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Stuvia 1516773 test bank for davis advantage for psychiatric
mental health nursing 10th edition karyn i
Mental Health Nursing (Valencia College)
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TEST BANK FOR DAVIS ADVANTAGE FOR
PSYCHIATRIC MENTAL HEALTH NURSING, 10TH
EDITION, KARYN I. MORGAN, MARY C. TOWNSEND,
ISBN-13: 9780803699670
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Brigette
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TEST BANK FOR DAVIS
ADVANTAGE FOR
PSYCHIATRIC MENTAL
HEALTH NURSING,
10TH EDITION, KARYN
I. MORGAN, MARY C.
TOWNSEND, ISBN- 13:
9780803699670
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Table of Contents
I. BASIC CONCEPTS IN PSYCHIATRIC-MENTAL HEALTH NURSING
1. The Concept of Stress Adaptation
2. Mental Health and Mental Illness: Historical and Theoretical Concepts
II. FOUNDATIONS FOR PSYCHIATRIC-MENTAL HEALTH NURSING
3. Concepts of Psychobiology
4. Psychopharmacology
5. Ethical and Legal Issues
III. THERAPEUTIC APPROACHES IN PSYCHIATRIC NURSING CARE
6. Relationship Development
7. Therapeutic Communication
8. The Nursing Process in Psychiatric-Mental Health Nursing
9. Therapeutic Groups
10. Intervention with Families
11. Milieu Therapy—The Therapeutic Community
12. Crisis Intervention
13. Assertiveness Training
14. Promoting Self Esteem
15. Anger and Aggression Management
16. Suicide Prevention
17. Behavior Therapy
18. Cognitive Behavioral Therapy
19. Electroconvulsive Therapy
20. The Recovery Model
IV. NURSING CARE OF PATIENTS WITH ALTERATIONS IN PSYCHOSOCIAL ADAPTATION
21. Caring for Patients with Mental Illness and Substance Use Disorders in General Practice Settings
22. Neurocognitive Disorders
23. Substance-Related and Addictive Disorders
24. Schizophrenia Spectrum and Other Psychotic Disorders
25. Depressive Disorders
26. Bipolar and Related Disorders
27. Anxiety, Obsessive-Compulsive, and Related Disorders
28. Trauma and Stressor-Related Disorders
29. Somatic Symptom and Dissociative Disorders
30. Eating Disorders
31. Personality Disorders
V. PSYCHIATRIC/MENTAL HEALTH NURSING OF SPECIAL POPULATIONS
32. Children and Adolescents
33. The Aging Individual
34. Survivors of Abuse or Neglect
35. Community Mental Health Nursing
36. The Bereaved Individual
37. Military Families
eBook Bonus Chapters
38. Theoretical Models of Personality Development
39. Cultural and Spiritual Concepts Relevant to Psychiatric Mental Health Nursing
40. Complementary and Psychosocial Therapies
41. Relaxation Therapy
42. Issues Related to Human Sexuality and Gender Dysphoria
43. Forensic Nursing
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Chapter 1. The Concept of Stress Adaptation
MULTIPLE CHOICE
1. A client has experienced the death of a close family member and at the same timebecomes
unemployed. The client’s 6-month score on the Recent Life Changes Questionnaire is 110. The nurse:
Understands the client is at risk for significant stress-related illness.
Determines the client is not at risk for significant stress-related illness.
Needs further assessment of the client’s coping skills to determine susceptibility tostress-related
illness.
Recognizes the client may view the losses as challenges and perceive them asopportunities.
ANS: 3
Chapter: Chapter 1, The Concept of Stress Adaptation
Objective: Explain the relationship between stress and diseases of adaptation.Page: 5
Heading: Stress as an Environmental Event Integrated Processes: Nursing Process: EvaluationClient
Need: Psychosocial Integrity
Cognitive Level: Application [Applying]Concept: Stress
Difficulty: Moderate
1.
2.
3.
Feedback
This is incorrect. Assessment is the first step of the nursing process. The nurse should
assess the client’s coping skills and available support before determining susceptibility
to stress-related physical and psychological illnesses. The Recent LifeChanges
Questionnaire is an expanded version of the Schedule of Recent Experiences and the
Rahe-Holmes Social Readjustment Rating Scale. A 6-month score of 300 or more or a
year-score total of 500 or more indicates high stress in a
client’s life and susceptibility to stress-related illnesses.
This is incorrect. Assessment is the first step in the nursing process. The nurse should
assess the client’s coping skills and available support before determining the client’s
perception of the current stresses. A 6-month score of 300 or more or a year-score total
of 500 or more on the Recent Life Changes Questionnaire indicates high stress in a
client’s life and susceptibility to stress-related physical and psychological illnesses.
This is correct. Assessment is the first step in the nursing process. The nurse should
assess the client’s coping skills and available support before determining susceptibility
to stress-related physical and psychological illnesses. A 6-month score
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4.
of 300 or more or a year-score of 500 or more indicates high stress in a client’s lifeand
risk for significant stress-related physical and psychological illness.
This is incorrect. Assessment is the first step in the nursing process. The nurse should
assess the client’s coping skills and available support before determining susceptibility
to stress-related illness. A 6-month score of 300 or more or a year- score of 500 or
more on the Recent Life Changes Questionnaire indicates high stressin a client’s life is
susceptible to significant stress-related physical and psychologicalillness.
CON: Stress
2. A physically and emotionally healthy client has just been fired. During a routine office visit, he tells
the nurse, “Perhaps this was the best thing to happen. Maybe I’ll
consider pursuing an art degree.” The nurse determines the client perceives the stressorof his job loss as:
Irrelevant
Harm or loss
Threatening
A challenge
ANS: 4
Chapter: Chapter 1, The Concept of Stress Adaptation
Objective: Discuss adaptive coping strategies in the management of stress.Page: 7
Heading: Stress as a transaction between the individual and the environment
>Individual’s Perception of the Event > Primary AppraisalIntegrated Processes: Nursing Process:
Assessment
Client Need: Psychosocial Integrity Cognitive Level: Application [Applying]Concept: Stress
Difficulty: Easy
1.
2.
3.
4.
Feedback
This is incorrect. An irrelevant perception is one where the event holds nosignificance
for the individual.
This is incorrect. A harm or loss appraisal refers to damage or loss alreadyexperienced
by the individual.
This is incorrect. A threatening appraisal is perceived as anticipated harms or losses.
This is correct. The client’s statement indicates he perceives the loss of his job as a
challenge and an opportunity for growth, demonstrated by his statement to consideran
art degree.
CON: Stress
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3. Which client statement alerts the nurse that the client may be maladaptivelyresponding to stress?
“Avoiding contact with others helps me cope.”
“I really enjoy journaling; it’s my private time.”
“I signed up for a yoga class this week.”
“I made an appointment to meet with a therapist.”
ANS: 1
Chapter: Chapter 1, The Concept of Stress Adaptation
Objective: Discuss adaptive coping strategies in the management of stress.Page: 8
Heading: Stress Management
Integrated Processes: Nursing Process: EvaluationClient Need: Psychosocial Integrity
Cognitive Level: Application [Applying]Concept: Stress
Difficulty: Easy
1.
2.
3.
4.
Feedback
This is correct. Reliance on social isolation as a coping mechanism is a maladaptive
method to relieve stress. It can prevent learning appropriate coping skills and can
prevent access to needed support systems.
This is incorrect. Journaling is a form of adaptive coping and interpersonal
communication.
This is incorrect. Group exercise is a form of adaptive coping, relaxation.
This is incorrect. Seeing a therapist is not considered a maladaptive coping method.
CON: Stress
4. A nursing student comes down with a sinus infection toward the end of every semester. Which stage
of stress is the student most likely experiencing when this occurs?
Alarm reaction
Resistance
Exhaustion
Fight or flight
ANS: 3
Chapter: Chapter 1, The Concept of Stress Adaptation
Objective: Explain the relationship between stress and diseases of adaptation.Page: 2
Heading: Stress as a Biological Response Integrated Processes: Nursing Process: Assessment
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Client Need: Psychosocial Integrity
Cognitive Level: Comprehension [Understanding]Concept: Stress
Difficulty: Easy
1.
2.
3.
4.
Feedback
This is incorrect. At the alarm reaction stage, physiological responses of the fight-orflight syndrome are initiated.
This is incorrect. At the stage of resistance, the individual uses the physiological
responses of the first stage as a defense in the attempt to adapt to the stressor.
Physiological symptoms may disappear.
This is correct. At the stage of exhaustion, the student’s exposure to stress has been
prolonged, and adaptive energy has been depleted. Diseases of adaptation occurmore
frequently in this stage.
This is incorrect. The fight-or-flight syndrome occurs during the alarm reactionstage.
CON: Stress
A school nurse is assessing a high school student who is overly concerned about herappearance.
The client’s parent states, “That’s not something to be stressed about!” Which response by the
nurse is best?
“Teenagers don’t truly understand stress.”
“Why are you so concerned about your appearance?”
“You surely know that isn’t something to be concerned with.”
“I understand you feel stressed about this; tell me more about your stress.”
ANS: 4
Chapter: Chapter 1, The Concept of Stress Adaptation
Objective: Describe the core concept of stress as an environmental event.Page: 8
Heading: Stress as a Transaction Between the Individual and the EnvironmentIntegrated Processes:
Nursing Process: Implementation
Client Need: Psychosocial Integrity Cognitive Level: Application [Applying]Concept: Stress
Difficulty: Moderate
1.
2.
3.
Feedback
This is incorrect. This response is judgmental and nontherapeutic. This response
minimizes the student’s concerns.
This is incorrect. This response puts the student in a defensive position to justify her
feelings. It is nontherapeutic.
This is incorrect. This is a nontherapeutic response that minimizes the student’s
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4.
feelings. This does not allow the student to verbalize her concerns.
This is correct. Determination of an event as stressful depends on the individual’s
cognitive appraisal of the situation, which is an individual’s evaluation of the personal
significance of the event or occurrence. Stress can be physical or psychological in
nature. A perceived threat to self-esteem can be as stressful as a physiological change.
This response recognizes the situation and helps to explore thesituation.
CON: Stress
6. A student confides in the school nurse that he is feeling stress about deciding whetherto go to college
or work to provide needed income for his family. Which is the best approach by the nurse to assist the
student?
Teach the student meditation techniques.
Assist the student with problem-solving strategies.
Suggest relaxation methods for the student.
Recommend getting a pet for the student.
ANS: 2
Chapter: Chapter 1, The Concept of Stress Adaptation
Objective: Discuss adaptive coping strategies in the management of stress.Page: 8
Heading: Stress Management> Adaptive coping strategiesIntegrated Processes: Nursing Process:
Implementation Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]Concept: Stress
Difficulty: Moderate
1.
2.
3.
4.
Feedback
This is incorrect. This is not the best approach because it only addresses a means to
reduce stress-related symptoms and does not address the underlying concern for the
student.
This is correct. The student is facing a problem that needs to be viewed objectively,and
the nurse can assist the student, if needed, to apply problem-solving strategies.
This is incorrect. While relaxation may assist the student with coping with thestressor,
it does not address the student’s underlying concern.
This is incorrect. Getting a pet can assist with coping with life stressors; however, the
student has already expressed financial concerns to which the pet will only add.
CON: Stress
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7. An unemployed college graduate confides in the clinic nurse that she is experiencingsevere anxiety
over not finding a teaching position and that she is having difficulty withindependent problem-solving.
Which nursing intervention is best?
Encourage her to seek counseling from a therapist.
Instruct her to listen to her favorite music daily.
Assist her with the problem-solving process.
Encourage her to keep a daily journal of feelings.
ANS: 3
Chapter: Chapter 1, The Concept of Stress Adaptation
Objective: Discuss adaptive coping strategies in the management of stress.Page: 8
Heading: Stress Management> Adaptive coping strategiesIntegrated Processes: Nursing Process:
Implementation Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]Concept: Stress
Difficulty: Moderate
1.
2.
3.
4.
Feedback
This is incorrect. Counseling is not likely needed in this case due to the situational
nature the student is describing.
This is incorrect. Listening to music may assist with the stress symptoms; however, it
does not address the underlying problem.
This is correct. Assist the client with problem-solving. During times of high anxiety
and stress, clients will need more assistance in problem-solving and decision- making.
This is incorrect. A daily journal may assist her with managing her symptoms butdoes
not address the underlying concern the client is expressing.
CON: Stress
8. The school nurse is assessing a high school student who is distraught because herparents cannot
afford horseback-riding lessons. The nurse recognizes the student’s perception is that the problem is:
Endangering her well-being
Personally relevant
Based on immaturity
Exceeding her capacity to cope
ANS: 2
Chapter: Chapter 1, The Concept of Stress Adaptation
Objective: Explain the concept of stress as a transaction between the individual and theenvironment.
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Page: 7
Heading: Stress as a Transaction Between the Individual and the EnvironmentIntegrated Processes:
Nursing Process: Evaluation
Client Need: Psychosocial Integrity Cognitive Level: Application [Applying]Concept: Stress
Difficulty: Moderate
1.
2.
3.
4.
Feedback
This is incorrect. The student is not expressing that it endangers her well-being; the
distress is related to the fact that she sees it as personally significant.
This is correct. Determination of an event as stressful depends on the individual’s
cognitive appraisal of the situation. An event becomes relevant to an individualwhen
the outcome holds personal significance.
This is incorrect. The distress the client is feeling is not related to immaturity; rather,
she sees it as having personal significance and therefore relevant.
This is incorrect. An event becomes relevant to an individual when the outcomeholds
personal significance.
CON: Stress
9. Meditation has been shown to be an effective stress management technique. Whichfinding indicates
meditation has been effective?
Achieving a state of relaxation
Attaining insight into one’s feelings
Demonstrating appropriate role behaviors
Enhanced problem-solving skills
ANS: 1
Chapter: Chapter 1, The Concept of Stress Adaptation
Objective: Discuss adaptive coping strategies in the management of stress.Page: 8
Heading: Stress Management > Adaptive Coping StrategiesIntegrated Processes: Nursing Process:
Evaluation
Client Need: Psychosocial Integrity Cognitive Level: Application [Applying]Concept: Stress
Difficulty: Easy
1.
2.
Feedback
This is correct. Meditation produces relaxation by creating a special state of
consciousness through focused concentration.
This is incorrect. Meditation does not necessarily result in attaining insight intoone’s
feelings.
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3.
This is incorrect. Meditation does not help to demonstrate appropriate rolebehaviors.
4.
This is incorrect. Meditation does not necessarily enhance one’s ability to solve
problems.
CON: Stress
10. A first-time parent is crying and asks the nurse, “How can I go to work if I can’t afford child care?”
Which is the appropriate initial response by the nurse to assist withproblem-solving?
Determine the risks and benefits for each alternative.
Formulate goals for resolution of the problem.
Evaluate the outcome of the implemented alternative.
Assess the facts of the situation.
ANS: 4
Chapter: Chapter 1, The Concept of Stress Adaptation
Objective: Discuss adaptive coping strategies in the management of stress.Page: 8
Heading: Stress Management >Adaptive Coping StrategiesIntegrated Processes: Nursing Process:
Implementation Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]Concept: Stress
Difficulty: Easy
1.
2.
3.
4.
Feedback
This is incorrect. Determining the risks and benefits of each alternative is done
approximately halfway through the problem-solving process.
This is incorrect. Assessment is the first step of the nursing process. Formulatinggoals
for resolving the stressful situation occurs after assessing the facts of the situation.
