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3. Which of the following terms is used to describe the process by which a person experiences the grief? A) Anticipatory grieving B) Disenfranchised grief C) Bereavement D) Mourning

Ans: C Feedback: Bereavement refers to the process by which a person experiences the grief. Anticipatory grieving is when people facing imminent loss begin to grapple with the very real possibility of the loss or death in the near future. Disenfranchised grief is grief over a loss that is not or cannot be acknowledged openly, mourned publicly, or supported socially. Mourning is the outward expression of grief.

26. A client is learning to cope with anxiety and stress. The expected outcome is that the client will A) change reactions to stressors. B) ignore situations that cause stress. C) limit major stressors in his or her life. D) avoid anxiety at all costs.

Ans: A Feedback: Stress and anxiety in life are unavoidable; managing the effects of stress is a reasonable goal for treatment. It is not possible or desirable to avoid anxiety at all costs as anxiety is a warning that the client is not dealing with stress effectively. Learning to heed this warning and to make needed changes is a healthy way to deal with the stress of daily events.

1. A nurse is working with a client who has frequent angry outbursts. Which of the following statements is most helpful when working with this client? A) ìAnger is a normal feeling, and you can use it to solve problems.î B) ìYou need to learn to suppress your angry feelings.î C) ìYou can reduce your anger by hitting a punching bag.î D) ìYou need to learn how to be less assertive in your communications.î

Ans: A Feedback: Anger can be a normal and healthy reaction when situations or circumstances are unfair or unjust, personal rights are not respected, or realistic expectations are not met. If the person can express his or her anger assertively, problem solving or conflict resolution is possible. Anger becomes negative when the person denies it, suppresses it, or expresses it inappropriately. A person may deny or suppress (i.e., hold in) angry feelings if he or she is uncomfortable expressing anger. Catharsis can increase rather than alleviate angry feelings. Effective methods of anger expression, such as using assertive communication, to express anger should replace angry aggressive outbursts.

20. Which of the following statements about the assessment of persons with anxiety and anxiety disorders is most accurate? A) When an elder person has an onset of anxiety for the first time in his or her life, it is possible that the anxiety is associated with another condition. B) Panic attacks are the most common late-life anxiety disorders. C) An elder person with anxiety may be experiencing ruminative thoughts. D) Agoraphobia that occurs in late life may be related to trauma experienced or anticipated.

Ans: A Feedback: Anxiety that starts for the first time in late life is frequently associated with another condition such as depression, dementia, physical illness, or medication toxicity or withdrawal. Phobias, particularly agoraphobia, and GAD are the most common late-life anxiety disorders. Most people with late-onset agoraphobia attribute the start of the disorder to the abrupt onset of a physical illness or as a response to a traumatic event such as a fall or mugging. Ruminative thoughts are common in late-life depression and can take the form of obsessions such as contamination fears, pathologic doubt, or fear of harming others.

10. The nurse is working with a client who lost her youngest child 2 months ago. When the nurse approaches, the client, the client yells, ìI don't want to talk to you. You have no idea what it's like to lose a child!î The nurse bases her response to the client on the understanding of which of the following? A) Hostility is a common behavioral response to grief. B) It is too soon after the loss to empathize with the client. C) Personality traits such as aggressiveness are exaggerated during the grief process. D) The nurse may have nonverbally indicated a judgmental attitude toward the client.

Ans: A Feedback: Behavioral responses to grief are often the easiest to observe. Irritability and hostility toward others reveal anger and frustration in the grief process.

19. A client states, ìI will just die if I don't get this job.î The nurse then asks the client, ìWhat will be the worst that will happen if you don't get the job?î The nurse is using this response to A) appraise his situation more realistically. B) assist the client to make alternative plans for the future. C) assess if the client has health problems compounded by stress. D) clarify the client's meaning.

Ans: A Feedback: Decatastrophizing involves the therapist's use of questions to more realistically appraise the situation. The therapist may ask, ìWhat is the worst that could happen? Is that likely? Could you survive that? Is that as bad as you imagine?î

25. The nurse is establishing outcomes for a grieving client. Which of the following is an appropriate outcome? A) The client will develop a plan for coping with the loss. B) The client will demonstrate self-reliance during the grief process. C) The client will suppress emotions related to the loss. D) The client will verbalize that loss will not adversely affect the quality of life.

Ans: A Feedback: Examples of outcomes for the grieving client are as follows: - Identify the effects of his or her loss. - Identify the meaning of his or her loss. - Seek adequate support while expressing grief. - Develop a plan for coping with the loss. - Apply effective coping strategies while expressing and assimilating all dimensions of human response to loss in his or her life. - Recognize the negative effects of the loss on his or her life. - Seek or accept professional assistance if needed to promote the grieving process

13. A client approaches the nurse and loudly states, ìI'm not putting up with this anymore!î The most appropriate response by the nurse would be which of the following? A) ìI can see you are angry. Tell me what's going on.î B) ìYou are not allowed to make threats. Please keep your voice down.î C) ìWhy do you say that?î D) ìYou are here voluntarily. You can leave if you want.î

Ans: A Feedback: In the triggering phase, the nurse should approach the client in a nonthreatening, calm manner in order to deescalate the client's emotion and behavior. Conveying empathy for the client's anger or frustration is important. The nurse can encourage the client to express his or her angry feelings verbally, suggesting that the client is still in control and can maintain that control. Use of clear, simple, short statements is helpful.

16. A client experiences panic attacks when confronted with riding in elevators. The therapist is teaching the client ways to relax while incrementally exposing the client to getting on an elevator. This technique is called A) systematic desensitization. B) flooding. C) cognitive restructuring. D) exposure therapy.

Ans: A Feedback: One behavioral therapy often used to treat phobias is systematic (serial) desensitization, in which the therapist progressively exposes the client to the threatening object in a safe setting until the client's anxiety decreases. Flooding is a form of rapid desensitization in which a behavioral therapist confronts the client with the phobic object (either a picture or the actual object) until it no longer produces anxiety. Cognitive restructuring involves challenging the client's irrational beliefs. Exposure therapy is similar to flooding.

8. Friends of a teenage male recently killed in a car accident are discussing their sense of loss. Which of the following comments best indicates that the friends are trying to make sense of the loss cognitively? A) ìWhy did he have to die so young?î B) ìHe shouldn't have been driving so recklessly.î C) ìIf we had only stayed longer, he would not have been on that road.î D) ìIt took the ambulance too long to get there.î

Ans: A Feedback: One of the cognitive responses to grief involves the grieving person making sense of the loss. He or she undergoes self-examination and questions accepted ways of thinking. The loss challenges old assumptions about life. Anger, sadness, and anxiety are the predominant emotional responses to loss. The grieving person may direct anger and resentment toward the dead person and his or her health practices, family members, or health-care providers or institutions.

12. Which of the following theories about anxiety is based upon intrapsychic theories? A) A person's innate anxiety is the stimulus for behavior. B) Anxiety is generated from problems in interpersonal relationships. C) A nurse can help the client to achieve health by attending to interpersonal and physiologic needs. D) Anxiety is learned through experiences.

Ans: A Feedback: Theories of anxiety can be classified as intrapsychic/psychoanalytic theories, interpersonal theories, and behavioral theories. Freud's intrapsychic theory views a person's innate anxiety as the stimulus for behavior. Interpersonal theories include Sullivan's theory that anxiety is generated from problems in interpersonal relationships and Peplau's belief that humans exist in interpersonal and physiologic realms. Behavioral theorists view anxiety as being learned through experiences.

16. An angry client has just thrown a chair across the room and is racing to pick up another chair to throw. The most appropriate action by the nurse would be which of the following? A) Call for an emergency response from trained personnel. B) Approach the client and firmly say, ìStop, put it down.î C) Calmly call the client by name and encourage verbal expression of anger. D) Assist the client to use problem-solving techniques instead of aggression.

Ans: A Feedback: When the client becomes physically aggressive (crisis phase), the staff must take charge of the situation for the safety of the client, staff, and other clients. Psychiatric facilities offer training and practice in safe techniques for managing behavioral emergencies, and only staff with such training should participate in the restraint of a physically aggressive client. Verbal expression and problem solving are ineffective once a client has reached the crisis phase. The priority is to maintain safety and regain control.

