Foundations and Modes of Care

A client experiencing a tremendously stressful situation says, "My baby was diagnosed with terminal cancer 2 months ago. I'm either crying or walking around like I'm in a dream. I can't believe this is happening. What did we do to deserve something so horrible? The doctors can transplant almost every human organ, but they can't stop my baby from dying. I'm so angry. Most days I just want to take my child and run away." The nurse determines that the client is mainly expressing what? Anger Denial Avoidance Anticipatory grief

Anticipatory grief Anticipatory grief is an intellectual and emotional response to a potential loss. Signs include a sense of disbelief and numbness. Emotions swing from sadness to anger. Individuals express the desire to avoid the situation by running away and an intense feeling of anger toward the medical community for failing to save their loved one. Anger, denial, and avoidance are each a single part of the client's reaction.

Alprazolam is prescribed for a client with the diagnosis of panic disorder. The client refuses to take the medication because of fears of addiction. What should the nurse do initially? Provide the client information about alprazolam. Assess the client's feelings about alprazolam further. Ask the practitioner about changing the client's medication. Have the practitioner speak with the client about the safety of this medication.

Assess the client's feelings about alprazolam further. Before deciding how to ease the client's fears of addiction, the nurse must explore the full extent of the client's knowledge and feelings about taking this medication. Information may or may not be helpful; the client's feelings are what must be addressed. Although the nurse may eventually ask the practitioner to consider changing the medication or to speak with the client about its safety, neither is the priority at this time.

A nurse understands that value clarification is a technique useful in therapeutic communication because initially it helps clients do what? Become aware of their personal values Gain information related to their needs Make correct decisions related to their health Alter their value systems to make them more socially acceptable

Become aware of their personal values Value clarification is a technique that reveals individuals' values so the individuals become more aware of them and their effect on others. Gaining information, making correct health decisions, and altering value systems to make them more socially acceptable are not outcomes of value clarification.

How should a nurse at an assisted living facility encourage a client to effectively complete the tasks of older adulthood? By redefining the resident's role in society By investing the resident's energies into nurturing others By trying to complete missed opportunities with significant others By fostering a sense of contentment when the client looks back on past achievements

By fostering a sense of contentment when the client looks back on past achievements Accepting one's past as meaningful and fulfilling is a sign of achieving the task of ego integrity. Redefining one's life indicates that ego integrity has not occurred. Investing the energies into nurturing others is a task of middle adulthood. An attempt to recapture lost opportunities is evidence of despair; it indicates that ego integrity has not been achieved.

When a person who wishes to be athletic is uncoordinated but also successful in a musical career, what defense mechanism might this be related to? Sublimation Transference Compensation Rationalization

Compensation Compensation is replacing a weak area or trait with a more desirable one. Sublimation is rechanneling unacceptable desires and drives into those that are socially acceptable. Transference is the unconscious tendency to assign to others in the current environment feelings and attitudes associated with another person. Rationalization is the use of justification to make tolerable certain feelings, behaviors, and motives.

A client reports drinking two drinks per day every day with no negative consequences. How should this person be classified? Daily drinker Substance abuser Functional alcoholic Substance dependent

Daily drinker If a client drinks two drinks per day every day with no negative consequences, the client is considered a daily drinker. If a client drinks over two drinks per day every day, the client has a potential for future problems. This person does not meet the criteria for any substance abuse or dependence diagnosis because there is no evidence of tolerance or other signs of substance dependence and no negative sequelae. There is no functional alcoholic diagnosis in the Diagnostic and Statistical Manual of Mental Disorders.

According to Erikson, a young adult must accomplish the tasks associated with which stage? Trust versus mistrust Intimacy versus isolation Industry versus inferiority Generativity versus stagnation

Intimacy versus isolation Major tasks of young adulthood are centered on human closeness and sexual fulfillment; lack of love results in isolation. The trust-versus-mistrust stage is associated with infancy. The industry-versus-inferiority stage is associated with middle childhood. The generativity-versus-stagnation stage is associated with middle adulthood.

A client is admitted to the mental health unit of the hospital because of agitation and unprovoked hostile verbal attacks toward others in the workplace. What is the priority nursing intervention for this client? Developing trust Maintaining safety Refocusing hostile energy Preventing hostile outbursts

Maintaining safety The client is potentially harmful to others, as evidenced by previous episodes of hostile behavior. Developing trust is impossible until the client's anger and agitation begin to subside. Although refocusing hostile energy is important, it is not the priority. Preventing hostile outbursts may not always be possible.

With the client's permission, the nurse should inform the family about what is happening. The main reason for this action is that informed families provide what benefit? They ease the client's anxiety. They are better equipped to assist the client. They appear more relaxed with the situation. They commonly cause fewer nursing problems.

They are better equipped to assist the client. Families who are informed about the client's status can help with treatment goals and discharge planning. Relief of anxiety, relaxation, and fewer nursing problems may all be secondary gains, but none is the primary purpose.

During a group therapy session some members accuse another client of intellectualizing to avoid discussing feelings. The client asks whether the nurse agrees with the others. What is the best response by the nurse? "It seems that way to me, too." "What's your perception of my behavior?" "Are you uncomfortable with what you were told?" "I'd rather not give my personal opinion at this time."

"Are you uncomfortable with what you were told?" Asking the confronted client whether he or she is uncomfortable with what he or she is being told will help the client identify behaviors and feelings in a nonthreatening manner. Agreeing with the confronting group members indicates a lack of acceptance of the client. The nurse's behavior is not the issue; the situation should be turned back to the client's behavior. Evasion and refusal to answer will have the psychological effect of removing the nurse from the group.

What developmental task should the nurse consider when caring for toddlers? Trust Industry Autonomy Identification

Autonomy Testing the self both physically and psychologically occurs during the toddler stage, after trust has been achieved. Trust is the task of infancy. The task of industry is accomplished between the ages of 6 and 12 years. Identification is not a developmental task. However, between the ages of 3 and 6 years a child starts to identify with the parent of the same sex.

A nurse is performing a mental status assessment. What is being assessed when the nurse notes that the client is cooperative? Mood Affect Attitude Perception

Attitude Attitude relates to the approach or manner of the client during the interaction with the interviewer (e.g., cooperative, resistive, friendly, ingratiating). Mood is a feeling state reported by the client (e.g., sad, depressed, angry, anxious, happy). Affect is a person's mood, feelings, or tone, observable as an outward manifestation; it may be referred to as inappropriate, flat, or blunted. Perception is how a person views and interprets a situation; a perception may or may not be based in reality.

A nurse is conducting a therapy group whose objectives are to assist the members to gain insight and to change behavior so they are able to participate in life in a more satisfying manner. What leadership style will best help the nurse achieve these objectives? Democratic, guiding Hierarchal, directing Autocratic, controlling Laissez-faire, observing

Democratic, guiding A democratic, guiding type of leader stimulates, directs, and assists the group to develop its maximum potential by facilitating and balancing group forces. A hierarchal, directing type of leader makes most of the decisions and controls the group, thus limiting group growth potential. An autocratic, controlling type of leader makes most of the decisions and controls the group, thus limiting group growth potential. A laissez-faire, observing type of leader allows group members to take over the group; if the group has no leader or leaders, little is gained from the group.

