Which would the nurse expect to assess in a client with long-term maladaption to stressful events

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Psychiatric Mental Health Nursing Success Practice Questions

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A client on an inpatient psychiatric unit has impulse control issues and at times can be irritable and hostile with little regard for others. Using psychoanalytic theory, which describes this behavior?

A) The behavior is id driven
B) The behavior is ego driven
C) The behavior is superego driven
D) The behavior is ego-ideal driven

A) The behavior is id driven

A client on an inpatient psychiatric unit is exhibiting extreme agitation. Using a biological approach, which nursing intervention should be implemented?

A) The nurse should discuss emotional triggers that precipitate angry outbursts.
B) The nurse should encourage the client to use exercise to deal with increased agitation.
C) The nurse should give ordered prn medications to decrease anxiety and agitation.
D) The nurse should develop a plan to address tension during family therapy.

C) The nurse should give ordered prn medications to decrease anxiety and agitation.

A client on an inpatient psychiatric unit is exhibiting extreme agitation. Using a behavioral approach, which nursing intervention should be implemented?

A) The nurse should role-play stressful situations to promote adaptive coping
B) The nurse should develop a plan to deal with stressors during a family meeting.
C) The nurse should give ordered prn medications to decrease agitation.
D) The nurse should discuss emotional triggers that precipitate angry outbursts.

A) The nurse should role-play stressful situations to promote adaptive coping

Which client statement indicates that the client understands the term temperament?

A) "I understand that my behaviors have affected my development, so I need to work hard now to fix the problem."
B) "I was born 'cranky,' and this continues to affect how I relate to others."
C) "The way I perceive, relate to others, and think of myself in social and personal situations makes up my temperament."
D) "My childhood really affected my ability to develop and appropriate temperament."

B) "I was born 'cranky,' and this continues to affect how I relate to others."

An 88-year-old client on an inpatient psychiatric unit states, "My children are refusing to visit me. I feel like giving up." This client has a deficit in which of Erikson's stages of development?

A) Initiative versus guilt
B) Industry versus inferiority
C) Identity versus role confusion
D) Integrity versus despair

D) Integrity versus despair

A client exhibits a pattern of terminating relationships with significant others and poor self-esteem. Using Sullivan's interpersonal theory, what major developmental state is this client struggling to master?

A) Late adolescence
B) Early adolescence
C) Preadolescence
D) Juvenile

A) Late adolescence

A client diagnosed with posttraumatic stress disorder (PTSD) is close to discharge. Which client statement would indicate that teaching about the psychosocial cause of PTSD was effective?

A) "My experience, how I deal with it, and my support system all affect my disease process."
B) "I have learned to try and avoid stressful situations as a way to decrease my emotional pain."
C) "So, natural opioids released during the trauma caused my body to become 'addicted.''"
D) "Because of the trauma, I have a negative perception of the world and feel hopeless."

A) "My experience, how I deal with it, and my support system all affect my disease process."

Counselors have been sent to a location that has experienced a natural disaster to assist the population in dealing with the devastation. This is an example of ________ prevention.

primary

A client has been fired from work because of downsizing. Although clearly upset, when explaining the situation to a friend, the client states, "Imagine what I can do with this extra time." Which defense mechanism is this client using?

A) Denial
B) Intellectualization
C) Rationalization
D) Suppression

B) Intellectualization

Which best exemplifies a client's use of the defense mechanism of reaction formation?

A) A client feels rage at being raped at a young age, which later is expressed by joining law enforcement.
B) A client is unhappy about being a father, although others notice how much attention he gives his son.
C) A client is drinking six to eight beers a day while still attending Alcoholics Anonymous and functioning as a group leader.
D) A client is angry that the call bell is not answered and decides to call the nurse when it is unnecessary.

B) A client is unhappy about being a father, although others notice how much attention he gives his son.

Which best exemplifies an individual's use of the defense mechanism of compensation?

A) A woman feels unattractive but also decides to pursue fashion design as a career.
B) A shy woman who abuses alcohol tells others that alcohol helps her overcome her shyness.
C) A poorly paid employee consistently yells at his assistant for minimal mistakes.
D) A teenager injures an ankle playing basketball and curls into a fetal position to deal with the pain.

A) A woman feels unattractive but also decides to pursue fashion design as a career.

Which best exemplifies the use of the defense mechanism of sublimation?

