Module 3: Mental Health Concepts

The home care nurse arrives at Louis's home for a daily visit. Laura tells the nurse that she is fatigued and needs help taking care of her husband. She tells the nurse that her daughter and son are her only family but notes that they work all day. Which suggestion by the nurse is most appropriate? Obtaining a referral for hospice care Trying to rest when Louis is resting Hiring a nursing assistant to help provide personal care Asking her daughter and son to take some time off from work

Obtaining a referral for hospice care RATIONALE: Hospice care ensures that the needs of the client and family are the focus of any intervention. Hospice exists to provide support and care for persons in the last phases of incurable diseases so that they may live as fully and comfortably as possible. Hospice services are available 24 hours a day, 7 days a week, to provide help to clients and families in their homes. Staff and volunteers are available, and a multidisciplinary team approach provides holistic health care. Trying to take rest periods while Louis is resting might be helpful for Laura but may not always be possible. Hiring a nursing assistant is also possible, but it is not the most appropriate suggestion by the nurse, because it would be inappropriate to place the additional burden of having to hire someone on the wife. Although asking her daughter and son to take time off from work would be helpful, it is not the most realistic or reasonable solution. TEST-TAKING STRATEGY: Focus on the data in the question. Recalling the services provided by hospice will direct you to the correct option. Also note that this is the umbrella option. Review: the services provided by hospice.

What factors put Rudy at a higher risk for COVID-19? Select all that apply. Male sex Older age Veteran status Black American race Low body mass index (BMI)

Older age Black American race RATIONALE: Populations at higher risk for COVID-19 include older adults and minority groups. Veterans, those with low BMI, and males are not necessarily at a higher risk for coronavirus. Homelessness may also put Rudy at higher risk because services are often provided in crowded settings, and many people in the homeless population are older adults with other health problems. Other risk factors include people who are immunocompromised, who have had cancer, people who live in crowded conditions, residents of nursing homes, inmates, and people who work in essential medical fields. TEST-TAKING STRATEGY: Focus on the subject - populations at high risk for the COVID-19 coronavirus. It is necessary to know this information to answer correctly. Think about the methods of transmission of the virus along with at-risk populations to answer correctly.

Just before a session with the nurse, Katie receives a call from her boss. After the call, Katie is extremely upset and unable to sit down. She paces the room, crying and repeating, "I don't know what to do. He hates me!" Which interventions will the nurse implement at this time? Select all that apply. Moving Katie to a quiet setting and staying with her Leaving Katie alone until she has settled down Assessing the need for medication at this time Exploring problem-solving strategies with Katie Speaking to Katie in slow, firm, short statements Using nonverbal cues, without speaking, to convey concern

Moving Katie to a quiet setting and staying with her Assessing the need for medication at this time Speaking to Katie in slow, firm, short statements RATIONALE: Katie is showing signs of a severe to panic level of anxiety. During this time, it is important to keep her safe, meet her physical needs, and reduce anxiety. Moving to a quiet environment and speaking to her in slow, firm, short statements can help. Medication may be considered if other measures do not help. Persons who are experiencing severe anxiety are not able to solve problems; leaving Katie alone would not be safe, and she would be too upset to respond to nonverbal cues from the nurse. TEST-TAKING STRATEGY: Use your knowledge of the subject, levels of anxiety, to assist with the process of option elimination. It is important to recognize that Katie is experiencing a severe to panic level of anxiety. Use the process of elimination to decide which interventions are appropriate at this time to keep her safe and to reduce her anxiety. Review the interventions for a severe to panic level of anxiety if you had difficulty answering this question.

The nurse is caring for a Muslim client who is dying of gastric cancer. Which specific request from the client's family might the nurse anticipate? "One of us must be present when he passes." "Can we please turn him to face the southwest?" "We are expecting the priest to come to administer sacraments." "We will need to cremate the body within 24 hours of his passing."

"Can we please turn him to face the southwest?" RATIONALE: At the end of life, the Muslim client or family may prefer the client face Mecca, which is in a south or southwest direction from the United States. Mecca is the birthplace of the prophet Muhammad and the spiritual center of Islam. Followers of Hinduism may wish for a relative to be present at death and request the body be cremated within 24 hours of passing. In the Catholic faith, the priest administers sacraments including Holy Communion and Reconciliation. TEST-TAKING STRATEGY: Knowledge regarding the subject, religious considerations in end-of-life care, is necessary to answer this question. Recalling that Mecca is important to followers of Islam, and that it lies west or southwest from the United States, will direct you to the correct option. Review: religion and end-of-life care.

The nurse is obtaining a health history on a 15-year-old male who has missed two days of school because of a stomachache. The nurse suspects the client might be experiencing stress related to bullying or victimization, perhaps owing to his sexual orientation. Which questions would the nurse include in the interview? Select all that apply. "Do you do a breast self-examination?" "Do you feel safe at home or where you live?" "Do you have any problems at school? Are you bullied?" "Can you describe your sexual orientation preferences?" "Do you have any problems with depression or anxiety? Have you ever felt suicidal? If so, do you have a plan?"

"Do you feel safe at home or where you live?" "Do you have any problems at school? Are you bullied?" "Can you describe your sexual orientation preferences?" "Do you have any problems with depression or anxiety? Have you ever felt suicidal? If so, do you have a plan?" RATIONALE: Important information for this client's care are related to his safety, sexual health, and mental health. Teenage members of the LGBTQ population are at risk for bullying and victimization by peers, and are at risk for abuse by family members. The nurse should assess the client's sexual orientation to determine his unique health and social risks. Depression and suicide are also a concern for this population and careful assessment of this risk is necessary. There is no data in the question that suggests the significance of questioning about a breast self-examination. TEST-TAKING STRATEGY: Focus on the subject - absenteeism potentially related to stress. Think about the health and social risks associated with adolescent members of the LGBTQ community to guide you to the correct answers. Review: LGBTQ individuals.

A nurse provides information to a client about stress-management techniques. Which statement by the client indicates a need for further information? "Listening to music can be really soothing." "Getting enough sleep every night will help me deal with the stress." "I should get regular exercise as part of my stress-management program." "Everyone thinks that caffeine can make the stress worse, but that's a myth."

"Everyone thinks that caffeine can make the stress worse, but that's a myth." RATIONALE: Stress-management techniques include listening to music, having pets around, getting a massage, laughter and humor, participating in a regular exercise program, getting adequate sleep, and reducing or eliminating caffeine intake. Reducing or eliminating caffeine intake can yield more energy and help produce a relaxing feeling. TEST-TAKING STRATEGY: Note the strategic words "indicates a need for further information." These words indicate a negative event query and the need to select the incorrect client statement. Focus on the subject, reducing stress, and recall that reducing caffeine intake will lead to increased energy and a more relaxed feeling. This will direct you to the correct option. Review stress-management techniques if you had difficulty with this question.

he family of a client at the end-of-life has requested their pastor visit the client in the hospital. Privately, the client tells the nurse, "He's not my pastor. My daughter is always trying to get me to go to her church. I don't want to see him." Which response by the nurse is most appropriate? "A crisis of faith is common at the end of life." "Have you shared your feelings with your family?" "Spiritual needs can be as important as the needs of the body." "I will communicate to your family that you do not want to see the pastor."

"I will communicate to your family that you do not want to see the pastor." RATIONALE: Care during the dying experience needs to be based on the client's wishes. Therefore, the nurse should recognize family dynamics and advocate on behalf of the client, who is in a vulnerable condition, and communicate the client's wishes to the family. By meeting separately with the family, the nurse may help the family understand how they can support the client's dignity and autonomy. The incorrect options are inappropriate and do not address the client's expressed wishes and needs. TEST-TAKING STRATEGY: Note the strategic words, most appropriate. This indicates that you will need to prioritize. Focus on the data in the question. The nurse's priorities are to act as a client advocate and address the client's preferences. This will direct you to the correct option.

A few weeks later, while under the care of a hospice program, Isabel dies peacefully at home. Her parents and her children, who have been at her side, are understandably upset. Which statements by the hospice nurse are appropriate at this time? Select all that apply. "It's OK to cry." "Everything will be fine." "I'll be here if you want to talk." "Don't cry. She wouldn't want that." "You need to be strong for your little brother." "Let me know if I can make any phone calls for you."

"It's OK to cry." "I'll be here if you want to talk." "Let me know if I can make any phone calls for you." RATIONALE: The nurse's statements should not minimize the family members' loss. The nurse must avoid trite statements such as "Everything will be fine," "Don't cry," and "You need to be strong." These statements are actually barriers to communication and do not demonstrate care and concern. The nurse should offer supportive statements, acknowledge the family's feelings, be ready to listen, remain present, and offer to help as needed. TEST-TAKING STRATEGY: Use the process of elimination. Read each option carefully. Recalling the principles of therapeutic communication and barriers to communication will direct you to the correct options. Review the principles of therapeutic communication if you had difficulty with this question.