This is incorrect. Evaluating the outcome is nearly the last step in the problem-solving
process.
This is correct. Assessment is the first step of the problem-solving process. Accurate
information about the situation must be gathered before any other steps can be taken,
CON: Stress
11. The client is hospitalized with coronary artery disease and demonstrates otherconditions often
associated with diseases of adaptation, including headaches and depression. Currently, the client is
demonstrating anxiety and states he is
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“really worried” about his spouse. Which is the most appropriate nursing response to thesituation?
Inform the client that he has to learn to cope with stressors.
Teach the client how to meditate when he is feeling anxious.
Encourage the client to talk through his concerns about his spouse.
Ask the client if he has a pet he would like to see while in the hospital.
ANS: 3
Chapter: Chapter 1, The Concept of Stress Adaptation
Objective: Discuss adaptive coping strategies in the management of stress.Page: 8
Heading: Stress Management
Integrated Processes: Nursing Process: EvaluationClient Need: Psychological Integrity
Cognitive Level: Comprehension [Understanding]Concept: Stress
Difficulty: Easy
1.
2.
3.
4.
Feedback
This is incorrect. Informing the client that he needs to learn something new at thistime
will likely increase his stress and is not helpful to the immediate situation.
This is incorrect. Teaching the client mediation is not appropriate at this time, whenhe
is expressing the anxiety and concerns about his spouse.
This is correct. Interpersonal communication can assist the nurse to understand the
client’s concerns and allows the client to reduce the escalation of stress at this time.
This is incorrect. While this may be helpful in some situations, it is not somethingthat
can address the client’s immediate needs.
CON: Stress
12. When an individual’s stress response is sustained over a long period, the nurseanticipates which
physiological effect?
Decreased resistance to disease
Increased libido
Decreased blood pressure
Increased feelings of well-being
ANS: 1
Chapter: Chapter 1, The Concept of Stress AdaptationObjective: Identify physiological responses to
stress. Page: 3
Heading: Stress as a Biological Response Integrated Processes: Nursing Process: Assessment
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Client Need: Physiological Integrity
Cognitive Level: Comprehension [Understanding]Concept: Stress
Difficulty: Moderate
1.
2.
3.
4.
Feedback
This is correct. Selye’s general adaptation syndrome identified that prolonged exposure
to stress leads to a decreased immune response and resistance to disease.During the
stage of exhaustion, the body’s compensatory mechanisms no longer function
effectively and diseases of adaptation occur.
This is incorrect. Selye’s general adaptation syndrome identified that prolonged
exposure to stress leads to a decreased immune response and resistance to disease.
The client is likely to experience decreases in libido rather than increases.
This is incorrect. Selye’s general adaptation syndrome identified that prolonged
exposure to stress leads to a decreased immune response and resistance to disease.The
client is likely to experience increases in blood pressure rather than decreases.
This is incorrect. Selye’s general adaptation syndrome identified that prolonged
exposure to stress leads to a decreased immune response and resistance to disease. The
client is not likely to have feelings of increased well-being due to the prolongedstress
response.
CON: Stress
13. Which is a typical part of the fight-or-flight syndrome?
Decreased heart rate
Decreased peristalsis
Increased salivation
Pupil constriction
ANS: 2
Chapter: Chapter 1, The Concept of Stress AdaptationObjective: Identify physiological responses to
stress. Page: 3
Heading: Stress as a Biological Response Integrated Processes: Nursing Process: AssessmentClient
Need: Physiological Integrity
Cognitive Level: Comprehension [Understanding]Concept: Stress
Difficulty: Easy
1.
2.
Feedback
This is incorrect. During the fight-or-flight syndrome, the heart rate increases in
response to the release of epinephrine.
This is correct. During the fight-or-flight syndrome, peristalsis decreases as the body
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3.
4.
slows nonessential functions.
This is incorrect. Salivation decreases as the body slows nonessential functions.
This is incorrect. During the fight-or-flight syndrome, pupils dilate to enhancevision.
CON: Stress
14. A nurse is assessing a client’s response to stress. The nurse concludes that the clientis performing a
secondary appraisal of a stressful event when the client determines:
The event is benign.
The event is irrelevant.
Resources are available.
The event is pleasurable.
ANS: 3
Chapter: Chapter 1, The Concept of Stress Adaptation
Objective: Explain the concept of stress as a transaction between the individual and theenvironment.
Page: 7
Heading: Stress as a Transaction Between the Individual and the Environment >Individual’s Perception
of the Event
Integrated Processes: Nursing Process: EvaluationClient Need: Psychosocial Integrity
Cognitive Level: Comprehension [Understanding]Concept: Stress
Difficulty: Easy
1.
2.
3.
4.
Feedback
This is incorrect. The benign-positive outcome is a primary appraisal that isperceived
as producing pleasure for the individual.
This is incorrect. When an event is judged as irrelevant, this is the primary appraisal
process.
This is correct. When the individual considers the resources and skills needed to deal
with the event, the individual is conducting a secondary appraisal.
This is incorrect. Judging an event as pleasurable is a part of the primary appraisal
process.
CON: Stress
15. Miller and Rahe (1997) identified a correlation between the effects of life changeand illness. This
research led to the development of the Recent Life Changes Questionnaire (RLCQ). Which principle
most limits the effectiveness of this tool?
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Specific physical and psychological illnesses are not identified.
Numerical values associated with specific life events are randomly assigned.
Stress is viewed as a solely physiological response.
An individual’s personal perception of the event is excluded.
ANS: 4
Chapter: Chapter 1, The Concept of Stress Adaptation
Objective: Explain the relationship between stress and diseases of adaptation.Page: 5
Heading: Stress as an Environmental Event Integrated Processes: Nursing Process: EvaluationClient
Need: Psychosocial Integrity
Cognitive Level: Comprehension [Understanding]Concept: Stress
Difficulty: Easy
1.
2.
3.
4.
Feedback
This is incorrect. Several physical and psychological illnesses are part of the
questionnaire
This is incorrect. The numerical values associated with specific life events are not
randomly assigned.
This is incorrect. Stress is seen as both a physiological and a psychological response.
This is correct. Individuals differ in response to life events, and this is not consideredin
many life changes questionnaires.
CON: Stress
16. A client tells the nurse, “I experience stress on a regular basis. Why do I feel soterrible this time?”
Which is the nurse’s most appropriate response?
“Genetics has nothing to do with your temperament or feelings.”
“Your reactions to past experiences influence your current feelings.”
“Your stress level is lower when you are in good physical health.”
“You’ll experience less stress if you use appropriate coping skills.”
ANS: 2
Chapter: Chapter 1, The Concept of Stress Adaptation
Objective: Explain the concept of stress as a transaction between the individual and theenvironment.
Page: 7
Heading: Stress as a Transaction Between the Individual and the Environment >Predisposing Factors
Integrated Processes: Nursing Process: ImplementationClient Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
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Concept: Stress Difficulty: Moderate
1.
2.
3.
4.
Feedback
This is incorrect. Genetic influences do impact the way a person responds to stressand
influences temperament and feelings.
This is correct. Past experiences are occurrences that result in learned patterns that can
influence an individual’s current adaptation response. They include previous exposure
to the stressor or other stressors in general, learned coping responses, anddegree of
adaptation to previous stressors.
This is incorrect. Stress levels are not lower when one is in good physical health;
however, one who is in good physical health has more reserves to deal with the
stressful event.
This is incorrect. Adaptive coping responses help to deal with stressful events;
however, this does not mean one will experience less stress.
CON: Stress
17. A nurse is providing education on anxiety and stress management. Which of thefollowing should be
identified as the most important initial step in learning how to manage anxiety?
Diagnostic blood tests
Awareness of factors creating stress
Relaxation exercises
Identification of support systems
ANS: 2
Chapter: Chapter 1, The Core concept of Stress Adaptation
Objective: Discuss adaptive coping strategies in the management of stress.Page: 8
Heading: Stress Management > Adaptive Coping StrategiesIntegrated Processes: Teaching and Learning
and Learning Client Need: Health Promotion and Maintenance
Cognitive Level: Comprehension [Understanding]Concept: Stress
Difficulty: Easy
1.
2.
3.
Feedback
This is incorrect. Diagnostic blood tests are not part of the initial steps in anxiety and
stress management.
This is correct. The initial step is awareness that stress is being experienced and
awareness of factors that create stress.
This is incorrect. Relaxation exercises can be implemented after the client becomes
aware of factors that create stress.
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4.
This is incorrect. Identifying support systems can be implemented after the client
becomes aware of factors that create stress.
CON: Stress
18. A 32-year-old person is speaking to the office nurse at an initial visit. The nurse asked, “What brings
you in today?” The client replied, “I have been having headaches three to four times a week for the past
month or so. I’m not sleeping well and feel tired
most of the time. I work 60 hours per week and am going through a divorce.” The nursedetermines the
client’s symptoms represent which of the following?
Adaptive coping
Maladaptive coping
Problem-solving
Self-awareness
ANS: 2
Chapter: Chapter 1, The Concept of Stress AdaptationObjective: Define adaptation and
maladaptation.
Page: 8
Heading: Core Concepts
Integrated Processes: Nursing Process Client Need: Psychosocial Integrity Cognitive Level: Application
[Applying]Concept: Stress
Difficulty: Easy
1.
2.
3.
4.
Feedback
This is incorrect. An adaptive response to stress is a behavior that maintains the
integrity of the individual.
This is correct. When behavior disrupts the integrity of the individual, it is perceivedas
maladaptive. Maladaptive responses are considered negative or unhealthy.
This is incorrect. Problem-solving is an adaptive approach to dealing with stress.
This is incorrect. Self-awareness is an adaptive approach to dealing with stress and
likely won’t result in the symptoms the client is describing.
CON: Stress
19. The emergency department nurse is providing discharge instructions to a 23-year-oldman who was
injured in a motor vehicle crash. The client stated, “My heart was racing when I saw the car coming
through the red light was going to hit me. I didn’t know my heart could go that fast!” Which is the
nurse’s best response?
“Don’t worry, your heart is strong because you are young and in good health.”
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“Everyone gets scared when they realize another car is going to hit them.”
“You had a panic attack when you saw the car that hit you was not going to stop.”
“Your body responded to the stress of knowing the car was going to hit you.”
ANS: 4
Chapter: Chapter 1, The Concept of Stress AdaptationObjective: Identify physiological responses to
stress. Page: 3
Heading: Stress as a Biological Response Integrated Processes: Teaching and LearningClient Need:
Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Stress
Difficulty: Moderate
1.
2.
3.
4.
Feedback
This is incorrect. The nurse’s response in this example is nontherapeutic.
This is incorrect. The nurse’s response does not explain the reason for the client’srapid
heart rate.
This is incorrect. The client did not experience a panic attack. This was a normal
response to the situation.
This is correct. The client experienced a physical reaction to the stressor of the
impending car crash. A stressor is a biological, psychological, social, or chemical
factor that causes physical or emotional tension. The client’s increased heart rate was
a physical response during the alarm reaction stage of the fight-or-flight syndrome.
CON: Stress
20. The nurse in the intensive care unit (ICU) is giving report to the nurse on the cardiacstep-down unit.
The nurse states, “The client is a 48-year-old admitted 3 days ago for chest pain and a stent placement.
Vital signs are stable, but I am worried about her stresslevel. She said she just moved here due to a job
transfer, and her spouse stayed behind tosell the house. She told me they have a high insurance
deductible, and she is worried about the hospital bill.” Which factor has the most significant influence
on the client’s health?
Coping skills
Existing conditions
Individual vulnerability
Perceived threat
ANS: 2
Chapter: Chapter 1, The Concept of Stress AdaptationObjective: Identify physiological responses to
stress. Page: 7
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Heading: Stress as a Transaction between the Individual and the Environment >Predisposing Factors
Integrated Processes: Nursing Process: AssessmentClient Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]Concept: Stress
Difficulty: Moderate
1.
2.
3.
4.
Feedback
This is incorrect. Coping skills do not have the most influence on the client’s healthat
this time.
This is correct. Existing conditions incorporate vulnerabilities that influence the
adequacy of an individual’s resources to deal with adaptive demands. Existing
stressors are the recent move, loss of the support system, and financial concerns.
This is incorrect. Individual vulnerabilities are part of the existing conditions that are
influencing the adequacy of the resources.
This is incorrect. The perceived threat is part of the primary appraisal of an event.
CON: Stress
MULTIPLE RESPONSE
21. A nurse is interviewing a distressed client who reports being fired after 15 years ofloyal
employment. Which of the following questions best assist the nurse to determinethe client’s appraisal of
the situation? Select all that apply.
“What resources have you previously used in stressful situations?”
“Have you ever experienced a similar stressful situation?”
“Who do you think is to blame for this situation?”
“Why do you think you were fired from your job?”
“What skills do you possess that might lead to gainful employment?”
ANS: 1, 2, 5
Chapter: Chapter 1, The Concept of Stress Adaptation
Objective: Explain the concept of stress as a transaction between the individual and theenvironment.
Page: 7
Heading: Stress as a Transaction Between the Individual and the Environment >Individual’s Perception
of the Event
Integrated Processes: Nursing Process: AssessmentClient Need: Psychosocial Integrity
Cognitive Level: Application [Applying]Concept: Stress
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Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
This is correct. This question specifically addresses the client’s coping resources.
This is correct. This question encourages the client to apply learning from past
experiences.
This is incorrect. Asking who is to blame does not assess coping abilities but rather
encourages maladaptive behavior.
This is incorrect. This question does not assess coping abilities. Requesting an
explanation is a nontherapeutic block to communication.
This is correct. This question focuses on coping strategies and alternative methodsfor
dealing with stress.
CON: Stress
22. A nurse is working with a client who has recently been under a great deal of stress. Which nursing
recommendations would be most helpful to assist the client to cope withstress? Select all that apply.
“Enjoy a pet.”
“Spend time with a loved one.”
“Listen to music.”
“Focus on the stressors.”
“Journal your feelings.”
ANS: 1, 2, 3, 5
Chapter: Chapter 1, The Concept of Stress Adaptation
Objective: Discuss adaptive coping strategies in the management of stress.Page: 8
Heading: Stress Management > Adaptive Coping StrategiesIntegrated Processes: Nursing Process:
Implementation Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]Concept: Stress
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
This is correct. Pets have been shown to decrease stress.
This is correct. Healthy relationships have been shown to decrease stress.
This is correct. Music has been shown to decrease stress.
This is incorrect. Focusing on the stressors is more likely to increase stress.
This is correct. Journaling feelings has been shown to decrease stress.
CON: Stress
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23. A client presents in the emergency department immediately following a shooting incident in a
school where she has been teaching. Which are common initial biologicalresponses to stress the teacher
might demonstrate? Select all that apply.
Constricted pupils
Watery eyes
Unusual food cravings
Increased heart rate
Increased respirations
ANS: 2, 4, 5
Chapter: Chapter 1, The Concept of Stress AdaptationObjective: Identify physiological responses to
stress. Page: 3
Heading: Stress as a Biological Response Integrated Processes: Nursing Process: AssessmentClient
Need: Physiological Integrity
Cognitive Level: Analysis [Analyzing]Concept: Stress
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
This is incorrect. Dilated pupils, rather than constricted pupils, are related to thefightor-flight syndrome.
This is correct. Increased lacrimal secretions, increased heart rate, and increased
respirations are identified as initial biological responses to stress.