A) A child who has been told by parents that stealing is wrong reminds a friend not to steal.
B) A man who loves sports but is unable to play decides to become an athletic trainer.
C) Having chronic asthma with frequent hospitalizations, a young girl admires her nurses. She later chooses nursing as a career.
D) A boy who feels angry and hostile decides to become a mental health therapist to help others.

D) A boy who feels angry and hostile decides to become a mental health therapist to help others.

A nursing instructor is teaching about defense mechanisms. Which of the following student statements indicate that learning has occurred? Select all that apply.

A) "Defense mechanisms are used when anxiety increases and the strength of the ego is tested."
B) "All individuals who use defense mechanisms as a means of stress adaptation exhibit healthy egos."
C) "When defense mechanisms are overused or maladaptive, unhealthy ego development may result."
D) "Defense mechanisms are used only by mentally ill individuals to assist them in coping with the stressors of life."
E) "At times of mild to moderate anxiety, defense mechanisms are used adaptively to deal with stress."

ANS: A, C, E

A client is admitted to the emergency department after a car accident but does not remember anything about it. The client is unconsciously using which defense mechanism?

A) Undoing
B) Rationalization
C) Suppression
D) Repression

D) Repression

A client in the emergency department was violently attacked and raped. When discussing the incident with the nurse, the client shows no emotion related to the event. Which defense mechanism is the client exhibiting?

A) Isolation
B) Displacement
C) Compensation
D) Regression

A) Isolation

After failing an examination, a physician in his psychiatric residency begins smoking a pipe and growing a beard to look like Sigmund Freud. The nurse manager, realizing the physician's insecurities, recognizes which defense mechanism?

A) Identification
B) Repression
C) Regression
D) Reaction formation

A) Identification

Which situation reflects the defense mechanism of projection?

A) A husband has an affair, then buys his wife a diamond anniversary bracelet.
B) A promiscuous wife accuses her husband of having an affair.
C) A wife who is unable to become pregnant works hard at becoming teacher of the year.
D) A man who was sexually assaulted as a child remembers nothing of the event.

B) A promiscuous wife accuses her husband of having an affair.

Which situation reflects the defense mechanism of denial?

A) When his twin brother excels in golf, the client begins lessons with a gold pro.
B) After a mother spanks her child for misbehaving, the child pulls the cat's tail.
C) After years of excessive drinking, the client fails to acknowledge a problem.
D) The client tells his family that 50% of people with his diagnosis survive.

C) After years of excessive drinking, the client fails to acknowledge a problem.

During visiting hours, a client who is angry at her ex-husband's charges of child neglect expresses this anger by lashing out at her sister-in-law. The nurse understands that the client is demonstrating the use of which defense mechanism?

A) Denial
B) Projection
C) Displacement
D) Rationalization

C) Displacement

A girl is jealous of her best friend for winning the scholarship she herself expected. She agrees to meet her friend for lunch and then arrives 1 hour late, apologizing and begging forgiveness. The girl is displaying which behavior?

A) Self-assertion
B) Passive-agressiveness
C) Splitting
D) Omnipotence

B) Passive-agressiveness

Which of the following are examples of cognitive responses to mild levels of anxiety? Select all that apply.

A) Increased respirations
B) Feelings of horror or dread
C) Pacing the hall
D) Increased concentration
E) Heightened alertness

ANS: D, E

Which is an example of a behavioral response to a moderate level of anxiety?

A) Narrowing perception
B) Heart palpitations
C) Limited attention span
D) Restlessness

D) Restlessness

Which is an example of a physiological response to a panic level of anxiety?

A) Inability to focus
B) Loss of consciousness
C) Dilated pupils
D) Possible psychosis

C) Dilated pupils

A nurse on an inpatient psychiatric unit is assessing a client at risk for acting-out behaviors. Which of the following behavioral symptoms would the nurse expect to be exhibited? Select all that apply.

A) Invasion of personal space
B) Flushed face
C) Increased Anxiety
D) Misinterpretation of stimuli
E) Pacing the halls

ANS: A, E

Which of the following medical diagnoses can be affected by psychological factors? Select all that apply.

A) Cancer
B) Asthma
C) Coronary artery disease
D) Upper respiratory tract infection
E) Sepsis

ANS: A, B, C

Which would the nurse expect to assess in a client with long-term maladaptation to stressful events?

