Townsend Chapter 16 NCLEX Review

A nursing school graduate failing the NCLEX exam and a 15-year-old high school girl not being selected for the cheer leading squad are examples of which of the following? A. Focal stimuli B. Contextual stimuli C. Residual stimuli D. Spatial stimuli

A. Focal stimuli is the correct answer because not being selected for the cheer leading squad is the immediate concern. Contextual stimuli are present in the environment and contribute to the behavior being caused by the focal stimuli. Residual stimuli are factors that may influence maladaptive behavior in response to focal and contextual stimuli. Spatial stimuli isn't even in the book.

Which of the following outcome criteria would be most appropriate for the client described in question 1? A. Karen is able to express positive aspects about herself and her life situation. B. Karen is able to accept constructive criticism without becoming defensive. C. Karen is able to develop positive interpersonal relationships. D. Karen is able to accept positive feedback from others.

A. Karen is able to express positive aspects about herself and her life situation is the correct answer from the back of the book and the first listed in the criteria. However, it is just one of the outcome criteria for situational low self-esteem. Other outcomes are ability to accept positive feedback from others, able to attempt new experiences, able to accept personal responsibility for own problems, able to accept constructive criticism withoth becoming defensive. uses good eye contact, is able to make independent decisions about life situations, is able to develop positive interpersonal relationships and able to communicate needs and wants to others assertively.

Tommy says to his friend, "I can't even talk to my Daddy until after he has read his newspaper." This is an example of which of the following? A. Rigid boundary B. A boundary violation C. Enmeshed boundary. D. Too flexible boundary

A. Rigid boundary is the correct answer. The father has set rigid boundaries to keep others out of his personal space.

Velma told Betty a secret that Mary told her. This is an example of which of the following? A. Too flexible boundary. B. A boundary violation. C. Rigid boundary. D. Enmeshed boundary

B. A boundary violation is the correct answer because Velma told Betty something that Mary shared with her in confidence. Other examples of boundary violations are invading someone's personal space, opening their mail, reading their diary, unwanted touching, even smoking in non-smoking public areas. Telling someone they "should" believe, feel, decide, choose or think in a certain way is another example of a boundary violation.

Twins Jan and Jean still dress alike even though they are grown and married. This is an example of which of the following? A. Rigid boundary B. Enmeshed boundary C. A boundary violation D. Boundary pliancy

B. Enmeshed boundary is the correct answer because when two people's boundaries are so blended together that neither can be sure where one stops and the other begins. They may be unable to differentiate his or her feelings, wants, and needs from the other person's. This does not only apply to twins. Boundary pliancy refers to a boundary being either rigid, flexible or enmeshed. A boundary violation would be an unwanted intrusion of anothers personal or psychological space.

Karen, age 23 graduated from nursing school with a 3.2/4.0 gpa. She recently took the NCLEX exam and did not pass. Because of this, she had to give up her graduate nursing job until she can pass the exam. She has become very depressed and has sought counseling at the mental health clinic. Karen says to the psychiatric nurse, "I am a complete failure. I'm so dumb, I can't do anything right." What is the most appropriate nursing dx. for Karen? A. Chronic low self-esteem. B. Situational low self-esteem C. Defensive coping D. Risk for situational low self esteem.

B. Situational low self-esteem is correct because it relates to Karen's feeling of failure in a situation of importance. The dx is evidenced by Karen's statement that she is a complete failure, she is dumb and can't do anything right based on this one experience. Karen is not a risk because she has had the failure and her dx is not chronic because it is not the result of repeated failures. Defensive coping is not applicable because Karen is asking for help.

A mother berates her child for breaking a cup and says, "Your are BAD and SO DESTRUCTIVE." This statement discourages the development of positive self-esteem by not meeting which parenting focus as described by Warren? A. A sense of competence B. Unconditional love C. A sense of survival D. Realistic goals

B. Unconditional love. According to warren, Parents promote self-esteem when they provide unconditional love for their children. CHILDREN NEED TO KNOW THAT THEY ARE LOVED AND ACCEPTED REGARDLESS OF SUCCESSES OR FAILURES. Criticism of behavior should not be linked with criticism of the child. In the situation presented the mother discourages the development of positive self-esteem by not meeting the child's need for unconditional love.

The psychiatric nurse encourages Nancy (the client in question 3) to express her anger. Why is this an appropriate nursing intervention? A. Anger is the basis for self-esteem problems. B. The nurse suspects that Nancy was abused as a child. C. The nurse is attempting to guide Nancy through the grief process. D. The nurse recognizes that Nancy has long-standing repressed anger.

C. The nurse is attempting to guide Nancy through the grief process is part of the evaluation process when reassessing to determine if the client has been successful.

The husband says to the wife, "What do you want to do tonight?" and the wife responds, "Whatever you want to do." This is an example of which of the following? A. Rigid boundary. B. A boundary violation C. Too flexible boundary. D. Showing respect for the boundary of another.

C. Too flexible boundary is the correct answer because the wife is too flexible, she is allowing her husband to make her choices and direct her behavior. People with rigid boundaries often have a hard time trusting others, keep others at a distance and are difficult to communicate with. They are often withdrawn emotionally and physically. Telling his wife what they would do without asking would be a boundary violation.

Nancy tried out for the cheer leading squad in junior high, but was rejected. At age 15, she had looked forward to trying out for the cheer leading squad in high school. She took cheer leading classes and practiced for many hours every day. However, when tryouts were held, she was not selected. She has become despondent, and her mother takes her to the mental health clinic for counseling. She tells the nurse, "What's the use of trying? I'm not good at anything!" Which of the following nursing interventions is best for Nancy's specific problem? A. Encourage Nancy to talk about her feeling of shame over the second failure. B. Assist Nancy to problem-solve her reasons for not making the team. C. Help Nancy understand the importance of good self-care and personal hygiene in the maintenance of self-esteem. D. Explore with Nancy her past successes and accomplishments.

D. Explore with Nancy her past successes and accomplishments.

Karen's counselor asked her if she would like a hug. This is an example of which of the following? A. Rigid boundary B. A boundary violation C. Enmeshed boundary D. Showing respect for the boundary of another

D. Showing respect for the boundary of another is the correct answer because the counselor respected Karen's personal and psychological space by asking if she would like a hug, not just hugging her.