One afternoon the nurse on the unit overhears a young female client having an argument with her boyfriend. A while later the client complains to the nurse that dinner is always late and the meals are terrible. The nurse identifies the defense mechanism that the client is using as what? Projection Dissociation Displacement Intellectualization

Displacement Displacement reduces anxiety by transferring the emotions associated with an object or person to another emotionally safer object or person. Projection is the attempt to deal with unacceptable feelings by attributing them to another. Dissociation is an attempt to detach emotional involvement or the self from an interaction or the environment. Intellectualization is the use of facts or other logical reasoning rather than feelings to deal with the emotional effect of a problem.

A nurse understands that autism is a form of a pervasive developmental disorder (PDD). Which factor unique to autism differentiates it from other forms of PDD? Less severe linguistic handicaps Early onset, before 36 months of age The only form that does not include seizures The only form that does not include cognitive impairment

Early onset, before 36 months of age Autism impairs bonding and communication and therefore becomes apparent early in life. Autism involves both delayed and deviant linguistic problems. About 25% of children with autism have a seizure disorder. Autism may, and often does, include cognitive impairment.

A college student visits the health center and describes anxiety about having to declare an academic major. What developmental conflict, according to Erikson, is this client still attempting to resolve? Initiative versus guilt Integrity versus despair Industry versus inferiority Identity versus role confusion

Identity versus role confusion The client is demonstrating a search for self and has not resolved the developmental conflict of adolescence, identity versus role confusion. Initiative versus guilt is the developmental conflict of early childhood. Integrity versus despair is the developmental conflict of old age. Industry versus inferiority is the developmental conflict of middle childhood.

The nurse is scheduled to be the co-leader of a therapy group being formed in the mental health clinic. When planning for the first meeting, it is of primary importance that the nurse consider what? Number of clients in the group Needs of the clients being included Diagnoses of the clients being included Socioeconomic status of the clients in the group

Needs of the clients being included When planning a group, the nurse must ensure that clients have similar needs to promote relationships and interactions; diverse needs do not foster group process. Although important, the number of clients is not a primary consideration. Behavior and needs, rather than diagnoses, are of primary importance. The socioeconomic status of the clients in the group has little effect on group process.

The nurse should first discuss terminating the nurse-client relationship with a client during which phase? Working phase, when the client initiates it Orientation phase, when a contract is established Working phase, when the client shows some progress Termination phase, when discharge plans are being made

Orientation phase, when a contract is established When the nurse and client agree to work together, a contract should be established and the length of the relationship should be discussed in terms of its ultimate termination. The client may discuss termination during the working phase; however, the subject should initially be discussed during the orientation phase. Termination and discharge plans may be discussed more thoroughly during this phase, but the subject should initially be discussed during the orientation phase.

What is the basic therapeutic tool used by the nurse to foster a client's psychologic coping? Self Milieu Helping process Client's intellect

Self The self is often the most important tool available to the nurse to help a client cope; to be therapeutic, the nurse must be present, actively listening, and attentive. The environment is important, but it is not the most basic tool. The nurse first must use the self before the helping process can begin. The client's intellect is not generally a therapeutic tool used by the nurse.

What is most important for a nurse to do when initially helping clients resolve a crisis situation? Encourage socialization. Meet dependency needs. Support coping behaviors. Involve them in a therapy group.

Support coping behaviors. In a crisis situation, the individual frequently just needs support to regroup and re-establish the ability to cope. Socialization is part of recovery; this is not done during the initial stage of a crisis. Meeting dependency needs is not possible or realistic. Involving clients in a therapy group may have the effect of increasing anxiety, thereby making the crisis situation worse.

A client with a diagnosis of major depression tells a nurse, "No matter what I do, everything turns out bad." The nurse recognizes this as an example of what? Using a cognitive distortion Seeking sympathy from the nurse Regressing to an earlier developmental level Avoiding responsibility for previous behavior

Using a cognitive distortion The client is using the cognitive distortions of overgeneralization and pessimism. Negative events are magnified and become the focus, whereas contrary positive experiences are minimized and ignored. With the focus on the negative events, the depressive mood is reinforced. There are no data to support the conclusion that the client is seeking sympathy, regressing, or avoiding responsibility.

A male nurse is caring for a client. The client states, "You know, I've never had a male nurse before." What is the best reply by the nurse? "Does it bother you to have a male nurse?" "How do you feel about having a male nurse?" "There aren't many male nurses; we're a minority." "You sound upset. I'll get a female nurse to care for you."

"How do you feel about having a male nurse?" Inquiring neutrally about the client's feelings about having a male nurse encourages the client to express and explore feelings in an open, nonjudgmental way. Asking the client whether having a male nurse is disturbing puts the client on the defensive. Stating that there aren't many male nurses does not encourage further conversation, and the client will not have the opportunity to express feelings; this response is focused on the nurse rather than on the client. Immediately volunteering to get a female nurse puts the client on the defensive rather than encouraging verbalization of feelings.

A client tells the nurse in the mental health clinic that the practitioner said that the cornerstone of therapy used in the clinic is cognitive therapy. The client asks what this therapy entails. What concept should the nurse explain as the basis of cognitive therapy? "Unconscious feelings influence actions." "Negative thoughts can precipitate anxiety." "People can act their way into a new way of thinking." "Maladaptive behaviors will continue as long as they are reinforced."

"Negative thoughts can precipitate anxiety." Cognitive behavioral therapy (CBT) is a highly structured psychotherapeutic method used to alter distorted beliefs and problem behaviors by identifying and replacing negative inaccurate thoughts and changing the rewards for behaviors. Cognitive therapy seeks to discover underlying thoughts that lead to feelings of depression and anxiety; also, it teaches the client to replace these thoughts with more positive, realistic thinking. The response, "Unconscious feelings influence actions," reflects a psychoanalytical approach to treatment. The response, "People can act their way into a new way of thinking," reflects a behavioral approach to treatment. The response, "Maladaptive behaviors will continue as long as they are reinforced," reflects a behavioral approach to treatment.

A nurse determines that confrontation is an appropriate tool for use with a client. What is an example of therapeutic confrontation? "I find that hard to believe." "I noticed that you're not wearing any makeup today." "You feel frustrated because you think your mother doesn't understand you." "You say you're not a good parent, but you were effective when you were talking with your son today."

"You say you're not a good parent, but you were effective when you were talking with your son today." "You say you're not a good parent, but you were effective when you were talking with your son today" is an example of positive confrontation; it points out the discrepancy between the client's statement and the observed behavior. "I find that hard to believe" is an example of voicing doubt. "I noticed that you're not wearing any makeup today" is an example of an observation. "You feel frustrated because you think your mother doesn't understand you" is an example of an empathetic statement.

At what age is a client in Freud's phallic stage of psychosexual development and Erikson's psychosocial phase of initiative versus guilt? Adolescence 6 to 12 years 3 to 5 years Birth to 1 year

3 to 5 years Three to five years is Freud's phallic stage and Erikson's stage of initiative versus guilt. Adolescence is Freud's genital stage and Erikson's stage of identity versus role confusion. Six to twelve years is Freud's latency stage and Erikson's stage of industry versus inferiority. Birth to 1 year is Freud's oral stage and Erikson's stage of trust versus mistrust.