A) Diarrhea
B) Pulse 100, blood pressure 150/94 mm Hg
C) Profuse diaphoresis
D) Ulcerative colitis

D) Ulcerative colitis

At an out-patient obstetric clinic, a pregnant client on welfare exhibits extreme anxiety when discussing a failure in school. This is an example of which type of crisis?

A) Dispositional crisis
B) Crisis of anticipated life transition
C) Maturational/developmental crisis
D) Crisis reflecting psychopathology

B) Crisis of anticipated life transition

The nurse should assess which of the following client behaviors when completing a risk assessment? Select all that apply.

A) Past history of violence
B) Disturbed thought process
C) Invasion of personal space
D) Flushed face
E) Self-mutilation

ANS: A, C, E

On an inpatient psychiatric unit, a nurse is completing a risk assessment on a newly admitted agitated client. Which expressed client symptom would the nurse categorize as cognitive?

A) Incarceration for fighting
B) Paranoid delusions
C) History of throwing objects on the unit
D) Reddened face

B) Paranoid delusions

A client diagnosed with PTSD states to the nurse, "All those wonderful people died, and yet I was allowed to live." Which is the client experiencing?

A) Denial
B) Social isolation
C) Anger
D) Survivor's guilt

D) Survivor's guilt

Which of the following would the nurse expect to assess in a client diagnosed with PTSD? Select all that apply.

A) Dissociative events
B) Intense fear and helplessness
C) Excessive attachment and dependence toward others
D) Full range of affect
E) Avoidance of activities that are associated with the trauma

ANS: A, B, E

When treating individuals with PTSD, which variable is included in the recovery environment?

A) Degree of ego strength
B) Availability of social supports
C) Severity and duration of the stressor
D) Amount of control over recurrence

B) Availability of social supports

A newly admitted client is diagnosed with PTSD. Which behavioral symptom would the nurse expect to assess?

A) Recurrent, distressing flashbacks
B) Intense fear, helplessness, and horror
C) Diminished participation in significant activities
D) Detachment or estrangement from others

C) Diminished participation in significant activities

A client is experiencing a high level of occupational stress and has a history of migraine headaches. Which nursing diagnosis takes priority?

A) Pain
B) Anxiety
C) Activity intolerance
D) Ineffective role performance

B) Anxiety

Which nursing diagnosis takes priority when a client experiences an acute asthma attack precipitated by the death of the client's father?

A) Anxiety R/T loss AEB increased respirations
B) Impaired gas exchange R/T stress AEB decreased O2 saturation levels
C) Risk for suicide R/T grief
D) Ineffective coping R/T grief AEB psychosomatic complaints

B) Impaired gas exchange R/T stress AEB decreased O2 saturation levels

A client has a nursing diagnosis of knowledge deficit R/T relationship of anxiety to hypertension. Which intervention addresses this client's problem?

A) Assess the client for suicidal or homicidal ideations
B) Encourage the client to verbalize feelings about anxiety
C) Role-play situations in which anxiety is experienced
D) Teach the client about the mind-body connection

D) Teach the client about the mind-body connection

A client with rigid posture and raised voice uses profanity while demanding to use the phone. Which correctly written nursing diagnosis is a priority?

A) Risk for injury toward others R/T anxiety AEB rigid posture and profanity
B) Ineffective coping R/T inability to express feelings AEB aggressive demeanor
C) Disturbed though process R/T altered perception AEB demanding behaviors
D) Social isolation R/T anger AEB inability to get along with staff

B) Ineffective coping R/T inability to express feelings AEB aggressive demeanor

In group therapy, an angry client becomes increasingly restless and irritable and shouts at the facilitator. Which nursing diagnosis takes priority?

A) Risk for violence toward others R/T inability to deal with frustration
B) Ineffective coping R/T inability to express feelings AEB raised voice
C) Anxiety R/T topic at hand AEB restlessness in group therapy
D) Social isolation R/T intimidation of others AEB solitary activities

A) Risk for violence toward others R/T inability to deal with frustration

A newly admitted client diagnosed with PTSD is exhibiting recurrent flashbacks, nightmares, sleep deprivation, and isolation from others. Which nursing diagnosis makes priority?

A) Posttrauma syndrome R/T a distressing event AEB flashbacks and nightmares
B) Social isolation R/T anxiety AEB isolating because of fear of flashbacks
C) Ineffective coping R/T flashbacks AEB inappropriate use of alcohol
D) Risk for injury R/T exhaustion because of sustained levels of anxiety

D) Risk for injury R/T exhaustion because of sustained levels of anxiety

On an inpatient unit, a client is isolating self in a room and refusing to attend group therapy. Which is an appropriate, correctly written short-term outcome for this client?