This is incorrect. Unusual food cravings have not been identified as a typicalbiological
response to stress.
This is correct. Increased heart rate is identified as an initial biological response to
stress.
This is correct. Increased respirations are identified as an initial biological responseto
stress.
CON: Stress
24. Which concepts are included in Hobfoll’s Conservation of Resources theory? Selectall that
apply.
Availability of resources
Disequilibrium
Genetics
Past experiences
Resilience
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ANS: 1, 3, 4
Chapter: Chapter 1, The Concept of Stress Adaptation
Objective: Explain the concept of stress as a transaction between the individual and theenvironment.
Page: 7
Heading: Stress as a Transaction Between the Individual and the EnvironmentIntegrated Processes:
Nursing Process: Assessment
Client Need: Psychosocial Integrity
Cognitive Level: Comprehension [Understanding]Concept: Stress
Difficulty: Easy
1.
2.
3.
4.
5.
Feedback
This is correct. Hobfoll’s Conservation of Resources theory asserts a variety of
elements influence an individual’s perception and response to a stressful event.
Available resources affect an individual’s perception of adaptive capabilities.
This is incorrect. Disequilibrium is not included as part of Hobfoll’s theory.
This is correct. Hobfoll’s Conservation of Resources theory asserts that a variety of
elements influence an individual’s perception and response to a stressful event.
Predisposing factors strongly influence whether the response is adaptive or
maladaptive. These include genetic influences, past experiences, and existing
conditions.
This is correct. Hobfoll’s Conservation of Resources theory asserts that a variety of
elements influence an individual’s perception and response to a stressful event.
These include genetic influences, past experiences, and existing conditions. An
individual who experiences stress in the present becomes more vulnerable to future
stress when there is a loss or lack of resources.
This is incorrect. Resilience is not included as part of Hobfoll’s theory.
CON: Stress
ORDERED RESPONSE
25. Place the selected steps of the problem-solving process in the correct order.
Determine risks and benefits of each option.
Formulate goals to resolve the stressful situation.
Implement a second alternative.
Study the alternatives for dealing with the situation.
ANS: The correct order is 2, 4, 1, 3
Chapter: Chapter 1, The Concept of Stress Adaptation
Objective: Discuss adaptive coping strategies in the management of stress.
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Page: 8
Heading: Stress Management > Adaptive Coping StrategiesIntegrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Comprehension [Understanding]Concept: Stress
Difficulty: Easy
Feedback: Problem-solving is an adaptive coping strategy in which an individual views the situation
objectively and applies a decision-making model. The steps of the problem-solving process are: (1)
Assessing the facts of the situation; (2) formulating goals for resolution of the stressful situation; (3)
studying the alternatives for dealing with the situation; (4) determining the risks and benefits of each
alternative; (5) selecting an alternative; (6) implementing the selected alternative; (7) evaluating the
outcome of the alternative implemented; and (8) if the first choice is ineffective, selecting and
implementing a second option.
CON: Stress
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Townsend
PMHN, 10e
Chapter 2 - ETB
abirb.com/test
Chapter 2. Mental Health and Mental Illness: Historical and Theoretical Concepts
abirb.com/test
MULTIPLE CHOICE
abirb.com/test
1. A nurse is assessing a client who is experiencing occasional feelings of sadness
because of the recent death of a beloved pet. The client’s appetite,
sleep patterns, and
abirb.com/test
daily routine have not changed. The nurse determines the client’s behaviors:
1. Demonstrate typical variations in daily mood, not mental illness
2. Are clinically significant and indicate serious mental illness
abirb.com/test
3. Are incongruent with cultural norms and indicate mental illness
4. Show common symptoms of grief and do not indicate mental illness
ANS: 4
abirb.com/test
Chapter: Chapter 2, Mental Health and Mental Illness: Historical and Theoretical
Concepts
Objective: Describe psychological adaptation responses to stress.
abirb.com/test
Page: 20
Heading: Grief
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Analysis [Analyzing]
Concept: Grief and Loss
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. Feelings of sadness are not a typical aspect of daily mood
abirb.com/test
variations.
This is incorrect. These symptoms are not clinically significant from the perspective
of mental illness. The client demonstrates a common grief response.
This is incorrect. Feelings of sadness are expected and normal
following the loss of a
abirb.com/test
pet. The client does not exhibit signs of mental illness, as daily functioning is not
impaired.
This is correct. Feelings of sadness are expected and normal following the loss of a
abirb.com/test
pet. This client does not demonstrate changes in daily function
but does demonstrate
common symptoms of grief.
CON: Grief and Loss
abirb.com/test
abirb.com/test
2. Which indicates a client is likely demonstrating a mental disorder?
abirb.com/test
abirb.com/test
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Townsend
PMHN, 10e
Chapter 2 - ETB
abirb.com/test
1. The client expresses mild anxiety and is eating more than usual before an
examination.
2. The client displays an inability to concentrate, including reduced job performance.
abirb.com/test
3. The client describes engaging in fidgeting behavior consistently
over a few days.
4. The client states an increase in smoking over a few days from 0.5 to 1 pack per day.
ANS: 2
abirb.com/test
Chapter: Chapter 2, Mental Health and Mental Illness: Historical and Theoretical
Concepts
Objective: Define mental health and mental illness.
abirb.com/test
Page: 14
Heading: Mental Illness
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Stress
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. The client is expressing normal behaviors related to mild anxiety
appropriate to a situation, in this case an examination. Mildabirb.com/test
anxiety can be beneficial
to improve performance.
This is correct. The client is unable to concentrate, and job performance has been
negatively impacted. This demonstrates a possible mental disorder.
abirb.com/test
This is incorrect. Fidgeting behavior over a short-term period is a common
psychological adaptive response to mild anxiety. This does not suggest a mental
disorder.
abirb.com/test
This is incorrect. Smoking or increasing smoking over a few
days is a common
response to stress and suggests mild anxiety, which does not suggest a mental
disorder.
abirb.com/test
CON: Stress
abirb.com/test
3. A mental health nurse is speaking with parents who are concerned about their teenage
children’s responses to stress. One child becomes anxious and irritable and the other
withdraws and cries. Which is the nurse’s best response?
abirb.com/test
1. “Individual responses to stress are affected by many factors and can vary.”
2. “Children from the same family should not react so differently to stress.”
3. “Children should have similar dispositions and responses to stress.”
abirb.com/test
4. “Environmental factors influence stress responses more than genetic
factors.”
ANS: 1
Chapter: Chapter 2, Mental Health and Mental Illness: Historicalabirb.com/test
and Theoretical
Concepts
abirb.com/test
abirb.com/test
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Townsend
PMHN, 10e
Chapter 2 - ETB
abirb.com/test
Objective: Describe psychological adaptation responses to stress.
Page: 16
Heading: Psychological Adaptation to Stress
abirb.com/test
Integrated Processes: Nursing Process: Implementation
Client Need: Teaching and Learning
Cognitive Level: Application [Applying]
Concept: Stress
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/test
This is correct. Responses to stress are variable among individuals and may be
influenced by perception, past experiences, environmental factors, and genetic
factors.
abirb.com/test
This is incorrect. Responses to stress vary among individuals;
even those within the
same family will have different stress responses.
This is incorrect. Children, like adults, will demonstrate various responses to stress,
depending on factors such as environment, past experiences,
and perceptions.
abirb.com/test
This is incorrect. Responses to stress depend on genetic factors, perception, past
experiences, and environmental factors.
CON: Stress
abirb.com/test
abirb.com/test
4. The nurse is interviewing a client with a history of excessive drinking and multiple
arrests for impaired driving. The client states, “I work hard to provide for my family. I
don’t see why I can’t drink to relax.” Which defense mechanism is the client
abirb.com/test
demonstrating?
1. Projection
2. Rationalization
3. Regression
abirb.com/test
4. Sublimation
ANS: 2
Chapter: Chapter 2, Mental Health and Mental Illness: Historicalabirb.com/test
and Theoretical
Concepts
Objective: Correlate adaptive and maladaptive responses to the mental health and mental
illness continuum.
abirb.com/test
Page: 16
Heading: Anxiety > Behavioral Adaptation Responses to Anxiety > Table 2–2, Ego
Defense Mechanisms
abirb.com/test
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
Cognitive Level: Comprehension [Understanding]
Concept: Addiction and Behaviors
abirb.com/test
Difficulty: Easy
abirb.com/test
abirb.com/test
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Townsend
PMHN, 10e
Chapter 2 - ETB
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. The client is using rationalization, a common defense mechanism.
The client is attempting to make excuses and create logicalabirb.com/test
reasons to justify
unacceptable feelings or behaviors. Projection is attributing feelings or impulses
unacceptable to one’s self to another person.
This is correct. The client is using rationalization, a common
defense mechanism.
abirb.com/test
The client is attempting to make excuses and create logical reasons to justify
unacceptable feelings or behaviors.
This is incorrect. The client is using rationalization, a common defense mechanism.
abirb.com/test
The client is attempting to make excuses and create logical reasons to justify
unacceptable feelings or behaviors. Regression is characterized by retreating to an
earlier level of development and the comfort measures associated with that level of
abirb.com/test
functioning.
This is incorrect. The client is using rationalization, a common defense mechanism.
The client is attempting to make excuses and create logical reasons to justify
unacceptable feelings or behaviors. Sublimation is the rechanneling
of drives or
abirb.com/test
impulses that are personally or socially unacceptable into activities that are
constructive.
CON: Addiction and Behaviors
abirb.com/test
abirb.com/test
5. Which best describes the impact that the National Mental Health Act of 1946 had on
care for the mentally ill in the United States?
1. People were no longer perceived as demonized when displaying mental illness.
2. Mental health professionals were provided funding to increaseabirb.com/test
their education.
3. A system of hospitals for the mentally ill was developed in communities.
4. The first hospital for just the mentally ill was opened and staffed by professionals.
abirb.com/test
ANS: 2
Chapter: Chapter 2, Mental Health and Mental Illness: Historical and Theoretical
Concepts
abirb.com/test
Objective: Discuss the history of psychiatric care.
Page: 13
Heading: Historical overview of psychiatric care
Integrated Processes: Nursing Process: Assessment
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Comprehension [Understanding]
Concept: Stress
abirb.com/test
Difficulty: Easy
1.
Feedback
This is incorrect. Hippocrates work around 400 BC and work
during the Middle
abirb.com/test
Ages reduced the perception that those with mental illness were demonized.
abirb.com/test
abirb.com/test
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Townsend
PMHN, 10e
Chapter 2 - ETB
abirb.com/test
2.
3.
4.
This is correct. The National Mental Health Act of 1946 helped provide funding for
educating mental health professionals who could provide care to the mentally ill.
This is incorrect. A system of hospitals for the mentally ill was developed largely
due to the work of Dorothea Dix during the19th century. abirb.com/test
This is incorrect. The first hospital for the mentally ill was opened in the mid-18th
century.
abirb.com/test
CON: Stress
abirb.com/test
6. A new psychiatric-mental health nurse states, “This client’s use of defense
mechanisms should be eliminated.” Which is the correct evaluation of the nurse’s
abirb.com/test
statement?
1. Defense mechanisms are self-protective responses to stress and do not need to be
eliminated.
2. Defense mechanisms are maladaptive attempts of the ego to manage
anxiety and
abirb.com/test
should be eliminated.
3. Defense mechanisms are used by individuals with weak ego integrity and should not
be eliminated.
abirb.com/test
4. Defense mechanisms cause disintegration of the ego and should
be fostered and
encouraged.
ANS: 1
abirb.com/test
Chapter: Chapter 2, Mental Health and Mental Illness: Historical and Theoretical
Concepts
Objective: Describe psychological adaptation responses to stress.
abirb.com/test
Page: 17
Heading: Anxiety > Behavioral Adaptation Responses to Anxiety
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Comprehension [Understanding]
Concept: Stress
Difficulty: Easy
abirb.com/test
1.
2.
3.
4.
Feedback
This is correct. Defense mechanisms serve the purpose of reducing anxiety during
times of stress. A client with no defense mechanisms may abirb.com/test
have a lower tolerance for
stress, predisposing him or her to anxiety disorders. Defense mechanisms should be
confronted when they impede the client from developing healthy coping skills.
This is incorrect. Defense mechanisms are protective to the ego. Some defense
mechanisms can become maladaptive when the individual abirb.com/test
cannot deal with reality;
however, they should not be eliminated.
This is incorrect. Defense mechanisms are used to relieve mild to moderate anxiety
and do not relate to the strength of ego integrity.
abirb.com/test
This is incorrect. Maladaptive use of defense mechanisms can cause disintegration of
abirb.com/test
abirb.com/test
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Townsend
PMHN, 10e
Chapter 2 - ETB
abirb.com/test
the ego and should not be fostered or encouraged.
CON: Stress
abirb.com/test
7. During an intake assessment, the nurse asks a client physiological
and psychosocial
abirb.com/test
questions. The client angrily responds, “I’m here for my heart problems, not for my
head.” Which is the nurse’s best response?
1. “We ask all clients these questions.”
abirb.com/test
2. “Why are you concerned about these questions?”
3. “Psychological stress can affect medical conditions.”
4. “We can skip these questions if you prefer.”
abirb.com/test
ANS: 3
Chapter: Chapter 2, Mental Health and Mental Illness: Historical and Theoretical
Concepts
abirb.com/test
Objective: Describe psychological adaptation responses to stress.
Page: 17
Heading: Anxiety > Moderate-to-Severe Anxiety
abirb.com/test
Integrated Processes: Nursing Process: Implementation
Client Need: Health Promotion and Maintenance
Cognitive Level: Analysis [Analyzing]
Concept: Stress
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
This is incorrect. This response is not therapeutic and doesabirb.com/test
not address the reason the
questions are asked, which is to screen for psychological/psychosocial concerns and
their possible relation to physiological conditions.
This is incorrect. This is a nontherapeutic response to the client’s
response to the
abirb.com/test
questions. It places the client in a defensive position and does not educate the client
about the purpose of the questions.
This is correct. The nurse should not skip either physiological or psychosocial
abirb.com/test
questions, as this would lead to an inaccurate assessment. The
nurse should always
attempt to educate the client on the negative effects of excessive stress on medical
conditions.
This is incorrect. The nurse should not skip the psychosocial
line of questioning
abirb.com/test
because it will result in an incomplete client assessment. This response does not
address the need for the questions or provide the client an opportunity to express
concerns not related to the heart problem.
abirb.com/test
CON: Stress
abirb.com/test
abirb.com/test
abirb.com/test
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Chapter 2 - ETB
abirb.com/test
8. Teaching regarding the concepts of mental health and mental illness is effective when
the student nurse states which of the following?
1. “The concepts are rigid and based on religious beliefs.”
2. “The concepts are multidimensional and culturally defined.” abirb.com/test
3. “The concepts are universal and unchanging.”
4. “The concepts are fixed and unidimensional.”
abirb.com/test
ANS: 2
Chapter: Chapter 2, Mental Health and Mental Illness: Historical and Theoretical
Concepts
abirb.com/test
Objective: Define mental health and mental illness.
Page 16
Heading: Core Concepts
Integrated Processes: Nursing Process: Evaluation
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Health Promotion
abirb.com/test
Difficulty: Easy
1.
2.
3.
4.
Feedback
This is incorrect. The concepts of mental health and mentalabirb.com/test
illness are not rigid and
are not based on religious beliefs; rather, they are based on cultural definitions.