A terminally ill client is moving gradually toward resolution of feelings about impending death. In a plan of care based on Elisabeth Kübler-Ross' research, the nurse should use nonverbal interventions after having assessed that the client is in which stage? Anger stage Denial stage Bargaining stage Acceptance stage

Acceptance stage When acceptance is reached, the individual is beginning to withdraw from life; communication is simple, concise, and most often nonverbal. Kübler-Ross' research has shown that at this stage, verbal communication is typically less important and touch and presence are most important. The client has moved past the anger, denial, and bargaining stages.

A female nurse has been caring for a depressed 75-year-old woman who reminds her of her grandmother. The nurse spends extra time with her every day and brings her home-baked cookies. What does the nurse's behavior reflect? Affiliation Displacement Compensation Countertransference

Countertransference With countertransference the professional provider of care exhibits an emotional reaction to a client based on a previous relationship or on unconscious needs or conflicts. Affiliation is turning to others for support and help when stressed or conflicted. Displacement is the discharge of pent-up feelings onto something or someone else that is less threatening than the original source of the feelings. Compensation is attempting to balance deficiencies in one area by excelling in another area.

A client in a psychiatric hospital requests an unaccompanied pass, but it is denied, and the client vocalizes anger toward the staff. The nurse concludes that this anger results from feelings of what? Hopelessness Indecisiveness Powerlessness Worthlessness

Powerlessness Anger is a common feeling when people do not have control over decisions that affect them. There is no information to indicate that the client is feeling hopeless, indecisive, or worthless.

A client in the mental health clinic who has concerns about getting married says to the nurse, "I guess I'd better get married. All the plans are made and paid for, and the invitations have all been mailed." What defense mechanism is the client using? Introjection Identification Compensation Rationalization

Rationalization In rationalization, seemingly logical reasons are used to justify behaviors or feelings that are unacceptable or painful. This is not introjection because the client has not assumed the feelings of another. This is not identification because the client has not attempted to emulate another person. This is not compensation because the client is not counterbalancing deficiencies in one area by excelling in another area.

A nurse is counseling a recently widowed client, who says, "His death has complicated my life even more than the hassles he caused when he was alive!" The nurse realizes the client is having difficulty with the grieving process and concludes that the relationship with the husband was probably what? Loving Long-term Ambivalent Subservient

Ambivalent If the relationship was ambivalent, the surviving spouse now has feelings of both anger and guilt to resolve. A loving relationship evokes fewer feelings of guilt and is followed by a less complicated grieving process. The length of the relationship seems to have little to do with the ease or difficulty in completing the grieving process. Individuals in the subservient role usually have learned to accept directions and either find a new director or are relieved to have a chance to express their own feelings.

A nurse is planning care for a group of hospitalized children. Which age group does the nurse anticipate will have the most problem with separation anxiety? 5 to 11 years 12 to 18 years 6 to 30 months 36 to 59 months

6 to 30 months Infants and toddlers ages 6 to 30 months experience separation anxiety; it is this age group's major life stressor and is most traumatic to the child and parent. Adolescents when hospitalized are often ambivalent about whether they want their parents with them. Peer group separation may pose more anxiety for the adolescent. The school-aged child is more accustomed to periods of separation from parents. Separation anxiety occurs in preschool and young school-aged children, but it is less obvious and less serious than it is in the toddler.

A nurse is with the parents of a 3-year-old child who has just died. What is the most therapeutic question for the nurse to ask the parents? "Do you feel ready to consent to an autopsy?" "Have you made a decision about organ donation?" "Would you like to talk about how you'll tell your other children?" "Can I be of any help with traditional practices that are important to you?"

"Can I be of any help with traditional practices that are important to you?" The nurse should be sensitive to any cultural or religious beliefs that may help the parents cope with their grief. Immediately discussing the topic of autopsy or organ donation is insensitive to the parents' grief at this time. The parents are too involved with their own grief at this time to consider their other children's grief.

An extremely anxious client enters a crisis center and asks a nurse for help. Which initial response best reflects the nurse's role in crisis intervention? "Tell me what you've done to help yourself." "I'll be here for you to help you figure things out." "I understand that in the past you've had problems." "Tell me about the things that are bothering you the most."

"I'll be here for you to help you figure things out." Clients in crisis need assistance with coping; the nurse must be involved with problem solving. Clients in crisis initially need to trust the nurse. Telling the client that they are there to help develops trust. Asking what the client has done to help himself, stating the patient has had problems in the past, and asking the patient to discuss what is most bothering them all do not focus on the nurse's involvement with problem solving.

Which of the following interventions will assist in creating and maintaining a therapeutic environment on an acute care mental health unit? Select all that apply. Reorienting clients to the rules of the unit whenever necessary Providing a posted schedule of unit activities Monitoring each client for the potential of aggressive behavior Assuring the clients that they will have unlimited access to the telephone Encouraging the clients to take an active role in planning the unit's activities

1, 2, 3, 5 Safety, structure, balance, and limit setting are elements that the nurse addresses when providing a therapeutic milieu. Privileges, such as telephone access, cannot be assured, because they are earned and often are factors that are affected by the client's needs and behaviors.

A depressed client whose spouse recently died attends an inpatient group therapy session in which the nurse is a co-leader. When another client talks about being divorced and the resulting feelings of abandonment, the nurse notices that tears are running down the depressed client's face. What should the nurse do to support this client? Ask group members to return to discuss this client's feelings. Have another client stay and spend time talking with the client. Observe the client's behavior carefully during the next several hours. Accompany the client to his or her room and encourage a discussion of his or her feelings.

Accompany the client to his or her room and encourage a discussion of his or her feelings. Helping a client cope with unresolved grief involves assisting the client in expressing thoughts and feelings about the lost object or person as a necessary part of grief work. Asking group members to return to discuss this client's feelings is too threatening; at this point the client needs therapeutic one-on-one interaction. Having another client stay and spend time talking with the client is the responsibility of the nurse; another client does not have the expertise to help this client. The current nonverbal behavior indicates that the client is dealing with feelings; an opportunity should be provided for a verbal exploration rather than merely observing the client.

A mother and her three young children arrive at the mental health clinic. The woman says that she is seeking help in leaving her husband. She reports that he has been beating her for years but just started hitting the children. What is the best initial action by the nurse? Arranging for a staff member to watch the children so the mother and nurse can talk Calling a facility where the mother and her children will be safe until the crisis is resolved Determining whether the mother is ambivalent about this decision before making permanent plans Suggesting that the mother and her husband return for couples counseling so the marriage can be saved

Arranging for a staff member to watch the children so the mother and nurse can talk This emotionally charged topic should be discussed with the client in a confidential session; after the nurse has assessed the situation, the woman and the nurse can plan the family's future. Although a safe facility may be called, a determination of the client's ambivalence may be made, and couples counseling may be recommended eventually, all three actions are premature if a thorough assessment of the situation has not been made.

