is therapeutic? - ANSWER-"Have you talked to your parents
about your frustrations?"
Rationale: The correct response is focused on the client's concerns and encourages
the therapeutic technique of formulating a plan of action. "It's important not to be
rude to your parents" and "You need to be more patient with your parents" are both
nontherapeutic, judgmental responses that do not encourage the client to further
explore her feelings and problem-solve. "Snapping at your parents is childish. How
could you?" is incorrect because it is sarcastic and condescending, which is
nontherapeutic.
A client says, "I have so much trouble caring for my husband's child from his first
marriage. I resent the money we have to pay for child support because we have to
deprive my own child of things. How can I stop feeling this way?" Which response by
the nurse is therapeutic? - ANSWER-"Have you shared your feelings with your
husband?"
Rationale: Remarried individuals often encounter problems as a result of the
stressors they bring into a marriage without prior discussion with the new partner.
Bonding sometimes does always occur when a child is not one's biological offspring.
The correct answer is focused on the client's feelings. "Your child benefits from
having a sibling" is not facilitative. "I wonder why you married him, knowing that he
wouldn't desert his biological child" is incorrect because it prejudges the client. "You
need to take a second job to give your child what you think she deserves" is not
open ended, does not facilitate feelings, and gives advice.
A client says to the nurse, "My wife retired last year from a lucrative law practice, and
I'm really discouraged. I'll be working until I die, even though I helped pay for her
education." Which response by the nurse is supportive? - ANSWER-"You sound very
troubled by this."
Rationale: Saying that the situation is unfair is judgmental and does not encourage
the client to express his feelings; nor does "That's such a tough break for you."
Suggesting that the husband approach the spouse for help is incorrect because it
prematurely gives advice, a nontherapeutic communication technique. The correct
option is focused on the client's feelings.
A gay man is brought to the emergency department by the police. The client tells the
nurse, "I was beaten up. I guess I just have to expect this kind of treatment for the
rest of my life." Which statement by the nurse is therapeutic? - ANSWER-"You feel
that being beaten up goes along with being gay?"
, Rationale: Many lesbians and gays encounter harassment or violence in the course
of their lives. "I think you should take some self-defense classes" is incorrect
because it advises the client, and giving advice is not therapeutic. "Maybe you
should be more discreet when you're in public" also gives advice and presumes that
the client has been indiscreet. "Why not try counseling to change your sexual
orientation?" is incorrect because it assumes that sexual orientation can or should be
changed. The correct option indicates reflection and is focused on the client's
feelings.
A client whose spouse recently died is experiencing dysfunctional grieving. Which
intervention has priority in the plan of care? - ANSWER-Assessing the client's risk for
violence toward self and others
Rationale: The priority intervention for a client with dysfunctional grieving is
assessment of the client's risk for violence toward self and others. Although the
nurse will assist the client in resolving the grief and monitor the client's sleep pattern,
these are not the priority interventions of the options given. Obtaining a prescription
for an antidepressant is not a priority.
A nurse develops a plan of care for a client in whom AIDS was recently diagnosed.
The client is experiencing difficulty adjusting to the illness. Which interventions are
appropriate for this client? Select all that apply. - ANSWER-Assisting the client in
verbalizing fears
Helping the client identify sources of hope
Monitoring the client for signs of self-harm
Assisting the client with problem-solving and decision-making
Rationale: Assisting the client with problem-solving and decision-making, helping the
client verbalize fears, helping the client identify sources of hope, and monitoring the
client for signs of self-harm are all appropriate interventions. In planning care for a
client having difficulty adjusting to an illness, the nurse develops interventions to
promote social networking that will provide needed support and information to the
client.
An emergency department nurse is caring for an older client who is a victim of
physical abuse. List in order of priority the following nursing actions, with number 1
representing the first action and number 4 the last. - ANSWER-1. Checking the client
for physical injuries
2. Contacting the appropriate state officials to report the abuse
3. Contacting a social worker to assist in planning care for the client
4. Calling a member of the clergy to address the client's spiritual needs
Rationale: The priority intervention in the event of physical abuse is to check the
client for physical injuries. The nurse should then fulfill the legal obligation of
reporting suspected elder abuse. The next action is to contact the social worker to
obtain assistance in planning care for the client. The client may need the social
worker's help with housing as well. Last, a referral to a member of the clergy is an
appropriate intervention if the client desires it.
