Test Bank For Psychiatric Mental Health Nursing: Concepts Of Care In Evidence-Based Practice, 8th Edition
Get ahead in your studies with Test Bank For Psychiatric Mental Health Nursing: Concepts Of Care In Evidence-Based Practice, 8th Edition, featuring exam-focused questions and solutions.
Madison Taylor
Contributor
4.0
94
4 months ago
Preview (31 of 428)
Sign in to access the full document!
Chapter 1. The Concept of Stress Adaptation
Chapter 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. This situation has resulted in a 6-month score of 110 on the Recent Life Changes
Questionnaire. How should the nurse evaluate this client data?
A. The client is experiencing severe distress and is at risk for physical and psychological illness.
B. A score of 110 on the Miller and Rahe Recent Life Changes Questionnaire indicates no significant
threat of stress-related illness.
C. Susceptibility to stress-related physical or psychological illness cannot be estimated without
knowledge of coping resources and available supports.
D. The client may view these losses as challenges and perceive them as opportunities.
ANS: C
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. However, positive
coping mechanisms and strong social support can limit susceptibility to stress-related illnesses.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client
Need: Psychosocial Integrity
2. A physically and emotionally healthy client has just been fired. During a routine office visit he
states to a nurse: “Perhaps this was the best thing to happen. Maybe I’ll look into pursuing an art
degree.” How should the nurse characterize the client’s appraisal of the job loss stressor?
A. Irrelevant
B. Harm/loss
C. Threatening
D. Challenging
Chapter 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. This situation has resulted in a 6-month score of 110 on the Recent Life Changes
Questionnaire. How should the nurse evaluate this client data?
A. The client is experiencing severe distress and is at risk for physical and psychological illness.
B. A score of 110 on the Miller and Rahe Recent Life Changes Questionnaire indicates no significant
threat of stress-related illness.
C. Susceptibility to stress-related physical or psychological illness cannot be estimated without
knowledge of coping resources and available supports.
D. The client may view these losses as challenges and perceive them as opportunities.
ANS: C
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. However, positive
coping mechanisms and strong social support can limit susceptibility to stress-related illnesses.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client
Need: Psychosocial Integrity
2. A physically and emotionally healthy client has just been fired. During a routine office visit he
states to a nurse: “Perhaps this was the best thing to happen. Maybe I’ll look into pursuing an art
degree.” How should the nurse characterize the client’s appraisal of the job loss stressor?
A. Irrelevant
B. Harm/loss
C. Threatening
D. Challenging
Chapter 1. The Concept of Stress Adaptation
Chapter 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. This situation has resulted in a 6-month score of 110 on the Recent Life Changes
Questionnaire. How should the nurse evaluate this client data?
A. The client is experiencing severe distress and is at risk for physical and psychological illness.
B. A score of 110 on the Miller and Rahe Recent Life Changes Questionnaire indicates no significant
threat of stress-related illness.
C. Susceptibility to stress-related physical or psychological illness cannot be estimated without
knowledge of coping resources and available supports.
D. The client may view these losses as challenges and perceive them as opportunities.
ANS: C
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. However, positive
coping mechanisms and strong social support can limit susceptibility to stress-related illnesses.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client
Need: Psychosocial Integrity
2. A physically and emotionally healthy client has just been fired. During a routine office visit he
states to a nurse: “Perhaps this was the best thing to happen. Maybe I’ll look into pursuing an art
degree.” How should the nurse characterize the client’s appraisal of the job loss stressor?
A. Irrelevant
B. Harm/loss
C. Threatening
D. Challenging
Chapter 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. This situation has resulted in a 6-month score of 110 on the Recent Life Changes
Questionnaire. How should the nurse evaluate this client data?
A. The client is experiencing severe distress and is at risk for physical and psychological illness.
B. A score of 110 on the Miller and Rahe Recent Life Changes Questionnaire indicates no significant
threat of stress-related illness.
C. Susceptibility to stress-related physical or psychological illness cannot be estimated without
knowledge of coping resources and available supports.
D. The client may view these losses as challenges and perceive them as opportunities.
ANS: C
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. However, positive
coping mechanisms and strong social support can limit susceptibility to stress-related illnesses.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client
Need: Psychosocial Integrity
2. A physically and emotionally healthy client has just been fired. During a routine office visit he
states to a nurse: “Perhaps this was the best thing to happen. Maybe I’ll look into pursuing an art
degree.” How should the nurse characterize the client’s appraisal of the job loss stressor?
A. Irrelevant
B. Harm/loss
C. Threatening
D. Challenging
ANS: D
The client perceives the situation of job loss as a challenge and an opportunity for growth.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client
Need: Psychosocial Integrity
3. Which client statement should alert a nurse that a client may be responding maladaptively to
stress?
A. “I’ve found that avoiding contact with others helps me cope.”
B. “I really enjoy journaling; it’s my private time.”
C. “I signed up for a yoga class this week.”
D. “I made an appointment to meet with a therapist.”
ANS: A
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.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client
Need: Psychosocial Integrity
4. A nursing student finds that she comes down with a sinus infection toward the end of every
semester. When this occurs, which stage of stress is the student most likely experiencing?
A. Alarm reaction stage
B. Stage of resistance
C. Stage of exhaustion
D. Fight-or-flight stage
ANS: C
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.
The client perceives the situation of job loss as a challenge and an opportunity for growth.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client
Need: Psychosocial Integrity
3. Which client statement should alert a nurse that a client may be responding maladaptively to
stress?
A. “I’ve found that avoiding contact with others helps me cope.”
B. “I really enjoy journaling; it’s my private time.”
C. “I signed up for a yoga class this week.”
D. “I made an appointment to meet with a therapist.”
ANS: A
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.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client
Need: Psychosocial Integrity
4. A nursing student finds that she comes down with a sinus infection toward the end of every
semester. When this occurs, which stage of stress is the student most likely experiencing?
A. Alarm reaction stage
B. Stage of resistance
C. Stage of exhaustion
D. Fight-or-flight stage
ANS: C
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.
ANS: D
The client perceives the situation of job loss as a challenge and an opportunity for growth.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client
Need: Psychosocial Integrity
3. Which client statement should alert a nurse that a client may be responding maladaptively to
stress?
A. “I’ve found that avoiding contact with others helps me cope.”
B. “I really enjoy journaling; it’s my private time.”
C. “I signed up for a yoga class this week.”
D. “I made an appointment to meet with a therapist.”
ANS: A
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.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client
Need: Psychosocial Integrity
4. A nursing student finds that she comes down with a sinus infection toward the end of every
semester. When this occurs, which stage of stress is the student most likely experiencing?
A. Alarm reaction stage
B. Stage of resistance
C. Stage of exhaustion
D. Fight-or-flight stage
ANS: C
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.
The client perceives the situation of job loss as a challenge and an opportunity for growth.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client
Need: Psychosocial Integrity
3. Which client statement should alert a nurse that a client may be responding maladaptively to
stress?
A. “I’ve found that avoiding contact with others helps me cope.”
B. “I really enjoy journaling; it’s my private time.”
C. “I signed up for a yoga class this week.”
D. “I made an appointment to meet with a therapist.”
ANS: A
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.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client
Need: Psychosocial Integrity
4. A nursing student finds that she comes down with a sinus infection toward the end of every
semester. When this occurs, which stage of stress is the student most likely experiencing?
A. Alarm reaction stage
B. Stage of resistance
C. Stage of exhaustion
D. Fight-or-flight stage
ANS: C
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.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client
Need: Psychosocial Integrity
5. 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 is the
most appropriate nursing response?
A. “Teenagers! They don’t know a thing about real stress.”
B. “Stress occurs only when there is a loss.”
C. “When you are in poor physical condition, you can’t experience psychological well-being.”
D. “Stress can be psychological. A threat to self-esteem may result in high stress levels.”
ANS: D
Stress can be physical or psychological in nature. A perceived threat to self-esteem can be as stressful
as a physiological change.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation
| Client Need: Psychosocial Integrity
6. A bright student confides in the school nurse about conflicts related to attending college or
working to add needed financial support to the family. Which coping strategy is most appropriate for
the nurse to recommend to the student at this time?
A. Meditation
B. Problem-solving training
C. Relaxation
D. Journaling
ANS: B
The student must assess his or her situation and determine the best course of action. Problem-solving
training, by providing structure and objectivity, can assist in decision making.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation
| Client Need: Psychosocial Integrity
Need: Psychosocial Integrity
5. 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 is the
most appropriate nursing response?
A. “Teenagers! They don’t know a thing about real stress.”
B. “Stress occurs only when there is a loss.”
C. “When you are in poor physical condition, you can’t experience psychological well-being.”
D. “Stress can be psychological. A threat to self-esteem may result in high stress levels.”
ANS: D
Stress can be physical or psychological in nature. A perceived threat to self-esteem can be as stressful
as a physiological change.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation
| Client Need: Psychosocial Integrity
6. A bright student confides in the school nurse about conflicts related to attending college or
working to add needed financial support to the family. Which coping strategy is most appropriate for
the nurse to recommend to the student at this time?