Louise calls the firm's nurse's office and schedules an appointment. She tells the nurse that she is feeling tired and stressed and that she is experiencing palpitations every time one of the lawyers places a document on her desk. Louise tells the nurse that she has heard that taking ginseng will relieve the stress and asks whether it is safe to take. How should the nurse respond to Louise? "Many reports indicate that ginseng reduces stress." "Ginseng is a natural herbal substance and is safe to take." "It's a good idea to try ginseng because it is so important to keep the stress level down to prevent illness." "It's best to consult a physician regarding the use of ginseng because it may not be appropriate for you."

"It's best to consult a physician regarding the use of ginseng because it may not be appropriate for you." RATIONALE: Herbal substances that have been used to relieve anxiety and stress include ginseng, St. John's wort, and kava. Contraindications to the use of these substances do exist. The client should be warned of this fact and advised to consult a health care provider regarding the use of herbal substances. Therefore, the other responses are inappropriate. TEST-TAKING STRATEGY: Use the process of elimination. Eliminate the comparable or alike options that indicate that ginseng keep the stress level down. Remember that herbal substances have side effects and contraindications associated with their use. This will direct you to the correct option from those remaining. Review client instructions related to the use of herbal substances if you had difficulty with this question.

A nurse is talking to a client in the mental health unit. The client says, "I'm really angry with my boyfriend about the things he says to me. Women always get put down, as if we don't matter or have anything important to offer." Which response is the most appropriate one for the nurse to make? "Tell me how you feel as a woman." "I know how you feel. I see that happening with some of my friends." "Yes, it's sad that women are treated that way. I guess we need to deal with it." "Many women's groups are developing ways to deal with this. I'll give you the names and contact numbers of some of these groups before you're discharged from the hospital."

"Tell me how you feel as a woman." RATIONALE: Focusing helps a client expand on a topic of importance. It also helps the client become more specific, move from vagueness to clarity, and concentrate on reality. The nurse should focus on the client's verbalization of concern. Agreeing with the client and avoiding the issue does not address the client's concern. Although the client may need to be provided with referrals to self-help or support groups before discharge, offering the names and contact numbers of women's groups is not the most appropriate response because it does not address the client's concern at the current time. TEST-TAKING STRATEGY: Use therapeutic communication techniques to answer the question. Select the option that focuses on the client's feelings and addresses the client's concern. Review therapeutic communication techniques if you had difficulty with this question.

Suicide precautions are enacted for Joseph, and the nurse assigned to care for Joseph sits down to talk with him. During the conversation Joseph states, "I don't want to live if I can't see my son. He's the only thing that matters to me." How should the nurse respond to Joseph? "Tell me more about how important your son is to you." "Do you have other family members with whom you enjoy spending time?" "I'm concerned about you, Joseph. You need to look for other activities to occupy your free time." "I understand what you mean. I have a daughter, and I always look forward to seeing her when I get home from work."

"Tell me more about how important your son is to you." RATIONALE: The correct option focuses on Joseph's thoughts and feelings and encourages him to talk about them. It also indicates that the nurse is listening to the client. The remaining statements are nontherapeutic, focus on other issues, and avoid the client's concern. TEST-TAKING STRATEGY: Use your knowledge of therapeutic communication techniques. Focus on the client's feelings and how they relate to the client's concern addressed in the question. Also remember to look for the option that encourages the client to communicate. This will direct you to the correct option. Review therapeutic communication techniques if you had difficulty with this question.

Isabel has begun outpatient chemotherapy. After each session, she goes home to rest, and she has been unable to care for her children. Her mother comes over in the afternoons to be there when the children come home from school and to cook dinner for the family. Trevor comes home one day with a note from his teacher. He has been rude at school, using "bad language" and talking back to the teacher. When asked about this, Trevor replies, "I'm fine. The teacher is stupid." Isabel calls the clinic nurse to talk about Trevor's behavior. Which statement by the nurse provides the best interpretation of Trevor's behavior? "Yes, he's being rude and insensitive, but he'll grow out of it soon." "Trevor needs to accept what's happening to you and stop acting out." "This may be his way of running away from the situation. Let's try to get him to talk about it." "The teacher just doesn't under

"This may be his way of running away from the situation. Let's try to get him to talk about it." RATIONALE: For a school-age child, the realization of impending death and loss is a major threat to the child's sense of security and ego strength. At this age, children are likely to show their fear through verbal uncooperativeness—using rude or bad language or being impolite and stubborn. The nurse should recognize this as an attempt to "run away" from stress and should encourage Trevor to talk about his feelings. The incorrect options avoid the situation and do not address Trevor's behavior or feelings. TEST-TAKING STRATEGY: Use your knowledge of therapeutic communication techniques to answer the question. Read each option carefully and think about the child's developmental stage to assist you in eliminating the incorrect options. Also note that the correct option addresses Trevor's feelings. Review the responses to loss in children of different ages if you had difficulty with this question.

After 2 weeks, Isabel undergoes surgery to remove her ovaries and surrounding tissues. One week later, she visits her physician and gets the news that the cancer has spread to three lymph nodes in the area. "Not the best prognosis," she is told, "but we can still give it a good try." The nurse, helping Isabel get ready to leave, sees that she is sitting very still with her eyes closed. She tells the nurse, "I don't know how I'm going to get through this. I don't want to leave my children alone!" Which response to Isabel's statement is therapeutic? "If I were you, I'd get a second opinion before doing anything." "This must be a terrible time for you. Would you like to talk about it?" "It's too early to be upset. You haven't even had any chemotherapy yet!" "Don't worry. Everything will be all right. Dr. Smythe is the best oncologist in the area."

"This must be a terrible time for you. Would you like to talk about it?" RATIONALE: When a person who is experiencing grief or facing death wants to talk, the nurse needs to take the time to listen and avoid creating barriers to communication. Offering to take the time to listen to Isabel's concerns is a therapeutic response. Providing unsolicited advice is nontherapeutic. Telling Isabel that it's "too early to be upset" essentially denies her grief; telling her not to worry offers false reassurance. These three options are examples of barriers to communication. TEST-TAKING STRATEGY: Use your knowledge of therapeutic communication techniques. Read each option carefully and consider the principles of therapeutic communication to help eliminate the incorrect options. Also note that the correct option is focused on the client's feelings. Review barriers to communication and principles of therapeutic communication if you had difficulty with this question.

The home care nurse makes a phone call to arrange a visit from a hospice nurse. A few hours later, the hospice nurse arrives to talk to the family and set up the hospice program. Laura takes the nurse into Louis' room, and says "He's been so sleepy for the last few hours. It won't bother him if we talk in here." Which of these responses by the hospice nurse would be appropriate? Select all that apply. "Sure. How long has he been like this?" "Well, first I'd like to introduce myself to your husband." "OK. Do you have his advance directive for me to review?" "Mrs. Mast, let's step into the next room to talk for a few minutes." "Yes, let's pull up some chairs and chat about what's going on."

"Well, first I'd like to introduce myself to your husband." "Mrs. Mast, let's step into the next room to talk for a few minutes." RATIONALE: Clients who are near death may be withdrawn from the external environment, but it is believed that the sense of hearing remains intact until death. Family members and caregivers should converse in the client's room or near the client as if the client is alert. This includes introducing yourself directly to the client. The caregiver should talk directly to the client in a soft tone. Reviewing the client's advance directive and having a conversation about him in his presence are inappropriate response. TEST-TAKING STRATEGY: Use knowledge of the subject, communication with a client who is near death, to help with this question. Read each option carefully and consider whether that response is appropriate in this situation, which is communication with a client who is near death. Review: appropriate communication techniques in end-of-life care situations.

Laura calls her daughter and son to inform them that Louis does not have much time left. The daughter comes quickly to her parents' house, and Louis dies shortly thereafter. The daughter, who is crying, says to the hospice nurse, "It's all my fault. If I hadn't refused to have that test 10 years ago, I could have donated a kidney, and my father would still be alive. It's all my fault!" Which response by the nurse is appropriate? "It's not your fault! You have to stop thinking that way." "You shouldn't feel so guilty. Your brother also refused to have anything to do with being a donor." "Probably so — but, then again, a lot has changed in 10 years. Ten years ago, there was more risk involved in the procedure." "You made the best decision at the time. Let's talk about what makes you feel as though your father's death is your fault."

"You made the best decision at the time. Let's talk about what makes you feel as though your father's death is your fault." RATIONALE: The correct option involves the therapeutic communication technique of paraphrasing. It is open ended as well, making it therapeutic. The nurse provides support, restates the daughter's message, and provides the daughter an opportunity to express her feelings. "It is not your fault" is an aggressive response and is a communication block because it does not encourage the daughter to express her feelings. Addressing guilt and change are incorrect because they reinforce the daughter's belief that she is responsible for her father's death. TEST-TAKING STRATEGY: Use therapeutic communication techniques and note that the client in this case is Louis's daughter. Remember to focus on the client's feelings. This will direct you to the correct option. Review: therapeutic communication techniques.

