HC3B Exam 3 | Complete Solutions (Answered)

HC3B Exam 3 | Complete Solutions (Answered) A mature, professional couple plans a large wedding in city that is 100 miles from their home. Which response is most likely to be associated with this experience? A) Distress B) Eustress C) Acute stress D) Depersonalization A college student has been experiencing significant stress associated with academic demands. Last month, the student began attending yoga sessions three times a week. Which outcome indicates this activity has been successful? A) The student reports improved feelings of well-being B) The student increases the use of caffeine to enhance concentration C) The student reports, "Now I am sleeping about 10 hours every day." D) The student says, "I withdrew from two courses to reduce my academic load." An adult required a heart transplant 5 years ago. Multiple medical complications followed, resulting in persistent irritability, depression, and insomnia. The adult's spouse says, "I've walked on eggshells for five years, never knowing when something else will go wrong." What is the nurse's priority intervention regarding the spouse? A) Explore the spouse's feelings, showing care and compassion B) Encourage the spouse to attend a community support group C) Teach stress reduction and relaxation techniques to the spouse D) Refer the spouse to the primary care provider for health assessment A veteran of the war in Afghanistan tells the nurse, "Every day, something happens that makes me feel like I'm still there. My family has grown impatient with me. They say it's time for me to move on from that time in my life but I can't." What is the nurse's first priority? A) Assess the veteran for suicide risk B) Refer the veteran for specialized mental health services C) Assess the veteran for evidence of traumatic brain injury D) Refer the veteran's family to a posttraumatic stress disorder group A patient diagnosed with dissociative identity disorder is hospitalized on an acute care psychiatric unit after a suicide attempt. During a team meeting, which staff nurse's comment should prompt the nursing supervisor to intervene? A) "I have never taken care of a patient diagnosed with this disorder." B) "I think this patient was misdiagnosed and probably has schizophrenia." C) "I find myself more fascinated and engaged with this patient than others." D) "I recently read an autobiographical book about someone with this problem." Friends invite an adult diagnosed with type 2 diabetes to go on a mountain hike next week. The adult replies, "I can't go because I don't have any hiking shoes." In actuality, this adult fears difficulty with blood glucose management during strenuous activity. Which defense mechanism is evident? A) Displacement B) Rationalization C) Passive aggression D) Reaction formation Four adult patients describe frightening events that resulted in panic levels of anxiety/fear. Which patient's report most clearly indicates a reasonable fear response? A) "I saw a large spider crawling along my kitchen wall." B) "I was at the mall when a gunman began firing an assault weapon." C) "I was at home when a storm with heavy thunder and lightning lasted over an hour." D) "I was trapped in an elevator that stopped between floors when the power went out." A nursing student arrives late for a clinical experience and is not wearing the correct attire. When the instructor privately criticizes the behavior, the student responds, "I'm always the one who gets caught. You're going to cause me to fail." Select the instructor's best response. A) "Other students get caught as well." B) "I am not trying to cause you to fail. I am here to help you." C) "I am sorry you feel that way. I try to treat all my students equally." D) "The requirements for this experience were discussed during our orientation." Select the best example of altruism. A) After recovering from a gunshot wound, a police officer attends a local support group B) After recovering from open-heart surgery, an individual plays tennis three times a week C) An individual who received a liver transplant volunteers at a local organ procurement agency D) An individual with a long-standing fear of animals volunteers at a community animal shelter A disaster relief nurse has just arrived to help efforts after a tornado that destroys a town. Which approach would be most appropriate when talking with survivors? A) Provide active listening B) Help the survivors generate possible solutions C) Help the survivors develop self-awareness to understand their stress response D) Offer firm, short, simple statements and instructions A person shoplifts merchandise from a community cancer thrift shop. When confronted, the thief replies, "All this stuff was donated, so I can take it." This comment suggests features of which personality