A. Meditation
B. Problem-solving training
C. Relaxation
D. Journaling
ANS: B
The student must assess his or her situation and determine the best course of action. Problem-solving
training, by providing structure and objectivity, can assist in decision making.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation
| Client Need: Psychosocial Integrity
7. An unemployed college graduate is experiencing severe anxiety over not finding a teaching
position and has difficulty with independent problem-solving. During a routine physical examination,
the graduate confides in the clinic nurse. Which is the most appropriate nursing intervention?
A. Encourage the student to use the alternative coping mechanism of relaxation exercises.
B. Complete the problem-solving process for the client.
C. Work through the problem-solving process with the client.
D. Encourage the client to keep a journal.
ANS: C
During times of high anxiety and stress, clients will need more assistance in problem-solving and
decision making.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation
| Client Need: Psychosocial Integrity
8. A school nurse is assessing a distraught female high school student who is overly concerned
because her parents can’t afford horseback riding lessons. How should the nurse interpret the
student’s reaction to her perceived problem?
A. The problem is endangering her well-being.
B. The problem is personally relevant to her.
C. The problem is based on immaturity.
D. The problem is exceeding her capacity to cope.
ANS: B
Psychological stressors to self-esteem and self-image are related to how the individual perceives the
situation or event. Self-image is of particular importance to adolescents, who feel entitled to have all
the advantages that other adolescents experience.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client
Need: Psychosocial Integrity
position and has difficulty with independent problem-solving. During a routine physical examination,
the graduate confides in the clinic nurse. Which is the most appropriate nursing intervention?
A. Encourage the student to use the alternative coping mechanism of relaxation exercises.
B. Complete the problem-solving process for the client.
C. Work through the problem-solving process with the client.
D. Encourage the client to keep a journal.
ANS: C
During times of high anxiety and stress, clients will need more assistance in problem-solving and
decision making.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation
| Client Need: Psychosocial Integrity
8. A school nurse is assessing a distraught female high school student who is overly concerned
because her parents can’t afford horseback riding lessons. How should the nurse interpret the
student’s reaction to her perceived problem?
A. The problem is endangering her well-being.
B. The problem is personally relevant to her.
C. The problem is based on immaturity.
D. The problem is exceeding her capacity to cope.
ANS: B
Psychological stressors to self-esteem and self-image are related to how the individual perceives the
situation or event. Self-image is of particular importance to adolescents, who feel entitled to have all
the advantages that other adolescents experience.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client
Need: Psychosocial Integrity
9. Meditation has been shown to be an effective stress management technique. When meditation is
effective, what should a nurse expect to assess?
A. An achieved state of relaxation
B. An achieved insight into one’s feelings
C. A demonstration of appropriate role behaviors
D. An enhanced ability to problem-solve
ANS: A
Meditation produces relaxation by creating a special state of consciousness through focused
concentration.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client
Need: Psychosocial Integrity
10. A distraught, single, first-time mother cries and asks a nurse, “How can I go to work if I can’t
afford childcare?” What is the nurse’s initial action in assisting the client with the problem-solving
process?
A. Determine the risks and benefits for each alternative.
B. Formulate goals for resolution of the problem.
C. Evaluate the outcome of the implemented alternative.
D. Assess the facts of the situation.
ANS: D
Before any other steps can be taken, accurate information about the situation must be gathered and
assessed.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation
| Client Need: Psychosocial Integrity
11. A nursing instructor is asking students about diseases of adaptation and when they are likely to
occur. Which student response indicates that learning has occurred?
effective, what should a nurse expect to assess?
A. An achieved state of relaxation
B. An achieved insight into one’s feelings
C. A demonstration of appropriate role behaviors
D. An enhanced ability to problem-solve
ANS: A
Meditation produces relaxation by creating a special state of consciousness through focused
concentration.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client
Need: Psychosocial Integrity
10. A distraught, single, first-time mother cries and asks a nurse, “How can I go to work if I can’t
afford childcare?” What is the nurse’s initial action in assisting the client with the problem-solving
process?
A. Determine the risks and benefits for each alternative.
B. Formulate goals for resolution of the problem.
C. Evaluate the outcome of the implemented alternative.
D. Assess the facts of the situation.
ANS: D
Before any other steps can be taken, accurate information about the situation must be gathered and
assessed.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation
| Client Need: Psychosocial Integrity
11. A nursing instructor is asking students about diseases of adaptation and when they are likely to
occur. Which student response indicates that learning has occurred?
Loading page 6...
A. “When an individual has limited experience dealing with stress”
B. “When an individual inherits maladaptive genes”
C. “When an individual experiences existing conditions that exacerbate stress”
D. “When an individual’s physiological and psychological resources have become depleted”
ANS: D
During the stage of exhaustion of the general adaptation syndrome, the individual loses the capacity
to adapt effectively because physiological and psychological resources have become depleted. This is
the time when diseases of adaptation may occur.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client
Need: Health Promotion and Maintenance
12. When an individual’s stress response is sustained over a long period of time, which physiological
effect of the endocrine system should a nurse anticipate?
A. Decreased resistance to disease
B. Increased libido
C. Decreased blood pressure
D. Increased inflammatory response
ANS: A
In a general adaptation syndrome, prolonged exposure to stress leads to the stage of exhaustion at
which time the body’s compensatory mechanisms no longer function effectively and diseases of
adaptation occur. A decreased immune response is seen at this stage.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client
Need: Physiological Integrity
13. Which symptom should a nurse identify as typical of the “fight-or-flight” response?
A. Pupil constriction
B. Increased heart rate
B. “When an individual inherits maladaptive genes”
C. “When an individual experiences existing conditions that exacerbate stress”
D. “When an individual’s physiological and psychological resources have become depleted”
ANS: D
During the stage of exhaustion of the general adaptation syndrome, the individual loses the capacity
to adapt effectively because physiological and psychological resources have become depleted. This is
the time when diseases of adaptation may occur.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client
Need: Health Promotion and Maintenance
12. When an individual’s stress response is sustained over a long period of time, which physiological
effect of the endocrine system should a nurse anticipate?
A. Decreased resistance to disease
B. Increased libido
C. Decreased blood pressure
D. Increased inflammatory response
ANS: A
In a general adaptation syndrome, prolonged exposure to stress leads to the stage of exhaustion at
which time the body’s compensatory mechanisms no longer function effectively and diseases of
adaptation occur. A decreased immune response is seen at this stage.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client
Need: Physiological Integrity
13. Which symptom should a nurse identify as typical of the “fight-or-flight” response?
A. Pupil constriction
B. Increased heart rate
Loading page 7...
C. Increased salivation
D. Increased peristalsis
ANS: B
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. OK
KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Assessment
| Client Need: Physiological Integrity
14. A nurse is evaluating a client’s response to stress. What would indicate to the nurse that the client
is experiencing a secondary appraisal of the stressful event?
A. When the individual judges the event to be benign
B. When the individual judges the event to be irrelevant
C. When the individual judges the resources and skills needed to deal with the event
D. When the individual judges the event to be pleasurable
ANS: C
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.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client
Need: Psychosocial Integrity
15. Research undertaken by Miller and Rahe in 1997 demonstrated 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?
A. Specific illnesses are not identified.
B. The numerical values associated with specific life events are randomly assigned
C. Stress is viewed as only a physiological response.
D. Increased peristalsis
ANS: B
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. OK
KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Assessment
| Client Need: Physiological Integrity
14. A nurse is evaluating a client’s response to stress. What would indicate to the nurse that the client
is experiencing a secondary appraisal of the stressful event?
A. When the individual judges the event to be benign
B. When the individual judges the event to be irrelevant
C. When the individual judges the resources and skills needed to deal with the event
D. When the individual judges the event to be pleasurable
ANS: C
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.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client
Need: Psychosocial Integrity
15. Research undertaken by Miller and Rahe in 1997 demonstrated 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?
A. Specific illnesses are not identified.
B. The numerical values associated with specific life events are randomly assigned
C. Stress is viewed as only a physiological response.
Loading page 8...
D. Personal perception of the event is excluded.
ANS: D
Individuals differ in response to life events. The RLCQ uses a scale that does not take these
differences into consideration.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client
Need: Health Promotion and Maintenance
16. A client who experiences stress on a regular basis asks a nurse what causes these feelings. Which
is the most appropriate nursing response?