A client tells the nurse that he is experiencing a great deal of work-related stress and is taking an anxiolytic medication. He tells the nurse that he read on the Internet that St. John's wort, an herbal product, is helpful in reducing stress and says that he would like to try taking it. Which is the best response for the nurse to give the client? "It's an herbal product made from a plant, so it's harmless." "You'll need to discuss the use of St. John's wort with your physician before taking it." "I read the same thing, and I know that you can buy St. John's wort at any health food store." "You should give it a try. I would suggest taking it every morning that you're scheduled to work."

"You'll need to discuss the use of St. John's wort with your physician before taking it." RATIONALE: The use of herbal therapies in combination with other medications can result in significant and potentially dangerous medication interactions. The nurse should tell the client that he should discuss the use of St. John's wort with his physician. Therefore the other options are incorrect. TEST-TAKING STRATEGY: Use the process of elimination and note the strategic word "best." Eliminate the comparable or alike options that indicate that it is acceptable for the client to take the medication. Finally, note that the client is taking an anxiolytic medication; this will help you determine that the best response is the one that indicates the need to discuss the use of St. John's wort with the physician. Review nursing responsibilities related to informing the client about the use of herbal therapies if you had difficulty with this question.

A nurse is providing physical care to a client who recently has been told that he has inoperable lung cancer with a poor prognosis. The client says to the nurse, "I am so scared of dying. You hear so many stories about death. If only someone could tell me what it is really like." Which response should the give the client? "What stories have you heard?" "You're scared of dying. Let's talk about what makes you scared." "I've heard a lot of stories, too. I wish I could give you an answer to this one." "People who have died and been resuscitated say it's a beautiful experience."

"You're scared of dying. Let's talk about what makes you scared." RATIONALE: The nurse should use the therapeutic communication technique of paraphrasing and a response that is open-ended, which is also therapeutic. The nurse should restate the client's message and provide the client an opportunity to express his feelings, concerns, and fears. The responses in the incorrect options do not focus on the client's concern. TEST-TAKING STRATEGY: Use therapeutic communication techniques. Eliminate the comparable or alike options that are nontherapeutic and do not address the client's feelings or concerns. Note that the correct option paraphrases the client's statement and provides the client an opportunity to express his feelings. Review therapeutic communication techniques if you had difficulty with this question.

Louise tells the nurse that she will try the deep-breathing exercises but asks whether there is anything else that she can try to help her feel calmer. The nurse reviews several stress-reducing strategies with Louise. Which statement by Louise indicates a good understanding of stress-reduction techniques? Select all that apply. - "I'll start going to bed 30 minutes earlier." - "A cup of hot tea will help me relax in the evening." - "I'll go to the gym at least three times a week after work." - "I'll exercise just before bedtime to help improve my sleep." - "I'll limit my coffee to one cup in the morning." - "During my break at work, I can find a quiet place and focus on feeling calmer."

- "I'll start going to bed 30 minutes earlier." - "I'll go to the gym at least three times a week after work." - "I'll limit my coffee to one cup in the morning." - "During my break at work, I can find a quiet place and focus on feeling calmer." RATIONALE: People who are stressed are often fatigued; for this reason, going to bed 30 to 60 minutes earlier each night may be helpful. Reducing or even eliminating caffeine can help a person feel more relaxed, and both tea and coffee contain caffeine. Exercise can help reduce stress, but it is best to exercise at least 3 hours before going to bed. Exercising for at least 30 minutes three or more times a week is recommended. Meditation takes practice, but it can help produce a relaxation response by quieting the sympathetic nervous system. TEST-TAKING STRATEGY: Focus on the strategic words "stress-reducing." Read each option carefully and think about how the technique will alleviate stress; this will direct you to the correct options. Review stress-reduction techniques if you had difficulty with this question.

Louise reads an article about herbal therapies for stress relief and decides that she wants to try drinking tea made with kava. She calls the company nurse to ask about using kava. Which instructions should the nurse provide? Select all that apply. "Herbal products are safe to use, because they aren't really medications." "You shouldn't use kava if you think you might be pregnant." "This herb helps some people feel more relaxed and may help you sleep." "It's safe to drink a small glass of wine at night with this tea right before bedtime." "If you drink this tea long enough, you may notice a yellow discoloration of your skin."

- "You shouldn't use kava if you think you might be pregnant." - "This herb helps some people feel more relaxed and may help you sleep." - "If you drink this tea long enough, you may notice a yellow discoloration of your skin." RATIONALE: Kava is commonly used to relieve anxiety and stress and to promote sleep. It may cause a temporary yellow discoloration of the skin, and it should not be taken with alcohol or psychoactive drugs or by women who are pregnant or breastfeeding. Even though kava is an herbal product, those who use it must be aware of potential side effects and contraindications. TEST-TAKING STRATEGY: This question involves the use of kava for the relief of stress. Keep in mind the subject, that herbal products, although they are not medications, do have certain contraindications to their use. Also use the general guidelines for medication administration and remember that the nurse would not recommend the use of alcohol to a client. Review the use of kava if you had difficulty with this question.

Which choices are therapeutic nursing actions in dealing with the husband of a client who is dying? Select all that apply. - Encouraging the husband to express his feelings and concerns - Making decisions for the husband to lessen his burden of grief - Determining how much the husband wishes to know about the care being provided to his wife - Refraining from demonstrating emotion over the client's terminal situation in the presence of the husband - Telling the husband that it will be easier to accept the loss if he avoids reminiscing and talking about his life with his wife

- Encouraging the husband to express his feelings and concerns - Determining how much the husband wishes to know about the care being provided to his wife RATIONALE: The nurse needs to assist the client, family, and significant others through the process of grief. The use of therapeutic communication techniques is important in promoting the process. It is important for the nurse to determine the needs of the family or significant other and how much information they wish to receive about the client's condition and the care being provided to their loved one. The nurse should also encourage reminiscing and the expression of feelings and concerns, which will help loved ones move through the grief process. The nurse should not make decisions for the family unless they specifically request that the nurse do so. Instead, the nurse should assist with the decision-making process if asked and avoid interjecting personal views or opinions. The nurse should acknowledge his or her own feelings. It is also acceptable for the nurse to express his or her own emotions with the family as appropriate. TEST-TAKING STRATEGY: Recall therapeutic communication techniques to answer the question. Eliminate the comparable or alike options that are nontherapeutic and do not address the husband's feelings or concerns and do not assist the husband in the grief process. Also note the words "making decisions for," "refraining from demonstrating emotion," and "avoids" in the incorrect options. Review therapeutic nursing actions for dealing with the family of a client who is dying if you had difficulty with this question.

Which are characteristics of constructive coping mechanisms? Select all that apply. - It is a protective response. - It is an effort to relieve anxiety. - It may involve behaviors such as using relaxation techniques. - It involves repression of a painful experience into the unconscious. - It is a mechanism used by the individual to consciously confront a threat.

- It is a protective response. - It is an effort to relieve anxiety. - It may involve behaviors such as using relaxation techniques. - It is a mechanism used by the individual to consciously confront a threat. RATIONALE: A coping mechanism is any effort to adjust and relieve anxiety. Constructive coping mechanisms are protective responses that an individual uses to consciously confront a threat. Constructive coping mechanisms can include distractions such as reading, praying, and meditation; relaxation techniques; or seeking social support. Destructive coping mechanisms involve repression into the unconscious and tend to be ineffective. Examples of destructive coping mechanisms include withdrawal from social contacts, poor dietary habits, smoking, and alcohol and drug abuse. TEST-TAKING STRATEGY: Focus on the subject, constructive coping mechanisms. Read each option, carefully noting the word "repression" in the incorrect option. Review the characteristics of constructive and destructive coping mechanisms if you had difficulty with this question.

A nurse plans care for a client experiencing stress. Which characteristics are associated with the stage of resistance in Selye's description of general adaptation syndrome? Select all that apply. All energy for adaptation has been expended. The body makes some effort to resist the stressor. When resources are adequate, the person may successfully recover from a stressor. Successful adaptation depends on the adequacy of the person's internal and external resources. The person in this stage may become ill and die if assistance from an outside source is not available.