11. Which of the following best explains the etiology of anxiety disorders from an interpersonal perspective? A) Anxiety is learned in childhood through interactions with caregivers. B) Anxiety is learned throughout life as a response to life experiences. C) Anxiety stems from an unconscious attempt to control awareness. D) Anxiety results from conforming to the norms of a cultural group.

Ans: A Feedback: Interpersonal theory proposes that caregivers can communicate anxiety to infants or children through inadequate nurturing, agitation when holding or handling the child, and distorted messages. In adults, anxiety arises from the person's need to conform to the norms and values of his or her cultural group. Psychoanalytic theories describe reducing anxiety through the use of defense mechanisms. Defense mechanisms are cognitive distortions that a person uses unconsciously to maintain a sense of being in control of a situation, to lessen discomfort, and to deal with stress.

19. When interacting with a client in the day room, the nurse determines that a violent outburst is imminent. Which of the following should the nurse do first? A) Call for assistance. B) Give the client choices. C) Remove the other clients. D) Talk to the client calmly.

Ans: A Feedback: Safety is the priority; the nurse needs assistance to remove other clients and to deal with the violent outburst. The other interventions may be implemented after calling for assistance.

31. When teaching a client with generalized anxiety disorder, which is the highest priority for the nurse to teach the client to avoid? A) Caffeine B) High-fat foods C) Refined sugars D) Sodium

Ans: A Feedback: The effects of caffeine are similar to some anxiety symptoms, and, therefore, caffeine ingestion will worsen anxiety. The other types of foods are also potentially harmful to physical as well as psychological health, but the worst offender is caffeine.

30. One of the first steps that a nurse should take to deal effectively with aggressive clients is which of the following? A) Reflect on abilities to handle own feelings of anger B) Learn professional skills of anger management C) Become proficient using reflective communication techniques D) Understand how to activate crisis response teams

Ans: A Feedback: The nurse must be aware of how he or she deals with anger before helping clients do so. The nurse who is afraid of angry feelings may avoid a client's anger, which allows the client's behavior to escalate. If the nurse's response is angry, the situation can escalate into a power struggle, and the nurse loses the opportunity to ìtalk downî the client's anger. Identifying how you handle angry feelings is an initial task. Once the nurse understands his or her own experiences with anger, the clients can be helped through learning the use of assertive communication and conflict resolution. Increasing your skills in dealing with your angry feelings will help you to work more effectively with clients. Activating a crisis response is a late option in dealing with anger.

11. Which of the following are eventual outcomes of the emotional dimension of grieving? Select all that apply. A) The survivor begins to reestablish a sense of personal identity, direction, and purpose for living. B) The survivor begins to gain independence and confidence. C) The survivor develops new ways of managing life and new relationships. D) The survivor's life returns to the same state as it was before the loss. E) The survivor forgets about the loss.

Ans: A, B, C Feedback: Eventually, the bereaved person begins to reestablish a sense of personal identity, direction, and purpose for living. He or she gains independence and confidence. New ways of managing life emerge and new relationships form. The person's life is reorganized and seems ìnormalî again, although different than that before the loss. The person still misses the deceased, but thinking of him or her no longer evokes painful feelings.

26. Which of the following interventions are most effective in managing the environment to reduce or eliminate aggressive behavior? Select all that apply. A) Planning group activities such as playing games B) Scheduling one-to-one interactions with the client C) Providing structure and consistency in the unit D) Avoiding discussions among clients on the unit E) Discouraging clients from negotiating solutions

Ans: A, B, C Feedback: Group and planned activities such as playing card games, watching and discussing movies, or participating in informal discussions give the clients the opportunity to talk about events or issues when they are calm. Scheduling one-to-one interactions with clients indicates the nurse's genuine interest in the client and a willingness to listen to the client's concerns, thoughts, and feelings. Knowing what to expect enhances the client's feelings of security. Avoiding discussions does not give clients the opportunity to talk about events or issues when they are calm. If clients have a conflict or dispute with one another, the nurse can offer the opportunity for problem solving or conflict resolution. Expressing angry feelings appropriately, using assertive communication statements, and negotiating a solution are important skills clients can practice. These skills will be useful for the client when he or she returns to the community.

22. Which of the following are cognitiveñbehavioral therapy techniques that may be used effectively with anxious clients? Select all that apply. A) Positive reframing B) Decatastrophizing C) Assertiveness training D) Humor E) Unlearning

Ans: A, B, C, E Feedback: Positive reframing means turning negative messages into positive messages. Decatastrophizing involves the therapist's use of questions to more realistically appraise the situation. Assertiveness training helps the person take more control over life situations. Positive reframing, decatastrophizing, and assertiveness training are cognitiveñbehavioral therapy techniques. Humor is not a cognitiveñbehavioral therapy technique. Unlearning is the theory underlying behavioral therapy.

6. Anger management is likely to be included in the care of clients with which of the following psychiatric diagnoses? Select all that apply. A) Alzheimer's dementia B) Schizophrenia C) Anorexia nervosa D) Acute alcohol intoxication E) Generalized anxiety disorder

Ans: A, B, D Feedback: Although most clients with psychiatric disorders are not aggressive, clients with a variety of psychiatric diagnoses can exhibit angry, hostile, and aggressive behavior. Clients with paranoid delusions may believe others are out to get them; believing they are protecting themselves, they retaliate with hostility or aggression. Some clients have auditory hallucinations that command them to hurt others. Aggressive behavior also is seen in clients with dementia, delirium, head injuries, intoxication with alcohol or other drugs, and antisocial and borderline personality disorders.

1. The nurse knows that which of the following are stages in Selye's general adaptation syndrome? Select all that apply. A) Alarm reaction stage B) Resistance stage C) Coping stage D) Exhaustion stage E) Panic stage

Ans: A, B, D Feedback: The stages in Selye's general adaptation syndrome include the alarm reaction stage, the resistance stage, and the exhaustion stage. Selye did not identify either a coping stage or a panic stage.

34. Which of the following are reasons that the nurse must understand why and how anxiety behaviors work? Select all that apply. A) To provide better care for the client B) To help understand the role anxiety plays in performing nursing responsibilities C) To help the nurse to mask his or her own feelings of anxiety D) So the nurse can identify that his or her own needs are more important than the clients E) To help nurses to function at a high level

Ans: A, B, E Feedback: Nurses must understand why and how anxiety behaviors work, not just for client care but to help understand the role anxiety plays in performing nursing responsibilities. Nurses are expected to function at a high level and to avoid allowing their own feelings and needs to hinder the care of their clients, but as emotional beings, nurses are just as vulnerable to stress and anxiety as others, and they have needs of their own.

17. Which techniques would be most effective for a client who has situational phobias? Select all that apply. A) Flooding B) Reminding the person to calm down C) Systematic desensitization D) Assertiveness training E) Decatastrophizing

Ans: A, C Feedback: Systematic desensitization is when the therapist progressively exposes the client to a threatening object in a safe setting until the client's anxiety decreases. Flooding is a form of rapid desensitization in which the behavior therapist confronts the client with the phobic object until it no longer produces anxiety. Systematic desensitization and flooding are behavioral therapies used in the treatment of phobias. Assertiveness training would help the person to take more control over life situations. Decatastrophizing helps the client to realistically appraise the situation. These are both used for general anxiety. When a person is exposed to a phobic object, the person is not likely in control. Reminding a person to calm down is not at all an effective way to manage anxiety.

19. Which of the following persons are most likely experiencing complicated grieving? Select all that apply. A) The spouse of a person who died 7 years ago and visits the grave several times a day. B) The grandchild of a soldier killed in war who visits the grave once a year on Memorial Day. C) A driver whose spouse and children all died as a result of his driving drunk. D) An adult who insisted for many years that he or she hated his or her deceased parent. E) The parent of a child who died after the having left the child in a car on a hot day.

Ans: A, C, D, E Feedback: The spouse of a person who died 7 years ago and visits the grave several times a day is likely experiencing complicated grieving as this is a prolonged period of time with expression of grief that is exaggerated. A driver whose spouse and children all died as a result of his driving drunk likely experiences feelings of guilt as well as loss. An adult who insisted for many years that he or she hated his or her deceased parent is likely experiencing complicated grief as he or she has experienced an ambivalent attachment. The parent of a child who died after having left the child in a car on a hot day is likely experiencing guilt as well as loss.