A nurse is speaking with a client who was sexually abused as a child. The client does not know what constitutes inappropriate touch by another person. What issue will have to be addressed with this client? Increased libido Phobic behavior Boundary violations Excessive aggression

Boundary violations Clients who have experienced childhood sexual abuse will have difficulty being aware of their personal boundaries and maintaining appropriate boundaries for themselves and others. Clients who have experienced childhood sexual abuse tend to have decreased, not increased, libidos. Phobic behavior, the irrational fear of an object or situation, is not necessarily a concern that the nurse should have for this client more than for other clients. Clients who have experienced childhood sexual abuse can exhibit aggressive behavior, but it does not directly address the identification of inappropriate touching.

When planning care for an older client, the nurse remembers that aging has little effect on what process? <p>When planning care for an older client, the nurse remembers that aging has little effect on what process?</p> Sense of taste or smell Muscle or motor strength Capacity to handle life's stresses Ability to remember recent events

Capacity to handle life's stresses An individual's ability to handle stress develops through experience with life; aging does not reduce this ability but often strengthens it. The senses of taste and smell; muscle or motor strength; and short-term memory are often diminished in older adults, whereas long-term memory remains strong.

A 68-year-old client who has metastatic carcinoma is told by the practitioner that death will occur within a month or two. Later the nurse enters the client's room and finds the client crying. Before responding, which factor should the nurse consider? Crying relieves depression and helps the client face reality. Crying releases tension and frees psychic energy for coping. Nurses should not interfere with a client's behavior and defenses. Accepting a client's tears maintains and strengthens the nurse-client bond.

Crying releases tension and frees psychic energy for coping. Crying is an expression of an emotion that, if not expressed, increases anxiety and tension; the increased anxiety and tension use additional psychic energy and hinder coping. Crying does not relieve depression, nor does it help a client face reality. It is not universally true that nurses should not interfere with a client's behavior and defenses. In most instances the client's defenses should not be taken away until they can be replaced by more healthy defenses. The nurse must interfere with behavior and defenses that may place the client in danger, but the client's current behavior poses no threat to the client. It is not always true that accepting a client's crying maintains and strengthens the nurse-client bond. Many clients are embarrassed by what they consider a "show of weakness" and have difficulty relating to the individual who witnessed it. The nurse must do more than just accept the crying to strengthen the nurse-client relationship.

A hospice nurse is caring for a dying client and the client's family members during the developing awareness stage of grief. What is the most important thing about the family that the nurse should assess before providing care? Cohesiveness Educational level Cultural background Socioeconomic status

Cultural background During the developing awareness stage of grief the degree of anguish experienced or expressed is influenced by the cultural background of the individual and family. Although cohesiveness does enter into the grief process, it is not as important in the developing awareness stage as cultural background is. Educational level has no relationship to the grieving process. Socioeconomic status is not a defining factor in how a family will respond to the loss of a loved one.

A client has had repeated hospitalizations for aggressive, violent behavior. While on the mental health service, the client becomes very angry, starts screaming at the nurse, and pounds the table. What is the priority nursing assessment at this time? Range of expressed anger Extent of orientation to reality Degree of control over the behavior Determination of whether the anger is justified

Degree of control over the behavior Degree of control over the behavior is the most important assessment because it will influence the nurse's intervention. Depending on the extent of the client's control, the nurse may or may not need assistance. It is not the degree of anger but instead the behavior it precipitates that is important to assess. The extent of orientation to reality may or may not influence the ability to control behavior. Anger is always justifiable to the person; the determination of whether the anger is justified will not help the nurse address the client's behavior.

A female client who is severely incapacitated by obsessive-compulsive behavior has been admitted to the mental health hospital. The client's compulsive ritual involves changing her clothing eight to 12 times a day. She continually asks the nurse for advice regarding her problems but then ignores it. What conflict is this an example of? Apathy versus anger Trust versus mistrust Intimacy versus isolation Dependence versus independence

Dependence versus independence A conflict exists between wanting to be taken care of and wanting to be self-reliant; ambivalence fosters lowered self-esteem. Apathy versus anger does not relate to the behavior described; people usually do not alternate these emotions, which are at opposite ends of the spectrum. Trust versus mistrust is the developmental conflict of the infant, according to Erikson; it is not related to the behavior described. Intimacy versus isolation is the developmental conflict of the young adult, according to Erikson; it is not related to the behavior described.

A nurse concludes that a 6-year-old child who has attained an acceptable level of psychosocial development has achieved Erikson's developmental conflicts related to trust, autonomy, and what other need? Identity Industry Intimacy Initiative

Initiative A 6-year-old child should have resolved the previous developmental conflicts of trust versus mistrust (infancy) and autonomy versus shame and doubt (toddlerhood). During the preschool years children learn to assume responsibility for themselves and their possessions and develop more socially acceptable behavior (initiative versus guilt). Resolution of identity versus role confusion occurs at adolescence. Resolution of industry versus inferiority does not occur until the end of the school-age years. Resolution of intimacy versus isolation occurs at adulthood.

The nurse explains to the mother of a preschool child that Erikson identified which developmental conflict for children from 3 to 5 years? Initiative versus guilt Industry versus inferiority Breaking away versus staying at home Sexual impulses versus psychosexual development

Initiative versus guilt Initiative versus guilt is the developmental conflict that faces the preschool child; the child will feel guilty if initiative is stifled by others. Industry versus inferiority is the conflict of the school-aged child. Neither breaking away versus staying at home nor sexual impulses versus psychosexual development is a developmental conflict identified by Erikson.

During a nursing assessment, a nurse notes that a client has begun to create new words. What term does the nurse use to document this finding? Neologism Perseveration Pressured speech Tangential speech

Neologism Neologism is the invention of new words with meanings understood only by the client. Perseveration is repetitive verbalizations or motions. Pressured speech is rapid speech with an urgent quality. Tangential speech is a tendency to digress from the original subject.

The nurse understands that a primary gain is distinguished from a secondary gain. What is the main function of a primary gain? Reduce anxiety Gain benefits from others Fulfill unconscious desires Control unacceptable impulses

Reduce anxiety A primary gain is always the reduction of anxiety. Gaining benefits from others is related to a secondary gain. Fulfillment of unconscious desires is unrelated to primary gains. Control of unacceptable impulses is unrelated to primary gains.

Unsatisfied needs create anxiety that motivates an individual to action. What should the nurse identify as the purpose for this action? Reducing tension Denying the situation Minimizing physical discomfort Problem-solving and focusing on the problem

Reducing tension The primary purpose for action when a client is anxious is the reduction of emotional tension and prevention of escalation of the anxiety. When tension is reduced, anxiety is diminished, and the person feels more comfortable, safe, and secure. When acting to reduce anxiety, the person is extremely aware of the presence of anxiety and is not attempting to deny its existence. When anxiety becomes severe, the client is unable to focus on or solve the problem. Emotional tension, not physical discomfort, needs to be reduced. Minimizing the escalation of anxiety has an effect on psychological, rather than physical, discomfort.

An adolescent client seeks help at a crisis intervention clinic. The client says, "I dropped out of college because the instructors were dumb. I tried waiting on tables but got fired. The boss said I was nasty to the customers. They were the nasty ones. If people were nicer, I wouldn't be in this mess." With the application of crisis theory, this client's stressful events can be seen as what? Experiential Age-related and frequent Usually non-crisis producing Situational and maturational

Situational and maturational The data presented indicate developmentally related struggles and specific situations that are extremely stressful, resulting in the adolescent's use of projection as a defense. Multiple stresses can produce a crisis situation for the individual when past coping mechanisms are ineffective. It is not the experience but the individual's response to the experience that determines a crisis. A crisis is not an age-related problem; a crisis results when the individual's past coping mechanisms are no longer effective for managing a present stressful situation. The individual's inability to cope indicates a crisis.