- The body makes some effort to resist the stressor. - When resources are adequate, the person may successfully recover from a stressor. - Successful adaptation depends on the adequacy of the person's internal and external resources. RATIONALE: In the stage of resistance, physiologic reserves are mobilized to increase the resistance to stress. Few overt physical signs and symptoms occur. The individual is expending energy to adapt, and successful adaptation depends on the adequacy of the person's internal and external resources. When resources are adequate, the person may successfully recover from a stressor; if adaptation does not occur, the person may move to the next stage, exhaustion. The stage of exhaustion occurs when all energy for adaptation has been expended. Physical symptoms of the alarm reaction stage may briefly reappear in a final effort by the body to survive. This stage of exhaustion can often be reversed with an external source of adaptive energy (e.g., medication or psychotherapy). However, the person in this stage may become ill and die if assistance from an outside source is not available. TEST-TAKING STRATEGY: Focus on subject of the question, the stage of resistance. Think about the stages of general adaption syndrome to answer correctly. Note the relationship of the word "resistance" and the correct options. Also, note that the incorrect options relate to the stage of exhaustion. Review Selye's general adaptation syndrome if you had difficulty with this question.

Which behaviors are characteristics of anticipatory grieving? Select all that apply. The person experiences grief weeks after the actual loss. A family member begins to withdraw emotionally from the terminally ill person. A family member may choose to be with friends instead of staying with a dying family member. A person is overwhelmed by grief and cannot carry out day-to-day actions such as going to work. A family member is unable to sleep after a loss but does not connect the altered sleeping pattern to the loss.

A family member begins to withdraw emotionally from the terminally ill person. A family member may choose to be with friends instead of staying with a dying family member. RATIONALE: Anticipatory grief is the process of letting go that occurs before an actual loss (such as death) has occurred. It occurs when there is time for the person or family members to accept the reality of a terminal illness. However, some family members may actually begin withdrawing emotionally from the ill person as a self-protective mechanism, leaving the ill person with less support at the end of his or her life. Delayed grief occurs later, some time after the actual loss, instead of at the time of loss. Exaggerated grief is when a person experiences grief to such a degree that he or she cannot carry out daily functions. Masked grief is when a person is unable to recognize that the physical or emotional symptoms he or she is experiencing is a result of the loss that has been experienced. TEST-TAKING STRATEGY: Focus on the subject, the characteristics of anticipatory grieving. Recalling that anticipatory grief occurs before the actual loss has occurred will direct you to the correct option. Also note that the correct options involve withdrawal from the ill person. Review the characteristics of anticipatory grieving and the other types of grief if you had difficulty with this question

A nurse employed in hospice care is reading the records of her assigned clients. Which client does the nurse identify as being at risk for disenfranchised grief? The mother of a child who was killed in an automobile accident A same-sex partner of a client with acquired immunodeficiency syndrome A client with terminal cancer who is receiving a great deal of support from his wife A client with end-stage renal disease who relies heavily on religious beliefs for hope

A same-sex partner of a client with acquired immunodeficiency syndrome RATIONALE: Disenfranchised grief occurs when societal norms do not define a loss as a loss within its traditional definition. Basically, the survivor is not acknowledged for the loss and as a result is not given support by others. One example of disenfranchised loss is the death of a same-sex partner. In such a situation, grief may need to be hidden for the surviving partner to avoid negative social pressure. The mother of a child killed in an automobile accident, a client with terminal cancer, and a client with end-stage renal disease who relies heavily on religious beliefs for hope are not at risk for disenfranchised grief. TEST-TAKING STRATEGY: Focus on the subject, the client at risk for disenfranchised grief. Recalling that disenfranchised grief occurs with nontraditional losses will direct you to the correct option. Review disenfranchised grief and other types of grief if you had difficulty with this question.

Which situation is an example of the maladaptive defense mechanism known as identification? A client criticizes a nurse after his family fails to visit him. A married man flirts with his secretary and then brings flowers home to his wife. A young boy thinks that a neighborhood gang leader who sells illegal drugs is someone to look up to. A nursing student who fears failure on a final exam develops a terrible headache and is unable to take the exam.

A young boy thinks that a neighborhood gang leader who sells illegal drugs is someone to look up to. RATIONALE: Identification is an unconscious attempt to change oneself to resemble an admired person. A young boy's belief that a neighborhood gang leader who sells illegal drugs is someone to look up to is identification as a maladaptive defense. Displacement is a defense mechanism in which feelings toward one person are directed at another who is less threatening, thereby satisfying an impulse with a substitute object. The client who criticizes a nurse after his family fails to visit him is engaging in displacement. Undoing is engaging in behavior that is considered the opposite of a previous unacceptable behavior, thought, or feeling (e.g., a married man flirts with his secretary and then brings flowers home to his wife). Conversion is the expression of emotional conflicts through physical symptoms. A nursing student who fears failure on a final exam and develops a terrible headache becoming unable to take the exam is an example of conversion. TEST-TAKING STRATEGY: Focus on the subject of the question, identification, and think about its definition. Next, note the strategic word "maladaptive," which will direct you to the correct option. Review examples of adaptive and maladaptive defense mechanisms if you had difficulty with this question.

A nurse employed in the mental health unit of a hospital is leading a group psychotherapy session. Which is the nurse's role in the termination stage of group development? Encourage problem-solving. Encourage accomplishment of the group's work. Acknowledge the contributions of each group member. Encourage members to become acquainted with one another.

Acknowledge the contributions of each group member. RATIONALE: In the termination stage, the group leader's task is to acknowledge the contributions of each member and the experience of the group as a whole. In this stage, the group members prepare for separation and help one another prepare for the future. Encouragement of problem-solving and accomplishment of the group's work is part of the working stage. Encouragement of members to become acquainted with one another is a task of the orientation stage. TEST-TAKING STRATEGY: Use the process of elimination and focus on the subject, the termination stage. Eliminate the options that address problem-solving and accomplishment of the group's work because they are comparable or alike options. To select from the remaining options, focus on the subject and note its relationship and the correct option. Review the stages of group development if you had difficulty with this question.

After a thorough mental health assessment, Joseph is transferred to the mental health unit in a voluntary admission. A nurse in the mental health unit reviews the emergency department notes in preparation for the interview with Joseph. Because Joseph has consented to voluntary admission, the nurse makes which determination? Joseph cannot request and be granted hospital discharge. Admission to the mental health unit was sought by Joseph. Admission to the hospital was made without Joseph's consent. Joseph will not be making decisions about his treatment or care.

Admission to the mental health unit was sought by Joseph. RATIONALE: Voluntary admission is generally sought by the client or by the client's guardian. Voluntary admitted clients have the right to request and be granted release from the hospital. Clients admitted to a mental health facility do not lose the right to informed consent or decision-making. Involuntary admission is made without the client's consent. TEST-TAKING STRATEGY: Use the process of elimination. Focusing on the strategic words "voluntary admission" will direct you to the correct option. Also note that the incorrect comparable or alike options reflect a restriction of Joseph's right to make decisions. Review the procedure for voluntary admission if you had difficulty with this question.

A client is told that the computed tomography scan she has just undergone has revealed a pancreatic mass that is most likely cancer. The client becomes upset and anxious on hearing this news and tells the nurse that she feels nauseated. Checking the client's vital signs, the nurse notes that the client's heart rate, respiratory rate, and blood pressure are increased compared with previous readings. Which stage of Selye's general adaptation syndrome is the client experiencing? Eustress Alarm reaction Stage of resistance Stage of exhaustion

Alarm reaction RATIONALE: According to Hans Selye, general adaption syndrome comprises three stages: the alarm reaction, the stage of resistance, and the stage of exhaustion. During the alarm reaction stage, the fight-or-flight response is initiated. Physical signs and symptoms of sympathetic nervous system stimulation appear. In the stage of resistance, few overt physical signs and symptoms occur. When internal and external resources are adequate, the individual may successfully recover from a stressor. If adaptation does not occur, the person may move to the next stage, exhaustion. In the stage of exhaustion, physical symptoms of the alarm reaction stage may briefly reappear in a final effort by the body to survive. This stage can often be reversed with external sources of adaptive energy such as medication or psychotherapy. Eustress is a term used by Selye that refers to stress associated with positive events. TEST-TAKING STRATEGY: Focus on the data in the question and note the physiological signs and symptoms. Think about the stages of general adaption syndrome and recall that physical signs and symptoms related to sympathetic nervous system stimulation appear in the alarm reaction stage. Review Selye's general adaptation syndrome if you had difficulty with this question.

The nurse is developing the plan of care for a family of seven who are recently arrived refugees from Central America. The nurse would prioritize the plan of care to take which action first? Provide vaccinations for the entire family. Assess the three-year-old child who has a rash, a cough and a high fever. Advise the mother with a seven-month-old child to continue breastfeeding. Obtain stool samples to determine if the family has a gastrointestinal illness.