9. Which of the following statements about the use of defense mechanisms in persons with anxiety disorders are accurate? Select all that apply. A) Defense mechanisms are a human's attempt to reduce anxiety. B) Persons are usually aware when they are using defense mechanisms. C) Defense mechanisms can be harmful when overused. D) Defense mechanisms are cognitive distortions. E) The use of defense mechanisms should be avoided. F) Defense mechanisms can control the awareness of anxiety.

Ans: A, C, D, F Feedback: Freud described defense mechanisms as the human's attempt to control awareness of and to reduce anxiety. Defense mechanisms are cognitive distortions that a person uses unconsciously to maintain a sense of being in control of a situation, to lessen discomfort, and to deal with stress. Because defense mechanisms arise from the unconscious, the person is unaware of using them. Some people overuse defense mechanisms, which stops them from learning a variety of appropriate methods to resolve anxiety-producing situations. The dependence on one or two defense mechanisms also can inhibit emotional growth, lead to poor problem-solving skills, and create difficulty with relationships.

2. Which of the following statements about anger, hostility and aggression are accurate? Select all that apply. A) Anger is an emotional response to a real or perceived provocation. B) Hostility stimulates the sympathetic nervous system. C) Physical aggression involves harming other persons or property. D) Anger, hostility, and physical aggression are normal human emotions. E) Hostility is also referred to as verbal aggression. F) Physical aggression often progresses to hostility.

Ans: A, C, E Feedback: Anger is an emotional response to a real or perceived provocation. Anger energizes the body physically for self-defense, when needed, by activating the ìfight-or-flightî response mechanism of the sympathetic nervous system. Hostility is different than anger. Physical aggression is behavior in which a person attacks or injures another person or that involves destruction of property. Hostility is also referred to as verbal aggression. Anger is a normal human emotion. Hostility is an emotion that is expressed through negative behavior. Physical aggression is behavior. Hostility may lead to physical aggression.

13. The nurse is caring for a hospice client whose death is imminent. In preparing the family for the death of their loved one, then nurse prepares to assist the family in which of the following, regardless of the family's cultural preferences? Select all that apply. A) Dealing with the shock of losing a loved one B) Burial plans after death had occurred C) Efforts to stay connected to the client after death D) Use of support from family and friends E) Anger at the loss of a loved one

Ans: A, C, E Feedback: Universal reactions include the initial response of shock and social disorientation, attempts to continue a relationship with the deceased, anger with those perceived as responsible for the death, and a time for mourning. Not all cultures bury their deceased. Some cultures mourn privately, not turning to the support of others.

25. When a client is experiencing a panic attack while in the recreation room, what interventions are the nurse's first priorities? Select all that apply. A) Provide a safe environment. B) Request a prescription for an antianxiety agent. C) Offer the client therapy to calm down D) Ensure the client's privacy. E) Engage the client in recreational activities.

Ans: A, D Feedback: During a panic attack, the nurse's first concern is to provide a safe environment and to ensure the client's privacy. If the environment is overstimulating, the client should move to a less stimulating place. Decreasing external stimuli will help lower the client's anxiety level. The client's safety is priority. Anxious behavior can be escalated by external stimuli. In a large area, the client can feel lost and panicked, but a smaller room can enhance a sense of security. An antianxiety agent may be helpful, but it is not the priority. It would likely be stimulating to engage the client in recreational activities.

30. The nurse is educating a client and family about managing panic attacks after discharge from treatment. The nurse includes which of the following in the discharge teaching? Select all that apply. A) Continued development of positive coping skills B) Weaning off of medications as necessary C) Lessening the amount of daily responsibilities D) Continued practice of relaxation techniques E) Development of a regular exercise program

Ans: A, D, E Feedback: Client/family education for panic disorder includes reviewing breathing control and relaxation techniques, discussing positive coping strategies, encouraging regular exercise, emphasizing the importance of maintaining prescribed medication regimen and regular follow-up, describing time management techniques such as creating ìto doî lists with realistic estimated deadlines for each activity, crossing off completed items for a sense of accomplishment, saying ìno,î and stressing the importance of maintaining contact with community and participating in supportive organizations. Medication should be adhered to as prescribed. Daily responsibilities cannot be avoided, rather should be successfully accomplished.

32. Which of the following are important issues for nurses to be aware of when working with angry, hostile, or aggressive clients? Select all that apply. A) Nurses must be aware of their own feelings about anger and their use of assertive communication and conflict resolution. B) Nurses must not allow themselves to become angry under any circumstances. C) Nurses must know that a client's anger or aggressive behavior is preventable by a skilled nurse. D) Nurses must discuss situations or the care of potentially aggressive clients with experienced nurses. E) Nurses must be calm, nonjudgmental, and nonpunitive when using techniques to control a client's aggressive behavior.

Ans: A, D, E Feedback: Nurses must identify how they handle angry feelings and assess their use of assertive communication and conflict resolution. Increasing their skills in dealing with their angry feelings will help the nurses to work more effectively with the client. Nurses must not take the client's anger or aggressive behavior personally or as a measure of their effectiveness as a nurse. Nurses must discuss situations or the care of potentially aggressive clients with experienced nurses. Nurses must be calm, nonjudgmental, and nonpunitive when using techniques to control a client's aggressive behavior

24. The nursing student understands correctly when identifying which objective is appropriate for all clients with anxiety disorders? A) The client will experience reduced anxiety and accept the fact that underlying conflicts cannot be treated. B) The client will experience reduced anxiety and develop alternative responses to anxiety-provoking situations. C) The client will experience reduced anxiety and learn to control primitive impulses. D) The client will experience reduced anxiety and strive for insight through psychoanalysis.

Ans: B Feedback: A primary client outcome is improved adaptive coping skills.

3. The nursing student answers the test item correctly when identifying which one of the following statements is true? A) Anxiety and fear are the same. B) Anxiety is unavoidable. C) Anxiety is always harmful. D) Fear is feeling threatened by an unknown entity.

Ans: B Feedback: Anxiety is distinguished from fear, which is feeling afraid or threatened by a clearly identifiable external stimulus that represents danger to the person. Anxiety is unavoidable in life and can serve many positive functions such as motivating the person to take action to solve a problem or to resolve a crisis.

15. A nurse is working with a client to develop assertive communication skills. The nurse documents achievement of treatment outcomes when the client makes a statement such as, A) ìI'm sorry. I'm not picking this up very quickly.î B) ìI feel upset when you interrupt me.î C) ìYou are pushing me too hard.î D) ìI'm not going to let people push me around anymore.î

Ans: B Feedback: Assertiveness training helps the person take more control over life situations. Techniques help the person negotiate interpersonal situations and foster self- assurance. They involve using ìIî statements to identify feelings and to communicate concerns or needs to others.

33. A client is scheduled for a mastectomy for breast cancer. She is quiet, shows little emotion, and states that she has no questions. The nurse's assessment would need to focus on A) the client's plans for reconstructive surgery. B) the meaning of the mastectomy to the client. C) whether the client truly understands the surgery. D) why the client seems depressed.

Ans: B Feedback: Assessment begins with exploration of the client's perception of the loss. A client who is scheduled for a mastectomy would possibly be having anticipatory loss of a physiologic nature. It would not be appropriate to discuss the client's plans for reconstructive surgery as this is not likely what is causing the client to be quiet and show little emotion. It is important to ascertain whether the client truly understands the surgery when witnessing the client's signature of the operative consent, but there is no indication that this is what is being addressed at this time. It would not be appropriate to assume that the client is depressed or not. It would be better to explore the client's perception of the loss.

8. A client who suffers from frequent panic attacks describes the attack as feeling disconnected from himself. The nurse notes in the client's chart that the client reports experiencing A) hallucinations. B) depersonalization. C) derealization. D) denial

Ans: B Feedback: During a panic attack, the client may describe feelings of being disconnected from himself or herself (depersonalization) or sensing that things are not real (derealization). Denial is not admitting reality. Hallucinations involve sensing something that is not there.