disorder? A) Antisocial B) Histrionic C) Borderline D) Schizotypal After a power outage, a facility must serve a dinner of sandwiches and fruit to patients. Which comment is most likely from a patient diagnosed with a narcissistic personality disorder? A) "These sandwiches are probably contaminated with bacteria." B) "I suppose it's the best we can hope for under these circumstances." C) "You should have ordered a to-go meal from a local restaurant for me." D) "I would rather wait to eat until the dietary department can prepare a meal." A nurse plans care for a patient diagnosed with borderline personality disorder. Which patient problem is most likely to apply to this patient? A) Ineffective relationships related to frequent splitting B) Social isolation related to fear of embarrassment or rejection C) Ineffective impulse control related to violence as evidenced by cruelty to animals D) Disturbed thought processes related to recurrent suspiciousness of people and situations The nurse assesses a new patient suspected of having a schizoid personality disorder. Which assessment question is this patient most likely to answer affirmatively? A) "Do some types of situations frighten you?" B) "Do you often have episodes of prolonged crying?" C) "Has anyone in your family ever been diagnosed with a mental illness?" D) "Is it ever very important for you to do everything correctly?" A mental health nurse assesses a patient diagnosed with an antisocial personality disorder. Which comorbid problem is most important for the nurse to include in the assessment? A) Generalized anxiety B) Alcohol or substance abuse use disorder C) Compulsions and phobias D) Dysfunctional sleep patterns While interacting with a 62-year-old adult diagnosed with a progressive neurocognitive disorder, the nurse observes that the adult has slow responses and difficulty finding the right words. What is the nurse's best initial action? A) Suggest words that the adult may be trying to remember B) Ask the adult, "Are you having problems saying what you mean?" C) Use silence to allow the adult an opportunity to compose responses D) Discontinue the interaction to prevent further frustration for the adult An adult diagnosed with stage 2 Alzheimer's disease begins a new prescription for rivastigmine (Exelon). Which nursing diagnosis has the highest priority to add to the plan of care? A) Risk for constipation B) Impaired perception C) Impaired oral mucous membranes D) Risk for impaired nutritional status Which newly hospitalized patient should the nurse monitor closely for the development of delirium? A) A 48-year-old who usually drinks a six-pack of beer daily B) A 68-year-old who takes aspirin 650 mg twice daily for arthritis pain C) A 72-year-old who says, "I have a glass of wine every evening to stimulate my appetite." D) A 78-year-old diabetic whose blood glucose levels are consistently greater than 250 mg/dL An 84-year-old tells the nurse, "I do four or five number puzzles every day to keep my brain healthy and sharp." When considering a holistic approach to maintaining mental health, the nurse should respond: A) "It is more important for you to have physical activity every day." B) "Let's think of some other activities we can add to your routine." C) "Repetition of the same activity is not helpful for keeping your brain healthy." D) "There are some herbal preparations that will also help keep your brain sharp." A family member asks the nurse, "I know my uncle's Alzheimer's disease has progressed but is there any medications that can help him now?" Which response by the nurse is correct? A) "I'm sorry, but there are no medications that help with severe Alzheimer's disease." B) "Alzheimer's disease sometimes stabilizes. Let's hope that happens in this situation." C) "There are a few medications that may help. Let's discuss it with the health care provider." D) "It sounds like you're having difficulty accepting that your uncle's disease is irreversible. Would you like to talk about those feelings?" What teaching will the nurse provide to an older adult who has a history of heat exhaustion? SATA. A) Take frequent rest breaks when doing activities B) Drink caffeinated beverages before going in the sun C) Wear dark clothing to protect the skin from burning D) Stay indoors in an air-conditioned room when possible E) Take warm baths or showers to regulate body temperature When caring for four clients, which does the nurse identify as at the highest risk for frostbite? A) 19-year-old who takes antihistamines B) 28-year-old who is a vegetarian C) 41-year-old who is being treated for hypothyroidism D) 57-year-old who drinks 4-5 beers per day For a client with OCD, which rationale explains the function of obsessions and compulsions? A) Unconscious control of acceptable feelings B) Intentional act to punish self for shortcomings C) Obedience to voices that direct behaviors D) Symbolic reenactment of punishing others Which personality disorder would the nurse suspect in a client telling a rambling, lengthy, unclear, and overly detailed story about their dog, who they say is president? SATA. A) Schizoid B) Paranoid C) Histrionic D) Borderline E) Narcissistic F) Schizotypal Which defense mechanism would be exhibited when a client with alcohol use disorder states, "I function better when I'm drinking than when I'm sober."