Assess the three-year-old child who has a rash, a cough and a high fever. RATIONALE: The nurse should prioritize the plan of care and first assess the three-year-old child who has a rash, a cough, and a fever. These could be the symptoms of a communicable disease. Providing vaccinations is important, but the child's current symptoms take priority. It is important to continue breastfeeding the seven-month-old child, but this is not as high a priority as the symptoms of rash, a cough, and a fever. Obtaining stool samples may not be necessary as there is no indication of gastrointestinal symptoms. TEST-TAKING STRATEGY: Note the strategic words, "prioritize" and "first". Utilize knowledge of Maslow's Hierarchy of Needs Theory to answer this question. Actual physiological needs, such as the child with symptoms of rash, a cough, and fever, take precedence over potential needs. Vaccinations, breastfeeding instructions, and obtaining stool samples are all comparable or alike options, which address potential, rather than actual needs.

Which action on the part of the nurse would best help Katie in regaining her self-worth? Suggesting that she quit her job and find a new one Assisting Katie in exploring solutions to the problem Teaching Katie how to stand up to her boss when he reprimands her Encouraging Katie to use any defense mechanism necessary to deal with the problem

Assisting Katie in exploring solutions to the problem RATIONALE: A client who is experiencing anxiety may feel helpless and may be overwhelmed by feelings of inadequacy. The fact that the client has found it necessary to seek outside help may further increase feelings of inadequacy. Therefore, increasing the client's self-esteem and feeling of self-worth is important. The nurse would help Katie regain her feelings of self-worth by communicating confidence that she can find solutions to problems. The nurse would also convey the impression that Katie is a worthwhile person by listening to and accepting her feelings, being respectful, and praising her help-seeking efforts. Quitting her job and finding a new one is unrealistic. Use of any defense mechanism to deal with the problem is incorrect because the use of nonconstructive defense mechanisms should be discouraged. Standing up to her boss might cause additional problems between Katie and her boss. TEST-TAKING STRATEGY: Use the process of elimination and eliminate the comparable or alike options that do not reflect a constructive defense mechanism. Eliminate the option that is an unrealistic action (quitting her job). Next eliminate the option recommending the use of "any" defense mechanism. Standing up to her boss could cause additional problems between Katie and her new boss, so eliminate this option. Review the techniques for helping a client use constructive defense mechanisms if you had difficulty with this question.

The nurse is providing preoperative instructions for day surgery scheduled in a week to a client who speaks Spanish only. Which action is the best way for the nurse to ensure that the client understands the instructions? Calling for a hospital-designated interpreter to communicate with the client Asking a family member who speaks English and Spanish to translate for the client Relying on the use of hand signals and demonstrations to teach the client about the preoperative procedures Writing the instructions on a piece of paper so that an English and Spanish speaking neighbor will be able to translate them for the client

Calling for a hospital-designated interpreter to communicate with the client RATIONALE: Arranging for a hospital-designated interpreter is the best practice for communication with a client who speaks a different language. This action will ensure that the client clearly understands the preoperative instructions. Asking a family member or a neighbor is not an appropriate action, because the nurse cannot be sure that the client will receive the correct information. Also, asking a family member or neighbor to translate violates the client's privacy. Likewise, the use of hand signals and demonstrations will not ensure that the client understands the instructions. TEST-TAKING STRATEGY: Note the strategic word "best" in the question. Eliminate the comparable or alike options that violate the client's right to privacy by asking the family member or neighbor to translate. Next remember that a hospital designated translator will be familiar with medical terminology and will be able to explain the instruction accurately in lay terms. Review: the best communication techniques for a client who speaks a different language.

Louis' respiration pattern is illustrated below. How should the hospice nurse document the respiratory findings in the medical record? Bradypnea Hyperventilation Biot respirations Cheyne-Stokes respirations

Cheyne-Stokes respirations RATIONALE: Cheyne-Stokes respirations are an abnormal pattern of respiration characterized by alternating periods of apnea and deep, rapid breathing. This type of breathing is a physical manifestation of approaching death. Bradypnea is an abnormally slow breathing rate. Hyperventilation is breathing at an abnormally rapid rate, thus increasing the rate of loss of carbon dioxide. Biot respirations is an abnormal pattern of breathing characterized by groups of regular deep inspirations that tend to be similar in size and are followed by regular or irregular periods of apnea. TEST-TAKING STRATEGY: Knowledge regarding the subject, the respiratory pattern associated with approaching death is needed to answer this question. Review: the various types of respiratory patterns.

While the COVID-19 infection is active, what signs/symptoms does the nurse expect Rudy to display? Select all that apply. Cough Fever Loss of taste/smell Weak, thready pulse Shortness of breath

Cough Fever Loss of taste/smell Shortness of breath RATIONALE: Signs/symptoms of an active COVID-19 infection include but are not limited to cough, shortness of breath, fever, muscle pain, sore throat, and loss of taste and/or smell. The nurse would not expect a weak, thready pulse in the client unless an underlying health problem exists that causes a weak and thready pulse, or a complication of the infection occurs.

The nurse is volunteering with an outreach program to provide basic health care for people experiencing homelessness. Which finding, if noted in a client, should be addressed first? Blood pressure 154/72 mmHg Visual acuity of 20/200 in both eyes Random blood glucose level of 206 mg/dL (11.77 mmol/L) Complaints of pain associated with numbness and tingling in both feet

Complaints of pain associated with numbness and tingling in both feet RATIONALE: The nurse should address the complaints of pain and numbness and tingling in both feet first with this population. The nurse needs to focus on reported symptoms first because this will encourage adherence to the treatment plan and return for follow-up. Subsequent care would include health maintenance and attention to common problems and concerns such as blood pressure, visual acuity, and blood glucose readings. If the client perceives value to the service provided, they will be more likely to return for follow up care. While the blood pressure, blood glucose and vision results are concerning, the client's stated concern should be addressed first. TEST-TAKING STRATEGY: Note the subject, the finding to be addressed, and focus on the strategic word, first. Recalling that adherence is a problem for this population will direct you to the correct option, the option that addresses the client's immediate complaint. Also note, the correct option is the only subjective finding.

The hospice nurse is caring for a client with end-stage heart failure. The nurse should monitor the client for which signs of impending death? Select all that apply. Diarrhea Increased urine output Increased pain perception Decreasing blood pressure Irregular and noisy respirations Mottled and cyanotic extremities

Decreasing blood pressure Irregular and noisy respirations Mottled and cyanotic extremities RATIONALE: Some signs of impending death are decreasing blood pressure, irregular and noisy respirations, and mottled, pale, or cyanotic extremities. The client is more likely to experience constipation from decreased peristalsis. The urine output decreases, rather than increasing. Pain perception decreases. TEST-TAKING STRATEGY: Use knowledge of the subject, signs of impending death, to help you with this question. Eliminate the comparable or alike options that indicate increasing functions of the body, such as diarrhea, increased urine output, and dulled pain perception. Review: signs of impending death.

With her parents beside her, Isabel carefully explains her situation to her children and outlines the plans for surgery and chemotherapy over the next few months. The children listen, in tears, and ask questions about what Isabel is facing. Later in the day, Regina starts to talk about looking forward to next summer's trip to Florida, a trip they have taken every year. Isabel says nothing about it but worries that her daughter may not fully understand her situation. Which stage of grief is Regina exhibiting at this time? Denial Bargaining Depression Acceptance

Denial RATIONALE: According to Elisabeth Kübler-Ross, a person who is undergoing a significant loss—the a person who is dying or people close to a dying person—will experience five stages of grief. The first of these stages is the denial stage, during which the person acts as if nothing has changed. The subsequent stages are anger, bargaining, depression, and finally, acceptance. TEST-TAKING STRATEGY: Focus on the strategic words "stage of grief," and identify which stage that Regina is experiencing in this situation. Noting that Regina speaks about a future event and keeping in mind that it is early in the process of her learning about her mother's illness will direct you to the correct option. Review Kübler-Ross' five stages of grief if you had problems with this question.

The nurse is developing a plan of care for a client who has a severe intellectual disability. The client has recently begun to suck on her right hand, which is becoming red and raw. She is also refusing to eat some of her favorite foods. Which intervention has the highest priority? Wrapping her hand in gauze Determining if the client has a mouth sore Frequently reminding her it is unsanitary to suck on her hands Giving her a small reward when she does not suck on her hand during meals

Determining if the client has a mouth sore RATIONALE: The nurse should be aware that altered behavior may be caused by illness. The highest priority should be to investigate any condition or illness that could cause altered behavior. Wrapping her hand in gauze is not a priority; an underlying cause of the new behavior needs to be investigated first. Reminding her it is unsanitary to suck on her hands may not be effective if the individual has a severe intellectual disability. Providing her with a small reward for not sucking on her hands would not be effective if the cause of the behavior is a sore mouth. TEST-TAKING STRATEGY: Note the strategic words, "highest priority." Eliminate options 1, 3, and 4 because they are comparable or alike options that focus on aspects other than addressing an underlying condition as the cause of the altered behavior. Wrapping the hand in gauze, giving reminders and rewards do not focus on the underlying illness.