9. A client is observed pacing the hall with clenched fists and swearing at others. The nurse intervenes immediately to prevent the client from moving to which phase of the aggressing cycle? A) Triggering B) Escalation C) Crisis D) Recovery

Ans: B Feedback: During escalation, the client's responses represent escalating behaviors that indicate movement toward a loss of control, including pale or flushed face, yelling, swearing, agitated, threatening, demanding, clenched fists, threatening gestures, hostility, loss of ability to solve the problem or think clearly. This phase is followed by the crisis phase. During a period of emotional and physical crisis, the client loses control. Behaviors may include loss of emotional and physical control, throwing objects, kicking, hitting, spitting, biting, scratching, shrieking, screaming, and inability to communicate clearly.

10. The client's son is yelling and is hitting his hand with a rolled up newspaper. Which stage of aggression does the nurse identify that the client's son is exhibiting? A) Triggering B) Escalation C) Crisis D) Recovery

Ans: B Feedback: During the escalation phase of aggression, a person may exhibit yelling and threatening, clenched fist, threatening gestures. During the triggering phase of aggression, a person may exhibit signs and symptoms and behaviors including restlessness, anxiety, irritability, pacing, muscle tension, rapid breathing, perspiration, loud voice, and anger.

11. The nurse is teaching a client to recognize early signs of anger and aggression. The nurse explores ways that the client can recognize which of the following? A) Decreased problem-solving ability B) Restlessness and irritability C) Remorse D) Severe muscle tension

Ans: B Feedback: Earliest signs of anger include restlessness, anxiety, irritability, pacing, muscle tension, rapid breathing, perspiration, loud voice, and anger. Escalated signs include pale or flushed face, yelling, swearing, agitation, threatening, demanding, increased muscle tension such as clenched fists, threatening gestures, hostility, and loss of ability to solve the problem or think clearly. Remorse is seen after the anger crisis when attempts are made at reconciliation.

18. The nurse is interviewing a client with a history of physical aggression. Which of the following should the nurse avoid? A) Anticipating that a loss of control is possible and planning accordingly B) Explaining the consequences the client will face if control is lost C) Interviewing the client with another staff member present D) Responding to verbal threats by terminating the interview and obtaining assistance

Ans: B Feedback: Giving the client an ultimatum is likely to foster hostile or aggressive behavior; the other measures are all appropriate for a client with a history of aggression.

15. In the psychiatric setting, what is the most effective intervention in preventing the hostile client's behavior from escalating to physical aggression? A) Getting as far away from him or her as possible B) Engaging the hostile person in dialogue C) Yelling at the client to settle down now D) Ensuring that the client gets his or her way

Ans: B Feedback: In a psychiatric setting, engaging the hostile person is most effective to prevent the behavior from escalating to physical aggression. In the psychiatric setting, it is not possible to get as far away from them as possible. Yelling at the client will likely escalate the hostility. Ensuring that the client gets his or her way may eliminate frustration that may lead to acting out, but is unrealistic and not ultimately helpful to the client.

4. The student nurse correctly identifies that which one of the following statements applies to the parasympathetic nervous system? A) It is activated during the alarm reaction stage. B) It is activated during the resistance stage. C) It is activated during the exhaustion stage. D) It is commonly referred to as the fight, flight, or freeze response.

Ans: B Feedback: In the alarm reaction stage, stress stimulates the body to send messages to the hypothalamus to the glands, which stimulates the sympathetic nervous system. Sympathetic nerve fibers ìcharge upî the vital signs at any hint of danger to prepare the body's defensesófight, flight, or freeze. The adrenal glands release adrenaline (epinephrine), which causes the body to take in more oxygen, dilate the pupils, and increase arterial pressure and heart rate while constricting the peripheral vessels and shunting blood from the gastrointestinal and reproductive systems and increasing glycogenolysis to release free glucose for the heart, muscles, and central nervous system. When the danger has passed, parasympathetic nerve fibers reverse this process and return the body to normal operating conditions until the next sign of threat reactivates the sympathetic nervous system. During the resistance stage of the generalized anxiety syndrome, if the threat has ended, the parasympathetic nervous system is stimulated and the body responses relax. If the threat persists, the body will eventually enter the exhaustion stage when the body stores are depleted as a result of the continual arousal of the physiologic responses and little reserve capacity.

33. Which of the following would be key points for the nurse to remember when working with persons who are suffering from anxiety disorders? A) It is important for the nurse to ìfixî the client's problems. B) Remember to practice techniques to manage stress and anxiety in your own life. C) If you have any uncomfortable feelings, do not tell anyone about them. D) Remember that only people who suffer from anxiety disorders have stress that can interfere with daily life and work.

Ans: B Feedback: It is critical for the nurse to remember to practice techniques to manage stress and anxiety in his or her own life. Remember that everyone occasionally suffers from stress and anxiety that can interfere with daily life and work. It is important for the nurse to avoid falling into the pitfall of trying to ìfixî the client's problems. It is important that the nurse should discuss any uncomfortable feelings with a more experienced nurse for suggestions on how to deal with his or her feelings toward these clients.

21. The client identifies anger management as a problem. What is the next step in planning therapeutic interactions? A) Give the client a variety of choices on how to express anger. B) Give the client permission to be angry. C) Point out the senselessness of anger. D) Tell the client not to be angry all the time.

Ans: B Feedback: Many people view anger as a negative and abnormal feeling in addition to feeling guilty about being angry; the nurse can help the client see anger as a normal, acceptable emotion. Giving choices on how to express anger would not be the next step in the planning stage. Pointing out the senselessness of anger and telling the client not to be angry all the time are not appropriate responses in this situation.

7. A student is preparing to give a class presentation. A few minutes before the presentation is to begin, the student seems nervous and distracted. The student is looking at and listening to the peer speaker and occasionally looking at note cards. When the peer speaker asks a question of the group, the student is able to answer correctly. The professor understands that the student is likely experiencing which level of stress? A) Mild B) Moderate C) Severe D) Panic

Ans: B Feedback: Moderate anxiety is the disturbing feeling that something is definitely wrong; the person becomes nervous or agitated. In moderate anxiety, the person can still process information, solve problems, and learn new things with assistance from others. He or she has difficulty concentrating independently but can be redirected to the topic. Mild anxiety is a sensation that something is different and warrants special attention. Sensory stimulation increases and helps the person focus attention to learn, solve problems, think, act, feel, and protect himself or herself. As the person progresses to severe anxiety and panic, more primitive survival skills take over, defensive responses ensue, and cognitive skills decrease significantly. A person with severe anxiety has trouble thinking and reasoning.

8. Which psychiatric disorder makes a person most susceptible to anger attacks that do not result in physical aggression? A) Delusions B) Depression C) Dementia D) Delirium

Ans: B Feedback: Some clients with depression have anger attacks that are sudden intense spells of anger that typically occur in situation where the depressed person feels emotionally trapped. Anger attacks involve verbal expressions of anger or rage but no physical aggression. Persons with delusions, dementia, and delirium are most likely to become physically aggressive.

22. The nurse decides to place an aggressive and violent client in mechanical restraints. The nurse bases this decision on which of the following? A) Client's mood B) Client's safety C) Court order D) Physician's order

Ans: B Feedback: The use of restraints is warranted only when the client's safety is in jeopardy and other, less restrictive measures have not been effective. The nurse does not base her decision on the client's mood or court order. Just because there is a physician's order for use of restraints, this does not mean that they are appropriate in every situation; this is based on nursing judgment.

12. The nurse is conducting a history and physical exam on a client who is grieving the unwanted loss of a marriage by divorce. Which of the following physical symptoms of grief would the nurse most likely expect to detect in the history? A) Headaches B) Insomnia C) Weight loss D) GI upset

Ans: B Feedback: Those grieving may complain of insomnia, headaches, impaired appetite, weight loss, lack of energy, palpitations, indigestion, and changes in the immune and endocrine systems. Sleep disturbances are among the most frequent and persistent bereavement- associated symptoms.