A. “Genetics have nothing to do with your temperament.”
B. “How you reacted to past experiences influences how you feel now.”
C. “If you’re in good physical health, your stress level will be low.”
D. “Stress can always be avoided if appropriate coping mechanisms are employed.”
ANS: B
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.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation
| Client Need: Psychosocial Integrity
Multiple Response
17. A nurse is interviewing a distressed client, who relates being fired after 15 years of loyal
employment. Which of the following questions would best assist 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. “Have you ever experienced a similar stressful situation?”
C. “Who do you think is to blame for this situation?”
D. “Why do you think you were fired from your job?”
ANS: D
Individuals differ in response to life events. The RLCQ uses a scale that does not take these
differences into consideration.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client
Need: Health Promotion and Maintenance
16. A client who experiences stress on a regular basis asks a nurse what causes these feelings. Which
is the most appropriate nursing response?
A. “Genetics have nothing to do with your temperament.”
B. “How you reacted to past experiences influences how you feel now.”
C. “If you’re in good physical health, your stress level will be low.”
D. “Stress can always be avoided if appropriate coping mechanisms are employed.”
ANS: B
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.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation
| Client Need: Psychosocial Integrity
Multiple Response
17. A nurse is interviewing a distressed client, who relates being fired after 15 years of loyal
employment. Which of the following questions would best assist 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. “Have you ever experienced a similar stressful situation?”
C. “Who do you think is to blame for this situation?”
D. “Why do you think you were fired from your job?”
Loading page 9...
E. “What skills do you possess that might lead to gainful employment?”
ANS: A, B, E
These questions specifically address the client’s coping resources and encourage the client to apply
learning from past experiences. These questions also encourage the client to consider alternative
methods for dealing with stress. Asking who is to blame does not assess coping abilities but, rather,
encourages maladaptive behavior. Requesting an explanation is a nontherapeutic block to
communication.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client
Need: Psychosocial Integrity
18. A nurse is working with a client who has recently been under a great deal of stress. Which
nursing recommendations would be most helpful when assisting the client in coping with
stress? Select all that apply.
A. “Enjoy a pet.”
B. “Spend time with a loved one.”
C. “Listen to music.”
D. “Focus on the stressors.”
E. “Journal your feelings.”
ANS: A, B, C, E
Focusing on the stressors is more likely to increase stress in the client’s life. However, pets, music,
journaling feelings, and healthy relationships have all been shown to decrease amounts of stress.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation
| Client Need: Psychosocial Integrity
19. A nurse is conducting 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. Awareness of factors creating stress
ANS: A, B, E
These questions specifically address the client’s coping resources and encourage the client to apply
learning from past experiences. These questions also encourage the client to consider alternative
methods for dealing with stress. Asking who is to blame does not assess coping abilities but, rather,
encourages maladaptive behavior. Requesting an explanation is a nontherapeutic block to
communication.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client
Need: Psychosocial Integrity
18. A nurse is working with a client who has recently been under a great deal of stress. Which
nursing recommendations would be most helpful when assisting the client in coping with
stress? Select all that apply.
A. “Enjoy a pet.”
B. “Spend time with a loved one.”
C. “Listen to music.”
D. “Focus on the stressors.”
E. “Journal your feelings.”
ANS: A, B, C, E
Focusing on the stressors is more likely to increase stress in the client’s life. However, pets, music,
journaling feelings, and healthy relationships have all been shown to decrease amounts of stress.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation
| Client Need: Psychosocial Integrity
19. A nurse is conducting 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. Awareness of factors creating stress
Loading page 10...
C. Relaxation exercises
D. Identifying support systems
ANS: B
Although all of the above answers may be useful in the comprehensive management of stress, the
initial step is awareness that stress is being experienced and awareness of factors that create stress.
KEY: Cognitive Level: Analysis | Integrated Processes: Teaching/Learning | Client
Need: Psychosocial Integrity
20. 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 of these symptoms manifested by the patient are common initial
biological responses to stress? Select all that apply.
A. Constricted pupils
B. Watery eyes
C. Unusual food cravings
D. Increased heart rate
E. Increased respirations
ANS: B, D, E
Increased lacrimal secretions, increased heart rate, and increased respirations are identified as initial
biological responses to stress. Since dilated pupils rather than constricted pupils are related to “Fight
or Flight” syndrome, this symptom should be assessed for other potential causes. Unusual food
cravings have not been identified as a typical biological response to stress.
KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client
Need: Physiological Integrity
Chapter 2. Mental Health/Mental Illness:
Historical and Theoretical Concepts
Chapter 2. Mental Health/Mental Illness: Historical and Theoretical Concepts
Multiple Choice
D. Identifying support systems
ANS: B
Although all of the above answers may be useful in the comprehensive management of stress, the
initial step is awareness that stress is being experienced and awareness of factors that create stress.
KEY: Cognitive Level: Analysis | Integrated Processes: Teaching/Learning | Client
Need: Psychosocial Integrity
20. 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 of these symptoms manifested by the patient are common initial
biological responses to stress? Select all that apply.
A. Constricted pupils
B. Watery eyes
C. Unusual food cravings
D. Increased heart rate
E. Increased respirations
ANS: B, D, E
Increased lacrimal secretions, increased heart rate, and increased respirations are identified as initial
biological responses to stress. Since dilated pupils rather than constricted pupils are related to “Fight
or Flight” syndrome, this symptom should be assessed for other potential causes. Unusual food
cravings have not been identified as a typical biological response to stress.
KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client
Need: Physiological Integrity
Chapter 2. Mental Health/Mental Illness:
Historical and Theoretical Concepts
Chapter 2. Mental Health/Mental Illness: Historical and Theoretical Concepts
Multiple Choice
Loading page 11...
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?
A. The client’s behaviors demonstrate mental illness in the form of depression.
B. The client’s behaviors are extensive, which indicates the presence of mental illness.
C. The client’s behaviors are not congruent with cultural norms.
D. The client’s behaviors demonstrate no functional impairment, indicating no mental illness.
ANS: D
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 client’s distress does not indicate a mental illness.
KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client
Need: Psychosocial Integrity
2. At what point should the nurse determine that a client is at risk for developing a mental disorder?
A. When thoughts, feelings, and behaviors are not reflective of the DSM-5 criteria
B. When maladaptive responses to stress are coupled with interference in daily functioning
C. When the client communicates significant distress
D. When the client uses defense mechanisms as ego protection
ANS: B
The nurse should determine that the client is at risk for mental disorder when responses to stress are
maladaptive and interfere with daily functioning. The DSM-5 indicates that in order to be diagnosed
with a mental disorder, there must be significant disturbance in cognition, emotion, regulation, or
behavior that reflects a dysfunction in the psychological, biological or developmental processes
underlying mental functioning. These disorders are usually associated with significant distress or
disability in social, occupational, or other important activities. The client’s ability to communicate
distress would be considered a positive attribute.
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?
A. The client’s behaviors demonstrate mental illness in the form of depression.
B. The client’s behaviors are extensive, which indicates the presence of mental illness.
C. The client’s behaviors are not congruent with cultural norms.
D. The client’s behaviors demonstrate no functional impairment, indicating no mental illness.
ANS: D
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 client’s distress does not indicate a mental illness.
KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client
Need: Psychosocial Integrity
2. At what point should the nurse determine that a client is at risk for developing a mental disorder?
A. When thoughts, feelings, and behaviors are not reflective of the DSM-5 criteria
B. When maladaptive responses to stress are coupled with interference in daily functioning
C. When the client communicates significant distress
D. When the client uses defense mechanisms as ego protection
ANS: B
The nurse should determine that the client is at risk for mental disorder when responses to stress are
maladaptive and interfere with daily functioning. The DSM-5 indicates that in order to be diagnosed
with a mental disorder, there must be significant disturbance in cognition, emotion, regulation, or
behavior that reflects a dysfunction in the psychological, biological or developmental processes
underlying mental functioning. These disorders are usually associated with significant distress or
disability in social, occupational, or other important activities. The client’s ability to communicate
distress would be considered a positive attribute.
Loading page 12...
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client
Need: Psychosocial Integrity
3. A nurse is assessing 15-year-old identical twins who respond very differently to stress. One twin
becomes anxious and irritable, while the other withdraws and cries. How should the nurse explain
these different responses to stress to the parents?
A. Reactions to stress are relative rather than absolute; individual responses to stress vary.
B. It is abnormal for identical twins to react differently to similar stressors.
C. Identical twins should share the same temperament and respond similarly to stress.
D. Environmental influences weigh more heavily than genetic influences on reactions to stress.
ANS: A
Responses to stress are variable among individuals and may be influenced by perception, past
experience, and environmental factors in addition to genetic factors.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation
| Client Need: Psychosocial Integrity
4. A client has a history of excessive drinking, which has led to multiple arrests for driving under the
influence (DUI). The client states, “I work hard to provide for my family. I don’t see why I can’t
drink to relax.” The nurse recognizes the use of which defense mechanism?