? A) Sublimation B) Suppression C) Compensation D) Rationalization A student is anxious about an exam but is able to effectively study despite the roommate's loud music. Which level of anxiety does the student display? A) Mild B) Panic C) Severe D) Moderate Which explanation best describes what is known about the pathophysiology of dementia of the Alzheimer type? A) There is a genetic predisposition and dysregulation of neurotransmitters B) The dementia is transient and secondary to a physical imbalance disorder C) Hypoxia and decreased perfusion of select areas of the brain causes tissue damage D) The presence of amyloid plaques is associated with brain tissue destruction Which description of symptoms is consistent with dementia of the Alzheimer's type? A) Symptom onset is fairly rapid B) Symptoms will subside periodically C) Symptoms are triggered by a personal crisis D) Symptoms reflect progressive disintegration For a client with the diagnosis of borderline personality disorder, which problem is most likely to underlie angry or hostile behavior? A) Low self-esteem B) Inability to test reality C) Reaction to command hallucination D) Ineffective verbal communication A delirious client sees a design on the wallpaper and perceives it as an animal. Which positive symptom is the client experiencing? A) A delusion B) An illusion C) A hallucination D) An idea of reference Which assessment finding would the nurse observe in a client who has been found to have an antisocial personality disorder? A) Pays great attention to detail and demonstrates a high level of anxiety B) Has scars from self-mutilation and a history of many negative relationships C) Displays charm, has above-average intelligence, and tends to manipulate others D) Demonstrates suspiciousness, avoids eye contact, and engages in limited conversation A client who uses ritualistic behavior taps other clients on the shoulder three times as part of the ritual. Which rationale best explains the client's behavior? A) Client demonstrates blurred personality identity B) Client has poor control of sudden urges C) Client has a disturbance in spatial boundaries D) Client has limited ability to adapt to stressors Which description is correct for Alzheimer's disease? A) Emerges in the fourth decade of life B) Is a slow, relentless deterioration of the mind C) Is functional in origin and occurs in the later years D) Is diagnosed through lab and psychological tests Which term would the nurse use to describe the thought processes of a male client who insists that he is the commander of an alien spaceship despite repeated reality orientation? A) Illusion B) Delusion C) Confabulation D) Hallucination An older adult client reports flashbacks related to his experiences in Vietnam; he exhibits startle reactions and poor concentration. Which mental health disorder is associated with these symptoms? A) Schizophrenia B) Bipolar disorder C) PTSD D) OCD Which behavior is characteristic of panic during a crisis? A) Being physically immobile B) Sobbing for no apparent reason C) Difficulties with falling asleep D) Startling to loud noises and touch For a client with OCD, which rationale supports giving the client time to perform a specific ritual? A) It demonstrates respect for the client's autonomy B) This behavior is viewed as a result of anger turned inward C) Denying this activity may precipitate an increased level of anxiety D) Successful performance of independent activities enhances self-esteem Which characteristic distinguishes PTSD from other anxiety disorders? A) Lack of interest in family and others B) Reliving the trauma in dreams and flashbacks C) Avoidance of situations that resemble the stress D) Blunted affect when discussing the traumatic situation Which feelings are often the basis of OCD? A) Anxiety and guilt B) Anger and hostility C) Embarrassment and shame D) Hopelessness and powerlessness For a client with OCD, which rationale explains the function of obsessions and compulsions? A) Unconscious control of unacceptable feelings B) Intentional act to punish self for shortcomings C) Obedience to voices that direct behaviors D) Symbolic reenactment of punishing others For a client with OCD, which event will increase the client's anxiety level? A) The day progresses and the sun is close to setting