Katie, very upset about her boss's comments, returns home from work to find her children sprawled on the couch, watching television and eating cookies and milk. She immediately yells at them, telling them to get off the couch and get their rooms cleaned and homework done. Which defense mechanism is exemplified by Katie's behavior toward her children? Introjection Dissociation Identification Displacement

Displacement RATIONALE: In using displacement, Katie directs her feelings toward one person (her boss) at another (or others; in this situation, her children) who is less threatening. Introjection is the incorporation or internalization of values, standards, or traits of another person with whom intense emotional ties exist. Dissociation involves the blocking off of an anxiety-provoking event or period from the conscious mind. Identification is an unconscious attempt to change oneself to resemble an admired person. TEST-TAKING STRATEGY: Use your knowledge of the subject, defense mechanisms, to answer the question. Focusing on the data in the question and noting that Katie is redirecting her feelings about her boss at others will direct you to the correct option. Review the defense mechanisms identified in the options if you had difficulty with this question.

The nurse is performing an assessment of a client who is Black American. Which question should the nurse ask to elicit information on a health risk associated with this cultural group? "Does anyone in your family have hepatitis?" "Does anyone in your family have tuberculosis?" "Does anyone in your family have hypertension?" "Does anyone in your family have iron deficiency anemia?"

Does anyone in your family have hypertension?" RATIONALE: Hypertension is a health risk in the Black American population. Other health risks associated with this cultural group include obesity, asthma, diabetes, heart disease, and cancer. Hepatitis is a health risk associated with Native Hawaiians and other Pacific Islanders, Native Americans and Alaska Natives, and Asian American groups. Tuberculosis is a health risk for Native Hawaiians and other Pacific Islanders and Asian American groups. There are many causes of iron deficiency anemia, including some chronic conditions; however, this is not a health risk specific to the Black American population. TEST-TAKING STRATEGY: Knowledge of the subject, health risks associated with the Black American group is needed to answer this question. Remember that members of this group are at risk for hypertension. Review: the health risks of the client who is Black American.

A nurse is assigned to work with a client who has just been admitted to the mental health unit. Which action does the nurse plan to take in the orientation or introductory phase of the nurse-client relationship? Establish a contract with the client. Increase the client's independence. Promote the use of constructive coping mechanisms. Refer and transfer the client to other sources of support.

Establish a contract with the client. RATIONALE: The tasks of the orientation or introductory phase of the nurse-client relationship are to establish trust, acceptance, and open communication and to formulate a mutual contract with the client. The contract begins with the introduction of the nurse and client, the exchange of names, and the explanation of roles. Promotion of the use of constructive coping mechanisms and increasing the client's independence are tasks of the working phase. Referring and transferring the client to other sources of support is a task of the termination or separation phase. TEST-TAKING STRATEGY: Use the process of elimination. Focus on the subject and note the relationship of the subject and the option describing establishing a contract with a client. Review the tasks of the orientation or introductory phase of the nurse-client relationship if you had difficulty with this question.

Joseph is discharged from the hospital, but his new mental health contract states that he will attend twice-weekly cognitive therapy sessions. During the working phase of the nurse-client relationship, what specific tasks does the nurse plan? Select all that apply. Establishing a rapport Gathering further data about Joseph's problems Promoting Joseph's problem-solving skills Summarizing the goals achieved in the relationship Helping Joseph explore how to practice alternative adaptive behaviors Discussing problems and goals, and redefining as needed

Gathering further data about Joseph's problems Promoting Joseph's problem-solving skills Helping Joseph explore how to practice alternative adaptive behaviors Discussing problems and goals, and redefining as needed RATIONALE: During the working phase of a nurse-client relationship, nurse and client work together to identify and explore issues that are causing problems in the client's life, then set goals for the sessions. It is also a time for data-gathering and identifying and promoting the client's problem-solving skills, as well as for exploring new behaviors for problem-solving. Establishing a rapport is part of the first phase of the nurse-client relationship, the orientation phase. Summarizing the goals that have been achieved is part of the termination phase. TEST-TAKING STRATEGY: Focus on the subject, "specific tasks of the working phase of the nurse-client relationship." Use the process of elimination to decide whether each activity belongs in the working phase or in one of the other phases (e.g., orientation phase, termination phase). Note that the incorrect options include the words "establishing" (orientation phase) and "summarizing" (termination phase). Review the components of the working phase of the nurse-client relationship if you had difficulty with this question.

Based on Rudy's status as a homeless veteran, which part of his health history is a priority for the nurse to assess? Housing status Mental health status History of substance use Sexual activity and history of STIs

History of substance use RATIONALE: Among both homeless and veteran populations, substance use disorders with tobacco, alcohol, or other drugs are more common. While clients in these groups are also at a higher risk for communicable diseases (including STIs) and mental health problems, the presence of a substance use disorder poses the most immediate threat to the client's health. Use of screening tools in identifying substance use disorder will help to plan appropriate care. Although housing status should also be addressed, this is not a priority from the options presented. TEST-TAKING STRATEGY: Note the strategic word, priority. This indicates that all options are important and are most likely correct. It is necessary to recall that substance use disorders can be detrimental to cardiopulmonary health and other organ system function, and that withdrawal from alcohol, benzodiazepines, and other substances put the client at risk for seizures. Therefore, identifying the presence of a substance use disorder is a priority.

A client with claustrophobia is seen in the mental health clinic and told that one treatment for the disorder is systematic desensitization. When the client asks the nurse to describe the treatment, what information does the nurse provide? It involves focus on the consequence of a behavior. A stimulus attractive to the client is paired with an unpleasant experience. The therapist will perform certain behaviors, and the client will imitate the behaviors. It involves exposure to the phobic situation, starting with short periods and gradually increasing until the fear has been eliminated.

It involves exposure to the phobic situation, starting with short periods and gradually increasing until the fear has been eliminated. RATIONALE: Systematic desensitization is a form of behavioral modification. In this type of therapy, incrementally increasing exposure to a feared stimulus is paired with an increasing level of relaxation, helping reduce the intensity of fear to a more tolerable level. Operant conditioning is the manipulation of selected reinforcers to elicit and strengthen desired behavioral responses; the reinforcer refers to the consequence of the behavior, which is defined as anything that increases the occurrence of a behavior. Aversion therapy is a form of behavioral therapy in which negative reinforcement is used to change behavior; for example, a stimulus attractive to the client is paired with an unpleasant event in the hope of endowing the stimulus with negative properties, thereby dissuading the behavior. Modeling is a type of behavioral therapy in which the therapist acts as a role model for specific identified behaviors so that the client learns through imitation. TEST-TAKING STRATEGY: Focus on the data in the question and use the process of elimination. Note the relationship between the words "systematic desensitization" in the question and the description in the correct option. Review systematic desensitization if you had difficulty with this question.

A client is seen in the emergency department for complaints of chest pain and difficulty breathing. The results of laboratory and diagnostic tests are normal, indicating that there is no physiological basis for the complaints. On further discussion, the client tells the nurse that chest pain and difficulty breathing are the symptoms that his wife had before she died. Which type of defense mechanism does the nurse recognize in this behavior? Projection Introjection Rationalization Reaction formation

Introjection RATIONALE: Introjection is a type of identification in which the individual incorporates the traits or values of another into himself or herself. Projection is the transfer of one's internal feelings, thoughts, and unacceptable ideas and traits to someone else. Rationalization is an attempt to make unacceptable feelings and behaviors acceptable by justifying the behavior. Reaction formation is the development of conscious attitudes and behaviors and acting out behaviors opposite of what one really feels. TEST-TAKING STRATEGY: Focus on the data in the question. Noting that the client's complaints are the same as those of his dead wife will help you determine the defense mechanism being used. Review the defense mechanisms identified in the options if you had difficulty with this question.

Two police officers arrive at the emergency department with a client who was been displaying violent behavior in a local park. The police report to the nurse that they tried unsuccessfully to reason with the client and that the client continued to direct violent behaviors at other individuals in the park. After a thorough psychosocial assessment of the client, the health care provider determines that the client requires emergency involuntary admission to the mental health facility. What determination does the nurse make with regard to this type of admission? It requires the client's consent. It eliminates the client's right to informed consent. It is normally sought by the client or the client's guardian. It is necessary for a client who is a danger to self or others.

It is necessary for a client who is a danger to self or others. RATIONALE: Involuntary admission is made without the client's consent. Generally involuntary admission is necessary when the client is a danger to self or others, is in need of psychiatric treatment, or is unable to meet his or her own needs. Voluntary admission is usually sought by the client or by the client's guardian. Clients who are involuntarily admitted do not lose their right to informed consent. TEST-TAKING STRATEGY: Focus on the data in the question and use the process of elimination. Noting the words "emergency involuntary admission" will direct you to the correct option. Review the types of admission procedures for the client with a mental health disorder if you had difficulty with this question.