This is correct. The concepts of mental health and mental illness are
multidimensional and culturally defined. It is important forabirb.com/test
nurses to be aware of
cultural norms when evaluating a client’s mental state.
This is incorrect. The concepts of mental health and mental illness are not universal
and unchanging. As history demonstrates, the understanding of mental health and
abirb.com/test
illness has changed or been defined by cultural norms.
This is incorrect. The concepts of mental health and mental illness are fluid, rather
than fixed, and multidimensional. This is demonstrated in the history of mental
health and the ongoing changes noted in current mental health
care.
abirb.com/test
CON: Health Promotion
abirb.com/test
9. A mental health technician asks the nurse, “How do psychiatrists determine which
diagnosis to give a client?” Which is the nurse’s best response? abirb.com/test
1. “Psychiatrists use criteria from the Diagnostic and Statistical Manual of Mental
Disorders (DSM).”
2. “Psychiatrists are required to follow hospital policy to diagnose mental disorders.”
abirb.com/test
3. “Psychiatrists make diagnoses based on the client’s behavior and
other factors.”
4. “Psychiatrists use one of the 10 diagnostic labels from the American Medical
Association (AMA).”
abirb.com/test
ANS: 1
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 2 - ETB
abirb.com/test
Chapter: Chapter 2, Mental Health and Mental Illness: Historical and Theoretical
Concepts
Objective: Define mental health and mental illness.
abirb.com/test
Page: 15
Heading: Mental Illness
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Health Promotion
abirb.com/test
1.
2.
3.
4.
Feedback
This is correct. The DSM is published by the American Psychiatric Association
(APA). It is an organized manual describing mental disorders and the criteria that
determine whether a given diagnosis is appropriate. The purpose
of the DSM is to
abirb.com/test
facilitate accurate and reliable psychiatric diagnosis and treatment.
This is incorrect. Hospital policy does not address diagnostic criteria for mental
health disorders.
abirb.com/test
This is incorrect. While behavior and other factors are considered in the diagnostic
criteria for the DSM, this response is not complete. The DSM provides the specific
criteria to address diagnoses.
abirb.com/test
This is incorrect. The AMA does not provide the diagnostic
labels for mental health
disorders; rather, these criteria are provided by the APA.
CON: Health Promotion
abirb.com/test
abirb.com/test
10. The nurse recognizes that a client is mildly anxious when beginning
a session that
incudes client teaching. Which is the most appropriate interpretation of the situation?
1. The nurse should wait until the client is more anxious to enhance learning.
2. The mild anxiety the client displays will likely enhance learning
for the client.
abirb.com/test
3. The nurse should wait until there is no anxiety to achieve the best learning.
4. The mild anxiety will have no impact on learning and does not need consideration.
abirb.com/test
ANS: 2
Chapter: Chapter 2, Mental Health and Mental Illness: Historical and Theoretical
Concepts
Objective: Describe psychological adaptation responses to stress.abirb.com/test
Page: 16
Heading: Anxiety > Mild Anxiety > Table 2–1, Levels of Anxiety
Integrated Processes: Nursing Process: Planning
abirb.com/test
Client Need: Health Promotion and Maintenance
Cognitive Level: Comprehension [Understanding]
Concept: Stress
Difficulty: Moderate
abirb.com/test
abirb.com/test
abirb.com/test
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Chapter 2 - ETB
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. Waiting until the client is more anxious will reduce learning. Mild
anxiety enhances learning.
abirb.com/test
This is correct. Mild anxiety sharpens the senses, increases the perceptual field, and
results in heightened awareness of the environment. Learning is enhanced.
This is incorrect. With no anxiety present, the client does not have heightened
abirb.com/test
awareness or increases in perceptions, which may reduce learning,
compared with a
state of mild anxiety.
This is incorrect. The presence of mild anxiety does have an impact on perception
and awareness, is likely to enhance learning, and does needabirb.com/test
to be considered when
interacting with a client.
CON: Stress
abirb.com/test
11. Which psychoneurotic responses to severe anxiety are identified
in the Diagnostic
abirb.com/test
and Statistical Manual of Mental Disorders, 5th edition (DSM-5)?
1. Somatic symptom disorder
2. Grief reaction
abirb.com/test
3. Psychosis
4. Bipolar disorder
ANS: 1
abirb.com/test
Chapter: Chapter 2, Mental Health and Mental Illness: Historical and Theoretical
Concepts
Objective: Describe psychological adaptation responses to stress.
abirb.com/test
Page: 16
Heading: Psychological adaptations to stress>Anxiety > Severe Anxiety
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Comprehension [Understanding]
Concept: Stress
Difficulty: Easy
abirb.com/test
1.
2.
3.
4.
Feedback
This is correct. Somatic symptom disorder is characterized by preoccupation with
physical symptoms for which there is no demonstrable organic
pathology. One of the
abirb.com/test
diagnostic criteria is a high level of anxiety about health concerns or illness.
This is incorrect. Grief reaction is not a psychoneurotic response to severe anxiety
identified in the DSM-5.
abirb.com/test
This is incorrect. Psychosis is not a psychoneurotic response to severe anxiety
identified in the DSM-5.
This is incorrect. Bipolar disorder is not a psychoneurotic response to severe anxiety
abirb.com/test
identified in the DSM-5.
abirb.com/test
abirb.com/test
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Chapter 2 - ETB
abirb.com/test
CON: Stress
abirb.com/test
12. A supervisor openly disagrees with an employee’s suggestions during a staff
meeting. Which response by the employee would demonstrate the defense mechanism of
displacement?
abirb.com/test
1. Confronting the supervisor assertively
2. Leaving the staff meeting abruptly
3. Criticizing a coworker after the meeting
abirb.com/test
4. Working to become a supervisor
ANS: 3
Chapter: Chapter 2, Mental Health and Mental Illness: Historicalabirb.com/test
and Theoretical
Concepts
Objective: Describe psychological adaptation responses to stress.
Page: 19
abirb.com/test
Heading: Anxiety > Behavioral Adaptation Responses to Anxiety > Table 2–2, Ego
Defense Mechanisms
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Stress
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. Assertively confronting the supervisor is not an example of
abirb.com/test
displacement.
This is incorrect. Abruptly leaving the staff meeting is not an example of
displacement.
This is correct. Displacement refers to transferring feelingsabirb.com/test
from one target to a
neutral or less-threatening target. Angrily criticizing a coworker after the
disagreement with the supervisor is an example of the defense mechanism of
displacement.
abirb.com/testthe defense
This is incorrect. Working to become a supervisor may demonstrate
mechanism of identification. It is not an example of displacement.
CON: Stress
abirb.com/test
abirb.com/test
13. A high school student is attracted to a female teacher. The student
is uncomfortable
with his feelings and says to his friend, “I know she wants me.” Which defense
mechanism is the student demonstrating?
1. Displacement
abirb.com/test
2. Projection
abirb.com/test
abirb.com/test
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Chapter 2 - ETB
abirb.com/test
3. Rationalization
4. Sublimation
abirb.com/test
ANS: 2
Chapter: Chapter 2, Mental Health and Mental Illness: Historical and Theoretical
Concepts
Objective: Describe psychological adaptation responses to stress.abirb.com/test
Page: 19
Heading: Anxiety > Behavioral Adaptation Responses to Anxiety > Table 2–2, Ego
Defense Mechanisms
abirb.com/test
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Stress
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/test
This is incorrect. Displacement refers to transferring feelings from one target to
another.
This is correct. Projection refers to the attribution of one’s unacceptable feelings or
abirb.com/test
impulses to another person. When the client “passes the blame”
of the undesirable
feelings, anxiety is reduced.
This is incorrect. Rationalization refers to making excuses to justify behavior.
This is incorrect. Sublimation refers to channeling unacceptable
drives or impulses
abirb.com/test
into more constructive, acceptable activities.
CON: Stress
abirb.com/test
14. An eighth-grade boy is uncomfortable with his feelings for anabirb.com/test
older girl and interest
in her. He teases the girl whenever he gets a chance and makes jokes about her
appearance. The school nurse identifies the boy as using which defense mechanism?
1. Displacement
abirb.com/test
2. Projection
3. Reaction formation
4. Sublimation
abirb.com/test
ANS: 3
Chapter: Chapter 2, Mental Health and Mental Illness: Historical and Theoretical
Concepts
Objective: Describe psychological adaptation responses to stress.abirb.com/test
Page: 19
Heading: Anxiety > Behavioral Adaptation Responses to Anxiety > Table 2–2, Ego
Defense Mechanisms
abirb.com/test
Integrated Processes: Nursing Process: Assessment
abirb.com/test
abirb.com/test
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Townsend
PMHN, 10e
Chapter 2 - ETB
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Stress
Difficulty: Moderate
1.
2.
3.
4.
abirb.com/test
Feedback
This is incorrect. Displacement refers to transferring feelings
from one target to
abirb.com/test
another.
This is incorrect. Projection refers to the attribution of unacceptable feelings or
behaviors to another person.
abirb.com/test
This is correct. The boy is using the defense mechanism of reaction formation.
Reaction formation is the attempt to prevent undesirable thoughts from being
expressed by expressing opposite thoughts or behaviors.
abirb.com/test
This is incorrect. Sublimation refers to channeling unacceptable
drives or impulses
into more constructive, acceptable activities.
CON: Stress
abirb.com/test
15. Which statement demonstrates that the nurse understands an abirb.com/test
individual’s experience
of neurosis?
1. “The individual is unaware he or she is experiencing distress.”
2. “The individual feels helpless to change his or her situation.” abirb.com/test
3. “The individual is aware of psychological causes of his or her behavior.”
4. “The individual has lost contact with reality.”
abirb.com/test
ANS: 2
Chapter: Chapter 2, Mental Health and Mental Illness: Historical and Theoretical
Concepts
Objective: Describe psychological adaptation responses to stress.abirb.com/test
Page: 18
Heading: Anxiety > Severe Anxiety
Integrated Processes: Nursing Process: Assessment
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Comprehension [Understanding]
Concept: Stress
Difficulty: Moderate
abirb.com/test
1.
2.
3.
Feedback
This is incorrect. The client with neurosis is aware that he or she is experiencing
abirb.com/test
distress and the behaviors are maladaptive.
This is correct. The client experiencing neurosis feels helpless to change his or her
situation.
This is incorrect. The client with neurosis is unaware of theabirb.com/test
psychological causes of
the distress.
abirb.com/test
abirb.com/test
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Chapter 2 - ETB
abirb.com/test
4.
This is incorrect. The client with neurosis has not lost contact with reality.
CON: Stress
abirb.com/test
16. A client routinely uses an excessive amount of alcohol when abirb.com/test
under stress. When her
husband arrived home one day and found her intoxicated, he began yelling at her about
her chronic alcohol abuse. Which of the wife’s actions demonstrates the defense
mechanism of denial?
abirb.com/test
1. Hiding liquor bottles in a closet
2. Yelling at her son for slouching
3. Intentionally burning dinner
4. Stating “I don’t drink too much!”
abirb.com/test
ANS: 4
Chapter: Chapter 2, Mental Health and Mental Illness: Historical and Theoretical
abirb.com/test
Concepts
Objective: Describe psychological adaptation responses to stress.
Page: 19
Heading: Anxiety > Behavioral Adaptation Responses to Anxietyabirb.com/test
> Table 2–2, Ego
Defense Mechanisms
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Stress
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. Hiding the liquor bottles in a closet does not demonstrate denial.
This is incorrect. Yelling at her son for slouching is an example
of displacement.
abirb.com/test
This is incorrect. Burning dinner does not demonstrate denial.
This is correct. The woman’s statement “I don’t drink too much!” represents the use
of the defense mechanism of denial. The client who refuses to acknowledge the
abirb.com/test
existence of a real situation and the feelings associated with
it is using the defense
mechanism of denial.
CON: Stress
abirb.com/test
abirb.com/test
17. A woman devastated by the divorce from her abusive husband
has been receiving
grief counseling. Which demonstrates the woman is in the acceptance stage of grief?
1. “If only we could have tried again, things might have worked out.”
2. “I am so angry that my children and I put up with him as long abirb.com/test
as we did.”
3. “It was a difficult marriage, but I think I learned from the experience.”
abirb.com/test
abirb.com/test
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Chapter 2 - ETB
abirb.com/test
4. “I still am not sleeping, don’t have any appetite, and am losing weight.”
ANS: 3
Chapter: Chapter 2, Mental Health and Mental Illness: Historicalabirb.com/test
and Theoretical
Concepts
Objective: Correlate adaptive and maladaptive responses to the mental health and mental
illness continuum.
abirb.com/test
Page: 20
Heading: Stages of Grief
Integrated Processes: Nursing Process: Evaluation
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
Concept: Grief and Loss
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. This statement represents denial, stage 1 of Kübler-Ross’s stages of
abirb.com/test
grief. The client is in the acceptance stage (stage 5) of the grief process. During this
stage, the client is able to focus on the reality of the loss and its meaning in relation
to life.
abirb.com/test
This is incorrect. This statement represents anger, stage 2 of
Kübler-Ross’s stages of
grief. The client is in the acceptance stage (stage 5) of the grief process. During this
stage, the client is able to focus on the reality of the loss and its meaning in relation
to life.
abirb.com/test
This is correct. The client is in the acceptance stage (stage 5) of Kübler-Ross’s
stages of grief. During this stage, the client is able to focus on the reality of the loss
and its meaning in relation to life.
abirb.com/test
This is incorrect. This statement represents depression, stage
4 of Kübler-Ross’s
stages of grief. The client is in the acceptance stage (stage 5) of the grief process.
During this stage, the client is able to focus on the reality of the loss and its meaning
in relation to life.
abirb.com/test
CON: Grief and Loss
abirb.com/test
18. A nurse is performing a mental health assessment on an adult client. The nurse
recognizes which action as demonstrating that the client has achieved
the highest level
abirb.com/test
of functioning according to Maslow’s hierarchy of needs?
1. Maintenance of a long-term, faithful, intimate relationship
2. A high level of self-confidence and autonomy
3. A feeling of self-fulfillment and realization of full potential abirb.com/test
4. Development of a sense of purpose and the ability to direct activities
ANS: 3
abirb.com/test
Chapter: Chapter 2, Mental Health and Mental Illness: Historical and Theoretical
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 2 - ETB
abirb.com/test
Concepts
Objective: Define mental health and mental illness.
Page: 15
Heading: Mental Health
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
Cognitive Level: Comprehension [Understanding]
Concept: Health Promotion
Difficulty: Moderate
abirb.com/test
abirb.com/test
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. The client who maintains a long-term, faithful, intimate
relationship has achieved love and belonging, which is not the highest level of
functioning on Maslow’s hierarchy of needs.
abirb.com/test
This is incorrect. The client who has a high level of self-confidence and autonomy
has achieved self-esteem, which is not the highest level of functioning on Maslow’s
hierarchy of needs.
abirb.com/test
This is correct. The client who possesses a feeling of self-fulfillment and realizes his
or her full potential has achieved self-actualization, the highest level of functioning
on Maslow’s hierarchy of needs.
This is incorrect. The client who has developed a sense of abirb.com/test
purpose and the ability to
direct activities has achieved self-esteem, which is not the highest level of
functioning on Maslow’s hierarchy of needs.
abirb.com/test
CON: Health Promotion
abirb.com/test
19. In which situation would the nurse be required to employ Maslow’s hierarchy of
needs to determine if immediate intervention is required to fulfill a lower-level need?