While assessing an older adult in the emergency department the nurse notes that the client is upset. The nurse asks what is wrong, and the client describes the current situation and then offers information that goes further and further off the topic. What pattern of communication does this conversation reflect? Perseveration Thought blocking Overcompensation Tangential thinking

Tangential thinking In tangential thinking the person never answers the question or returns to the central point of the conversation. It often is seen in people with dementia. Perseveration is the repetitive expression of a single idea in response to different questions; it is found most often in clients with cognitive impairments and those experiencing catatonia. Thought blocking is a sudden stoppage of the spontaneous flow of speaking for no apparent external reason; it is seen most often in clients who are experiencing auditory hallucinations. Overcompensation, also known as reaction formation, is a defense mechanism, not a pattern of communication.

A nurse is working with a child who was physically abused by a parent. What is the most important goal for this family? The child will live in a safe environment. The parents will use verbal discipline effectively. The family will feel comfortable in its relationship with the counselor. The parents will gain an understanding of their abusive behavior patterns.

The child will live in a safe environment. The most important goal and top priority is to ensure the safety of the child. Once this is ensured, other goals can be identified and fulfilled, including the parents using verbal discipline effectively, the family feeling comfortable in its relationship with the counselor, and the parents gaining an understanding of their abusive behavior patterns.

A disturbed client who has been out of touch with reality has been hospitalized for several weeks. One day the nurse notes that the client's hair is dirty and asks whether the client wants to wash it. The client answers, "Yes, and I'd like to shower and change my clothes, too." What can the nurse conclude about the client in relation to this response? The client has some feelings of self-worth. The client is open to suggestions from others. The client may be entering a hyperactive phase. The client has a need for social reassurance from others.

The client has some feelings of self-worth. When individuals express interest in physical appearance, it demonstrates a rebuilding of the self-image and the return of feelings of worth and concern for how others see them. The client's response goes further than the nurse's suggestion to wash the hair. The client has identified the need to shower and change clothes. The client's response is well within the expected range; it does not indicate the beginning of a hyperactive phase. The information provided does not demonstrate a need for social reassurance or approval.

What is a goal for a client who has difficulty with verbal communication precipitated by psychologic barriers? The client will be free of injury. The client will demonstrate decreased acting-out behavior. The client will identify consequences of acting-out behavior. The client will interact with other people in the environment.

The client will interact with other people in the environment. Interacting with other people in the environment is appropriate and measurable. Being free of injury is not related to the client's problem; the priority for this client is to facilitate interaction with others. Acting-out behavior is not inherent in the situation.

A group of clients from a psychiatric unit are going to a professional baseball game accompanied by staff members. What is the purpose of visits into the community under the supervision of staff members? They help clients adjust to stressors in the community. They help clients return to reality under controlled conditions. They broaden the clients' experiences by providing exposure to cultural activities. The staff members can observe the clients' abilities to cope with a more complex society.

The staff members can observe the clients' abilities to cope with a more complex society. The staff members' observations can help identify those clients who are ready to cope with outside stress and those who are not. Attendance at a ball game will not help clients adjust to community stressors or return to reality under controlled conditions. There is nothing to indicate that any of these clients needed to broaden their cultural experiences.

In the care of a withdrawn, reclusive psychotic client, the priority goal is for the client to develop what? Trust Self-worth A sense of identity An ability to socialize

Trust Trust is basic to all therapies; without trust a therapeutic relationship cannot be established. The development of self-worth is a long-term goal; developing trust is the priority. There is nothing to indicate that the client does not have a sense of identity. Although helping the client relate to others is a part of the treatment, it is not a priority goal at this time.

A nurse is preparing a teaching plan for a client who is to undergo electroconvulsive therapy. What instructions should the nurse include? Void just before the procedure. Wear cotton clothing during the procedure. Sleep for several hours after the procedure. Eat a light breakfast 1 hour before the procedure.

Void just before the procedure. During the expected seizure the client may become incontinent. The client will awaken 20 to 30 minutes after the procedure. Although the client will be groggy and confused, there is no requirement that the client sleep for several hours. The client should be supervised until oriented and capable of self-care. There are no restrictions concerning the type of fabrics that should be worn; however, the clothing should be comfortable and metal hair accessories should not be worn. Food or fluid should not be consumed for at least 4 hours before therapy as a means of preventing vomiting and aspiration.

The parents of an adolescent who engages in self-injurious cutting behavior ask the nurse why their child self-mutilates. What should the nurse give as the reason for the cutting? Cry for help Suicide attempt Attention-seeking behavior Way to manage overwhelming feelings

Way to manage overwhelming feelings Self-injurious behavior is used to soothe or override painful feelings. Recent studies do not link cutting to suicidal thinking. Cutting behavior is often hidden from others; it is not attention-seeking behavior.

A nurse working in a crisis center understands that a crisis can best be defined as what? A threat to equilibrium An imbalance of emotions The perception of the problem by the client The circumstance that requires help other than personal resources

A threat to equilibrium Caplan's theory states that a crisis is an internal disturbance caused by a stressful event that alters the usual way of coping with a threat to the self; this temporarily disturbs the equilibrium of the person involved. An imbalance of emotions is not the definition of a crisis. The perception of the problem by the client is not the definition of a crisis; it is the assessment that the nurse must make in the first phase of crisis intervention. The circumstance that requires help other than personal resources is not the definition of a crisis, but instead is how a crisis is resolved.

A nurse is assessing a client for the use of defense mechanisms. In the presence of which defense mechanism does the client express emotional conflicts through motor, sensory, or somatic disabilities? Projection Conversion Dissociation Compensation

Conversion The defense mechanism is called conversion because the individual reduces emotional anxiety to a physical disability. Projection occurs when people assign their own unacceptable thoughts and feelings to others. With dissociation there is separation of certain mental processes from consciousness as though they belonged to another; a dissociative reaction is expressed as amnesia, fugue, multiple personality, aimless running, depersonalization, sleepwalking, and other behaviors. Compensation is a mechanism used to make up for a lack in one area by emphasizing capabilities in another.

A nurse is preparing to teach a mental health course at a community health center. What information should the nurse include as one of the most effective ways to limit the occurrence of mental illness in the community? Developing multiple coping strategies Reporting strange behaviors by others Correcting myths about mentally ill people Addressing genetic issues related to mental illness

Developing multiple coping strategies A variety of strategies gives people options when they are attempting to cope with stress. Different strategies work better in different situations. Reporting strange behaviors by others is too vague; the definition of "strange" may vary, depending on the individual. Although correcting myths about mentally ill people is useful, it will not limit the occurrence of mental illness. Although some mental disorders may have familial tendencies and may have a genetic link, this information is too limited.

A nurse is interviewing an 8-year-old girl who has been admitted to the pediatric unit. Which statement by the child needs to be explored? "Wow! This place has bright colors." "Is my mother allowed to visit me tonight?" "Those boys are so cute. I hope their room is next to mine!" "I'm scared about being here. Can you stay with me awhile?"