1. A young couple just ended their relationship after a 9-month engagement. The one of the individuals is seeking short-term counseling to assist in grieving this loss. Which type of loss best describes what this client is experiencing? A) Safety loss B) Loss of security and sense of belonging C) Loss of self-esteem D) Loss related to self-actualization

Ans: B Feedback: Types of loss include safety loss (loss of a safe environment), loss of security and a sense of belonging (loss of a loved one affects the need to love and the feeling of being loved), loss of self-esteem (any change in how a person is valued at work or in relationships or by him or herself), or loss related to self-actualization (external or internal crisis that blocks or inhibits strivings toward fulfillment).

24. Which of the following interventions would assist the client with the appropriate expression of anger? A) Encourage catharsis B) Encourage verbalization C) Improve self-esteem D) Isolate the client from others

Ans: B Feedback: Verbally expressing angry feelings is a safe and appropriate way to deal with anger. Isolation and catharsis can increase angry and hostile feelings. The other choices are not appropriate responses in this situation.

7. Which is most likely to be the subject of an aggressive attack from a client with mental illness? A) Other people B) The client C) Animals D) Objects

Ans: B Feedback: Clients with psychiatric disorders are more likely to hurt themselves than other people.

14. The most effective way for the nurse to provide culturally competent care to individuals who are grieving is which of the following? A) Understand the practices associated with a client's culture. B) Suggest developing a new ritual to make mourning meaningful. C) Ask the client what rituals are personally meaningful. D) Contact a spiritual leader from the client's culture to become involved.

Ans: C Feedback: Rather than assuming that he or she understands a particular culture's grieving behaviors, the nurse must encourage clients to discover and use what is effective and meaningful to them.

13. Which of the following are interpersonal theories regarding the etiologies of major anxiety disorders? Select all that apply. A) Sigmund Freud's theory B) Henry Stack Sullivan's theory C) Hildegard Peplau's theory D) Pavlov's theory

Ans: B, C Feedback: Theories of anxiety can be classified as intrapsychic/psychoanalytic theories, interpersonal theories, and behavioral theories. Freud's intrapsychic theory views a person's innate anxiety as the stimulus for behavior. Interpersonal theories include Sullivan's theory that anxiety is generated from problems in interpersonal relationships and Peplau's belief that humans exist in interpersonal and physiologic realms. Behavioral theorists view anxiety as being learned through experiences.

21. Which of the following are critical components to assess in a grieving person? Select all that apply. A) Genetic risk B) Perception of the loss C) Support system D) Coping behaviors E) Religion

Ans: B, C, D Feedback: The interaction of the dimensions of human response is fluid and dynamic. What a person thinks about during grieving affects his or her feelings, and those feelings influence his or her behavior. The critical factors of perception, support, and coping are interrelated as well and provide a framework for assessing and assisting the client. Genetic risk and religion are not critical components to assess in a grieving person.

17. Which of the following losses are likely to result in disenfranchised grief? Select all that apply. A) A young adult whose spouse has just died suddenly B) A family whose long-time pet snake has just died C) A nurse who has just witnessed the death of a patient D) A couple who has just experienced pregnancy loss E) The gay lover of a man who just died from AIDS F) The mother and sister of a soldier who was killed in war

Ans: B, C, D, E Feedback: Circumstances that can result in disenfranchised grief include a relationship that has no legitimacy, the loss itself is not recognized, the griever is not recognized, or the loss involves social stigma. A young adult whose spouse has just died suddenly is not likely to experience disenfranchised grief because of their legal relationship. A family whose long-time pet snake had died is likely to experience disenfranchised grief because the death of a pet is not seen as socially significant. A nurse who had just witnessed the death of a patient is at risk for disenfranchised grief because the needs of nurses and hospital chaplains are not recognized. A couple who had just experienced a pregnancy loss are at increased risk for disenfranchised grief because the loss of an unborn child is not recognized. The gay lover of a man who just died from AIDS is at risk for disenfranchised grief as the relationship had no legitimacy and the loss involves social stigma. The mother and sister of a soldier who was killed in war would not likely experience disenfranchised grief because they have a kin relationship with the decedent.

7. Kubler-Ross developed a model of five stages to explain what people experience as they grieve and mourn. Which is stage V of Kubler-Ross's stages of grieving? A) Denial B) Bargaining C) Acceptance D) Anger

Ans: C Feedback: Acceptance occurs when the person shows evidence of coming to terms with death. Denial is shock and disbelief regarding the loss. Bargaining occurs when the person asks God or fate for more time to delay the inevitable loss. Anger may be expressed toward God, relatives, friends, or health-care providers.

28. After an angry outburst, a client quickly appears more calm and rational. The nurse approaches the client. Which of the following is the most helpful response to the client at this time? A) ìWe will have to talk about this later.î B) ìYou really scared me. I'm glad you are okay.î C) ìWhat happened that got you so upset?î D) ìWhat can you do differently next time you get angry?î

Ans: C Feedback: As the client regains control (recovery phase), he or she is encouraged to talk about the situation or triggers that led to the aggressive behavior. The nurse should help the client relax, perhaps sleep, and return to a calmer state. Talking about the event at a later time does let the client rest, but it does less to address the client's feelings associated with the angry outburst. It is too early postcrisis to discuss behavior change for the future as the client needs to recover from intense emotions first.

33. What a culture considers acceptable strongly influences the expression of anger. Which culture-bound syndrome is a dissociative episode characterized by a period of brooding followed by an outburst of violent, aggressive, or homicidal behavior directed at other people and objects? A) Hwa-Byung B) Hwabyeong C) Amok D) BouffÈe delirante

Ans: C Feedback: BouffÈe delirante, a condition observed in West Africa and Haiti, is characterized by a sudden outburst of agitated and aggressive behavior, marked confusion, and psychomotor excitement. Hwa-Byung or hwabyeong is a culture-bound syndrome that literally translates as anger syndrome, or fire illness, attributed to the suppression of anger. Amok is a dissociative episode characterized by a period of brooding followed by an outburst of violent, aggressive, or homicidal behavior directed at other people and objects.

6. The client says to the nurse, ìI really want to see my first grandchild born before I die. Is that too much to ask?î The nurse would recognize that the client is in which stage of grieving, according to Kubler-Ross? A) Acceptance B) Anger C) Bargaining D) Depression

Ans: C Feedback: Clients often set goals such as living until a certain time or to experience a particular event, and then they will be ready to die: that is the bargain. Acceptance occurs when the person shows evidence of coming to terms with death. Anger may be expressed toward God, relatives, friends, or health-care providers. Depression results when awareness of the loss becomes acute.

23. A young client tells the nurse that her husband died 3 months ago, and she is feeling alone and vulnerable. Which statement by the client would indicate that her coping skills are adequate? A) ìI can't understand why this happened to me.î B) ìI'm mentally healthy. I can solve my own problems.î C) ìI will find a support group.î D) ìWhat can I do? My husband abandoned me.î

Ans: C Feedback: Finding a support group indicates that the client recognizes her need for help and is taking action to get the support she needs. The other choices are not indications that the client's coping skills are adequate for the situation.

28. A client asks how his prescribed alprazolam (Xanax) helps his anxiety disorder. The nurse explains that antianxiety medications such as alprazolam affect the function of which neurotransmitter that is believed to be dysfunctional in anxiety disorders? A) Serotonin B) Norepinephrine C) GABA D) Dopamine

Ans: C Feedback: Gamma-aminobutyric acid (GABA) is the amino acid neurotransmitter believed to be dysfunctional in anxiety disorders. GABA reduces anxiety, and norepinephrine increases it; researchers believe that a problem with the regulation of these neurotransmitters occurs in anxiety disorders. Serotonin is usually implicated in psychosis and mood disorders. Dopamine is indicated in psychosis.

14. A client is clenching his fists and yelling at another client on the unit. He appears to be close to losing control of his anger. Which of the following actions by the nurse is appropriate at this time? A) Clear others out of the immediate area. B) Prepare a PRN sedative. C) Tell the client to stop and take a time-out. D) Alert the security department of an impending aggressive outburst.

Ans: C Feedback: If the client progresses to the escalation phase (period when client builds toward loss of control), the nurse must take control of the situation. The nurse should provide directions to the client in a calm, firm voice. The client should be directed to take a time-out for cooling off in a quiet area or his or her room. Clearing others from the area or alerting security does not help the client regain control. Administering a sedative is not the least restrictive intervention at this time.