B) Family members come to the unit to visit C) The nurse performs the morning physical assessment D) Limits are set on the performance of a ritual Which behavior is most typical for clients with borderline personality disorder? A) Arrogant B) Eccentric C) Impulsive D) Dependent Which term or description would the nurse use for a client who repeatedly performs ritualistic behaviors throughout the day to limit anxious feelings? A) Obsessions B) Compulsions C) Under personal control D) Related to rebelliousness For a client with OCD, which purpose is served by ritualistic behavior? A) The rituals are useless but uncontrollable B) Rituals lessens rigidity and inflexibility C) Ritualistic behavior decreases depression D) The rituals temporarily relieve anxiety Which benefit accompanies mild apprehension? A) Physiological functions are slowed B) There is an increase in alertness C) Behavioral responses become automatic D) Ego defense mechanisms are mobilized Which signs and symptoms are the 'four A's of Alzheimer's disease'? A) Amnesia, apraxia, agnosia, aphasia B) Avoidance, aloofness, asocial, asexual C) Autism, loose association, apathy, affect D) Aggressive, amoral, ambivalent, attractive Which characteristics usually accompany OCD? A) Marked emotional maturity B) Rapid, frequent mood swings C) Elaborate delusional systems D) Doubt, fears, and indecisiveness Which behavior is typical for antisocial personality disorder? A) Sexual acting out B) Disregard for others C) Loss of contact with reality D) Compulsive, repetitive behaviors Which signs and symptoms are characteristic of Alzheimer's dementia? SATA. A) Ambivalence B) Forgetfulness C) Flight of ideas D) Loose associations E) Expressive aphasia An obviously upset client comes to the mental health clinic and, after pushing ahead of the other clients, states, "I had an argument with my daughter, and now I'm tense, and worried, and angry." What level of anxiety does the nurse determine that the client is experiencing? A) Mild B) Panic C) Severe D) Moderate Compulsive behavior usually incorporates the use of which defense mechanism? A) Projection B) Regression C) Displacement D) Rationalization According to the DSM-5, which behaviors describe an individual with a cluster A personality disorder? A) Odd and eccentric B) Anxious and fearful C) Dramatic and erratic D) Hostile and impulsive A client, diagnosed with borderline personality disorder, declares that the whole staff is 'bad' after being disappointed by one staff member. Which defense mechanism is the client using? A) Splitting B) Rationalization C) Undoing D) Reaction formation Which defense mechanism is a client using when the client's hands are raw and bloody from a ritual involving frequent hand washing? A) Undoing B) Projection C) Introjection D) Suppression Which level of anxiety enhances the client's learning abilities? A) Mild B) Panic C) Severe D) Moderate A client has been diagnosed with generalized anxiety disorder (GAD). Which behavior would the nurse expect to observe? A) Making huge efforts to avoid 'any kind of bug or spider' B) Experiencing flashbacks to an event that involved a sexual attack C) Spending hours each day worrying about something 'bad happening' D) Becoming suddenly tachycardic and diaphoretic for no apparent reason Which primary purpose is served when an individual takes action to reduce anxiety? A) Reduction of tension B) Denial of the situation C) Avoidance of physical discomfort D) Resolution in decision-making The client can no longer recognize familiar objects such as his glasses and toothbrush. Which term describes these assessment findings? A) Apraxia B) Agnosia C) Aphasia D) Amnesia Which defense mechanism is considered a conscious measure that is used to cope with anxiety? A) Undoing B) Projection C) Suppression D) Intellectualization Which intervention is best for a client who has a borderline personality disorder? A) Establishing clear boundaries B) Exploring vocational possibilities C) Discussing feelings of being victimized D) Spending 1-2 hours per day with the client Which therapeutic technique can the nurse use when an anxious client exhibits pressured and rambling speech? A) Touch B) Silence C) Focusing D) Summarizing Before discharging an anxious client, which information about anxiety would the nurse teach the family? A) Anxiety is a totally unique feeling and experience B) Apprehension is generalized to the total environment C) Fears results from conscious actions, thoughts, and wishes D) Anxiety is a pattern of emotional and behavioral responses to stress Which physical manifestation would the nurse expect to observe if a client is anxious? A) Constricted pupils B) Narrowed bronchioles C) Decreased BP D) Increased blood glucose level Which defense mechanism is a client displaying when the client