A. Projection
B. Rationalization
C. Regression
D. Sublimation
ANS: B
The nurse should recognize that the client is using rationalization, a common defense mechanism.
The client is attempting to make excuses and create logical reasons to justify unacceptable feelings or
behaviors.
Need: Psychosocial Integrity
3. A nurse is assessing 15-year-old identical twins who respond very differently to stress. One twin
becomes anxious and irritable, while the other withdraws and cries. How should the nurse explain
these different responses to stress to the parents?
A. Reactions to stress are relative rather than absolute; individual responses to stress vary.
B. It is abnormal for identical twins to react differently to similar stressors.
C. Identical twins should share the same temperament and respond similarly to stress.
D. Environmental influences weigh more heavily than genetic influences on reactions to stress.
ANS: A
Responses to stress are variable among individuals and may be influenced by perception, past
experience, and environmental factors in addition to genetic factors.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation
| Client Need: Psychosocial Integrity
4. A client has a history of excessive drinking, which has led to multiple arrests for driving under the
influence (DUI). The client states, “I work hard to provide for my family. I don’t see why I can’t
drink to relax.” The nurse recognizes the use of which defense mechanism?
A. Projection
B. Rationalization
C. Regression
D. Sublimation
ANS: B
The nurse should recognize that the client is using rationalization, a common defense mechanism.
The client is attempting to make excuses and create logical reasons to justify unacceptable feelings or
behaviors.
Loading page 13...
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client
Need: Psychosocial Integrity
5. Which client should the nurse anticipate to be most receptive to psychiatric treatment?
A. A Jewish, female journalist
B. A Baptist, homeless male
C. A Catholic, black male
D. A Protestant, Swedish business executive
ANS: A
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 as physical health.
Women are also more likely than men to seek treatment for mental health problems.
KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Planning | Client
Need: Psychosocial Integrity
6. A new psychiatric nurse states, “This client’s use of defense mechanisms should be eliminated.”
Which is a correct evaluation of this nurse’s statement?
A. Defense mechanisms can be self-protective responses to stress and need not be eliminated.
B. Defense mechanisms are a maladaptive attempt of the ego to manage anxiety and should always
be eliminated.
C. Defense mechanisms, used by individuals with weak ego integrity, should be discouraged and not
eliminated.
D. Defense mechanisms cause disintegration of the ego and should be fostered and encouraged.
ANS: A
The nurse should know that defense mechanisms serve the purpose of reducing anxiety during times
of stress. A client with no defense mechanisms may have a lower tolerance for stress, predisposing
him or her to anxiety disorders. Defense mechanisms should be confronted when they impede the
client from developing healthy coping skills.
Need: Psychosocial Integrity
5. Which client should the nurse anticipate to be most receptive to psychiatric treatment?
A. A Jewish, female journalist
B. A Baptist, homeless male
C. A Catholic, black male
D. A Protestant, Swedish business executive
ANS: A
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 as physical health.
Women are also more likely than men to seek treatment for mental health problems.
KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Planning | Client
Need: Psychosocial Integrity
6. A new psychiatric nurse states, “This client’s use of defense mechanisms should be eliminated.”
Which is a correct evaluation of this nurse’s statement?
A. Defense mechanisms can be self-protective responses to stress and need not be eliminated.
B. Defense mechanisms are a maladaptive attempt of the ego to manage anxiety and should always
be eliminated.
C. Defense mechanisms, used by individuals with weak ego integrity, should be discouraged and not
eliminated.
D. Defense mechanisms cause disintegration of the ego and should be fostered and encouraged.
ANS: A
The nurse should know that defense mechanisms serve the purpose of reducing anxiety during times
of stress. A client with no defense mechanisms may have a lower tolerance for stress, predisposing
him or her to anxiety disorders. Defense mechanisms should be confronted when they impede the
client from developing healthy coping skills.
Loading page 14...
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation
| Client Need: Psychosocial Integrity
7. 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?
A. “It’s just a routine part of our assessment. All clients are asked these same questions.”
B. “Why are you concerned about these types of questions?”
C. “Psychological factors, like excessive stress, have been found to affect medical conditions.”
D. “We can skip these questions, if you like. It isn’t imperative that we complete this section.”
ANS: C
The nurse should attempt to educate the client on the negative effects of excessive stress on medical
conditions. It is not appropriate to skip either physiological or psychosocial questions, as this would
lead to an inaccurate assessment.
KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client
Need: Health Promotion and Maintenance
8. Which statement reflects a student nurse’s accurate understanding of the concepts of mental health
and mental illness?
A. “The concepts are rigid and religiously based.”
B. “The concepts are multidimensional and culturally defined.”
C. “The concepts are universal and unchanging.”
D. “The concepts are unidimensional and fixed.”
ANS: B
The student nurse should understand that mental health and mental illness are multidimensional and
culturally defined. It is important for nurses to be aware of cultural norms when evaluating a client’s
mental state.
| Client Need: Psychosocial Integrity
7. 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?
A. “It’s just a routine part of our assessment. All clients are asked these same questions.”
B. “Why are you concerned about these types of questions?”
C. “Psychological factors, like excessive stress, have been found to affect medical conditions.”
D. “We can skip these questions, if you like. It isn’t imperative that we complete this section.”
ANS: C
The nurse should attempt to educate the client on the negative effects of excessive stress on medical
conditions. It is not appropriate to skip either physiological or psychosocial questions, as this would
lead to an inaccurate assessment.
KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client
Need: Health Promotion and Maintenance
8. Which statement reflects a student nurse’s accurate understanding of the concepts of mental health
and mental illness?
A. “The concepts are rigid and religiously based.”
B. “The concepts are multidimensional and culturally defined.”
C. “The concepts are universal and unchanging.”
D. “The concepts are unidimensional and fixed.”
ANS: B
The student nurse should understand that mental health and mental illness are multidimensional and
culturally defined. It is important for nurses to be aware of cultural norms when evaluating a client’s
mental state.
Loading page 15...
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client
Need: Safe and Effective Care Environment
9. A mental health technician asks the nurse, “How do psychiatrists determine which diagnosis to
give a patient?” Which of these responses by the nurse would be most accurate?
A. Psychiatrists use pre-established criteria from the APA’s Diagnostic and Statistical Manual of
Mental Disorders (DSM-5).
B. Hospital policy dictates how psychiatrists diagnose mental disorders.
C. Psychiatrists assess the patient and identify diagnoses based on the patient’s unhealthy responses
and contributing factors.
D. The American Medical Association identifies 10 diagnostic labels that psychiatrists can choose
from.
ANS: A
The DSM-5 is an organized manual describing mental disorders and the criteria that determine
whether a given diagnosis is appropriate. It is published by the American Psychiatric Association
(APA). It intends to facilitate accurate and reliable medical diagnosis and treatment. Item C describes
nursing rather than medical diagnosis.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client
Need: Psychosocial Integrity
10. The nurse is preparing to provide medication instruction for a patient. Which of the following
understandings about anxiety will be essential to effective instruction?
A. Learning is best when anxiety is moderate to severe.
B. Learning is enhanced when anxiety is mild.
C. Panic level anxiety helps the nurse teach better.
D. Severe anxiety is characterized by intense concentration and enhances the attention span.
ANS: B
Need: Safe and Effective Care Environment
9. A mental health technician asks the nurse, “How do psychiatrists determine which diagnosis to
give a patient?” Which of these responses by the nurse would be most accurate?
A. Psychiatrists use pre-established criteria from the APA’s Diagnostic and Statistical Manual of
Mental Disorders (DSM-5).
B. Hospital policy dictates how psychiatrists diagnose mental disorders.
C. Psychiatrists assess the patient and identify diagnoses based on the patient’s unhealthy responses
and contributing factors.
D. The American Medical Association identifies 10 diagnostic labels that psychiatrists can choose
from.
ANS: A
The DSM-5 is an organized manual describing mental disorders and the criteria that determine
whether a given diagnosis is appropriate. It is published by the American Psychiatric Association
(APA). It intends to facilitate accurate and reliable medical diagnosis and treatment. Item C describes
nursing rather than medical diagnosis.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client
Need: Psychosocial Integrity
10. The nurse is preparing to provide medication instruction for a patient. Which of the following
understandings about anxiety will be essential to effective instruction?
A. Learning is best when anxiety is moderate to severe.
B. Learning is enhanced when anxiety is mild.
C. Panic level anxiety helps the nurse teach better.
D. Severe anxiety is characterized by intense concentration and enhances the attention span.
ANS: B
Loading page 16...
Mild anxiety sharpens the senses, increases the perceptual field, and results in heightened awareness
of the environment. Learning is enhanced. As anxiety increases, attention span decreases and
learning becomes more difficult.
KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Planning | Client
Need: Health Promotion and Maintenance
11. Which of the following are identified as psychoneurotic responses to severe anxiety as they
appear in the DSM-5?