A) Client participation will be expected in one group session
B) Provide opportunities for the client to increase self-esteem by discharge
C) The client will interact with staff by the end of the 3-to-11 shift
D) The client will demonstrate socialization skills when in the milieu

C) The client will interact with staff by the end of the 3-to-11 shift

A hospitalized client diagnosed with PTSD has a nursing diagnosis of ineffective coping R/T history of rape AEB abusing alcohol. Which is the expected short-term outcome for this client problem?

A) The client will recognize triggers that precipitate alcohol abuse by day 2
B) The client will attend follow-up weekly therapy sessions after discharge
C) The client will refrain from self-blame regarding the rape by day 2
D) The client will be free from injury to self throughout the shift

A) The client will recognize triggers that precipitate alcohol abuse by day 2

A client on an inpatient psychiatric unit is sarcastic to staff and avoids discussions in group therapy. Which correctly written short-term outcome is appropriate for this client?

A) The client will not injure self or anyone else
B) The client will express feelings of anger in group therapy by end of shift
C) The client will take responsibility for his or her own feelings
D) The client will participate in out-patient group therapy after discharge

B) The client will express feelings of anger in group therapy by end of shift

Which of the following interventions should the nurse include when caring for a client experiencing migraine headaches? Select all that apply.

A) Monitor pain level using a pain scale
B) Explore with the client how stress may trigger this disorder
C) Encourage the client to note patterns of exacerbation triggers by journaling
D) Assess for suicidal ideations
E) Administer divalproex sodium as prescribed

ANS: A, B, C, E

A client has been diagnosed with an exacerbation of tension headaches. Which of the following behavior interventions would assist the client during active symptoms? Select all that apply.

A) Help the client to decrease stress by teaching assertiveness skills
B) Help the client to acknowledge and address the source anger
C) Administer medications, such as propranolol
D) Discuss how personality type may affect exacerbations of tension headaches
E) Teach the client progressive relaxation

ANS: A, E

A severely anxious client experiencing headaches, palpitations, and inability to concentrate is admitted to a medical floor. Which nursing intervention would take priority?

A) Encourage the client to express feelings
B) Discuss alternative coping strategies with the client
C) Use a distraction, such as having the client attend group
D) Sit with the client and use a calm but directive approach

D) Sit with the client and use a calm but directive approach

A client is exhibiting tension and needs direction to solve problems. Which of the following interventions would the nurse implement using a behavioral approach? Select all that apply.

A) Asses the client's family history for anxiety disorders
B) Encourage the client to use deep breathing techniques
C) Ask the client to think of a time in the past when anxiety was manageable
D) Encourage journal writing to express feelings
E) Educate the client of aroma therapy

ANS: B, E

The nursing student is developing a plan of care for a client experiencing a crisis situation. Number the following in priority order for implementation of this plan.

1. ______ Assess for suicidal and homicidal ideation
2. _____ Discuss coping skills used in the past and note if they were effective
3. _____ Establish a working relationship by active listening
4. _____ Develop a plan of action for dealing with future stressors
5. _____ Evaluate the developed plan's effectiveness.

ANS: 1, 3, 2, 4, 5

The nurse is assessing clients on an inpatient psychiatric unit. Which client would require immediate intervention?

A) A client experiencing rapid, pressured speech and poor personal boundaries
B) A client expressing homicidal ideations toward the neighborhood butcher
C) A client who has slept only 1 to 2 hours per night for the past 2 nights
D) A client secluding self from others and refusing to attend groups in the milieu

A) A client experiencing rapid, pressured speech and poor personal boundaries

A 17-year-old client whose boyfriend has recently broken their engagement is brought into emergency department after taking a handful of lorazepam. Which nursing intervention would take priority during this psychiatric crisis?

A) Discuss the client's feelings about the breakup with her boyfriend
B) Monitor vital signs and note any signs of central nervous system depression
C) Allow the client time to rest because lorazepam is sedating
D) Decrease fluids and place the client on close observation

B) Monitor vital signs and note any signs of central nervous system depression

An agency nurse is coming to an inpatient psychiatric unit for the first time. The charge nurse of the unit would assign which client to this nurse?