"Those boys are so cute. I hope their room is next to mine!" An 8-year-old child should be more concerned with same-gender relationships. A child who demonstrates a strong attraction to opposite-gender relations should be questioned further to explore the possibility of sexual abuse. A statement such as "Wow! This place has bright colors" is not unusual because 8-year-old children are usually attracted to colorful environments. A statement such as "Is my mother allowed to visit me tonight?" or "I'm scared about being here. Can you stay with me awhile?" is not unusual because 8-year-old children will want the support of a trusted person when experiencing stress.

A young child in whom sexual abuse is suspected asks the nurse, "Did I do something bad?" What is the most therapeutic response by the nurse? "Do you think you did something bad?" "Who said that you did something bad?" "What do you mean by something bad?" "Are you worried that I think you did something bad?"

"What do you mean by something bad? "What do you mean by something bad?" elicits further clarification of what the child means by "bad." The nurse must determine what the child means by the word "bad" before reflecting the term back to the child. "Who said that you did something bad?" is not helpful; it will do nothing to clarify the child's idea of what "bad" means or the child's feelings about what happened. Before the nurse can explore the child's concerns ("Do you think you did something bad?" or "Are you worried that I think you did something bad?"), the nurse must first understand the child's use of words and their meaning to the child.

A female client terminally ill with cancer says to the nurse, "My husband is avoiding me. He doesn't love me anymore because of this awful tumor!" What is the nurse's most appropriate response? "What makes you think he doesn't love you?" "Avoidance is a defense. He needs your help to cope." "Do you think he's having difficulty dealing with your illness?" "You seem very upset. Tell me how your husband is avoiding you."

"You seem very upset. Tell me how your husband is avoiding you." The response "You seem very upset. Tell me how your husband is avoiding you" validates the client's feelings and encourages the client to look at the basis or reality of the expressed concern. The response "What makes you think he doesn't love you?" ignores the client's statement; the client has already told the nurse the basis for the feelings. The response "Avoidance is a defense. He needs your help to cope" puts the responsibility for the husband's behavior on the client, who may not be able to handle it. The husband may or may not be having difficulty dealing with the client's illness, and this question does not focus on the client's feelings.

When presenting a workshop on adolescent suicide, a community health nurse identifies which risk factors? Select all that apply. Victim of family violence Limited or strained family finances Member of a single-parent household Dependence on alcohol, drugs, or both Uncertainty related to sexual orientation Repeated demonstration of poor impulse control

1, 4, 5, 6 Being a victim of family violence of any kind increases the risk of suicide. Alcohol or drug abuse is a significant factor in adolescent suicide. A concern about sexual orientation or being accepted as homosexual is a risk factor for suicide, especially among adolescents. Poor impulse control can lead to an increased tendency toward risk taking, which is a factor in suicide, especially among adolescents. Although economic problems and absence of a parent can both stress a family and its members, there is no research to support that either is a major factor in adolescent suicide.

According to Erikson, what will an individual who fails to master the maturational crisis of adolescence most often do? Rebel at parental orders. Experience role confusion. Experience interpersonal isolation. Become a substance abuser.

Experience role confusion. According to Erikson, adolescents are struggling with identity versus role confusion. Rebellion against parental orders reflects part of the struggle for independence; it does not indicate failure to resolve the conflicts of adolescence. Adolescents tend to be group oriented, not isolated; they struggle to belong, not to escape. Adolescents may experiment with drug and alcohol use, but most of them do not become abusers.

A nurse is teaching a class about child abuse. What defense mechanism most often used by the physically abusive individual should the nurse include? Repression Manipulation Transference Displacement

Displacement Displacement is a defense mechanism in which one's pent-up feelings toward a threatening person are discharged on those who are less threatening. Repression is the unintentional putting out of the mind unacceptable or troubling thoughts, desires, or experiences. Transference is a mechanism by which affects or emotional tones are shifted from one individual to another; it is unrelated to child abuse. Manipulation is a mechanism by which individuals attempt to manage, control, or use others to suit their own purpose or to gain an advantage; it is unrelated to child abuse.

When leading the first session of a newly formed group of clients in a mental health clinic, the nurse notes that group members frequently assume self-serving roles. What does the nurse understand about this? Early group development involves these behaviors. Some group members will need to be placed in another group. Certain group members may be emerging to control attention seekers. The group is attempting to reconcile conflicting viewpoints among its members.

Early group development involves these behaviors. These behaviors are a necessary phase of group development because they help members discover what they can expect from the leader and other members. It is inappropriate to assume at the first meeting that some clients will need to be switched to another group. Group factions are unlikely to emerge in the first session; moreover, factions seldom emerge to control disruptive group behavior. The group has not yet developed to the phase of reconciling conflict; conflict resolution and management occur only in operating groups.

An older adult tells the nurse, "I regret so many of the choices I've made during my life." Which of Erikson's developmental conflicts has the client probably failed to accomplish? Ego integrity versus despair Identity versus role confusion Generativity versus stagnation Autonomy versus shame and doubt

Ego integrity versus despair The sense of ego integrity comes from satisfaction with life and acceptance of what has been and what is. Despair reflects guilt or remorse over what might have been. During puberty adolescents attempt to find themselves and integrate their own values with those of society; an inability to solve conflict results in confusion and hinders mastery of future roles. During early and middle adulthood the individual is concerned with the ability to produce and to care for that which is produced or created; failure during this stage leads to self-absorption or stagnation. Autonomy, the ability to control the body and environment, is developed during the toddler period; doubt may result when the child is made to feel ashamed or embarrassed.

In an attempt to remain objective and support a client during a crisis, the nurse uses imagination and determination to project the self into the client's emotions. What is this technique known as? Empathy Sympathy Projection Acceptance

Empathy Empathy is the projection of self into another's emotions to share the emotions and the other's state of mind; this technique helps the nurse understand the meaning and significance of the experience to the client. Sympathy is a shared expression of sorrow over a real or imagined loss. Projection is an unconscious defense mechanism, not a therapeutic technique. Acceptance does not require the nurse to project the self into the client's emotions; rather, it involves accepting the client and the emotions.

What is the most important information for a nurse to teach to prevent relapse in a client with a psychiatric illness? Develop a close support system Create a stress-free environment Refrain from activities that cause anxiety Follow the prescribed medication regimen

Follow the prescribed medication regimen Following the prescribed medication regimen is important because side effects and denial of illness may cause clients to stop taking their medications; this is a common cause of relapse or recurrence of symptoms. Although a close support system is beneficial, it may not always be possible to achieve. It is impossible to create a stress-free environment; clients need to learn better ways to cope with stress. Refraining from any activity that may cause anxiety is too restrictive.