A. Somatic symptom disorders
B. Grief responses
C. Psychosis
D. Bipolar disorder
ANS: A
Somatic symptom disorder is characterized by preoccupation with physical symptoms for which
there is no demonstrable organic pathology. One of the diagnostic criteria is a high level of anxiety
about health concerns or illness.
KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Assessment
| Client Need: Psychosocial Integrity
12. An employee uses the defense mechanism of displacement when the boss openly disagrees with
suggestions. What behavior would be expected from this employee?
A. The employee assertively confronts the boss
B. The employee leaves the staff meeting to work out in the gym
C. The employee criticizes a coworker
D. The employee takes the boss out to lunch
ANS: C
of the environment. Learning is enhanced. As anxiety increases, attention span decreases and
learning becomes more difficult.
KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Planning | Client
Need: Health Promotion and Maintenance
11. Which of the following are identified as psychoneurotic responses to severe anxiety as they
appear in the DSM-5?
A. Somatic symptom disorders
B. Grief responses
C. Psychosis
D. Bipolar disorder
ANS: A
Somatic symptom disorder is characterized by preoccupation with physical symptoms for which
there is no demonstrable organic pathology. One of the diagnostic criteria is a high level of anxiety
about health concerns or illness.
KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Assessment
| Client Need: Psychosocial Integrity
12. An employee uses the defense mechanism of displacement when the boss openly disagrees with
suggestions. What behavior would be expected from this employee?
A. The employee assertively confronts the boss
B. The employee leaves the staff meeting to work out in the gym
C. The employee criticizes a coworker
D. The employee takes the boss out to lunch
ANS: C
Loading page 17...
The client using the defense mechanism of displacement would criticize a coworker after being
confronted by the boss. Displacement refers to transferring feelings from one target to a neutral or
less-threatening target.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client
Need: Psychosocial Integrity
13. A teenage boy is attracted to a female teacher. Without objective evidence, a school nurse
overhears the boy state, “I know she wants me.” This statement reflects which defense mechanism?
A. Displacement
B. Projection
C. Rationalization
D. Sublimation
ANS: B
The nurse should determine that the client’s statement reflects the defense mechanism of projection.
Projection refers to the attribution of one’s unacceptable feelings or impulses to another person.
When the client “passes the blame” of the undesirable feelings, anxiety is reduced. Displacement
refers to transferring feelings from one target to another. Rationalization refers to making excuses to
justify behavior. Sublimation refers to channeling unacceptable drives or impulses into more
constructive, acceptable activities.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client
Need: Psychosocial Integrity
14. 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?
A. Displacement
B. Projection
C. Reaction formation
D. Sublimation
confronted by the boss. Displacement refers to transferring feelings from one target to a neutral or
less-threatening target.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client
Need: Psychosocial Integrity
13. A teenage boy is attracted to a female teacher. Without objective evidence, a school nurse
overhears the boy state, “I know she wants me.” This statement reflects which defense mechanism?
A. Displacement
B. Projection
C. Rationalization
D. Sublimation
ANS: B
The nurse should determine that the client’s statement reflects the defense mechanism of projection.
Projection refers to the attribution of one’s unacceptable feelings or impulses to another person.
When the client “passes the blame” of the undesirable feelings, anxiety is reduced. Displacement
refers to transferring feelings from one target to another. Rationalization refers to making excuses to
justify behavior. Sublimation refers to channeling unacceptable drives or impulses into more
constructive, acceptable activities.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client
Need: Psychosocial Integrity
14. 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?
A. Displacement
B. Projection
C. Reaction formation
D. Sublimation
Loading page 18...
ANS: C
The nurse should identify that the boy is using reaction formation as a defense mechanism. Reaction
formation is the attempt to prevent undesirable thoughts from being expressed by expressing opposite
thoughts or behaviors. Displacement refers to transferring feelings from one target to another.
Rationalization refers to making excuses to justify behavior. Projection refers to the attribution of
unacceptable feelings or behaviors to another person. Sublimation refers to channeling unacceptable
drives or impulses into more constructive, acceptable activities.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client
Need: Psychosocial Integrity
15. Which nursing statement about the concept of neuroses is most accurate?
A. “An individual experiencing neurosis is unaware that he or she is experiencing distress.”
B. “An individual experiencing neurosis feels helpless to change his or her situation.”
C. “An individual experiencing neurosis is aware of psychological causes of his or her behavior.”
D. “An individual experiencing neurosis has a loss of contact with reality.”
ANS: B
The nurse should understand that the concept of neuroses includes the following characteristics. The
client feels helpless to change his or her situation, the client is aware that he or she is experiencing
distress, the client is aware the behaviors are maladaptive, the client is unaware of the psychological
causes of the distress, and the client experiences no loss of contact with reality.
KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Assessment
| Client Need: Psychosocial Integrity
16. Which nursing statement about the concept of psychoses is most accurate?
A. “Individuals experiencing psychoses are aware that their behaviors are maladaptive.”
B. “Individuals experiencing psychoses experience little distress.”
C. “Individuals experiencing psychoses are aware of experiencing psychological problems.”
D. “Individuals experiencing psychoses are based in reality.”
The nurse should identify that the boy is using reaction formation as a defense mechanism. Reaction
formation is the attempt to prevent undesirable thoughts from being expressed by expressing opposite
thoughts or behaviors. Displacement refers to transferring feelings from one target to another.
Rationalization refers to making excuses to justify behavior. Projection refers to the attribution of
unacceptable feelings or behaviors to another person. Sublimation refers to channeling unacceptable
drives or impulses into more constructive, acceptable activities.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client
Need: Psychosocial Integrity
15. Which nursing statement about the concept of neuroses is most accurate?
A. “An individual experiencing neurosis is unaware that he or she is experiencing distress.”
B. “An individual experiencing neurosis feels helpless to change his or her situation.”
C. “An individual experiencing neurosis is aware of psychological causes of his or her behavior.”
D. “An individual experiencing neurosis has a loss of contact with reality.”
ANS: B
The nurse should understand that the concept of neuroses includes the following characteristics. The
client feels helpless to change his or her situation, the client is aware that he or she is experiencing
distress, the client is aware the behaviors are maladaptive, the client is unaware of the psychological
causes of the distress, and the client experiences no loss of contact with reality.
KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Assessment
| Client Need: Psychosocial Integrity
16. Which nursing statement about the concept of psychoses is most accurate?
A. “Individuals experiencing psychoses are aware that their behaviors are maladaptive.”
B. “Individuals experiencing psychoses experience little distress.”
C. “Individuals experiencing psychoses are aware of experiencing psychological problems.”
D. “Individuals experiencing psychoses are based in reality.”
Loading page 19...
ANS: B
The nurse should understand that the client with psychoses experiences little distress, because of his
or her lack of awareness of reality. The client with psychoses is unaware that his or her behavior is
maladaptive or that he or she has a psychological problem.
KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Assessment
| Client Need: Psychosocial Integrity
17. When under stress, a client routinely uses an excessive amount of alcohol. Finding her drunk, her
husband yells at her about the chronic alcohol abuse. Which reaction should the nurse recognize as
the use of the defense mechanism of denial?
A. Hiding liquor bottles in a closet
B. Yelling at their son for slouching in his chair
C. Burning dinner on purpose
D. Saying to the spouse, “I don’t drink too much!”
ANS: D
The nurse should associate the client statement “I don’t drink too much!” with the use of the defense
mechanism of denial. The client who refuses to acknowledge the existence of a real situation and the
feelings associated with it is using the defense mechanism of denial.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client
Need: Psychosocial Integrity
18. 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?
A. “If only we could have tried again, things might have worked out.”
B. “I am so mad that the children and I had to put up with him as long as we did.”
C. “Yes, it was a difficult relationship, but I think I have learned from the experience.”
D. “I still don’t have any appetite and continue to lose weight.”
ANS: C
The nurse should understand that the client with psychoses experiences little distress, because of his
or her lack of awareness of reality. The client with psychoses is unaware that his or her behavior is
maladaptive or that he or she has a psychological problem.
KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Assessment
| Client Need: Psychosocial Integrity
17. When under stress, a client routinely uses an excessive amount of alcohol. Finding her drunk, her
husband yells at her about the chronic alcohol abuse. Which reaction should the nurse recognize as
the use of the defense mechanism of denial?
A. Hiding liquor bottles in a closet
B. Yelling at their son for slouching in his chair
C. Burning dinner on purpose
D. Saying to the spouse, “I don’t drink too much!”
ANS: D
The nurse should associate the client statement “I don’t drink too much!” with the use of the defense
mechanism of denial. The client who refuses to acknowledge the existence of a real situation and the
feelings associated with it is using the defense mechanism of denial.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client
Need: Psychosocial Integrity
18. 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?