14. The student nurse correctly identifies that according to Selye (1956, 1974), which stage of reaction to stress stimulates the body to send messages from the hypothalamus to the glands and organs to prepare for potential defense needs? A) Resistance B) Exhaustion C) Alarm reaction D) Autonomic

Ans: C Feedback: In the alarm reaction stage, stress stimulates the body to send messages from the hypothalamus to the glands and organs to prepare for potential defense needs. In the resistance stage, the digestive system reduces function to shunt blood to areas needed for defense. The exhaustion stage occurs when the person has responded negatively to anxiety and stress. There is no autonomic stage.

5. At which point in the stages of aggressive incidents is intervention least likely to be effective in preventing physically aggressive behavior? A) Triggering B) Escalation C) Crisis D) Postcrisis

Ans: C Feedback: Interventions during the triggering and escalation phases are key to prevent physically aggressive behavior. During the crisis phase, behavior escalation may lead to physical aggression. During the postcrisis phase, the physically aggressive behavior has stopped and the client returns to the level of functioning before the aggressive incident.

4. A married couple has just received the news that the husband has terminal cancer. The wife tells the nurse, ìMaybe if we get another opinion and start treatment right way there is a chance of survival.î The nurse documents that the wife is expressing signs of which of Kubler-Ross's stages of grief? A) Denial B) Anger C) Bargaining D) Depression

Ans: C Feedback: Kubler-Ross developed a model of five stages to explain what people experience as they grieve and mourn: (1) Denial is shock and disbelief regarding the loss. (2) Anger may be expressed toward God, relatives, friends, or health-care providers. (3) Bargaining occurs when the person asks God or fate for more time to delay the inevitable loss. (4) Depression results when awareness of the loss becomes acute. (5) Acceptance occurs when the person shows evidence of coming to terms with death.

18. Which of the following is most likely to prevent the client from experiencing complicated grief? A) Tendency to suppress emotions B) History of depression C) Places trusts familiar others D) Dependent on others to meet needs

Ans: C Feedback: People who are vulnerable to complicated grieving include those with low self-esteem, low trust in others, a previous psychiatric disorder, previous suicide threats or attempts, or absent or unhelpful family members.

6. A client says to the nurse, ìI just can't talk in front of the group. I feel like I'm going to pass out.î The nurse assesses the client's anxiety to be at which level? A) Mild B) Moderate C) Severe D) Panic

Ans: C Feedback: Physiologic responses to severe anxiety include headache, nausea, vomiting, diarrhea, trembling, rigid stance, vertigo, pale, tachycardia, and chest pain

23. The nurse is teaching about postoperative wound care. As the wound is uncovered, the client begins mumbling, breathing rapidly, and trying to get out of bed, and the client does not respond when the nurse calls his name. Which of the following should be the nurse's first action? A) Ask the client to describe his feelings. B) Proceed with wound care quickly. C) Replace the dressing on the wound. D) Get the assistance of another nurse.

Ans: C Feedback: The client has severe anxiety; the priority is to lower the client's anxiety level. The first action should be to replace the dressing on the wound to decrease the client's level of anxiety and to prevent contamination of the wound before a new dressing can be applied. The other choices could be done after replacing the dressing on the wound.

3. A married man expresses to the nurse that his wife's frequent nagging angers him. The nurse role-plays assertive communication techniques with the husband. Which of the following indicates the husband understands how to use assertive techniques effectively? A) ìI really wish you would stop nagging me.î B) ìYou are not perfect either.î C) ìI feel unappreciated when you criticize me.î D) ìAre you telling me you want me to change?î

Ans: C Feedback: The nurse can help clients express anger appropriately by serving as a model and by role-playing assertive communication techniques. Assertive communication uses ìIî statements that express feelings and are specific to the situation; for example, ìI feel angry when you interrupt me,î or ìI am angry that you changed the work schedule without talking to me.î Statements such as these allow appropriate expression of anger and can lead to productive problem-solving discussions and reduced anger.

28. An elderly woman who lives alone is beginning to have difficulty maintaining her household and performing daily tasks. The nurse asks her to identify someone who can help her. The woman replies, ìI don't need help. I've been managing for years.î Which of the following responses helps the client shift from denial to consciously coping with her situation? A) ìYou don't think you need any help? But your family is worried about you.î B) ìIt must be hard to lose your independence. I'll ask a social worker to see what can be arranged.î C) ìIf you were to need help with your house, who might you ask for help?î D) ìIf you don't ask for some help. then the only option is to move to an assisted living facility.î

Ans: C Feedback: The nurse can help the client to reach out and accept what others want to give in support of his or her grieving process. Help the client shift from an unconscious mechanism of denial to conscious coping with reality by using reflective communication skills. Do not force people through the coping process by insisting they take certain actions.

29. The nurse is teaching a client with an anxiety disorder ways to manage anxiety. The nurse suggests which of the following schedules for practicing stress management techniques? A) Practice the techniques each morning and night as part of a daily routine. B) Use the techniques as needed when experiencing severe anxiety. C) Practice the techniques when relatively calm. D) Expect to practice the techniques when meeting with a therapist.

Ans: C Feedback: The nurse can teach the client relaxation techniques to use when he or she is experiencing stress or anxiety, including deep breathing, guided imagery and progressive relaxation, and cognitive restructuring techniques. For any of these techniques, it is important for the client to learn and to practice them when he or she is relatively calm.

31. A client comes to the physician's office for an annual checkup. During the interview, the nurse learns that the client's husband died unexpectedly of a heart attack 2 months ago. The most appropriate response by the nurse would be, A) ìAt least you and your husband enjoyed life right until the end.î B) ìIt's better to go quickly like your husband did instead of suffering.î C) ìThe loss of your husband must be very painful for you.î D) ìYou'll feel better after you get over the shock of your husband's death.î

Ans: C Feedback: The nurse makes an empathetic response, acknowledging the client's loss. ìAt least you and your husband enjoyed life right until the end,î is judgmental. ìIt's better to go quickly like your husband did instead of suffering,î does not address the client's grief. ìYou'll feel better after you get over the shock of your husband's death,î is false reassurance. Thus, choices A, B, and D would not be the most appropriate responses.

20. The client with a history of explosive outbursts becomes angry and states, ìI am really getting angry.î The nurse sees this as A) controlling. B) manipulation. C) progress. D) regression

Ans: C Feedback: When the client is able to verbalize angry feelings, this is progress from having an outburst. The client is not trying to control the situation. Manipulation occurs when a person tries to persuade another to act in a desired way. Regression occurs when one retreats to an earlier level of functioning and development.

17. A client who has been physically aggressive arrives at the emergency room for a psychiatric assessment. Which would be the best approach for the nurse to use? A) Have a sense of humor to show a lack of fear. B) Provide close contact to increase the client's sense of safety. C) Use brief statements and questions to obtain information. D) Use open-ended questions, so the client can elaborate.

Ans: C Feedback: Following an aggressive episode, clients may have difficulty expressing themselves; short, concise statements and questions will get needed information. Humor or open- ended questions may be frustrating or annoying for the client. It is not safe for the nurse to provide close contact under these circumstances.

26. The nurse approaches a client who looks very sad and is sitting alone crying. The best response by the nurse in this situation is, A) ìI'm sorry you are sad. Is there anything I can do to help you feel better?î B) ìPlease don't cry. It will get better.î C) ìYou look very sad. What is happening?î D) ìWhat is bothering you?î

Ans: C Feedback: It is essential to accept the person's feelings without trying to dissuade him or her from feeling angry or upset. The nurse needs to encourage the person to express any and all feelings without trying to calm or placate him or her.

18. A client is currently experiencing a panic attack. Which of the following is the most appropriate response by the nurse? A) ìJust try to relax.î B) ìThere is nothing here to harm you.î C) ìYou are safe. Take a deep breath.î D) ìWhat are you feeling right now?î

Ans: C Feedback: Nursing interventions for panic disorder include providing a safe environment and ensuring the client's privacy during a panic attack, remaining with the client during a panic attack, helping the client to focus on deep breathing, talking to the client in a calm, reassuring voice, teaching the client to use relaxation techniques, helping the client to use cognitive restructuring techniques, and the engaging client to explore how to decrease stressors and anxiety-provoking situations.