1. A client rudely complaining about limited visiting hours
abirb.com/test
2. A client exhibiting aggressive behavior toward another client
3. A client stating expressing feelings of sadness and loneliness
4. A client verbalizing feelings of failure and hopelessness
abirb.com/test
ANS: 2
Chapter: Chapter 2, Mental Health and Mental Illness: Historical and Theoretical
Concepts
abirb.com/test
Objective: Correlate adaptive and maladaptive responses to the mental health and mental
illness continuum.
Page: 15
abirb.com/test
Heading: Mental Health
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
abirb.com/test
Concept: Stress
abirb.com/test
abirb.com/test
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Chapter 2 - ETB
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/test
This is incorrect. A client rudely complaining does not demonstrate
that an
immediate intervention is required to fulfill a lower level need.
This is correct. The nurse should immediately intervene when a client exhibits
aggressive behavior toward another client. Maslow’s hierarchy
of needs indicates
abirb.com/test
that safety and security are lower-level needs, which must be fulfilled before higherlevel needs can be met. This client demonstrates the lower-level need for safety and
security.
abirb.com/test
This is incorrect. Feelings of sadness and loneliness demonstrate a possible higherlevel need and do not require immediate intervention.
This is incorrect. Feelings of hopelessness and failure demonstrate that a need is not
abirb.com/test
met but do not suggest that an immediate intervention is necessary.
CON: Stress
abirb.com/test
20. Which demonstrates use of the ego defense mechanism of regression?
1. A parent blames the teacher for their child’s failure in school. abirb.com/test
2. A teenager becomes hysterical after seeing a friend killed in a car accident.
3. A person chooses a spouse exactly like a beloved parent.
4. An adult throws a temper tantrum when he does not get his own
way.
abirb.com/test
ANS: 4
Chapter: Chapter 2, Mental Health and Mental Illness: Historical and Theoretical
abirb.com/test
Concepts
Objective: Describe psychological adaptation responses to stress.
Page: 19
Heading: Anxiety > Behavioral Adaptation Responses to Anxietyabirb.com/test
> Table 2–2, Ego
Defense Mechanisms
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Analysis [Analyzing]
Concept: Stress
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. This demonstrates displacement.
This is incorrect. This could demonstrate denial as one experiences grief.
abirb.com/test
This is incorrect. This does not demonstrate regression.
This is correct. Regression is the retreating to an earlier level of development and the
comfort measures associated with that level of functioning. An adult throwing a
abirb.com/test
temper tantrum demonstrates regression.
abirb.com/test
abirb.com/test
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Chapter 2 - ETB
abirb.com/test
CON: Stress
abirb.com/test
21. Which is the most significant consequence of excessive use of regression?
1. The superego is suppressed.
2. Emotions are experienced intensely.
abirb.com/test
3. Learning and personal growth are enhanced.
4. Problem-solving is limited.
abirb.com/test
ANS: 4
Chapter: Chapter 2, Mental Health and Mental Illness: Historical and Theoretical
Concepts
Objective: Describe psychological adaptation responses to stress.abirb.com/test
Page: 19
Heading: Anxiety > Behavioral Adaptation Responses to Anxiety > Table 2–2, Ego
Defense Mechanisms
abirb.com/test
Integrated Processes: Nursing Process: Evaluation
Client Need: Psychosocial Integrity
Cognitive Level: Comprehension [Understanding]
Concept: Stress
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/test
This is incorrect. Excessive use of regression does not cause the superego to be
suppressed.
This is incorrect. Regression does not cause emotions to be experienced intensely.
abirb.com/test
This is incorrect. Regression does not cause enhancement of
learning and personal
growth.
This is correct. Regression is the retreating to an earlier level of development and the
comfort measures associated with a previous level of functioning.
Regression results
abirb.com/test
in limited problem-solving abilities.
CON: Stress
abirb.com/test
22. The mental health nurse is conducting an intake interview with
a couple seeking
abirb.com/test
marital counseling. Which action by the husband demonstrates the ego defense
mechanism of projection?
1. He stamps his feet and demands his wife honor her vows.
abirb.com/test
2. He ignores his wife’s continued absence from the home.
3. He accuses his wife of infidelity and betrayal.
4. He takes out his frustration by verbally abusing his coworkers.
abirb.com/test
ANS: 3
abirb.com/test
abirb.com/test
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Chapter 2 - ETB
abirb.com/test
Chapter: Chapter 2, Mental Health and Mental Illness: Historical and Theoretical
Concepts
Objective: Describe psychological adaptation responses to stress.
abirb.com/test
Page: 19
Heading: Anxiety > Behavioral Adaptation Responses to Anxiety > Table 2–2, Ego
Defense Mechanisms
Integrated Processes: Nursing Process: Assessment
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Stress
abirb.com/test
Difficulty: Difficult
1.
2.
3.
4.
Feedback
This is incorrect. Stamping his feet and making demands may
represent regression.
abirb.com/test
This is incorrect. Ignoring his wife’s absence from the home could be an example of
repression.
This is correct. Projection is the attribution of feelings or impulses
unacceptable to
abirb.com/test
one’s self to another person. In this situation, the husband is attributing his feelings
of betrayal to his wife.
This is incorrect. Verbally abusing his coworkers demonstrates displacement.
abirb.com/test
CON: Stress
abirb.com/test
23. Which disorder does the nurse recognize as a disorder in the Diagnostic and
Statistical Manual of Mental Disorders, 5th edition (DSM-5)?
abirb.com/test
1. Morbid obesity
2. Generalized anxiety disorder
3. Essential hypertension
4. Bereavement
abirb.com/test
ANS: 2
Chapter: Chapter 2, Mental Health and Mental Illness: Historical and Theoretical
abirb.com/test
Concepts
Objective: Define mental health and mental illness.
Page: 14
Heading: Mental Illness
abirb.com/test
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
Cognitive Level: Comprehension [Understanding]
abirb.com/test
Concept: Stress
Difficulty: Easy
1.
Feedback
abirb.com/test
This is incorrect. Morbid obesity is a medical disorder. The DSM-5 delineates
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 2 - ETB
abirb.com/test
2.
3.
4.
diagnostic criteria for psychiatric disorders.
This is correct. The DSM-5 identifies several mental health disorders that are related
to anxiety, including generalized anxiety disorder, somatic symptom disorder, and
abirb.com/test
dissociative disorders.
This is incorrect. Essential hypertension is a medical disorder. The DSM-5 delineates
diagnostic criteria for psychiatric disorders.
abirb.com/test
This is incorrect. Bereavement is considered a normal response
to loss and is not
included in the DSM-5. The DSM-5 delineates diagnostic criteria for psychiatric
disorders.
CON: Stress
abirb.com/test
abirb.com/test
24. A nurse is educating a client about the difference between mental health and mental
illness. Which statement indicates that the teaching was effective?
1. “Mental health is characterized by an absence of stressors.” abirb.com/test
2. “Mental health is reflected by successful adaptation to stressors.”
3. “Mental health is incongruence between feelings and behavior.”
4. “Mental health is included in the diagnostic categories in the Diagnostic and
Statistical Manual of Mental Disorders, 5th edition (DSM-5).” abirb.com/test
ANS: 2
Chapter: Chapter 2, Mental Health and Mental Illness: Historicalabirb.com/test
and Theoretical
Concepts
Objective: Define mental health and mental illness.
Page: 14
abirb.com/test
Heading: Mental Illness
Integrated Processes: Teaching and Learning
Client Need: Health Promotion and Maintenance
Cognitive Level: Analysis [Analyzing]
abirb.com/test
Concept: Stress
Difficulty: Easy
1.
2.
3.
4.
abirb.com/test
Feedback
This is incorrect. All individuals experience stressors; this statement does not
differentiate mental health and mental illness.
This is correct. There are several definitions of mental health.
This definition
abirb.com/test
highlights concepts of successful adaptation to stressors, including thoughts,
feelings, and behaviors that are age appropriate and congruent with cultural and
societal norms.
abirb.com/test
This is incorrect. Incongruence between feelings and behavior
does not define
mental health.
This is incorrect. The DSM-5 does not include mental health among the diagnostic
categories.
abirb.com/test
abirb.com/test
abirb.com/test
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Chapter 2 - ETB
abirb.com/test
CON: Stress
abirb.com/test
25. Most cultures label behavior as mental illness based on which of the following
criteria?
1. Incomprehensibility and cultural relativity
abirb.com/test
2. Strength of character and ethics
3. Goal directedness and high energy
4. Creativity and good coping skills
abirb.com/test
ANS: 1
Chapter: Chapter 2, Mental Health and Mental Illness: Historical and Theoretical
Concepts
abirb.com/test
Objective: Discuss cultural elements that influence attitudes toward mental health and
mental illness.
Page: 15
abirb.com/test
Heading: Mental Illness
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
Cognitive Level: Comprehension [Understanding]
abirb.com/test
Concept: Culture
Difficulty: Easy
abirb.com/test
1.
2.
3.
4.
Feedback
This is correct. Incomprehensibility and cultural relativity are most often the criteria
used to define whether something is labeled mental illness.
abirb.com/test
This is incorrect. Strength of character and ethics is associated
with health rather
than illness.
This is incorrect. Goal directedness and high energy would be associated with health
rather than illness.
abirb.com/test
This is incorrect. Creativity and coping skills would be associated with health rather
than illness.
CON: Culture
abirb.com/test
abirb.com/test
26. Which of the following does the nurse recognize as an example of the defense
mechanism of repression?
1. A student who goes to a movie instead of studying for tomorrow’s math test
abirb.com/test
2. A parent who does not believe the military report that his or her
son was killed in Iraq
3. A person who is unhappily married and goes to school to become a marriage
counselor
4. A person who was raped at 12 years old and does not remember
it
abirb.com/test
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 2 - ETB
abirb.com/test
ANS: 4
Chapter: Chapter 2, Mental Health and Mental Illness: Historical and Theoretical
Concepts
Objective: Describe psychological adaptation responses to stress.abirb.com/test
Page: 19
Heading: Anxiety > Behavioral Adaptation Responses to Anxiety > Table 2–2, Ego
Defense Mechanisms
abirb.com/test
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Stress
Difficulty: Easy
1.
2.
3.
4.
Feedback
abirb.com/test
This is incorrect. Attending a movie instead of studying for a test could demonstrate
suppression.
This is incorrect. The parent not believing that his or her son was killed demonstrates
abirb.com/test
the grief process of denial.
This is incorrect. The person who becomes a marriage counselor due to an unhappy
marriage may demonstrate sublimation.
abirb.com/testfeelings and
This is correct. Repression is the involuntary blocking of unpleasant
experiences from one’s awareness.
CON: Stress
abirb.com/test
27. Who believed mental illness was curable?
1. Benjamin Rush
2. Dorothea Dix
3. Florence Nightingale
4. Linda Richards
abirb.com/test
abirb.com/test
ANS: 2
Chapter: Chapter 2, Mental Health and Mental Illness: Historicalabirb.com/test
and Theoretical
Concepts
Objective: Discuss the history of psychiatric care.
Page: 13
abirb.com/test
Heading: Historical Overview of Psychiatric Care
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Comprehension [Understanding]
Concept: Health Promotion
Difficulty: Easy
abirb.com/test
Feedback
abirb.com/test
abirb.com/test
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Chapter 2 - ETB
abirb.com/test
1.
2.
3.
4.
This is incorrect. Benjamin Rush was considered the father of American psychiatry
and was a physician at the first hospital in America to admit clients with mental
illness.
This is correct. Dorothea Dix was among the first nurses toabirb.com/test
advocate for those with
mental illness. She was unfaltering in her belief that mental illness was curable
through humanistic therapeutic care.
This is incorrect. Florence Nightingale is considered the founder
of modern nursing.
abirb.com/test
This is incorrect. Linda Richards is known as the first American psychiatric-mental
health nurse.
CON: Health Promotion
abirb.com/test
abirb.com/test
28. The nurse is caring for a client admitted to the palliative care unit. The client’s
spouse has been at the client’s bedside since the client was admitted. One week ago, the
spouse began to visit 2 or 3 hours a day. Which is the spouse experiencing?
abirb.com/test
1. Anticipatory grief
2. Bereavement overload
3. Depression
abirb.com/test
4. Resolution
ANS: 1
Chapter: Chapter 2, Mental Health and Mental Illness: Historicalabirb.com/test
and Theoretical
Concepts
Objective: Correlate adaptive and maladaptive responses to the mental health and mental
illness continuum.
abirb.com/test
Page: 20
Heading: Grief > Anticipatory Grief
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Grief and Loss
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is correct. The client’s spouse is experiencing anticipatory grief. Individuals
may begin the grieving process before the actual loss occurs.
Family members facing
abirb.com/test
the death of a loved one experience anticipatory grief when they complete the
mourning process prematurely. They disengage from the dying person, who may
then feel rejected during a time when psychological support is most needed.
This is incorrect. Grief can become bereavement overload,abirb.com/test
and people will perceive
this as difficult to overcome.
This is incorrect. Depression occurs as part of the grief process when the full impact
of the loss is understood.
abirb.com/test
This is incorrect. Resolution occurs when an individual is able to redefine his or her
abirb.com/test
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PMHN, 10e
Chapter 2 - ETB
abirb.com/test
life in the absence of the person lost.
CON: Grief and Loss
abirb.com/test
29. Which is determined by the degree to which thoughts, feelings,
and behaviors
abirb.com/test
interfere with an individual’s functioning?
1. Anxiety
2. Defense mechanisms
abirb.com/test
3. Mental health
4. Adaptation
ANS: 4
abirb.com/test
Chapter: Chapter 2, Mental Health and Mental Illness: Historical and Theoretical
Concepts
Objective: Describe psychological adaptation responses to stress.
abirb.com/test
Page: 16
Heading: Psychological Adaptation to Stress
Integrated Processes: Nursing Process: Assessment
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Comprehension [Understanding]
Concept: Stress
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. Anxiety is a feeling of discomfort and apprehension related to fear
abirb.com/test
of impending danger.
This is incorrect. Defense mechanisms are protective devices used to relieve mild to
moderate anxiety.
This is incorrect. Mental health may be viewed as a relative
state that occurs along a
abirb.com/test
continuum of thoughts, feelings, and behaviors that are all part of the human
psychological experience and are influenced by the perceived magnitude of stressors
interacting with adaptive capabilities.
abirb.com/test
This is correct. Adaptation is determined by the degree to which
thoughts, feelings,
and behaviors interfere with an individual’s functioning.
CON: Stress
abirb.com/test
abirb.com/test
30. When the general population cannot understand the motivation
behind one’s
behavior, which would be the appropriate term to use?
1. Anxiety
2. Defense mechanisms
abirb.com/test
3. Cultural relativity
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 2 - ETB
abirb.com/test
4. Incomprehensibility
ANS: 4
Chapter: Chapter 2, Mental Health and Mental Illness: Historicalabirb.com/test
and Theoretical
Concepts
Objective: Define mental health and mental illness.
Page: 15
abirb.com/test
Heading: Mental Illness
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Comprehension [Understanding]
Concept: Stress
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. Anxiety is a feeling of discomfort and apprehension related to fear
of impending danger.
abirb.com/test
This is incorrect. Defense mechanisms are protective devices used to relieve mild to
moderate anxiety.
This is incorrect. Cultural relativity is the understanding that rules, conventions, and
abirb.com/test
understandings are based on one’s culture.