can no longer remember why an event was stressful, even though it happened just 3 days ago? A) Denial B) Regression C) Repression D) Dissociation Which defense mechanism is related to paranoid delusions? A) Projection B) Regression C) Repression D) Identification The nurse is meeting with a client on the psychiatric unit when another client diagnosed with antisocial personality disorder walks into the room and sits down. Which response by the nurse is best? A) "This client and I are talking. If you'd like to sit with us for awhile, you'll have to remain quiet." B) "Get out of this room! This is a private conversation!" C) "Do you have something you'd like to discuss?" D) "Right now we are talking. Please leave this room and I'll talk to you later." The nurse cares for a client with OCD. The nurse observes that the client has difficulty getting to meals on time because of a handwashing ritual. Which statement by the nurse is best? A) "Starting tomorrow, you can eat in your room." B) "I know you are feeling anxious, but it is important to eat properly." C) "Tomorrow, I will call you 15 minutes earlier to help you get ready." D) "It is important that you discuss this with your health care provider." The nurse orients the client to the unit. The nurse observes the client is pacing, talking rapidly, and has elevated respirations. Which action by the nurse is best? A) Provide an informational booklet B) Keep the explanation simple C) Delay the orientation until the anxiety has ceased D) Stress the positive aspects of the unit The nurse instructs the client's spouse about how to cope with the client's anxiety. The nurse determines teaching is successful if the spouse makes which statement? A) "Anxiety is a conscious means of resolving conflict." B) "Anxiety represents an unconscious conflict of needs." C) "It is important to confront my spouse during periods of anxiety." D) "Anxiety is increased by using defense mechanisms." One day a parent of an adolescent client diagnosed with antisocial personality disorder says to the nurse, "My child seems much better. I feel my child will finally grow up and assume responsibility for their own actions." What teaching is most important for the nurse to provide the parent? A) The client is not exhibiting any psychotic behaviors at this time, which means the client is in complete remission and the statement by the parent is absolutely true B) Psychotherapy is the only treatment that works, and family sessions are not recommended C) The prognosis is good because with medication and psychotherapy, the problem will be resolved D) The prognosis is doubtful because only some antisocial clients change their behavior, and consistently follow the treatment plan The client with a diagnosis if antisocial personality disorder fails to arrive on time for a scheduled appointment with the nurse. The nurse contacts the client to remind the client of the appointment, and the client states, "I would rather meet between 12 and 1." Which response by the nurse is best? A) "Perhaps we can make that change the next time." B) "Is there something you are having trouble discussing?" C) "I would have to discuss any changes with the team first." D) "Are you having some difficulty with the time you agreed to?" The nurse cares for clients in the mental health clinic. The client diagnosed with OCD tells the nurse of being afraid of contracting AIDS. The client reports spending much of the day washing the hands and spraying disinfectant in the room. The nurse understands this hand washing behavior represents which statement? A) A drive that needs to be denied B) A dissociative response to trauma C) A hidden wish to become ill and disabled D) A symbolic expression of conflict and guilt The nurse plans care for the client diagnosed with antisocial personality disorder. The nurse understands which is the purpose of group therapy for this client? A) To provide extra time to explore the client's past B) To demonstrate acceptance of the client and their behavior C) To set limits on the client in a non-punitive manner D) To encourage sublimation of the client's leadership potential The nurse cares for the client diagnosed with antisocial personality disorder. Which client statement best indicates improvement in the client's condition? A) "I get into trouble because I don't think before I act." B) "My parents have difficulty accepting my independence." C) "I've spent very little time actually enjoying life." D) "It's sad that others don't recognize my potential." The home care nurse makes an initial visit to the client diagnosed with an MI. The client's spouse states the family is having difficulty coping with the client's "obsessive-compulsive" tendencies. Which client statement is consistent with OCD? A) "I have difficulty making decisions and adjusting to