A. “If only we could have tried again, things might have worked out.”
B. “I am so mad that the children and I had to put up with him as long as we did.”
C. “Yes, it was a difficult relationship, but I think I have learned from the experience.”
D. “I still don’t have any appetite and continue to lose weight.”
ANS: C
Loading page 20...
The nurse should recognize that the client is in the acceptance stage of grief. 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.
KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Evaluation | Client
Need: Psychosocial Integrity
19. 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?A. Maintaining a long-term, faithful, intimate relationship
B. Achieving a sense of self-confidence
C. Possessing a feeling of self-fulfillment and realizing full potential
D. Developing a sense of purpose and the ability to direct activities
ANS: C
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.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment |Client
Need: Psychosocial Integrity
20. According to Maslow’s hierarchy of needs, which situation on an inpatient psychiatric unit would
require priority intervention by a nurse?A. A client rudely complaining about limited visiting hours
B. A client exhibiting aggressive behavior toward another client
C. A client stating that no one cares
D. A client verbalizing feelings of failure
ANS: B
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. 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.
grief process, the client would be able to focus on the reality of the loss and its meaning in relation to
life.
KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Evaluation | Client
Need: Psychosocial Integrity
19. 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?A. Maintaining a long-term, faithful, intimate relationship
B. Achieving a sense of self-confidence
C. Possessing a feeling of self-fulfillment and realizing full potential
D. Developing a sense of purpose and the ability to direct activities
ANS: C
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.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment |Client
Need: Psychosocial Integrity
20. According to Maslow’s hierarchy of needs, which situation on an inpatient psychiatric unit would
require priority intervention by a nurse?A. A client rudely complaining about limited visiting hours
B. A client exhibiting aggressive behavior toward another client
C. A client stating that no one cares
D. A client verbalizing feelings of failure
ANS: B
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. 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.
Loading page 21...
KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client
Need: Psychosocial Integrity
21. Which is an example of the ego defense mechanism of regression?A. A mother blames the
teacher for her child’s failure in school.B. A teenager becomes hysterical after seeing a friend killed
in a car accident.C. A woman wants to marry a man exactly like her beloved father.
D. An adult throws a temper tantrum when he does not get his own way.
ANS: D
Regression is the retreating to an earlier level of development and the comfort measures associated
with that level of functioning.
KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client
Need: Psychosocial Integrity
22. Which is the most significant consequence of the excessive use of defense mechanisms?A. The
superego will be suppressed.
B. Emotions will be experienced intensely.C. Learning and the ability to grow will be enhanced.
D. Problem-solving will be limited.
ANS: D
Defense mechanisms become maladaptive when they are used by an individual to such a degree that
there is interference with the ability to deal with reality, effective interpersonal relations, or
occupational performance.
KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Evaluation
| Client Need: Psychosocial Integrity
23. A husband accuses his wife of infidelity. Which situation would indicate to the nurse the
husband’s use of the ego defense mechanism of projection?A. The husband cries and stamps his feet,
demanding that his wife be true to her marriage vows. B. The husband ignores the wife’s continued
absence from the home.C. The husband has already admitted to having an affair with a coworker.
D. The husband takes out his marital frustrations through employee abuse.
ANS: C
Need: Psychosocial Integrity
21. Which is an example of the ego defense mechanism of regression?A. A mother blames the
teacher for her child’s failure in school.B. A teenager becomes hysterical after seeing a friend killed
in a car accident.C. A woman wants to marry a man exactly like her beloved father.
D. An adult throws a temper tantrum when he does not get his own way.
ANS: D
Regression is the retreating to an earlier level of development and the comfort measures associated
with that level of functioning.
KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client
Need: Psychosocial Integrity
22. Which is the most significant consequence of the excessive use of defense mechanisms?A. The
superego will be suppressed.
B. Emotions will be experienced intensely.C. Learning and the ability to grow will be enhanced.
D. Problem-solving will be limited.
ANS: D
Defense mechanisms become maladaptive when they are used by an individual to such a degree that
there is interference with the ability to deal with reality, effective interpersonal relations, or
occupational performance.
KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Evaluation
| Client Need: Psychosocial Integrity
23. A husband accuses his wife of infidelity. Which situation would indicate to the nurse the
husband’s use of the ego defense mechanism of projection?A. The husband cries and stamps his feet,
demanding that his wife be true to her marriage vows. B. The husband ignores the wife’s continued
absence from the home.C. The husband has already admitted to having an affair with a coworker.
D. The husband takes out his marital frustrations through employee abuse.
ANS: C
Loading page 22...
Projection is the attribution of feelings or impulses unacceptable to one’s self to another person. In
this situation, the husband attributes his infidelity to his wife.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client
Need: Psychosocial Integrity
24. Which should the nurse recognize as a DSM-5 disorder?A. Obesity
B. Generalized anxiety disorder
C. Hypertension
D. Grief
ANS: B
The DSM-5 identifies several disorders that are related to anxiety, including generalized anxiety
disorder, somatic symptom disorder, and dissociative disorders.
KEY: Cognitive Level: Knowledge | Integrated Processes: Nursing Process: Assessment | Client
Need: Psychosocial Integrity
25. A nurse is educating a patient about the difference between mental health and mental illness.
Which statement by the patient reflects an accurate understanding of mental health?
A. Mental health is the absence of any stressors.
B. Mental health is successful adaptation to stressors in the internal and external environment.
C. Mental health is incongruence between thoughts, feelings, and behavior
D. Mental health is a diagnostic category in the DSM-5.
ANS: B
Several definitions of mental health exist, but this definition highlights concepts of successful
adaptation to stressors, including thoughts, feelings, and behaviors that are age-appropriate and
congruent with cultural and societal norms.
KEY: Cognitive Level: Analysis | Integrated Processes: Teaching/Learning | Client Need: Health
Promotion and Maintenance
26. Most cultures label behavior as mental illness on the basis of which of the following criteria?
A. Incomprehensibility and cultural relativity
this situation, the husband attributes his infidelity to his wife.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client
Need: Psychosocial Integrity
24. Which should the nurse recognize as a DSM-5 disorder?A. Obesity
B. Generalized anxiety disorder
C. Hypertension
D. Grief
ANS: B
The DSM-5 identifies several disorders that are related to anxiety, including generalized anxiety
disorder, somatic symptom disorder, and dissociative disorders.
KEY: Cognitive Level: Knowledge | Integrated Processes: Nursing Process: Assessment | Client
Need: Psychosocial Integrity
25. A nurse is educating a patient about the difference between mental health and mental illness.
Which statement by the patient reflects an accurate understanding of mental health?
A. Mental health is the absence of any stressors.
B. Mental health is successful adaptation to stressors in the internal and external environment.
C. Mental health is incongruence between thoughts, feelings, and behavior
D. Mental health is a diagnostic category in the DSM-5.
ANS: B
Several definitions of mental health exist, but this definition highlights concepts of successful
adaptation to stressors, including thoughts, feelings, and behaviors that are age-appropriate and
congruent with cultural and societal norms.
KEY: Cognitive Level: Analysis | Integrated Processes: Teaching/Learning | Client Need: Health
Promotion and Maintenance
26. Most cultures label behavior as mental illness on the basis of which of the following criteria?
A. Incomprehensibility and cultural relativity
Loading page 23...
B. Strength of character and ethics
C. Goal directedness and high energy
D. Creativity and good coping skills
ANS: A
Incomprehensibility and cultural relativity are most often the criteria used to define whether
something is labeled mental illness. The other identified behaviors would be more associated with
health than illness.
KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Assessment
| Client Need: Psychosocial Integrity
27. Which should the nurse recognize as an example of the defense mechanism of repression?A. A
student aware of the need to study for tomorrow’s test goes to a movie instead.
B. A woman whose son was killed in Iraq does not believe the military report.
C. A man who is unhappily married goes to school to become a marriage counselor.
D. A woman was raped when she was 12 and no longer remembers the incident.
ANS: D
Repression is the involuntary blocking of unpleasant feelings and experiences from one’s awareness.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client
Need: Psychosocial Integrity
Multiple Response
28. Which of the following statements should a nurse recognize as true about defense
mechanisms? Select all that apply.
A. They are employed when there is a threat to biological or psychological integrity.
B. They are controlled by the id and deal with primal urges.C. They are used in an effort to relieve
mild to moderate anxiety.
D. They are protective devices for the superego.
C. Goal directedness and high energy
D. Creativity and good coping skills
ANS: A
Incomprehensibility and cultural relativity are most often the criteria used to define whether
something is labeled mental illness. The other identified behaviors would be more associated with
health than illness.
KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Assessment
| Client Need: Psychosocial Integrity
27. Which should the nurse recognize as an example of the defense mechanism of repression?A. A
student aware of the need to study for tomorrow’s test goes to a movie instead.