A) A client newly admitted for suicidal ideations with a plan to jump off a bridge
B) A client admitted 2 days ago for alcohol detoxifications with a history of seizures
C) A client grimacing and pacing the halls with a grim, defiant affect
D) A client starting clozapine therapy to treat auditory hallucinations

A) A client newly admitted for suicidal ideations with a plan to jump off a bridge

The nurse is using an intrapersonal approach to assist a client in dealing with survivor's guilt. Which intervention would be appropriate?

A) Encourage the client to attend a survivor's group for peer support.
B) Facilitate expression of feelings during one-to-one interactions with the nurse.
C) Ask the client to challenge the irrational beliefs associated with the event.
D) Administer scheduled paroxetine to deal with depressive symptoms.

B) Facilitate expression of feelings during one-to-one interactions with the nurse.

A client on an inpatient psychiatric unit is experiencing a flashback. Which intervention takes priority?

A) Maintain and reassure the client of his or her safety and security
B) Encourage the client to express feelings
C) Decrease extraneous external stimuli
D) Use a nonjudgmental and matter-of-fact approach

A) Maintain and reassure the client of his or her safety and security

A widow is diagnosed with adjustment disorder with depressed mood. Symptoms include chronic migraines, feelings of hopelessness, social isolation, and self-care deficit. Which nursing intervention would be most appropriate?

A) Present the reality of the consequences of impulsive behaviors
B) Encourage independent completion of activities of daily living
C) Discuss the effects of behaviors that guarantee immediate gratification
D) Teach techniques to improve positive body image

B) Encourage independent completion of activities of daily living

The nursing student is reviewing information about crisis. Which of the following student statements indicates that learning has occurred? Select all that apply.

A) "A crisis is associated with psychopathology."
B) "A crisis is precipitated by a specific identifiable event."
C) "A crisis is chronic in nature and needs multiple interventions over time."
D) "A crisis is specific to an individual, and the cause may vary."
E) "A crisis contains the potential for psychological growth or deterioration."

ANS: B, D, E

A student is learning about "prodromal syndrome." Which student statement indicates that learning has occurred?

A) "Behaviors associated with prodromal syndrome necessitate immediate action by the nurse."
B) "Prodromal syndrome occurs after a client's outburst."
C) "Staff cannot assist clients who are experiencing prodromal syndrome in gaining control."
D) "Very few symptoms are associated with prodromal syndrome."

A) "Behaviors associated with prodromal syndrome necessitate immediate action by the nurse."

A client diagnosed with PTSD has a nursing diagnosis of disturbed sleep pattens R/T nightmares. Which evaluation would indicate that the stated nursing diagnosis was resolved?

A) The client expresses feelings about the nightmares during group
B) The client asks for prn trazodone (Desyrel) before bed to fall asleep
C) The client states "My nightmares have stopped, and I feel rested."
D) The client avoids napping during the day to help enhance sleep.

C) The client states "My nightmares have stopped, and I feel rested."

The nurse teaches an anxious client diagnosed with PTSD a breathing technique. Which client action would indicate that the teaching was successful?

A) The client eliminates anxiety by using the breathing technique.
B) The client performs activities of daily living independently by discharge.
C) The client recognizes signs and symptoms of escalating anxiety.
D) The client maintains a 3/10 anxiety level without medications.

D) The client maintains a 3/10 anxiety level without medications.

A nursing instructor is teaching about clients diagnosed with an adjustment disorder. Which student statement indicates that learning has occurred?

A) "A client with this disorder should exhibit symptoms within 1 year of the precipitating event."
B) "A client with this disorder should exhibit symptoms within 3 months of the precipitating event."
C) "A client with this disorder should exhibit symptoms within 6 months of the precipitating event."
D) "A client with this disorder should exhibit symptoms within 9 months of the precipitating event."

B) "A client with this disorder should exhibit symptoms within 3 months of the precipitating event."

A client diagnoses with PTSD is prescribed paroxetine 30 mg qhs. Paroxetine is supplied as a 20-mg tablet. The nurse would administer ______ tablets.

1.5 tablets

A client rates anxiety at 8 out of 10 on a scale of 1 to 10, is restless, and has narrowed perceptions. Which of the following medications could be appropriately prescribed to address these symptoms? Select all that apply.

A) Chlordiazepoxide
B) Clonazepam
C) Lithium carbonate
D) Clozapine
E) Oxazepam

ANS: A, B, E

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