This is correct. Incomprehensibility relates to the inability of the general population
to understand the motivation behind one’s behavior.
abirb.com/test
CON: Stress
abirb.com/test
MULTIPLE RESPONSE
abirb.com/test
31. Which of the following are included in Jahoda’s six indicators of mental health?
Select all that apply.
abirb.com/test
1. Acceptance
2. Creativity
3. Environmental mastery
4. Fulfillment
abirb.com/test
5. Integration
ANS: 3, 5
Chapter: Chapter 2, Mental Health and Mental Illness: Historicalabirb.com/test
and Theoretical
Concepts
Objective: Define mental health and mental illness.
Page: 14
abirb.com/test
Heading: Mental Health
abirb.com/test
abirb.com/test
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Chapter 2 - ETB
abirb.com/test
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
Cognitive Level: Comprehension [Understanding]
Concept: Patient-Centered Care
Difficulty: Moderate
1.
2.
3.
4.
5.
abirb.com/test
Feedback
abirb.com/test
This is incorrect. Acceptance is not one of Jahoda’s six indicators of mental health.
This is incorrect. Creativity is not one of Jahoda’s six indicators of mental health.
This is correct. Jahoda’s six indicators of mental health include environmental
abirb.com/test
mastery.
This is incorrect. Fulfillment is not one of Jahoda’s six indicators of mental health.
This is correct. Jahoda’s six indicators of mental health include integration.
abirb.com/test
CON: Patient-Centered Care
abirb.com/test
32. Mental illness was attributed to which of the following factors prior to the influence
of Middle Eastern countries? Select all that apply.
abirb.com/test
1. Supernatural forces
2. Medical conditions
3. Disequilibrium of humors
4. Personality
abirb.com/test
5. Demons
ANS: 1, 3, 5
Chapter: Chapter 2, Mental Health and Mental Illness: Historicalabirb.com/test
and Theoretical
Concepts
Objective: Discuss the history of psychiatric care.
Page: 13
abirb.com/test
Heading: Historical Overview of Psychiatric Care
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Comprehension [Understanding]
Concept: Patient-Centered Care
Difficulty: Moderate
abirb.com/test
1.
2.
3.
Feedback
This is correct. Middle Eastern countries believed mental illness was a medical
condition. Prior to this, mental illnesses were attributed to several things, including
abirb.com/test
supernatural forces.
This is incorrect. Middle Eastern countries believed mental illness was a medical
condition and not result of supernatural forces.
abirb.com/test
This is correct. Middle Eastern countries believed mental illness
was a medical
condition. Prior to this, mental illnesses were attributed to several things including
abirb.com/test
abirb.com/test
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Chapter 2 - ETB
abirb.com/test
4.
5.
disequilibrium of humors.
This is incorrect. Mental health was not attributed to personality.
This is correct. Middle Eastern countries believed mental illness was a medical
abirb.com/test
condition. Prior to this, mental illnesses were attributed to several things, including
demons.
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
33. Which statements regarding defense mechanisms are true? Select all that apply.
1. They are employed when there is a threat to biological or psychological integrity.
2. They are controlled by the id and deal with primal urges.
abirb.com/test
3. They are used to relieve mild to moderate anxiety.
4. They are protective devices for the superego.
5. They are mechanisms that are characteristically self-deceptive.
abirb.com/test
ANS: 1, 3, 5
Chapter: Chapter 2, Mental Health and Mental Illness: Historical and Theoretical
Concepts
Objective: Describe psychological adaptation responses to stress.abirb.com/test
Page: 17
Heading: Anxiety > Behavioral Adaptation Responses to Anxiety
Integrated Processes: Nursing Process: Assessment
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Knowledge [Remembering]
Concept: Stress
abirb.com/test
Difficulty: Easy
1.
2.
3.
4.
5.
Feedback
This is correct. Defense mechanisms are employed by the ego
in the face of threats
abirb.com/test
to biological and psychological integrity.
This is incorrect. Defense mechanisms are not controlled by the id and do not deal
with primal urges.
abirb.com/test
This is correct. Defense mechanisms are employed by the ego
to relieve mild to
moderate anxiety.
This is incorrect. Defense mechanisms are not protective devices for the superego.
This is correct. Defense mechanisms are employed by the ego
in the face of threats
abirb.com/test
to biological and psychological integrity to relieve mild to moderate anxiety.
Because they redirect focus, they are characteristically self-deceptive.
CON: Stress
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 2 - ETB
abirb.com/test
34. Which behaviors indicate a client is experiencing moderate anxiety? Select all that
apply.
1. Gastric discomfort
abirb.com/test
2. Urinary frequency
3. Palpitations
4. Focus on self
5. Feelings of dread
abirb.com/test
ANS: 1, 4
Chapter: Chapter 2, Mental Health and Mental Illness: Historical and Theoretical
abirb.com/test
Concepts
Objective: Describe psychological adaptation responses to stress.
Page: 16
Heading: Anxiety
abirb.com/test
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Stress
Difficulty: Moderate
1.
2.
3.
4.
5.
abirb.com/test
Feedback
This is correct. Gastric discomfort occurs with moderate anxiety.
This is incorrect. Urinary frequency occurs with severe anxiety.
This is incorrect. Palpitations are symptoms of severe anxiety.
abirb.com/test
This is correct. Moderate anxiety may result in an increased focus on self.
This is incorrect. Feelings of dread are symptomatic of severe anxiety.
CON: Stress
abirb.com/test
abirb.com/test
35. For which reasons is the Diagnostic and Statistical Manual of Mental Disorders, 5th
edition (DSM-5) useful in the practice of psychiatric-mental health nursing? Select all
that apply.
abirb.com/test
1. It informs the nurse of accurate and reliable psychiatric diagnoses.
2. It represents progress toward a more holistic view of mind and body.
3. It provides a framework for interdisciplinary communication.
4. It provides a template for psychiatric-mental health nursing care
plans.
abirb.com/test
5. It provides a framework for communication with the client.
ANS: 1, 2, 3
Chapter: Chapter 2, Mental Health and Mental Illness: Historicalabirb.com/test
and Theoretical
Concepts
Objective: Define mental health and mental illness.
Page: 21
abirb.com/test
Heading: Mental illness
abirb.com/test
abirb.com/test
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Chapter 2 - ETB
abirb.com/test
Integrated Processes: Nursing Process: Assessment
Client Need: Safe and Effective Care Environment
Cognitive Level: Comprehension [Understanding]
Concept: Patient-Centered Care
Difficulty: Moderate
1.
2.
3.
4.
5.
abirb.com/test
Feedback
abirb.com/test
This is correct. The DSM-5 is useful in the practice of psychiatric-mental health
nursing because it provides information about accurate and reliable psychiatric
diagnoses.
abirb.com/test
This is correct. The DSM-5 encourages a holistic view of mind and body and
provides a framework for interdisciplinary communication.
This is correct. The DSM-5 provides a framework for interdisciplinary
abirb.com/test
communication.
This is incorrect. The DSM-5 does not provide templates for nursing care plans.
This is incorrect. The DSM-5 does not provide a framework for communication with
the client.
abirb.com/test
CON: Patient-Centered Care
abirb.com/test
ORDERED RESPONSE
abirb.com/test
36. Place Kübler-Ross’ stages of grief in the correct order.
1. _____Anger
2. _____Bargaining
3. _____Denial
4. _____Depression
5. _____Acceptance
abirb.com/test
abirb.com/test
ANS: 3, 1, 2, 4, 5
Chapter: Chapter 2, Mental Health and Mental Illness: Historicalabirb.com/test
and Theoretical
Concepts
Objective: Describe psychological adaptation responses to stress.
Page: 20
abirb.com/test
Heading: Grief > Stages of Grief
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Knowledge [Remembering]
Concept: Grief and Loss
Difficulty: Easy
abirb.com/test
abirb.com/test
abirb.com/test
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Chapter 2 - ETB
abirb.com/test
Feedback: The five stages of feelings and behaviors individuals experience in response
to real, perceived, or anticipated loss are denial, anger, bargaining, depression, and
acceptance.
abirb.com/test
CON: Grief and Loss
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
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Chapter 3 - ETB
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Chapter 3. Concepts of Psychobiology
abirb.com/test
MULTIPLE CHOICE
abirb.com/test
1. Which disorder is genetically inherited?
1. Autism
2. Parkinson’s disease
3. Anorexia nervosa
4. Obsessive compulsive disorder
abirb.com/test
abirb.com/test
ANS: 1
Chapter: Chapter 3, Concepts of Psychobiology
Objective: Describe the role of genetics in the development of psychiatric
abirb.com/testdisorders.
Page: 35
Heading: Genetics
Integrated Processes: Nursing Process
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Comprehension [Understanding]
Concept: Neurological Regulation
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is correct. Autism, attention deficit-hyperactivity disorder, bipolar disorder,
abirb.com/test
major depression, and schizophrenia all show some common gene variations,
including differences in two genes that regulate the flow of calcium into cells.
This is incorrect. Parkinson’s disease is caused by a deficiency in dopamine levels
abirb.com/test
and is rarely genetic.
This is incorrect. Anorexia nervosa is not genetic.
This is incorrect. Obsessive compulsive disorder is not an inherited condition.
abirb.com/test
CON: Neurological Regulation
abirb.com/test
2. A client diagnosed with major depressive disorder asks, “Which part of my brain
controls my emotions?” Which nursing response is best?
1. “The occipital lobe judges perceptions as positive or negative.”abirb.com/test
2. “The parietal lobe has been linked to depression.”
3. “The medulla regulates key biological and psychological activities.”
4. “The limbic system is largely responsible for one’s emotional state.”
abirb.com/test
ANS: 4
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Chapter 3 - ETB
abirb.com/test
Chapter: Chapter 3, Concepts of Psychobiology
Objective: Identify gross anatomical structures of the brain and describe their functions.
Page: 27
Heading: The Nervous System: An Anatomical Review>Limbic abirb.com/test
System
Integrated Processes: Teaching and Learning
Nursing Process: Implementation
Client Need: Health Promotion and Maintenance
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Health Promotion
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. The occipital lobe is the primary area of visual reception and
interpretation.
abirb.com/test
This is incorrect. The parietal lobe is where perception and interpretation of most
sensory information occurs (including touch, pain, taste, and body position).
This is incorrect. The medulla is the pathway for all ascending
and descending fiber
abirb.com/test
tracts. It contains vital centers that regulate heart rate, blood pressure, respiration,
and reflexes for swallowing, sneezing, coughing, and vomiting.
This is correct. The limbic system is largely responsible for one’s emotional state.
abirb.com/test
This system is often called the “emotional brain” and is associated
with feelings,
sexuality, and social behavior.
CON: Health Promotion
abirb.com/test
abirb.com/test
3. Which part of the nervous system would the nurse identify as playing
a major role
during stressful situations?
1. Peripheral nervous system
2. Somatic nervous system
abirb.com/test
3. Sympathetic nervous system
4. Parasympathetic nervous system
abirb.com/test
ANS: 3
Chapter: Chapter 3, Concepts of Psychobiology
Objective: Discuss the physiology of neurotransmission in the central nervous system.
Page: 33
abirb.com/test
Heading: Autonomic Nervous System
Integrated Processes: Physiological Integrity
Client Need: Nursing Process: Assessment
abirb.com/test
Cognitive Level: Knowledge [Remembering]
Concept: Neurological Regulation
Difficulty: Easy
abirb.com/test
Feedback
abirb.com/test
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Chapter 3 - ETB
abirb.com/test
1.
2.
3.
4.
This is incorrect. The peripheral nervous system is the part of the nervous system
outside of the brain and spinal cord and includes the 12 cranial nerves. The
sympathetic and parasympathetic nervous systems are part of the peripheral nervous
abirb.com/test
system.
This is incorrect. The somatic nervous system is part of the peripheral nervous
system and is associated with voluntary control of body movements via skeletal
muscles.
abirb.com/test
This is correct. The sympathetic nervous system plays a major role during stressful
situations. The sympathetic nervous system prepares the body for the fight-or-flight
response.
abirb.com/test
This is incorrect. The parasympathetic nervous system is dominant when an
individual is in a nonstressed state.
CON: Neurological Regulation
abirb.com/test
abirb.com/test
4. Which client statement indicates the nurse’s teaching about the effect of circadian
rhythms is effective?
1. “When I dream about my mother’s horrible train accident, I become hysterical.”
abirb.com/test
2. “I get really irritable during my menstrual cycle.”
3. “I’m a morning person, so I get my best work done in the a.m.”
4. “Every February, I tend to experience periods of sadness.”
abirb.com/test
ANS: 3
Chapter: Chapter 3, Concepts of Psychobiology
Objective: Discuss the association of endocrine functioning to the development of
abirb.com/test
psychiatric disorders.
Page: 41
Heading: Circadian Rhythms
Integrated Processes: Teaching and Learning
abirb.com/test
Nursing Process: Evaluation
Client Need: Physiological Adaptation
Cognitive Level: Analysis [Analyzing]
abirb.com/test
Concept: Sleep and Rest
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/test
This is incorrect. This statement indicates an alteration in REM sleep.
This is incorrect. The client’s statement demonstrates symptoms associated with
premenstrual dysphoric disorder.
abirb.com/test
This is correct. The client’s statement demonstrates understanding
that circadian
rhythms may influence a variety of regulatory functions, including the sleep–wake
cycle, regulation of body temperature, and patterns of activity. Most humans follow
a 24-hour cycle that is largely affected by light and darkness.
abirb.com/test
This is incorrect. This statement indicates the client is depressed in winter months
abirb.com/test
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Chapter 3 - ETB
abirb.com/test
when the amount of daylight decreases (seasonal affective disorder).
CON: Sleep and Rest
abirb.com/test
5. Six months after a client’s spouse and children were killed in aabirb.com/test
car accident, the client
is diagnosed with ulcerative colitis. The nurse should recognize that this situation
validates which study perspective?
1. Neuroendocrinology
abirb.com/test
2. Psychoneuroimmunology
3. Diagnostic technology
4. Neurophysiology
abirb.com/test
ANS: 2
Chapter: Chapter 3, Concepts of Psychobiology
Objective: Discuss the influence of psychological factors on the immune system.
abirb.com/test
Page: 39
Heading: Psychoneuroimmunology > Implications of the Immune System in Psychiatric
Illness
abirb.com/test
Integrated Processes: Caring
Nursing Process: Assessment
Client Need: Physiological Adaptation
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Neurological Regulation
Difficulty: Moderate
1.
2.
3.
4.
abirb.com/test
Feedback
This is incorrect. Neuroendocrinology is the study of the interaction between the
nervous and endocrine systems and the effects of various hormones on cognitive,
emotional, and behavioral functioning.
abirb.com/test
This is correct. Psychoneuroimmunology is the branch of medicine that studies the
effects of social and psychological factors on the functioning of the immune system.
Studies of the biological response to stress hypothesize that individuals become
more susceptible to physical illness following exposure to abirb.com/test
stressful stimuli.
This is incorrect. Diagnostic technology is the imaging and other technological
procedures used for identifying alterations in brain structure and function associated
with mental illness.
abirb.com/test
This is incorrect. Neurophysiology is the functioning of various parts of the brain
and their correlation to human behavior and psychopathology.
CON: Neurological Regulation
abirb.com/test
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 3 - ETB
abirb.com/test
6. A client who is diagnosed with schizophrenia expresses little emotion and refuses to
attend group therapy is influenced by which component of the nervous system?