B. A woman whose son was killed in Iraq does not believe the military report.
C. A man who is unhappily married goes to school to become a marriage counselor.
D. A woman was raped when she was 12 and no longer remembers the incident.
ANS: D
Repression is the involuntary blocking of unpleasant feelings and experiences from one’s awareness.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client
Need: Psychosocial Integrity
Multiple Response
28. Which of the following statements should a nurse recognize as true about defense
mechanisms? Select all that apply.
A. They are employed when there is a threat to biological or psychological integrity.
B. They are controlled by the id and deal with primal urges.C. They are used in an effort to relieve
mild to moderate anxiety.
D. They are protective devices for the superego.
Loading page 24...
E. They are mechanisms that are characteristically self-deceptive.
ANS: A, C, E
Defense mechanisms are employed by the ego in the face of threats to biological and psychological
integrity, in an effort to relieve mild to moderate anxiety. Because they redirect focus, they are
characteristically self-deceptive.
KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client
Need: Psychosocial Integrity
29. A nurse is assessing a client who appears to be experiencing moderate anxiety during
questioning. Which symptoms might the client demonstrate? Select all that apply.
A. Fidgeting
B. Laughing inappropriately
C. Palpitations
D. Nail biting
E. Extremely limited attention span
ANS: A, B, D
The nurse should assess that fidgeting, laughing inappropriately, and nail biting are indicative of
heightened stress levels. The client would not be diagnosed with mental illness unless there is
significant impairment in other areas of daily functioning. Other indicators of more serious anxiety
are restlessness, difficulty concentrating, muscle tension, and sleep disturbance.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client
Need: Psychosocial Integrity
30. Which of the following are cultural aspects of mental illness? Select all that apply.
A. Local or cultural norms define pathological behavior.
B. The higher the social class the greater the recognition of mental illness behaviors.
C. Psychiatrists typically see patients when the family can no longer deny the illness.
ANS: A, C, E
Defense mechanisms are employed by the ego in the face of threats to biological and psychological
integrity, in an effort to relieve mild to moderate anxiety. Because they redirect focus, they are
characteristically self-deceptive.
KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client
Need: Psychosocial Integrity
29. A nurse is assessing a client who appears to be experiencing moderate anxiety during
questioning. Which symptoms might the client demonstrate? Select all that apply.
A. Fidgeting
B. Laughing inappropriately
C. Palpitations
D. Nail biting
E. Extremely limited attention span
ANS: A, B, D
The nurse should assess that fidgeting, laughing inappropriately, and nail biting are indicative of
heightened stress levels. The client would not be diagnosed with mental illness unless there is
significant impairment in other areas of daily functioning. Other indicators of more serious anxiety
are restlessness, difficulty concentrating, muscle tension, and sleep disturbance.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client
Need: Psychosocial Integrity
30. Which of the following are cultural aspects of mental illness? Select all that apply.
A. Local or cultural norms define pathological behavior.
B. The higher the social class the greater the recognition of mental illness behaviors.
C. Psychiatrists typically see patients when the family can no longer deny the illness.
Loading page 25...
D. The greater the cultural distance from the mainstream of society, the greater the likelihood that the
illness will be treated with sensitivity and compassion.
ANS: A, B, C
The fewer ties that a group has with mainstream society, the greater the likelihood of a negative
response by society to mental illness. Coercive treatments and involuntary hospitalizations are more
common in this population.
KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client
Need: Psychosocial Integrity
.
31. How is the DSM-5 useful in the practice of psychiatric nursing? Select all that apply.
A. It informs the nurse of accurate and reliable medical diagnosis.
B. It represents progress toward a more holistic view of mind–body.
C. It provides a framework for interdisciplinary communication.
D. It provides a template for nursing care plans.
E. It provides a framework for communication with the client.
ANS: A, B, C
The DSM-5 is useful in the practice of psychiatric nursing because it facilitates comprehensive
evaluation of the client. In addition, it encourages a holistic view and provides a framework for
interdisciplinary communication.
KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client
Need: Safe and Effective Care Environment
Chapter 3. Theoretical Models of Personality
Development
Chapter 3. Theoretical Models of Personality Development
Multiple Choice
illness will be treated with sensitivity and compassion.
ANS: A, B, C
The fewer ties that a group has with mainstream society, the greater the likelihood of a negative
response by society to mental illness. Coercive treatments and involuntary hospitalizations are more
common in this population.
KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client
Need: Psychosocial Integrity
.
31. How is the DSM-5 useful in the practice of psychiatric nursing? Select all that apply.
A. It informs the nurse of accurate and reliable medical diagnosis.
B. It represents progress toward a more holistic view of mind–body.
C. It provides a framework for interdisciplinary communication.
D. It provides a template for nursing care plans.
E. It provides a framework for communication with the client.
ANS: A, B, C
The DSM-5 is useful in the practice of psychiatric nursing because it facilitates comprehensive
evaluation of the client. In addition, it encourages a holistic view and provides a framework for
interdisciplinary communication.
KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client
Need: Safe and Effective Care Environment
Chapter 3. Theoretical Models of Personality
Development
Chapter 3. Theoretical Models of Personality Development
Multiple Choice
Loading page 26...
1. According to Erikson’s developmental theory, when planning care for a 47-year-old client, which
developmental task should a nurse identify as appropriate for this client?A. To develop a basic trust
in others
B. To achieve a sense of self-confidence and recognition from others
C. To reflect back on life events to derive pleasure and meaning
D. To achieve established life goals and consider the welfare of future generations
ANS: D
The nurse should identify that an appropriate developmental task for a 47-year-old client would be to
achieve established life goals and consider the welfare of future generations. According to Erikson,
the client would be in the generativity versus stagnation stage of development.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client
Need: Psychosocial Integrity
2. A jilted college student is admitted to a hospital following a suicide attempt and states, “No one
will ever love a loser like me.” According to Erikson’s theory of personality development, a nurse
should recognize a deficit in which developmental stage?A. Trust versus mistrust
B. Initiative versus guilt
C. Intimacy versus isolation
D. Ego integrity versus despair
ANS: C
The nurse should recognize that the client who states, “No one will ever love a loser like me” has not
adequately completed the intimacy versus isolation stage of development. The intimacy versus
isolation stage is presumed to occur in young adulthood between the ages of 20 and 30 years. The
major developmental task in this stage is to establish intense, lasting relationships or commitment to
another person, cause, institution, or creative effort.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client
Need: Psychosocial Integrity
developmental task should a nurse identify as appropriate for this client?A. To develop a basic trust
in others
B. To achieve a sense of self-confidence and recognition from others
C. To reflect back on life events to derive pleasure and meaning
D. To achieve established life goals and consider the welfare of future generations
ANS: D
The nurse should identify that an appropriate developmental task for a 47-year-old client would be to
achieve established life goals and consider the welfare of future generations. According to Erikson,
the client would be in the generativity versus stagnation stage of development.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client
Need: Psychosocial Integrity
2. A jilted college student is admitted to a hospital following a suicide attempt and states, “No one
will ever love a loser like me.” According to Erikson’s theory of personality development, a nurse
should recognize a deficit in which developmental stage?A. Trust versus mistrust
B. Initiative versus guilt
C. Intimacy versus isolation
D. Ego integrity versus despair
ANS: C
The nurse should recognize that the client who states, “No one will ever love a loser like me” has not
adequately completed the intimacy versus isolation stage of development. The intimacy versus
isolation stage is presumed to occur in young adulthood between the ages of 20 and 30 years. The
major developmental task in this stage is to establish intense, lasting relationships or commitment to
another person, cause, institution, or creative effort.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client
Need: Psychosocial Integrity
Loading page 27...