A client is admitted to the emergency department after ingesting a tricyclic antidepressant in an amount 30 times the daily recommended dose. What is the immediate treatment anticipated by the nurse? Administration of physostigmine as soon as possible Closer monitoring to prevent further suicidal attempts Gastric lavage with activated charcoal and support of physiologic function Intravenous administration of an anticholinergic in response to changes in vital signs

Gastric lavage with activated charcoal and support of physiologic function Gastric lavage with charcoal may help decrease the level of tricyclic antidepressant overdose. Supportive measures such as mechanical ventilation may be needed until the medical crisis passes. Physostigmine salicylate was used in the past to promote improvement in consciousness. Now its use is contraindicated because it can cause bradycardia, asystole, and seizures in clients with tricyclic antidepressant toxicity. Prevention of suicidal behavior is always advantageous; however, in this case immediate emergency intervention is necessary. The acetylcholine level is depressed as a result of the tricyclic antidepressant; anticholinergics are most effective in managing the side effects of antipsychotic and neuroleptic drugs, not tricyclic antidepressant drugs.

A mother whose child has been killed in a school bus accident tells the nurse that her child was just getting over the chickenpox and did not want to go to school but she insisted that the child go. The mother cries bitterly and says that her child's death is her fault. The nurse understands that perceiving a death as preventable most often will influence the grieving process in that it may do what? Grow in intensity and duration Progress to a psychiatric illness Be easier to understand and to accept Cause the mourner to experience a pathological grief reaction

Grow in intensity and duration Deaths that are perceived as preventable cause more guilt for the mourners and therefore increase the intensity and duration of the grieving process. Perceiving a death as preventable will not necessarily result in a pathological reaction, but it will usually make it harder to understand and accept the death

A nurse on the mental health unit is caring for a newly admitted client. What is the most important aspect of the therapeutic contract with this client? Determining the time for meetings with the client Helping the client define treatment goals and expectations Helping the client determine the frequency and duration of meetings Explaining the professional responsibilities of the nurse to the client

Helping the client define treatment goals and expectations Helping the client define treatment goals and expectations gives direction to the relationship and provides a blueprint for future evaluation of progress. Determining the time for meetings with the client and helping the client set the frequency and duration of meetings, and explaining the professional responsibilities of the nurse to the client are not the most important aspects of the therapeutic relationship; what the client wants to achieve takes priority.

A nurse in the mental health clinic concludes that a client is using confabulation when the client does what? The flow of thoughts is interrupted. Imagination is used to fill in memory gaps. Speech flits from one topic to another with no apparent meaning. Connections between statements are so loose that only the speaker understands them.

Imagination is used to fill in memory gaps. Using imagination to fill in memory gaps is the definition of confabulation; it is a defense mechanism used by people experiencing memory deficits. Interruption of the flow of thoughts is the definition of thought blocking. Flitting of speech from one topic to another with no apparent meaning is the definition of flight of ideas. The definition of associative looseness is connections between statements so loose that only the speaker understands them.

To provide appropriate psychosocial support to clients, a nurse must understand development across the life span. What theory is the nurse using in considering relationships and resulting behaviors as the central factors that influence development? Cognitive theory Psychosocial theory Interpersonal theory Psychosexual theory

Interpersonal theory The interpersonal theory of human development by Harry Stack Sullivan highlights interpersonal behaviors and relationships as the central factors influencing child and adolescent development across six "eras"; the need to satisfy social attachments and a longing to meet biologic and psychological needs are two dimensions associated with this theory. Cognitive theory is associated with Jean Piaget; cognitive theory explains how thought processes develop, are structured, and influence behavior. Psychosocial theory is associated with Erik Erikson; psychosocial theory identifies social interaction as the source that influences human development. Erikson identified eight stages of human life, with each stage built on the previous stages and influenced by past experiences. Psychosexual theory is associated with Sigmund Freud; psychosexual theory views child development as a biologically driven series of conflicts and gratifying internal needs.

What conflict associated with Erikson's psychosocial stages of development should the nurse remember when caring for a client who is 30 years of age? Integrity versus despair Intimacy versus isolation Industry versus inferiority Identity versus role confusion

Intimacy versus isolation The major task of the young adult is to develop close, sharing relationships that may include a sexual partnership; the person develops a sense of belonging and avoids isolation. During the integrity-versus-despair stage, the adjusted older adult can look back with satisfaction and acceptance of life and resolve the inevitability of death; failure at these tasks results in despair. The middle school-aged child gains a sense of competence and self-assurance as social interactions and academic pursuits are mastered; failure in these tasks leads to feelings of inferiority. During adolescence the individual develops a sense of self, self-esteem, and emotional stability; failure to establish self-identity results in a lack of self-confidence and difficulty with occupational choices.

A client in the mental health clinic who has been seeing a therapist for more than 6 months begins to talk and act like a therapist who is analyzing coworkers. What defense mechanism does the nurse identify? Undoing Projection Introjection Intellectualization

Introjection Introjection is treating something outside the self as if it is actually inside the self; it is unconsciously incorporating the wishes, values, and attitudes of another as if they were one's own. Undoing is taking some action to counteract or make up for a wrongdoing. Projection is attributing to another person or group one's own unacceptable attitudes or characteristics. Intellectualization is using logical explanations without feelings or an affective component.

A nurse is conducting a group therapy session. Why is a group setting especially conducive to therapy? It provides a new learning environment. It decreases the focus on the individual. It fosters one-on-one personal relationships. It confronts individual members with their shortcomings.

It provides a new learning environment. The group setting provides an individual with the opportunity to learn that others share the same problems and needs. The group also provides a safe arena in which new, healthier, more meaningful methods of relating to others can be explored. The focus is still on the individual, but more on the individual's learning how to relate to others. Groups promote interaction among many people rather than one-on-one relationships. Confronting individual members with their shortcomings may happen from time to time, with support given to the individual by the group, but it is not a main function of the group.

When a newly admitted client with paranoid ideation tells the nurse about people coming through the doors to commit murder, what should the nurse do? Ignore the client's stories. Listen to what the client is saying. Explain that no one can get through the door. Ask for an explanation of where the information was obtained.

Listen to what the client is saying. Listening to what the client is saying demonstrates that the nurse believes that what the client has to say is important; it also encourages verbalization of feelings. Ignoring the client's stories may increase the client's feelings of worthlessness and persecution. Explaining that no one can get through the door will accomplish little; a paranoid individual cannot be talked out of his or her feelings. These are feelings, not information, and they cannot always be explained; asking where the information came from forces the client to further develop the delusional system.

A client who is to be discharged from an inpatient mental health facility is referred to a mental health daycare center in the community. What should the nurse identify as the primary reason for this referral? Improving social skills Getting out of the house for a few hours daily Maintaining gains achieved during hospitalization Avoiding direct confrontation with the community

Maintaining gains achieved during hospitalization The daycare center provides the client with a therapeutic setting for a few hours each day during the transitional stage between hospital and total discharge. The goal is to maintain and enhance progress made during inpatient treatment. Daycare treatment may improve social skills or allow the client to get out of the house for a few hours, but neither is its primary purpose. Avoiding direct confrontation with the community may help during the transition stage, but it is not the primary goal of daycare.

Personality disorders are identified in the DSM-V in clusters. How should the nurse describe the behaviors of an individual with a cluster A personality disorder? Odd and eccentric Anxious and fearful Dramatic and erratic Hostile and impulsive

Odd and eccentric Cluster A includes paranoid, schizoid, and schizotypal personality disorders. These clients are odd and eccentric and use strange speech, are angry, and have impaired relationships. Cluster C includes avoidant, dependent, and obsessive-compulsive personality disorders. These clients are anxious, fearful, tense, and rigid. Cluster B includes antisocial, borderline, histrionic, and narcissistic personality disorders. These clients are dramatic, erratic, labile, impulsive, hostile, and manipulative.