1. Dendrites
abirb.com/test
2. Axons
3. Neurotransmitters
4. Synapses
abirb.com/test
ANS: 3
Chapter: Chapter 3, Concepts of Psychobiology
Objective: Discuss the correlation of altered brain function to various psychiatric
abirb.com/test
disorders.
Page: 33
Heading: Nerve Tissue>Synapses
Integrated Processes: Caring
abirb.com/test
Nursing Process: Assessment
Client Need: Physiological Adaptation
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Neurological Regulation
Difficulty: Moderate
1.
2.
3.
4.
abirb.com/test
Feedback
This is incorrect. Dendrites are processes that transmit impulses toward the cell
body.
This is incorrect. Axons transmit impulses away from the cell
body.
abirb.com/test
This is correct. Excessive or deficient activity of neurotransmitters influences a
variety of cognitive and emotional symptoms.
This is incorrect. A synapse is the junction between two neurons.
abirb.com/test
CON: Neurological Regulation
abirb.com/test
7. Which diagnostic imaging procedure would the nurse prepare the client for to
determine neurotransmitter–receptor interaction?
abirb.com/test
1. Electroencephalography (EEG)
2. Computed tomographic (CT) scan
3. Magnetic resonance imaging (MRI)
4. Positron emission tomography (PET) scan
abirb.com/test
ANS: 4
Chapter: Chapter 3, Concepts of Psychobiology
abirb.com/test
Objective: Identify diagnostic procedures used to detect alteration
in biological
functioning that may contribute to psychiatric disorders.
Page: 46
Heading: Table 3-5 Diagnostic Procedures Used to Detect Altered
Brain Functioning
abirb.com/test
Integrated Processes: Nursing Process
abirb.com/test
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PMHN, 10e
Chapter 3 - ETB
abirb.com/test
Nursing Process: Implementation
Client Need: Physiological Adaptation
Cognitive Level: Comprehension [Understanding]
Concept: Neurological Regulation
Difficulty: Moderate
1.
2.
3.
4.
abirb.com/test
Feedback
abirb.com/test
This is incorrect. EEG measures brain electrical activity; identifies dysrhythmias,
asymmetries, or suppression of brain rhythms; and is used in the diagnosis of
epilepsy, neoplasm, stroke, metabolic, or degenerative disease.
abirb.com/test
This is incorrect. A CT scan measures accuracy of brain structure to detect possible
lesions, abscesses, areas of infarction, or aneurysm. CT scans have also identified
various anatomical differences in clients with schizophrenia, organic mental
abirb.com/test
disorders, and bipolar disorder.
This is incorrect. MRI measures the anatomical and biochemical statuses of various
segments of the brain and detects brain edema, ischemia, infection, neoplasm,
trauma, and other changes, such as demyelination. Morphological
differences have
abirb.com/test
been noted in the brains of clients with schizophrenia when compared with control
subjects.
This is correct. PET scan measures specific brain functioning, such as glucose
abirb.com/test
metabolism, oxygen utilization, blood flow, and, of particular
interest in psychiatry,
neurotransmitter–receptor interaction.
CON: Neurological Regulation
abirb.com/test
abirb.com/test
8. Which neurotransmitter is associated with the fight-or-flight response
of a restless,
agitated client?
1. Acetylcholine
2. Dopamine
abirb.com/test
3. Serotonin
4. Norepinephrine
abirb.com/test
ANS: 4
Chapter: Chapter 3, Concepts of Psychobiology
Objective: Describe the role of neurotransmitters in human behavior.
Page: 35
abirb.com/test
Heading: Monoamines > Norepinephrine
Integrated Processes: Nursing Process
Nursing Process: Evaluation
abirb.com/test
Client Need: Physiological Integrity
Cognitive Level: Analysis [Analyzing]
Concept: Neurological Regulation
Difficulty: Moderate
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 3 - ETB
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. The functions of acetylcholine are manifold and include sleep,
arousal, pain perception, modulation and coordination of movement, and memory
abirb.com/test
acquisition and retention.
This is incorrect. Dopamine is responsible for regulating movement and
coordination, emotions, and voluntary decision-making. It also inhibits the release of
prolactin.
abirb.com/test
This is incorrect. Serotonin plays a role in sleep and arousal, libido, appetite, mood,
aggression, and pain perception. Too much and too little serotonin is associated with
anxiety.
abirb.com/test
This is correct. Norepinephrine is associated with the fight-or-flight response.
Norepinephrine produces activity in the sympathetic postsynaptic nerve terminal and
is associated with the regulation of mood, cognition, perception, locomotion, sleep,
abirb.com/test
and arousal.
CON: Neurological Regulation
abirb.com/test
9. Which neurotransmitters would the nurse expect to be elevated in a client with a
abirb.com/test
diagnosis of catatonic schizophrenia?
1. Serotonin
2. Dopamine
3. Norepinephrine
abirb.com/test
4. Histamine
ANS: 2
abirb.com/test
Chapter: Chapter 3, Concepts of Psychobiology
Objective: Describe the role of neurotransmitters in human behavior.
Page: 34
Heading: Neurotransmitters > Dopamine
abirb.com/test
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Neurological Regulation
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/test
This is incorrect. Elevated serotonin levels can lead to anxiety and aggression.
This is correct. Elevated dopamine levels may be a contributing factor to the client’s
current level of functioning. Dopamine functions include regulation of movements
abirb.com/test
and coordination, emotions, and voluntary decision-making
ability.
This is incorrect. Elevated norepinephrine levels would lead to increased excitability,
anxiety, and euphoria.
abirb.com/test disturbances
This is incorrect. Elevated histamine levels can lead to gastrointestinal
and anxiety.
abirb.com/test
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Chapter 3 - ETB
abirb.com/test
CON: Neurological Regulation
abirb.com/test
10. A client’s spouse of 34 years dies unexpectedly. The client cries often and becomes
socially isolated. The client’s therapist stresses the importance ofabirb.com/test
proper sleep, nutrition,
and exercise. Which statement is true regarding the rationale for the therapist’s advice?
1. An interpersonal approach is indicated for depressed clients.
2. Sleep, nutrition, and exercise affect imbalances in neurotransmitters.
abirb.com/test
3. Sleep, nutrition, and exercise will alleviate symptoms of depression.
4. The client is susceptible to illness due to effects of stress on the immune system.
ANS: 4
abirb.com/test
Chapter: Chapter 3, Concepts of Psychobiology
Objective: Discuss the influence of psychological factors on the immune system.
Page: 44
abirb.com/test
Heading: Psychoneuroimmunology > Implications of the Immune System in Psychiatric
Illness
Integrated Processes: Caring
Nursing Process: Evaluation
abirb.com/test
Client Need: Physiological Integrity
Cognitive Level: Application [Applying]
Concept: Immunity
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/test
This is incorrect. The therapist’s advice is not based on evidence
supporting
interpersonal approach for depressed clients; rather, it is based on evidence
supporting the effects of stress on the immune system.
This is incorrect. Sleep, nutrition, and exercise do not directly
affect
abirb.com/test
neurotransmitters.
This is incorrect. Sleep, nutrition, and exercise will not completely alleviate
symptoms of depression.
abirb.com/test
This is correct. The therapist’s advice is based on the knowledge
that the client is at
increased risk of developing illness due to the effects of stress (the loss of the
spouse) on the immune system. The study of this branch of medicine is called
psychoneuroimmunology.
abirb.com/test
CON: Immunity
abirb.com/test
11. Which mental illness would a nurse identify as being associated with a decrease in
prolactin levels?
abirb.com/test
1. Attention deficit disorder
abirb.com/test
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Chapter 3 - ETB
abirb.com/test
2. Schizophrenia
3. Anorexia nervosa
4. Alzheimer’s disease
abirb.com/test
ANS: 2
Chapter: Chapter 3, Concepts of Psychobiology
Objective: Discuss the association of endocrine functioning to the
development of
abirb.com/test
psychiatric disorders.
Page: 41
Heading: The Anterior Pituitary (Adenohypophysis) > Prolactin
abirb.com/test
Integrated Processes: Nursing Process
Nursing Process: Assessment
Client Need: Physiological Integrity
Cognitive Level: Analysis (Analyzing)
abirb.com/test
Concept: Neurological Regulation
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. Prolactin levels are not low in a client with attention deficit
disorder.
This is correct. Although the exact mechanism is unknown,abirb.com/test
there may be some
correlation between decreased levels of the hormone prolactin and the diagnosis of
schizophrenia. Some studies have shown an inverse relationship between prolactin
concentrations and symptoms of schizophrenia.
abirb.com/test
This is incorrect. There is no correlation between anorexia nervosa and a decrease in
prolactin level.
This is incorrect. There is no correlation between Alzheimer’s disease and a decrease
abirb.com/test
in prolactin level.
CON: Neurological Regulation
abirb.com/test
12. Teaching is effective if the students identify which cerebral structure as the
abirb.com/test
“emotional brain?”
1. Cerebellum
2. Limbic system
3. Cerebral cortex
abirb.com/test
4. Left temporal lobe
ANS: 2
abirb.com/test
Chapter: Chapter 3, Concepts of Psychobiology
Objective: Identify gross anatomical structures of the brain and describe their functions.
Page: 31
Heading: The Nervous System: An Anatomical Review > Limbicabirb.com/test
System
Integrated Processes: Teaching/Learning
abirb.com/test
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Chapter 3 - ETB
abirb.com/test
Client Need: Physiological Integrity
Cognitive Level: Comprehension [Understanding]
Concept: Neurological Regulation
Difficulty: Easy
1.
2.
3.
4.
abirb.com/test
Feedback
This is incorrect. The cerebellum is responsible for regulating
muscle tone and
abirb.com/test
coordination in addition to maintaining posture and equilibrium.
This is correct. The limbic system is often referred to as the “emotional brain.” The
limbic system is largely responsible for one’s emotional state and is associated with
abirb.com/test
feelings, sexuality, and social behavior.
This is incorrect. The cerebral cortex is the surface of the cerebrum and consists of
gray matter. It controls movement, speech, memory, and intelligence.
This is incorrect. The function of the left temporal lobe (inabirb.com/test
conjunction with the left
parietal lobe) is language interpretation.
CON: Neurological Regulation
abirb.com/test
abirb.com/test
13. The nurse understands that abnormal levels of growth hormone
may play a role in
which disorder?
1. Acute mania
2. Schizophrenia
abirb.com/test
3. Anorexia nervosa
4. Alzheimer’s disease
abirb.com/test
ANS: 3
Chapter: Chapter 3, Concepts of Psychobiology
Objective: Discuss the association of endocrine functioning to the development of
psychiatric disorders.
abirb.com/test
Page: 40
Heading: Growth Hormone
Integrated Processes: Nursing Process
abirb.com/test
Nursing Process: Assessment
Client Need: Physiological Integrity
Cognitive Level: Comprehension [Understanding]
Concept: Neurological Regulation
abirb.com/test
Difficulty: Moderate
1.
2.
3.
Feedback
abirb.com/test
This is incorrect. There is not a correlation between abnormal
levels of growth
hormone and acute mania.
This is incorrect. Research does not show a correlation between abnormal levels of
growth hormone and schizophrenia.
abirb.com/test
This is correct. Research has shown there is a correlation between abnormal levels of
abirb.com/test
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Chapter 3 - ETB
abirb.com/test
4.
growth hormone and anorexia nervosa. Growth hormone is responsible for growth in
children as well as continued protein synthesis throughout life.
This is incorrect. There is no evidence to support a correlation between abnormal
abirb.com/test
levels of growth hormone and Alzheimer’s disease.
CON: Neurological Regulation
abirb.com/test
14. Which alteration in brain chemistry would the nurse correlate with a client
abirb.com/test
presenting with decreased motor function and memory deficit?
1. Abnormal levels of serotonin
2. Decreased levels of dopamine
abirb.com/test
3. Increased levels of norepinephrine
4. Decreased levels of acetylcholine
ANS: 4
abirb.com/test
Chapter: Chapter 3, Concepts of Psychobiology
Objective: Describe the role of neurotransmitters in human behavior.
Page: 33
abirb.com/test
Heading: Neurotransmitters > Cholinergic Neurotransmitters > Acetylcholine
Integrated Processes: Nursing Process
Nursing Process: Assessment
Client Need: Physiological Integrity
abirb.com/test
Cognitive Level: Analysis [Analyzing]
Concept: Neurological Regulation
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. Abnormal levels of serotonin can lead to aggression, anxiety,
alteration in coordination or judgment, and alteration in libido.
abirb.com/test
This is incorrect. Decreased levels of dopamine lead to muscle cramps or tremors
and loss of balance.
This is incorrect. A client experiencing an increased level of norepinephrine would
abirb.com/test
present with locomotion symptoms (increased heart rate and
blood pressure, anxiety,
restlessness, and agitation).
This is correct. Decreased levels of acetylcholine are associated with memory
deficits and decreased motor function. Acetylcholine is a major
effector chemical of
abirb.com/test
the autonomic nervous system. Functions of acetylcholine include sleep regulation,
pain perception, the modulation and coordination of movement, and memory.
CON: Neurological Regulation
abirb.com/test
abirb.com/test
15. A decrease in norepinephrine levels plays a significant role in which disorder?
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 3 - ETB
abirb.com/test
1. Mania
2. Schizophrenia
3. Anxiety
4. Major depressive disorder
abirb.com/test
ANS: 4
Chapter: Chapter 3, Concepts of Psychobiology
abirb.com/test
Objective: Discuss the correlation of altered brain function to various psychiatric
disorders.
Page: 45
abirb.com/test
Heading: Monoamines > Norepinephrine
Integrated Processes: Nursing Process
Nursing Process: Assessment
Client Need: Physiological Integrity
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Neurological Regulation
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. An increase in norepinephrine levels can lead to mania.
This is incorrect. An increase in norepinephrine levels can abirb.com/test
lead to schizophrenia.
This is incorrect. An increase in norepinephrine levels can lead to anxiety.
This is correct. Decreased levels of norepinephrine play a significant role in major
depressive disorder. The functions of norepinephrine include
the regulation of mood,
abirb.com/test
cognition, perception, locomotion, cardiovascular functioning, sleep, and arousal.
CON: Neurological Regulation
abirb.com/test
16. Which client diagnosis would the nurse associate with a decrease
in gammaabirb.com/test
aminobutyric acid (GABA) levels?
1. Alzheimer’s disease
2. Anorexia nervosa
abirb.com/test
3. Panic disorder
4. Depression
ANS: 3
abirb.com/test
Chapter: Chapter 3, Concepts of Psychobiology
Objective: Discuss the correlation of altered brain function to various psychiatric
disorders.
abirb.com/test
Page: 37
Heading: Amino Acids > Inhibitory Amino Acids > Gamma-Aminobutyric Acid
Integrated Processes: Nursing Process
Nursing Process: Evaluation
abirb.com/test
Client Need: Physiological Integrity
abirb.com/test
abirb.com/test
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Chapter 3 - ETB
abirb.com/test
Cognitive Level: Comprehension [Understanding]
Concept: Neurological Regulation
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. Decreased GABA levels are not associated with Alzheimer’s
disease.
abirb.com/test
This is incorrect. Anorexia nervosa is not associated with decreased GABA levels.
This is correct. A decrease in GABA levels is associated with panic disorder.
Enhancement of the GABA system is the mechanism of action by which
abirb.com/test
benzodiazepines produce a calming effect, thus reducing anxiety. Alterations in the
GABA system are also associated with movement disorders and epilepsy.