27. A woman has just been served divorce papers from her husband. She has no financial resources and little social support. She states, ìHe's not really leaving. He'll be back.î The most appropriate response by the nurse would be which of the following? A) ìHas he done this before?î B) ìI'll call social services and get you signed up for financial assistance.î C) ìYou have to face reality. Here are the papers.î D) ìHow is this affecting you right now?î

Ans: D Feedback: Adaptive denial, in which the client gradually adjusts to the reality of the loss, can help the client let go of previous (before the loss) perceptions while creating new ways of thinking about himself or herself, others, and the world. While taking in the loss in its entirety all at once seems overwhelming, gradually dealing with the loss in smaller increments seems much more manageable. Help the client shift from an unconscious mechanism of denial to conscious coping with reality by using reflective communication skills.

32. An anxiolytic agent, lorazepam (Ativan), has been prescribed for the client. Which of the following statements by the client would indicate to the nurse that client education about this medication has been effective? A) ìMy anxiety will be eliminated if I take this medication as prescribed.î B) ìThis medication presents no risk of addiction or dependence.î C) ìI will probably always need to take this medication for my anxiety.î D) ìThis medication will relax me, so I can focus on problem solving.î

Ans: D Feedback: Anxiolytics are designed for short-term use to relieve anxiety. These drugs are designed to relieve anxiety so that the person can deal more effectively with whatever crisis or situation is causing stress. Benzodiazepines have a tendency to cause dependence. Clients need to know that antianxiety agents are aimed at relieving symptoms such as anxiety but do not treat the underlying problems that cause the anxiety.

9. The nurse is working with a woman who lost her partner nearly 3 weeks prior. The woman has recently become less emotional and expressed that few things in her life have meaning right now. Which response by the nurse is most appropriate at this time? A) ìI am concerned. You are starting to show signs of ineffective grieving.î B) ìYou must feel some anger. It is alright to let that out.î C) ìLet's look at the things in your life that you still enjoy.î D) ìYou are just starting to accept that this loss is real.î

Ans: D Feedback: As the bereaved person begins to understand the loss's permanence, he or she recognizes that patterns of thinking, feeling, and acting attached to life with the deceased must change. As the person relinquishes all hope of recovering the lost one, he or she inevitably experiences moments of depression, apathy, or despair. The acute sharp pain initially experienced with the loss becomes less intense and less frequent.

10. Which one of the following can be a positive outcome of using defense mechanisms? A) Defense mechanisms can inhibit emotional growth. B) Defense mechanisms can lead to poor problem-solving skills. C) Defense mechanisms can create difficulty with relationships. D) Defense mechanisms can help a person to reduce anxiety.

Ans: D Feedback: Defense mechanisms can help a person to reduce anxiety. This is the only positive outcome of using defense mechanisms. The dependence on defense mechanisms can inhibit emotional growth, lead to poor problem-solving skills, and create difficulty with relationships. These are all negative outcomes of using defense mechanisms.

16. A woman has just had a therapeutic abortion to end an unintended pregnancy. Afterward, the woman cries because although she wanted to have children in future years, this pregnancy was not well-timed. Which type of grief is this woman most likely to experience? A) Anticipatory grief B) Absence of grief C) Complicated grief D) Disenfranchised grief

Ans: D Feedback: Disenfranchised grief is grief over a loss that is not or cannot be acknowledged openly, mourned, publicly, or supported socially. Anticipatory grief occurs when a person experiences imminent loss and begin to grapple with the very real possibility of loss or death in the near future. It is not absence of grief as the woman is grieving. It is not currently complicated grief as the loss has just occurred and does not seem out of proportion to the loss.

31. Which of the following is most important to maintain therapeutic boundaries when working with aggressive clients? A) Encourage clients to express how the nurse can avoid causing emotional irritation. B) Discuss difficult patient care situations with a supervisor. C) Reflect on your actions that may have instigated the client's anger, D) Do not personalize a client's anger

Ans: D Feedback: Do not take the client's anger or aggressive behavior personally or as a measure of your effectiveness as a nurse. The client's aggressive behavior, however, does not necessarily reflect the nurse's skills and abilities. Clients should not dictate nurses' behaviors. The nurse is not responsible for angering the client. Individuals are responsible for their own emotional control. If the nurse cannot maintain boundaries, assistance should be sought form a supervisor.

23. The nurse observes two clients in the day room arguing. One client runs into the corner and huddles while the other follows and continues with verbal abuse. Which is the best action by the nurse? A) Take an authoritatively step between the two clients. B) Comfort the client huddled in the corner. C) Directly address both clients and ask what is going on. D) Engage the attention of the client who is still yelling and ask what is happening.

Ans: D Feedback: Engaging the attention of the dominant person will diffuse the situation and stop the argument from continuing. The other choices would not be appropriate actions in this situation. The nurse placing herself in between two arguing clients is a safety concern.

27. Which of the following statements about the crisis phase of aggression when the client becomes physically aggressive is true? A) All staff should act to take charge of the situation. B) The client must be restrained or sedated at once. C) Staff should avoid communicating with the client. D) Four to six trained staff members are needed to restrain

Ans: D Feedback: Four to six trained staff members are needed to restrain, with four staff members each handling a limb and one protecting the client's head and one helps control the client's torso, if needed. When a client becomes physically aggressive, the staff must take charge of the situation for the safety of the client, staff, and other clients. Only staff with training in safe techniques for managing behavioral emergencies should participate. All staff may not have had this training, and if the team is not working in a cooperative and coordinated fashion, it is less safe to restrain the client. The nurse should follow the facility's protocols and standards for restraint and seclusion. Staff should inform the client that his or her behavior is out of control and that the staff is taking control to provide safety and prevent injury.

29. After an angry outburst, the client is tearful and remorseful. Which statement by the nurse would be most supportive? A) ìYou still need to work on your problem-solving skills.î B) ìI will not allow you to get that angry again.' C) ìYou should not have let your anger buildup like you did.î D) ìWhat could you have done when you first started to feel angry?î

Ans: D Feedback: In the postcrisis phase, the nurse should not lecture or chastise the client for the aggressive behavior but should discuss the behavior in a calm, rational manner. The client can be given feedback for regaining control, with the expectation that he or she will be able to handle feelings or events in a nonaggressive manner in the future.

5. The nurse plans to teach a client about dietary modifications to manage diabetes. Teaching would be most effective if the client displayed which one of the following characteristics? A) Focusing only on immediate task B) Faster rate of speech C) Narrowed perceptual field D) Heightened focus

Ans: D Feedback: Mild anxiety is associated with increased learning ability. It involves a sensation that something is different and warrants special attention. Sensory stimulation increases and helps the person focus attention to learn, solve problems, think, act, feel, and protect himself or herself. Mild anxiety often motivates people to make changes or to engage in goal-directed activity. Focusing only on immediate task, a faster rate of speech, and a narrowed perceptual field are associated with moderate levels of anxiety.

15. A nurse has been caring for a gunshot victim who has just died. Various family and friends are present. One of the visitors privately discloses to the nurse that she and the client were having an illicit affair. Which of the following is the best action by the nurse after learning of this relationship? A) Give the name of a clergy to the visitor and suggest she contact him for support B) Encourage the visitor to ask for support from the friends who are present C) Ignore the information about the affair and tend to the family D) Privately offer support to the visitor who was having the affair with the client

Ans: D Feedback: Relationships between lovers, friends, neighbors, foster parents, colleagues, and caregivers may be long-lasting and intense, but people suffering loss in these relationships may not be able to mourn publicly with the social support and recognition given to family members. In addition, some relationships are not always recognized publicly or sanctioned socially such as extramarital affairs. The grief process is more complex because the usual supports that facilitate grieving and healing are absent. Therefore, nurses should be mindful to provide needed support.

21. The nurse enters the client's room and finds the client anxiously pacing the floor. The client begins shouting at the nurse, ìGet out of my room!î The best intervention by the nurse would be to A) approach the client and ask, ìWhat's wrong?î B) call for help and say, ìCalm down.î C) turn and walk away from the room without saying anything. D) stand at the doorway and say, ìYou seem upset.î

Ans: D Feedback: Staying with the client while allowing personal space is an important and safe intervention; this therapeutic communication technique is designed to get the client to communicate feelings. It may not be safe for the nurse to approach the client. Help is not needed at this time, and saying, ìCalm down,î is not effective. Turning and walking away from the client may seem like rejection and may worsen the client's anxiety as well as damage the nurseñclient relationship.