The nurse teaches Louise deep-breathing exercises to help her relax and reduce stress. She tells Louise that she may perform these exercises while sitting at her desk and that she should perform them whenever she begins to feel stressed. Which observation by the nurse indicates that Louise is performing the breathing exercises correctly? - Louise breathes in through her nose, holds her breath for 10 seconds, and then breaths out through her nose. - Louise breathes in through her mouth, holds her breath for 3 seconds, and then breathes out slowly through her nose. - Louise breathes in through her nose, holds her breath for 15 seconds, and then breathes out quickly through her mouth. Louise quickly breathes in through her mouth, holds her breath for 10 seconds, and then quickly breathes out quickly through her nose.

Louise breathes in through her mouth, holds her breath for 3 seconds, and then breathes out slowly through her nose. RATIONALE: To perform deep-breathing exercises, the client should shift to relaxed abdominal breathing. The client breathes in through the mouth, holds the breath for 3 seconds, and slowly breathes out through the nose. With every breath, the client should pay attention to the muscle sensations that accompany the expansion of the abdomen. TEST-TAKING STRATEGY: Use the process of elimination. Eliminate the comparable or alike options that involve holding the breath for an extended time. Review the procedure for performing deep-breathing exercises if you had difficulty with this question.

After Louis has died, his family members gather around his bedside to pray and mourn. A little later, Laura asks the hospice nurse to call the funeral home and requests help in preparing her husband's body before the funeral home arrives. Which actions are appropriate components of postmortem care? Select all that apply. Placing a small pillow under the head Elevating the head of the bed to 45 degrees or higher Gently pulling the eyelids over the eyes to close them Removing Louis' dentures and placing them in a denture cup Washing soiled body parts and placing an absorbent pad under the buttocks

Placing a small pillow under the head Gently pulling the eyelids over the eyes to close them Washing soiled body parts and placing an absorbent pad under the buttocks RATIONALE: Postmortem care should be performed as soon as possible to prevent tissue damage, because the body goes through many physical changes after death. The head of the bed is elevated 30 degrees to prevent livor mortis of the face, and a small pillow is placed under the head. Dentures should be left in the mouth, because they give the face a more natural appearance. Closing the eyes helps convey a calm, natural appearance. At the time of death, the urinary and bowel sphincters may relax, resulting in the release of urine and feces, so the perineal area may need to be cleansed and an absorbent pad placed under the buttocks. The nurse should allow the family members to assist with these actions if they want to help. TEST-TAKING STRATEGY: Focus on the subject "appropriate components of postmortem care." Reading each option carefully and recalling those that will help prevent tissue damage during this time will direct you to the correct options. Review: postmortem care.

Testlet Question 4 What health problem would the nurse most likely suspect is related to Rudy's wartime experiences? Bipolar disorder Dental problems Posttraumatic stress disorder (PTSD) Human Immunodeficiency Virus (HIV)

Posttraumatic stress disorder (PTSD) RATIONALE: PTSD is common among military veterans and others who have experienced traumatic events. Although the other disorders listed in the options may be concerns, they are not the most likely health problem related to the client's wartime experiences. TEST-TAKING STRATEGY: Note the strategic words, "most likely" and focus on the subject, a health problem related to Rudy's status as a combat veteran. Recall that individuals in this special population group may have PTSD. The use of questioning in a variety of ways may be necessary to obtain the necessary assessment data.

The nurse is assisting with data collection of a client who is an alcoholic. During the interview, the client preaches about the evils of drinking. Which adaptive defense mechanism does the nurse recognize in the client's behavior? Projection Identification Rationalization Reaction formation

Reaction formation RATIONALE: Reaction formation is the development of conscious attitudes and behaviors and the acting out of behaviors that may conflict with what one really feels. The client's proclamations about the evils of drinking are an example of this adaptive defense mechanism. Projection is the transfer of one's internal feelings, thoughts, and unacceptable ideas and traits to someone else. Identification is an unconscious attempt to change oneself to resemble an admired person. Rationalization is an attempt to make unacceptable feelings and behaviors acceptable by justifying the behavior. TEST-TAKING STRATEGY: Focus on the data in the question. Next, think about the description of each item in the options. Noting that the client is an alcoholic yet preaches about the evils of alcohol will direct you to the correct option. Review the defense mechanisms identified in the options if you had difficulty with this question.

The home care nurse making a visit to a client who is receiving hospice care understands that hospice care is intended to achieve certain outcomes. What are these outcomes? Select all that apply. Relief of symptoms Postponement of death Hastening of disease remission Facilitation of a peaceful death Provision of the best possible quality of life

Relief of symptoms Facilitation of a peaceful death Provision of the best possible quality of life RATIONALE: In hospice care, an interdisciplinary approach is used to assess and address the holistic needs of clients and families to ensure the best possible quality of life and a peaceful death. The holistic approach neither hastens nor postpones death, nor does it hasten remission of the disease; instead, it provides relief of symptoms. TEST-TAKING STRATEGY: Focus on the subject, the purpose of hospice care. It is necessary to recall that hospice care focuses on addressing the unmet needs of the terminally ill client. This will help you select

The nurse assesses Katie's level of anxiety and records the information (refer below). What level of anxiety does the nurse conclude that Katie is experiencing? Perceptual FieldFocused on detailsAttention scatteredCompletely self-absorbed Ability to LearnPerceptions distortedCannot see connections between events Physical or Other CharacteristicsRespiratory rate: 24 breaths/minutePulse: 110 beats/min, regular rhythmExpresses feelings of dread and a sense of impending doomComplains of extreme nausea and frequent headaches

Severe RATIONALE: The data listed in each area (perceptual field, ability to learn, physical or other characteristics) are indicative of a severe level of anxiety. A person at a mild level is able to grasp what is happening in the environment but is still able to work effectively toward a goal and examine possible actions. A client with this level of anxiety may experience slight discomfort, restlessness, irritability, or impatience. A person at a moderate level of anxiety grasps less of what is going on (compared with someone experiencing a mild level of anxiety) and may experience selective inattention. Some problem-solving may still be possible. Physical characteristics of moderate anxiety include voice tremors, shakiness, and some complaints of headache, backache, or insomnia. A person at the panic level is unable to focus on the environment and experiences terror and possibly hallucinations and delusions. Reasoning is disorganized or irrational, and the person may not be in touch with reality. A person at the panic level may either be immobile or severely hypoactive, may fight, or may be unable to speak. TEST-TAKING STRATEGY: This question may be difficult to answer correctly unless you are familiar with the subject, the characteristics of the levels of anxiety. When reviewing the data, tie together the characteristics that have been listed to determine the correct level of anxiety and note that all of the data listed are abnormal. Review the various levels of anxiety and their characteristics if you had difficulty with this question.

During the assessment, Joseph discusses his feelings of self-harm with the nurse and hints that he even had a plan for carrying out his suicide if his life "got worse." Which methods of suicide are considered of lower risk, or "soft"? Select all that apply. Hanging Swallowing pills Inhaling natural gas Slashing one's wrists Staging a high-speed car crash into a cement wall

Swallowing pills Inhaling natural gas Slashing one's wrists RATIONALE: The evaluation of a suicide plan is extremely important in determining the degree of suicide risk. The lethality of a method in person's suicide plan indicates how quickly the individual would die if that plan were enacted. Guns, hanging, carbon monoxide, and car crashes are extremely lethal and are therefore considered higher risk, or "hard," methods. Slashing the wrists, inhaling natural gas, and ingesting pills are lower risk, or "soft," methods. TEST-TAKING STRATEGY: The question involves knowledge of the subject, differentiating lower- and higher-risk methods of suicide. Use the process of elimination. For each item listed, decide on its lethality. This will direct you to the correct options. Review the lethality of various suicide plans if you had difficulty with this question.

Testlet Question 5 After seven days of inpatient care, Rudy is apyretic and his other symptoms have improved. Fortunately, his treatment did not require mechanical ventilator support. Nasopharyngeal testing indicates that he is no longer shedding the virus, and the provider has cleared him for discharge. However, the latest guidelines from the state Department of Health indicate that Rudy must self-isolate for at least 14 days after the onset of symptoms. Because he lacks adequate housing, the county services personnel have arranged for Rudy to stay in a hotel.

Teach-back RATIONALE: When providing education to members of special populations, return explanation and demonstration (teach-back) are of particular importance to ensure safety and mutual understanding. This method is the most reliable in confirming client understanding of the instructions. Video instruction, written materials, and verbal explanation are helpful and may be helpful to incorporate with the teach-back method. TEST-TAKING STRATEGY: Note the strategic words, most effective. Note that the correct option—the teach-back method—is the umbrella option, which encompasses all other options. Recall that asking the client to perform a return demonstration is the best way to confirm his or her understanding.