change." B) "I am sure I am being followed by someone from work." C) "All of my life I've had problems with being unkempt." D) "I spend money excessively, which upsets my spouse." The nurse is interacting with the client diagnosed with OCD. The client says to the nurse, "I don't understand what is wrong with rules, organization, and schedules." The nurse understands the client uses defense mechanisms in order to accomplish which goal? A) To apply a logical approach to a need B) To provide a feeling of safety and protect the person's sense of self-worth C) To fragment the personality causing mental illness D) To bring suppressed material into awareness When developing the plan of care for a client diagnosed with a personality disorder, the nurse plans to assist the the client primarily with what factor? A) Specific dysfunctional behaviors B) Psychopharmacologic compliance C) Examination of developmental conflicts D) Manipulation of the environment A client is diagnosed with paranoid personality disorder is hospitalized for physically threatening his wife because he suspects her of having an affair with a coworker. What approach should the nurse employ with this client? A) Authoritarian B) Parental C) Matter of fact D) Controlling When planning care for a client diagnosed with schizotypal personality disorder, which intervention helps the client become involved with others? A) Participating solely in group activities B) Being involved with primarily one-to-one activities C) Leading a sing-along in the afternoon D) Attending an activity with the nurse A client diagnosed with paranoid personality disorder is being admitted on an involuntary 24-hour hold after a physical altercation with a police officer who was investigating the client's threatening phone calls to his neighbors. He states that his neighbors are spying on him for the government, saying, "I want them to stop and leave me alone. Now they have you nurses and doctors involved in their conspiracy." Which nursing approaches are most appropriate? SATA. A) Approach the client in a professional, matter-of-fact manner B) Avoid intrusive interactions with the client C) Gently present reality to counteract the client's current paranoid beliefs D) Develop trust consistently with the client E) Avoid pressuring the client to attend any groups A young adult client is admitted to a psychiatric unit with a diagnosis of alcohol abuse and personality disorder. The client's mother states, "He's always in trouble, just like when he was a boy. Now he's just a bigger prankster and out of control." In view of the client's history, which intervention is most important initially? A) Letting the client know the staff has the authority to subdue him if he gets unruly B) Keeping the client isolated from other clients until he is better known by the staff C) Emphasizing to the client that he will have to pay for any damage he causes D) Closely observing the client's behavior to establish a baseline pattern of functioning The nurse orients a UAP new to the mental health unit about the principles for the care of a client diagnosed with a personality disorder. What information should the nurse include? A) The clients are accepted, although their behavior may not be B) The clients need limits on their behavior C) The staff members are the primary ones left to care about these clients D) The staff should use minimal humor when working with these clients The nurse is talking with a client who has been diagnosed with antisocial personality disorder about how to socialize during activities without being seductive. The nurse should focus on the discussion on which area? A) Explaining the negative reactions of others toward his behavior B) Suggesting he apologize to others for his behavior C) Asking him to explain the reasons for his seductive behavior D) Discussing his relationship with his mother Which approach is most appropriate to use with a client diagnosed with narcissistic personality disorder when discrepancies exist between what the client states and what actually exists? A) Limit setting B) Supportive confrontation C) Consistency D) Rationalization The client with histrionic personality disorder is melodramatic and responds to others and situations in an exaggerated manner. The nurse should recommend which activity for this client? A) Party planning B) Music group C) Cooking class D) Role-playing An adolescent female client who has been treated for an anxiety disorder since middle school with behavioral treatment and as needed (PRN) anxiety medication is preparing to go to college. The parents are concerned that she will experience an exacerbation of symptoms if she attends college out of town and want their daughter to attend the local community college and live at home. The girl believes she can handle the challenge of