2. The nurse knows that which one of the following statements is true about stress and anxiety? A) All people handle stress in the same way. B) Stress is a person's reaction to anxiety. C) Anxiety occurs when a person has trouble dealing with life situations, problems, and goals. D) Stress is the wear and tear that life causes on the body.

Ans: D Feedback: Stress is the wear and tear that life causes on the body. It occurs when a person has difficulty dealing with life situations, problems, and goals. Each person handles stress differently. Anxiety is a vague feeling of dread or apprehension; it is a response to external or internal stimuli that can have behavioral, emotional, cognitive, and physical symptoms. Anxiety is a response to stress.

29. A client who has been grieving the loss of his wife 2 weeks ago says to the nurse, ìThe best part of my day is when I am back at work. Is that wrong?î The nurse educates that work and other daily activities serve which purpose? A) ìYou cannot work effectively this soon. You should finish grieving first.î B) ìWorking reminds you of your loss. It may be too early to go back.î C) ìWorking is your way of avoiding grief, which will make it harder for you to move on.î D) ìWorking is letting you take an emotional break from grieving. There's nothing wrong with that.î

Ans: D Feedback: The bereaved person can often take a break from the exhausting process of grieving. Going back to a routine of work or focusing on other members of the family may provide that respite. Familiar routines can affirm the client's talents and abilities and can renew feelings of self-worth

27. A client asks the nurse, ìWhy do I have to go to counseling? Why can't I just take medications?î The best response by the nurse would be, A) ìBoth therapies are effective. You can eventually choose one or the other.î B) ìYou cannot get the full effect of your medications without cognitive therapy as well.î C) ìAs soon as your medications reach therapeutic level, you can omit the therapy.î D) ìMedications combined with therapy help you change how well you function.î

Ans: D Feedback: Treatment for anxiety disorders usually involves medication and therapy. This combination produces better results than either one alone.

25. A client lost control of his behavior, broke a window, and made verbal threats to staff and other clients. The client was placed in mechanical restraints. Which statement should the nurse make to explain the use of restraints to the client? A) ìThe length of time you'll be in restraints is undetermined.î B) ìThe staff will monitor your behavior closely.î C) ìThis is what happens when you lose control.î D) ìThis is a means of keeping you and others safe.î

Ans: D Feedback: Use of restraints is a temporary, short-term way of ensuring the safety of everyone until the client regains behavioral control; it is not a punishment. The other choices are not appropriate explanations of the use of restraints.

4. Which one of the following statements about anger is most accurate? A) Anger is an abnormal human emotion that is always negative. B) It is best to express anger by whatever means possible to minimize its consequences. C) Most men are socialized to suppress anger. D) Anger awareness and expression are necessary for women's growth and development.

Ans: D Feedback: Women must recognize that anger awareness and expression are necessary for their growth and development. Anger is a normal human emotion and is often perceived as a negative feeling. However, anger becomes negative when denied, suppressed, or expressed inappropriately. Anger that is expressed inappropriately can lead to hostility and aggression. Catharsis can increase rather than alleviate angry feelings. Men are often socialized to believe that it is acceptable to express anger, while women are often socialized to maintain and enhance relationships with others and avoid expression of emotions such as anger.

22. A client with terminal cancer has been told he has 3 or 4 months to live. Which of the following would indicate to the nurse that further interventions are needed? A) The client says he wants to live life to the fullest. B) The client hopes for a peaceful and dignified death. C) The client is reviewing his life and talking about death. D) The client says he is well and is making future plans.

Ans: D Feedback: Choice D would indicate that the client is proceeding as though there is no impending loss, so the nurse would need to assist the client with grieving as the client is in denial. The other choices are positive coping behaviors toward death.

2. A child who has witnessed the murder of his classmate while at school would experience which kind of loss? A) Physiologic loss B) Loss of self-esteem C) Loss related to self-actualization D) Safety loss

Ans: D Feedback: Safety loss is the loss of a safe environment. That feeling of safety is shattered when public violence occurs. Examples of physiologic loss include amputation of a limb, a mastectomy or hysterectomy, or loss of mobility. A loss of self-esteem includes any change in how a person is valued at work or in relationships or by himself or herself can threaten self-esteem. Loss related to self-actualization includes an external or internal crisis that blocks or inhibits strivings toward fulfillment that may threaten personal goals and individual potential.

5. After being laid off from work, a client becomes increasingly withdrawn and fatigued, spends entire days in bed, is unkempt, and is eating and sleeping poorly. The nurse would recognize that the client is in which stage of grieving, according to Kubler-Ross? A) Anger B) Bargaining C) Denial D) Depression

Ans: D Feedback: The client's symptoms are characteristics of depression, which usually occurs when awareness of the loss becomes acute. Anger may be expressed toward God, relatives, friends, or health-care providers. Bargaining occurs when the person asks God or fate for more time to delay the inevitable loss. Denial is shock and disbelief regarding the loss.

12. A client suddenly jumps up from the chair and begins yelling and cursing at the nurse. Which would be the best response by the nurse? A) ìI can see that you need attention; you should calmly ask for what you want.î B) ìI don't want to hear that kind of language; don't ever do that again.î C) ìI will limit your smoking privileges if you can't control yourself.î D) ìYou seem angry. Tell me more about how you're feeling.î

Ans: D Feedback: The nurse recognizes and validates the client's feelings and offers to focus on those feelings and what the client needs. In this situation, the client is not at a point where he can be calm. Taking away privileges will not help the current situation. ìI don't want to hear that kind of language; don't ever do that againî is demeaning to the client.

32. A woman has just delivered a stillborn baby boy. Which of the following would be the most appropriate nursing response? A) ìCan I do anything for you?î B) ìIf something was wrong, it's better this way.î C) ìYour son is in heaven with God now.î D) ìWould you like to hold your son?î

Ans: D Feedback: The opportunity to hold the baby may help the woman deal with the first stage of grieving: denial; it also allows her to express emotions over the loss. Asking the client, ìCan I do anything for you,î is a closed-ended question and will likely be replied to with a yes or no answer. Stating, ìIf something was wrong, it's better this way,î is not sensitive to the woman's loss. Stating ìYour son is in heaven with God now,î would be inappropriate because it may not be consistent with the woman's beliefs.

30. Which of the following are critical components in assessment of a person's grief? Select all that apply. A)Adequate perception regarding the loss B)Adequate time to experience the loss C)Adequate support while grieving for the loss D)Adequate opportunities to say goodbye to the person E)Adequate coping behaviors during the process

Ans:A,C,E Feedback: While observing for client responses in the dimensions of grieving, the nurse explores three critical components in assessment: ï Adequate perception regarding the loss ï Adequate support while grieving for the loss ï Adequate coping behaviors during the process The time to experience the loss varies significantly from person to person, and the reality is that there may not be adequate opportunities to say goodbye to the person.

20. The nurse is meeting a client for the first time who has just spontaneously lost her unborn child. After establishing rapport, the priority nursing intervention should focus on which of the following? A)Assessing the clients support system B)Exploring what this loss means to the client C)Discussing helpful ways to cope with the loss D)Assessing what knowledge the client desires about the situation

Ans:B Feedback: Assessment begins with exploration of the client's perception of the loss. What does the loss mean to the client? The question is valuable for beginning to facilitate the grief process. Further assessment and intervention will be determined based largely on the client's perception of the event.

24. A couple came to the emergency department with their 5-month-old son. He was pronounced dead of sudden infant death syndrome (SIDS). In the next day or two, it will be important for this couple to A)Accept that they could do nothing to prevent this death B)Delay the grieving process until they are ready to cope C)minimize their discussion the death with others D)Plan funeral arrangements for their son

Ans:D Feedback: Funerals are often the beginning outward sign of mourning and help begin the grieving process. This couple will need to talk about their son's death repeatedly as they begin to grieve. It will not likely be possible for them to accept that they could do nothing to prevent this death within this time period, but they must begin to hear this. They should not delay the grieving process.