The nurse is evaluating the grief process for a woman whose husband died in an automobile accident 2 months ago. Which outcomes would the nurse identify as successful? Select all that apply. The client refuses to take on new responsibilities. The client demonstrates lengthening periods of stability. The client expresses positive expectations about the future. The client reports decreased preoccupation with the loss of her husband. The client's daughter reports that her mother has not paid any bills since the death of her husband.

The client demonstrates lengthening periods of stability. The client expresses positive expectations about the future. The client reports decreased preoccupation with the loss of her husband. RATIONALE: Grieving is a normal process in which people come to terms with losses. Successful outcomes associated with the grief process include the ability to tolerate intense emotions, reduced preoccupation with the deceased (loss), demonstration of increasing periods of stability, tending to previous responsibilities, taking on new roles and responsibilities, having the energy to invest in new endeavors, the expression of positive expectations about the future, and remembering positive as well as negative aspects of the deceased loved one. Refusing to take on new responsibilities and not attending to responsibilities are unsuccessful outcomes. TEST-TAKING STRATEGY: Focus on the subject of the question, successful outcomes of grieving. Eliminate the comparable or alike options (i.e., refusing to take on responsibilities and not paying bills). Review the grief process and the successful outcomes of the process if you had difficulty with this question.

A nurse in a mental health clinic is interviewing a client who was referred to the clinic by the client's primary physician. Which finding indicates to the nurse that the client needs assistance to restore and maintain mental health? The client has a positive self-concept. The client identifies strengths and uses these for goal attainment. The client has a distorted view of the world and communicates inappropriately. The client identifies coping mechanisms used to successfully manage threats to the self.

The client has a distorted view of the world and communicates inappropriately. RATIONALE: A client who experiences a disturbance in homeostasis as a result of a threat to the self and experiences an alteration in reality may come to have a distorted view of the world and may communicate inappropriately and inadequately. This psychic discomfort felt by the individual may be manifested through various mental health problems such as adjustment disorders, psychophysiological manifestations, psychotic disorders, and behaviors indicative of sensory deprivation. The remaining options are all healthy mental health behaviors. TEST-TAKING STRATEGY: Use the process of elimination and note the strategic words "needs assistance to restore and maintain mental health." Next, note the relationship between these words and the words "distorted view" in the correct option. Also note that the incorrect comparable or alike options that all describe healthy mental health behaviors. Review the characteristics of mental health and mental illness if you had difficulty with this question.

A nurse providing information to the wife of a client who abuses alcohol encourages the woman to attend an Al-Anon support group. The wife tells the nurse that she is embarrassed by her husband's behavior and that it would be difficult for her to face other people. Which response should the nurse give the woman to help alleviate her concerns? The support group is always led by a nurse and health care provider. She will not know any of the members of the support group. She does not need to provide her name or any other identifying information to the group. The members of the group have experienced or are experiencing the same problem she is facing.

The members of the group have experienced or are experiencing the same problem she is facing. RATIONALE: Al-Anon is a support group for spouses and friends of alcoholics or addicts. Support groups are based on the premise that people who have experienced a particular problem are able to help others with the same problem. Although a nurse or other health care professional may be asked to speak at a support group meeting, the members lead the group. The nurse cannot ensure that the wife will not know any of the members. Although the wife does not need to provide her name or any other identifying information to the group, this response is not helpful and will not alleviate the wife's concerns. TEST-TAKING STRATEGY: Use the process of elimination. First eliminate the option using the closed-ended word "always." Next eliminate the comparable or alike options that focus on the wife's identity. Focusing on the subject, alleviating the wife's concerns, will direct you to the correct option. Review the purpose and function of a support or self-help group if you had difficulty with this question.

Rudy's discharge instructions include a follow-up in three months' time, at which point he will receive another COVID test. What information would the nurse obtain that could help with follow-up care for this client? Rudy's preferred diet Rudy's incarceration history Rudy's family history of chronic diseases The name of Rudy's nephew as his emergency contact

The name of Rudy's nephew as his emergency contact RATIONALE: Adherence among members of the homeless population is more successful when the health care team treats the problems the client feels are important. After treating Rudy's reported symptoms, subsequent care would include health maintenance, attention to common problems and concerns, and establishing an emergency contact person if available. Having a contact person on file may help the nurse understand the client's support system and provide an avenue for follow-up. Although preferred diet, incarceration history, and family history of chronic diseases may be helpful, having a contact provides a direct avenue for promoting follow-up.

Katie, anxious about her work, is now afraid of her new boss. She dislikes going to work because she is afraid of being reprimanded, hates feeling inadequate and worthless, and fears demotion. Katie decides to seek help for her problem because she doesn't like taking out her frustrations on her children, so she makes an appointment to speak to the nurse at the mental health clinic. Which conclusion regarding Katie's defense mechanisms does the nurse make? They need restructuring. They must be used at work to deal with this situation. They are used to cope with the stress and to maintain self-esteem and ego integrity. They should not be used at all because Katie must learn to deal with the situation on her own.

They are used to cope with the stress and to maintain self-esteem and ego integrity. RATIONALE: A defense mechanism is used to protect oneself from painful awareness of feelings that can provoke anxiety. Use of defense mechanisms help an individual cope with stressful situations and maintain self-esteem and ego integrity. The nurse would encourage the client to use constructive defenses and discourage the use of nonconstructive defenses. Returning the client to an earlier level of function, not the restructuring of defenses, is the goal of the nurse-client interaction. TEST-TAKING STRATEGY: Use the process of elimination. Eliminate the options that include the closed-ended words "must" and "not." To choose from the remaining options, recall the purpose of defense mechanisms, which will direct you to the correct option. Review the effect of using defense mechanisms if you had difficulty with this question.

Hospice care has been initiated for Louis, and he is being provided with several daytime services. His condition is deteriorating. During the night, Laura notices that Louis' breathing pattern has changed, and she calls the hospice nurse. The nurse comes quickly to assess Louis and notes periods of apnea alternating with periods of deep, rapid breathing. What is the appropriate explanation for the nurse to give to Laura? Louis probably has some sinus congestion. This type of breathing is a sign of pneumonia. This type of breathing is a sign of approaching death. Louis needs to be turned and repositioned more frequently.

This type of breathing is a sign of approaching death. RATIONALE: An abnormal pattern of respiration characterized by alternating periods of apnea and deep, rapid breathing is a physical manifestation of approaching death. Sinus congestion, pneumonia, and the need for more frequent repositioning are not associated with this type of breathing. TEST-TAKING STRATEGY: Use knowledge of the subject, signs of impending death, to help answer this question. Note the relationship between the word "apnea" in the question and "death" in the correct option. Review: the physical manifestations of impending death.

Several family members are sitting at the hospital with a client who is dying of cancer of the bladder. The dying client's roommate is found waiting outside the room after visiting hours have ended. He tells the nurse that he wants to give his roommate's family privacy. Which action should the nurse take? Transferring the roommate to another room Reminding the dying client's family that visiting hours have ended Informing the dying client's family that the client may have just two visitors at a time Telling the roommate that he may return to his room and that the curtain will be drawn around the dying client's bed to provide privacy

Transferring the roommate to another room RATIONALE: When a client is dying, it is important for the client and family members to acknowledge their sadness and say goodbye. The client and family should be given privacy to express their feelings and comfort one another. However, the nurse should also consider the needs of nearby clients, such as the client's roommate. Because the client is dying, it is inappropriate to prohibit family from visiting or to require them to leave once visiting hours have ended. In this situation, it would be best to transfer the roommate to another room. This action will meet the needs of both clients. TEST-TAKING STRATEGY: Note that the subject of the question involves both clients, the dying client and the roommate. And note that the only option that will address the needs of both clients is transferring the roommate to another room. Review: nursing interventions for the dying client.

Testlet Question 5 continues He will be given a mask and a paper bag in which to store the mask while not in use. His discharge instructions include monitoring for a recurrence of symptoms, staying in the hotel room, cleaning "high touch" surfaces, laundry procedures, and hand hygiene. Which method of teaching hand hygiene is most effective for this client? Teach-back Demonstration Showing a video Providing a pamphlet

Veteran's Affairs RATIONALE: Substance use disorder frequently can occur alongside PTSD. In fact, treatment of PTSD or moral injury may help to address substance use disorders. Veterans' Affairs services can assist in managing some of the health problems experienced by these individuals. A homeless shelter is not equipped to treat disorders. Community outreach programs address certain specific needs in its community and provide services to the people who need it. A rehabilitation facility is helpful in returning the person back to a normal healthy condition but the Veteran's Affairs will be able to provide this service in addition to other services. TEST-TAKING STRATEGY: Note the strategic word, best. Recalling that Veterans' Affairs has support services designed to meet the sometimes-complicated comorbidities of this population will guide you to the right answer. Also, note that Veteran's Affairs is also the umbrella option.