3. A nurse observes a 3-year-old client willingly sharing candy with a sibling. According to Peplau,
which psychological stage of development should the nurse recognize that this child has
completed?A. “Learning to count on others”B. “Learning to delay satisfaction”C. “Identifying
oneself”D. “Developing skills in participation”
ANS: B
The nurse should recognize that this client has completed the “Learning to delay satisfaction” stage
of development according to Peplau’s interpersonal theory. This stage typically occurs in
toddlerhood when one learns the satisfaction of pleasing others.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client
Need: Psychosocial Integrity
4. When a mother brings her 9-month-old to daycare, the child smiles and reaches for the daycare
caregiver. The nurse should recognize that according to Mahler’s developmental theory, this child’s
development is at which phase?A. The autistic phase
B. The symbiotic phaseC. The differentiation subphase of the separation–individuation phase
D. The rapprochement subphase of the separation–individuation phase
ANS: C
The nurse should understand that this client is in the differentiation subphase of the separation–
individuation phase. This subphase begins with the child’s initial physical movements away from the
mothering figure. A primary recognition of separateness commences.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client
Need: Psychosocial Integrity
5. A 12-year-old girl becomes hysterical every time she strikes out in softball, falls down when
roller-skating, or loses when playing games. According to Peplau’s interpersonal theory, in which
stage of development should the nurse identify a need for improvement?A. “Learning to count on
others”B. “Learning to delay satisfaction”C. “Identifying oneself”
D. “Developing skills in participation”
ANS: D
which psychological stage of development should the nurse recognize that this child has
completed?A. “Learning to count on others”B. “Learning to delay satisfaction”C. “Identifying
oneself”D. “Developing skills in participation”
ANS: B
The nurse should recognize that this client has completed the “Learning to delay satisfaction” stage
of development according to Peplau’s interpersonal theory. This stage typically occurs in
toddlerhood when one learns the satisfaction of pleasing others.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client
Need: Psychosocial Integrity
4. When a mother brings her 9-month-old to daycare, the child smiles and reaches for the daycare
caregiver. The nurse should recognize that according to Mahler’s developmental theory, this child’s
development is at which phase?A. The autistic phase
B. The symbiotic phaseC. The differentiation subphase of the separation–individuation phase
D. The rapprochement subphase of the separation–individuation phase
ANS: C
The nurse should understand that this client is in the differentiation subphase of the separation–
individuation phase. This subphase begins with the child’s initial physical movements away from the
mothering figure. A primary recognition of separateness commences.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client
Need: Psychosocial Integrity
5. A 12-year-old girl becomes hysterical every time she strikes out in softball, falls down when
roller-skating, or loses when playing games. According to Peplau’s interpersonal theory, in which
stage of development should the nurse identify a need for improvement?A. “Learning to count on
others”B. “Learning to delay satisfaction”C. “Identifying oneself”
D. “Developing skills in participation”
ANS: D
Loading page 28...
The nurse should identify that this client needs to improve in the “Developing skills in participation”
stage of Peplau’s interpersonal theory. Older children in this phase learn the skills of compromise,
competition, and cooperation with others.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client
Need: Health Promotion and Maintenance
6. According to Peplau, a nurse who provides an abandoned child with parental guidance and praise
following small accomplishments is serving which therapeutic role?A. The role of technical expert
B. The role of resource person
C. The role of surrogate
D. The role of leader
ANS: C
The nurse who provides an abandoned child with parental guidance and praise is serving the role of
the surrogate according to Peplau’s interpersonal theory. A surrogate serves as a substitute for
another person—in this case, the child’s parent.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation
| Client Need: Psychosocial Integrity
7. A nurse directs the client interaction and plans for interventions to achieve client goals. According
to Peplau’s framework for psychodynamic nursing, what therapeutic role is this nurse assuming?
A. The role of technical expert
B. The role of resource person
C. The role of teacher
D. The role of leader
ANS: D
The nurse who directs client interaction and plans for interventions is assuming the role of leader.
According to Peplau, a leader directs the nurse–client interaction and ensures that actions are taken to
achieve goals.
stage of Peplau’s interpersonal theory. Older children in this phase learn the skills of compromise,
competition, and cooperation with others.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client
Need: Health Promotion and Maintenance
6. According to Peplau, a nurse who provides an abandoned child with parental guidance and praise
following small accomplishments is serving which therapeutic role?A. The role of technical expert
B. The role of resource person
C. The role of surrogate
D. The role of leader
ANS: C
The nurse who provides an abandoned child with parental guidance and praise is serving the role of
the surrogate according to Peplau’s interpersonal theory. A surrogate serves as a substitute for
another person—in this case, the child’s parent.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation
| Client Need: Psychosocial Integrity
7. A nurse directs the client interaction and plans for interventions to achieve client goals. According
to Peplau’s framework for psychodynamic nursing, what therapeutic role is this nurse assuming?
A. The role of technical expert
B. The role of resource person
C. The role of teacher
D. The role of leader
ANS: D
The nurse who directs client interaction and plans for interventions is assuming the role of leader.
According to Peplau, a leader directs the nurse–client interaction and ensures that actions are taken to
achieve goals.
Loading page 29...
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation |
Client Need: Psychosocial Integrity
8. When assessing clients, a psychiatric nurse should understand that psychoanalytic theory is based
on which underlying concept?
A. A possible genetic basis for the client problems
B. The structure and dynamics of the personality
C. Behavioral responses to stressors
D. Maladaptive cognitions
ANS: B
The nurse should understand that psychoanalytic theory is based on the underlying concepts of the
structure and dynamics of personality. Psychoanalytic theory was developed by Sigmund Freud and
explains the structure of personality in three different components: the id, ego, and superego.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment |Client
Need: Psychosocial Integrity
9. Which underlying concept should a nurse associate with interpersonal theory when assessing
clients?
A. The effects of social processes on personality development
B. The effects of unconscious processes and personality structures
C. The effects on thoughts and perceptual processes
D. The effects of chemical and genetic influences
ANS: A
The nurse should associate interpersonal theory with the underlying concept of effects of social
process on personality development. Sullivan developed stages of personality development based on
his theory of interpersonal relationships and their effect on personality and individual behavior.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client
Need: Psychosocial Integrity
Client Need: Psychosocial Integrity
8. When assessing clients, a psychiatric nurse should understand that psychoanalytic theory is based
on which underlying concept?
A. A possible genetic basis for the client problems
B. The structure and dynamics of the personality
C. Behavioral responses to stressors
D. Maladaptive cognitions
ANS: B
The nurse should understand that psychoanalytic theory is based on the underlying concepts of the
structure and dynamics of personality. Psychoanalytic theory was developed by Sigmund Freud and
explains the structure of personality in three different components: the id, ego, and superego.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment |Client
Need: Psychosocial Integrity
9. Which underlying concept should a nurse associate with interpersonal theory when assessing
clients?
A. The effects of social processes on personality development
B. The effects of unconscious processes and personality structures
C. The effects on thoughts and perceptual processes
D. The effects of chemical and genetic influences
ANS: A
The nurse should associate interpersonal theory with the underlying concept of effects of social
process on personality development. Sullivan developed stages of personality development based on
his theory of interpersonal relationships and their effect on personality and individual behavior.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client
Need: Psychosocial Integrity
Loading page 30...
10. A physically healthy, 35-year-old single client lives with parents who provide total financial
support. According to Erikson’s theory, which developmental task should a nurse assist the client to
accomplish?A. Establishing the ability to control emotional reactions
B. Establishing a strong sense of ethics and character structure
C. Establishing and maintaining self-esteem
D. Establishing a career, personal relationships, and societal connections
ANS: D
The nurse should assist the client in establishing a career, personal relationships, and societal
connections. According to Erikson, nonachievement in the generativity versus stagnation stage
results in self-absorption, including withdrawal from others and having no capacity for giving of the
self to others.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client
Need: Health Promotion and Maintenance
11. A 1-month-old infant is left alone for extended periods, has little physical stimulation, and is
malnourished. Based on this infant’s history, in which phase of development according to Mahler’s
theory should a nurse expect to see a potential deficit?
A. The symbiotic phase
B. The autistic phase
C. The consolidation phase
D. The rapprochement phase
ANS: B
The nurse should expect that a 1-month-old infant who is left alone, has little physical stimulation,
and is malnourished would not meet the autistic phase of development. The autistic phase of
development usually occurs from birth to 1 month, at which time the infant’s focus is on basic needs
and comfort.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client
Need: Psychosocial Integrity
support. According to Erikson’s theory, which developmental task should a nurse assist the client to
accomplish?A. Establishing the ability to control emotional reactions
B. Establishing a strong sense of ethics and character structure
C. Establishing and maintaining self-esteem
D. Establishing a career, personal relationships, and societal connections
ANS: D
The nurse should assist the client in establishing a career, personal relationships, and societal
connections. According to Erikson, nonachievement in the generativity versus stagnation stage
results in self-absorption, including withdrawal from others and having no capacity for giving of the
self to others.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client
Need: Health Promotion and Maintenance
11. A 1-month-old infant is left alone for extended periods, has little physical stimulation, and is
malnourished. Based on this infant’s history, in which phase of development according to Mahler’s
theory should a nurse expect to see a potential deficit?
A. The symbiotic phase
B. The autistic phase
C. The consolidation phase
D. The rapprochement phase
ANS: B
The nurse should expect that a 1-month-old infant who is left alone, has little physical stimulation,
and is malnourished would not meet the autistic phase of development. The autistic phase of
development usually occurs from birth to 1 month, at which time the infant’s focus is on basic needs
and comfort.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client
Need: Psychosocial Integrity
Loading page 31...
28 more pages available. Scroll down to load them.
Preview Mode
Sign in to access the full document!
100%
Study Now!
XY-Copilot AI
Unlimited Access
Secure Payment
Instant Access
24/7 Support
Document Chat
Document Details
Subject
Nursing