Which statements describe a mentally healthy person? Select all that apply. One who accepts aging One who engages available strengths One who maintains minimum autonomy One who sustains positive relationships One who engages available weaknesses

One who accepts aging One who engages available strengths One who sustains positive relationships A mentally healthy person is one who accepts the aging self as an active being. A mentally healthy person is one who engages available strengths to compensate for weaknesses in order to create personal meaning. A mentally healthy person is one who sustains positive relationships with others. A mentally healthy person is one who maintains maximum autonomy by mastering the environment. A mentally healthy person does not engage available weaknesses.

Which relationship is of most concern to the nurse because of its importance in the formation of the personality? Peer relationships Sibling relationships Spousal relationships Parent-child relationships

Parent-child relationships Children base their own worth on the feedback they receive from their parents. This sense of worth sets the basic ego strengths and is vital to the formation of the personality. Peer groups come later in a child's development, but the parent-child relationship is still the most important. Although sibling relationships are important, they are not as important as the parent-child relationship. Spousal relationships come later in life, after the basic personality has been formed.

An older depressed person at an independent living facility constantly complains about her health problems to anyone who will listen. One day the client says, "I'm not going to any more activities. All these old crabby people do is talk about their problems." What defense mechanism does the nurse conclude that the client is using? Projection Introjection Somatization Rationalization

Projection The client is assigning to others those feelings and emotions that are unacceptable to herself. Introjection is treating something outside the self as if it is inside the self. Somatization is the unconscious transformation of anxiety into a physical symptom that has no organic cause. Rationalization is the use of a socially acceptable logical explanation to justify personally unacceptable material.

A client is admitted to a long-term care facility and placed in a semiprivate room. After the second night on the unit, the client's roommate reports that the client is masturbating at night and demands another room. What is the most appropriate intervention by the nurse? Moving the roommate who made the report to another room Providing the client who was masturbating with periods of private time Telling the roommate that this is acceptable behavior and that the client has the right to engage in it Informing the client who is masturbating that this behavior is inappropriate and should not continue

Providing the client who was masturbating with periods of private time Masturbating is a healthy human sexual behavior. The client should be provided with private time. Moving the roommate to another room could be ineffective because this may happen with the client's future roommate. Telling the roommate that this is acceptable behavior and that the client has the right to engage in it does not address either client's needs. The client has the right to meet physical needs but should not impose the behavior on others.

A primary healthcare provider writes a prescription of "Restraints PRN" for a client who has a history of violent behavior. What is the nurse's responsibility in regard to this prescription? Asking that the prescription indicate the type of restraint Recognizing that PRN prescriptions for restraints are unacceptable Implementing the restraint prescription when the client begins to act out Ensuring that the entire staff is aware of the prescription for the restraints

Recognizing that PRN prescriptions for restraints are unacceptable A new prescription must be written each time a client requires restraints. When a client is acting out, the nurse may use restraints or a seclusion room and then obtain the necessary prescription. Less restrictive interventions should be used when the client begins to act out; restraints are used as a last resort.

An older, confused client is being cared for at home by an adult child who works full-time. The client has lost weight and is wearing soiled and inappropriate clothing. The home care nurse suspects elder neglect. What should the nurse do? Discuss the situation with the adult child. Ask the client whether the adult child is neglectful. Avoid reporting the situation to prevent alienation of the adult child. Report the suspicion of neglect by the adult child to adult protective services.

Report the suspicion of neglect by the adult child to adult protective services. The nurse has a legal responsibility to report suspicions of neglect to adult protective services; failure to do so can result in the bringing of charges against the nurse. Although concerns may be addressed with the caregiver, the nurse has a legal responsibility to report suspicions of neglect to the appropriate authorities. The client is confused and may be unable to respond appropriately. Although the nurse may be concerned about preventing alienation of the adult child, the nurse is legally bound to report the situation to the appropriate authorities.

Three days after a stressful incident a client can no longer remember why it was stressful. The nurse, in relating to this client, can be most therapeutic by identifying that the inability to recall the situation is an example of what defense mechanism? Denial Regression Repression Dissociation

Repression The client's inability to recall is an example of repression, which is the unconscious and involuntary forgetting of painful events, ideas, and conflicts. There is nothing to demonstrate that denial, an unconscious refusal to admit an unacceptable situation, exists. There is nothing to demonstrate that regression, a return to an earlier, more comfortable developmental level, has occurred. There is nothing to demonstrate that dissociation, the separation and detachment of emotional affect and significance from a particular idea, situation, or incident, has occurred.

What is the most appropriate long-term goal for a client experiencing dysfunctional grieving after the death of a spouse? Resuming previously enjoyed activities Eating at least two meals a day with another person Decreasing negativistic thinking about other people Relocating to a state in which other family members reside

Resuming previously enjoyed activities Resuming previously enjoyed activities is realistic, specific, and measurable; it relates to the client's acceptance of a new reason for being. Eating at least two meals a day with another person may be an unrealistic goal. There are no data to indicate that the client is thinking negatively about others. Relocating to a state in which other family members reside may be an unrealistic goal, or the client may not want to do this.

What is a constructive but lengthy method of confronting the stress of adolescence and preventing a negative and unhealthy developmental outcome? Role experimentation Adherence to peer standards Sublimation through schoolwork Development of dependence on parents

Role experimentation Adolescents learn about who they are by assuming and experiencing a variety of roles; experimentation results in the retention or rejection of behavior and roles. Adherence to peer standards is not constructive; it does not allow experimentation with a variety of roles. Sublimation is not constructive and delays and interferes with the successful completion of the struggle to formulate one's identity. Development of dependence on parents is not constructive; it does not allow the development of independence.

On which principle should the nurse's role be based in the maintenance or promotion of the health of older adults? There is a strong correlation between successful retirement and good health. Thoughts of impending death are common and depressing to most older adults. Some of the physiologic changes that occur as a result of aging are reversible. Older adults can better accept the dependent state that chronic illness often causes.

There is a strong correlation between successful retirement and good health Individuals who can reflect on life and accept it for what it was and who are able to adjust and enjoy the changes retirement brings are less likely to experience health problems, especially stress-related health problems. Most emotionally healthy older adults do not focus on death. The changes of aging are usually not reversible. Dependency often is more threatening to this age group.

A nurse is considering Erikson's stages of psychosocial development while caring for a client. Which behavior is consistent with a problem involving trust versus mistrust? Woman in an abusive relationship who refuses to leave the abuser Man with paranoid schizophrenia who demands placement in a private room Woman whose parents were chronic alcoholics and who has problems making friends Man with borderline personality disorder who has been caught stealing from other clients

Woman whose parents were chronic alcoholics and who has problems making friends Trust is learned in infancy. Being parented by individuals who were not able to consistently meet the client's basic physiologic and safety needs is likely to result in an inability to engage in healthy interpersonal relationships as an adult. The response of the client in an abusive relationship is based not on events that occurred during infancy but rather on events in adulthood. The responses of the clients with paranoid schizophrenia and borderline personality disorder are symptoms of a psychiatric disorder rather than of an event that occurred during infancy.