This is incorrect. There is no evidence suggesting depression is caused by decreased
abirb.com/test
GABA levels.
CON: Neurological Regulation
abirb.com/test
17. An increase in dopamine activity might play a significant role in the development of
abirb.com/test
which disorder?
1. Schizophrenia
2. Major depressive disorder
3. Body dysmorphic disorder
abirb.com/test
4. Parkinson’s disease
ANS: 1
abirb.com/test
Chapter: Chapter 3, Concepts of Psychobiology
Objective: Discuss the correlation of altered brain function to various psychiatric
disorders.
Page: 37
abirb.com/test
Heading: Amino Acids > Inhibitory Amino Acids > Gamma-Aminobutyric Acid
Integrated Processes: Nursing Process
Nursing Process: Evaluation
abirb.com/test
Client Need: Physiological Integrity
Cognitive Level: Comprehension [Understanding]
Concept: Neurological Regulation
Difficulty: Moderate
abirb.com/test
1.
2.
Feedback
This is correct. An increase in dopamine activity might play a significant role in the
abirb.com/test
development of schizophrenia. Dopamine functions include
regulation of emotions,
coordination, and voluntary decision-making ability. Increased dopamine activity is
also associated with mania.
This is incorrect. A decrease in dopamine activity can leadabirb.com/test
to major depressive
disorder.
abirb.com/test
abirb.com/test
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Chapter 3 - ETB
abirb.com/test
3.
4.
This is incorrect. There is no correlation between dopamine activity and body
dysmorphic disorder.
This is incorrect. A decrease in dopamine activity is associated with Parkinson’s
abirb.com/test
disease.
CON: Neurological Regulation
abirb.com/test
18. Which student statement indicates that teaching has been effective regarding the
abirb.com/test
function of the monoamine category of neurotransmitters?
1. “Their function is to regulate movement, coordination, and emotions.”
2. “These regulate mood, cognition, and perception.”
abirb.com/test
3. “Norepinephrine functions to regulate arousal, libido, and appetite.”
4. “They function to regulate pain and the inflammatory response.”
ANS: 2
abirb.com/test
Chapter: Chapter 3, Concepts of Psychobiology
Objective: Describe the role of neurotransmitters in human behavior.
Page: 45
abirb.com/test
Heading: Monoamines > Norepinephrine
Nursing Process: Evaluation
Integrated Processes: Teaching/Learning
Client Need: Physiological Integrity
abirb.com/test
Cognitive Level: Analysis [Analyzing]
Concept: Neurological Regulation
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. Dopamine regulates movement, coordination, and emotions.
This is correct. The functions of norepinephrine include theabirb.com/test
regulation of mood,
cognition, perception, locomotion, and cardiovascular function. Norepinephrine has
also been implicated in certain mood disorders such as depression and mania,
anxiety states, and schizophrenia.
abirb.com/test
This is incorrect. Serotonin regulates arousal, libido, and appetite.
This is incorrect. The function of histamine is to regulate pain and the inflammatory
response.
abirb.com/test
CON: Neurological Regulation
abirb.com/test
19. Learning has occurred when the student identifies that the neurotransmitter serotonin
is catabolized by which enzyme?
1. Catechol-O-methyltransferase (COMT)
abirb.com/test
2. GABA transaminase
abirb.com/test
abirb.com/test
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Chapter 3 - ETB
abirb.com/test
3. Acetylcholinesterase
4. Monoamine oxidase
abirb.com/test
ANS: 4
Chapter: Chapter 3, Concepts of Psychobiology
Objective: Discuss the physiology of neurotransmission in the central nervous system.
Page: 46
abirb.com/test
Heading: Monoamines > Serotonin
Integrated Processes: Teaching/Learning
Client Need: Physiological Integrity
abirb.com/test
Cognitive Level: Comprehension [Understanding]
Concept: Neurological Regulation
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. COMT inactivates dopamine and norepinephrine, not serotonin.
This is incorrect. GABA transaminase catabolizes GABA, not serotonin.
abirb.com/test
This is incorrect. Acetylcholinesterase inhibits the activity of acetylcholine, not
serotonin.
This is correct. Serotonin that is not returned to be stored in the axon terminal
vesicles is catabolized by the enzyme monoamine oxidase.abirb.com/test
CON: Neurological Regulation
abirb.com/test
20. A client experiencing sleep apnea underwent a sleep study. During stage 3 of sleep, a
abirb.com/test
delta rhythm was recorded. The nurse recognizes that a delta rhythm
is characterized by
which sleep activity?
1. Dozing
2. Deep and restful sleep
abirb.com/test
3. Relaxed waking
4. Dreaming
abirb.com/test
ANS: 2
Chapter: Chapter 3, Concepts of Psychobiology
Objective: Identify diagnostic procedures used to detect alteration in biological
functioning that may be contributing to psychiatric disorders. abirb.com/test
Page: 42
Heading: Sleep
Integrated Processes: Nursing Process
abirb.com/test
Nursing Process: Assessment
Client Need: Physiological Integrity
Cognitive Level: Application [Applying]
Concept: Sleep and Rest
abirb.com/test
Difficulty: Moderate
abirb.com/test
abirb.com/test
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Chapter 3 - ETB
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. Dozing occurs during stage 1 (beta rhythm) of sleep. The client
abirb.com/test
experiences a period of dozing in which thoughts wander and
the person drifts in and
out of sleep.
This is correct. The delta rhythm that occurs during stage 3 of sleep is characterized
by a period of deep and restful sleep. Muscles are relaxed, abirb.com/test
heart rate and blood
pressure fall, and breathing slows. No eye movement occurs. Delta rhythm that
occurs at stage 4 of sleep is the period of deepest sleep, during which eye movement
and muscular activity are minimal.
abirb.com/test
This is incorrect. Relaxed waking occurs during stage 0 (alpha rhythm) stage. The
client experiences a sleep-wakefulness cycle characterized by a relaxed waking state
with their eyes closed.
This is incorrect. Dreaming occurs during the REM sleep, abirb.com/test
or beta rhythm, cycle.
CON: Sleep and Rest
abirb.com/test
21. Psychotropic medications improve symptoms of mental disorders by acting on which
abirb.com/test
component of the brain?
1. Basal ganglia
2. Hypothalamus
3. Interneurons
abirb.com/test
4. Neural synapse
ANS: 4
abirb.com/test
Chapter: Chapter 3, Concepts of Psychobiology
Objective: Describe the biological mechanisms of psychoactive drugs at neural
synapses.
Page: 32
abirb.com/test
Heading: Synapses
Integrated Processes: Nursing Process
Client Need: Physiological Integrity
abirb.com/test
Cognitive Level: Comprehension [Understanding]
Concept: Neurological Regulation
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. Basal ganglia are not the primary site of action for psychotropic
medications.
abirb.com/test
This is incorrect. The primary site of action for psychotropic
medications is the
neural synapse, not the hypothalamus.
This is incorrect. Psychotropic medications do not act primarily on the interneurons
but on the neural synapse.
abirb.com/test
This is correct. Excessive or deficient activity of neurotransmitters influences a
abirb.com/test
abirb.com/test
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Chapter 3 - ETB
abirb.com/test
variety of cognitive and emotional symptoms. The neural synapse is believed to be
the primary site of activity for psychotropic drugs.
CON: Neurological Regulation
abirb.com/test
abirb.com/test
22. Which hormone is used experimentally to increase socialization?
1. Prolactin
2. Oxytocin
abirb.com/test
3. Gonadotropic hormones
4. Growth hormone
ANS: 2
abirb.com/test
Chapter: Chapter 3, Concepts of Psychobiology
Objective: Discuss the association of endocrine functioning to the development of
psychiatric disorders.
abirb.com/test
Page: 37
Heading: Oxytocin
Integrated Processes: Nursing Process
abirb.com/test
Nursing Process: Assessment
Client Need: Physiological Integrity
Cognitive Level: Application [Applying]
Concept: Neurological Regulation
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/test
This is incorrect. Prolactin levels do not promote socialization.
In clients with
psychotic disorders, prolactin has been associated with tardive dyskinesia.
This is correct. Oxytocin is known to promote social bonding and is used
experimentally in individuals with autism to promote socialization.
Oxytocin
abirb.com/test
increases antianxiety effects.
This is incorrect. Gonadotropic hormones affect sexual behavior and aggressiveness.
This is incorrect. Growth hormone abnormalities lead to anorexia nervosa.
abirb.com/test
CON: Neurological Regulation
abirb.com/test
23. Elevated levels of adrenocorticotropic hormone (ACTH) are associated with which
symptom?
abirb.com/test
1. Fatigue
2. Anxiety
3. Depression
4. Psychosis
abirb.com/test
abirb.com/test
abirb.com/test
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Chapter 3 - ETB
abirb.com/test
ANS: 4
Chapter: Chapter 3, Concepts of Psychobiology
Objective: Discuss the association of endocrine functioning to the development of
abirb.com/test
psychiatric disorders.
Page: 39
Heading: The Anterior Pituitary (Adenohypophysis) > Adrenocorticotropic Hormone >
Table 3-3, Hormones of the Neuroendocrine System
abirb.com/test
Integrated Processes: Nursing Process
Nursing Process: Evaluation
Client Need: Physiological Integrity
abirb.com/test
Cognitive Level: Comprehension [Understanding]
Concept: Neurological Regulation
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. Decreased levels of ACTH are associated with fatigue.
This is incorrect. There is no correlation between increased ACTH levels and
abirb.com/test
anxiety.
This is incorrect. A decrease in ACTH levels can lead to depression.
This is correct. ACTH is regulated by the anterior pituitary. Increased levels of
ACTH are associated with psychosis and mood disorders. abirb.com/test
CON: Neurological Regulation
abirb.com/test
MULTIPLE RESPONSE
abirb.com/test
24. Which information would the nurse include when teaching a abirb.com/test
client about the causes
of anorexia nervosa? Select all that apply.
1. There is a possible correlation between abnormal secretion of growth hormone and
anorexia nervosa.
abirb.com/test
2. There is a possible correlation between antidiuretic hormone levels
and anorexia
nervosa.
3. There is a possible correlation between low levels of gonadotropin and anorexia
nervosa.
abirb.com/test
4. There is a possible correlation between increased levels of prolactin and anorexia
nervosa.
5. There is a possible correlation between abnormal levels of oxytocin and anorexia
abirb.com/test
nervosa.
ANS: 1, 3
Chapter: Chapter 3, Concepts of Psychobiology
abirb.com/test
Objective: Discuss the correlation of altered brain function to various psychiatric
abirb.com/test
abirb.com/test
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Chapter 3 - ETB
abirb.com/test
disorders.
Page: 39
Heading: Hormones of the Neuroendocrine System Table 3–3: Biological Implications
abirb.com/test
of Psychiatric Disorders
Integrated Processes: Teaching/Learning
Nursing Process: Implementation
Client Need: Health Promotion and Maintenance
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Health Promotion; Self
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
5.
Feedback
This is correct. There is a possible correlation between anorexia nervosa and
decreased levels of growth hormone and gonadotropin. Anorexia
nervosa has also
abirb.com/test
been correlated with increased cortisol levels.
This is incorrect. There is no correlation between ADH and anorexia nervosa.
This is correct. There is a possible correlation between anorexia
nervosa and
abirb.com/test
decreased levels of growth hormone and gonadotropin. Anorexia nervosa has also
been correlated with increased cortisol levels.
This is incorrect. There is no correlation between increased levels of prolactin and
abirb.com/test
anorexia nervosa.
This is incorrect. There is no correlation between abnormal levels of oxytocin and
anorexia nervosa.
abirb.com/test
CON: Health Promotion; Self
abirb.com/test
25. The nurse anticipates the client with an increased thyroid-stimulating hormone
(TSH) level will exhibit which symptoms? Select all that apply.
1. Depression
abirb.com/test
2. Fatigue
3. Increased libido
4. Mania
abirb.com/test
5. Hyperexcitability
ANS: 1, 2
Chapter: Chapter 3, Concepts of Psychobiology
abirb.com/test
Objective: Discuss the association of endocrine functioning to the development of
psychiatric disorders.
Page: 40
abirb.com/test
Heading: The Anterior Pituitary (Adenohypophysis) > Thyroid-Stimulating
Hormone
Integrated Processes: Nursing Process
Nursing Process: Assessment
Client Need: Physiological Integrity
abirb.com/test
Cognitive Level: Application [Applying]
abirb.com/test
abirb.com/test
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Chapter 3 - ETB
abirb.com/test
Concept: Metabolism
Difficulty: Moderate
1.
2.
3.
4.
5.
abirb.com/test
Feedback
This is correct. Elevated TSH levels are indicative of hypothyroidism. Symptoms
include depression and fatigue. Memory impairment, decreased libido, and suicidal
ideation can occur with chronic hypothyroidism.
abirb.com/test
This is correct. Elevated TSH levels are indicative of hypothyroidism. Symptoms
include depression and fatigue. Memory impairment, decreased libido, and suicidal
ideation can occur with chronic hypothyroidism.
abirb.com/test
This is incorrect. Increased libido is not a symptom of hypothyroidism or increased
TSH levels.
This is incorrect. Mania is not a symptom of hypothyroidism or increased TSH
abirb.com/test
levels.
This is incorrect. Hyperexcitability is not a symptom of hypothyroidism or elevated
TSH levels.
abirb.com/test
CON: Metabolism
abirb.com/test
26. Which symptoms would the nurse expect to assess in a client experiencing decreased
levels of thyroid hormone? Select all that apply.
1. Emotional lability
abirb.com/test
2. Depression
3. Insomnia
4. Restlessness
abirb.com/test
5. Apathy
ANS: 1, 3, 4
Chapter: Chapter 3, Concepts of Psychobiology
abirb.com/test
Objective: Discuss the association of endocrine functioning to the development of
psychiatric disorders.
Page: 40
abirb.com/test
Heading: The Anterior Pituitary (Adenohypophysis) > Thyroid-Stimulating
Hormone
Integrated Processes: Nursing Process
Nursing Process: Assessment
Client Need: Physiological Integrity
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Metabolism
Difficulty: Moderate
abirb.com/test
1.
Feedback
This is correct. The nurse’s assessment of a client with a decreased level of thyroid
hormone will include evidence of emotional lability, insomnia,
and restlessness.
abirb.com/test
Decreased levels of thyroid hormone indicate a diagnosis of hyperthyroidism or
abirb.com/test
abirb.com/test
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Chapter 3 - ETB
abirb.com/test
2.
3.
4.
5.
Grave’s disease, which is also associated with the symptoms of irritability, anxiety,
and weight loss.
This is incorrect. A client experiencing an elevated level of thyroid hormone or
hypothyroidism may experience depression and apathy. abirb.com/test
This is correct. The nurse’s assessment of a client with an elevated level of thyroid
hormone will include evidence of emotional lability, insomnia, and restlessness.
Elevated levels of thyroid hormone indicate a diagnosis ofabirb.com/test
hyperthyroidism or
Grave’s disease, which is also associated with the symptoms of irritability, anxiety,
and weight loss.
This is correct. The nurse’s assessment of a client with an elevated level of thyroid
abirb.com/test
hormone will include evidence of emotional lability, insomnia, and restlessness.
Elevated levels of thyroid hormone indicate a diagnosis of hyperthyroidism or
Grave’s disease, which is also associated with the symptoms of irritability, anxiety,
abirb.com/test
and weight loss.
This is incorrect. A client experiencing an elevated level of thyroid hormone or
hypothyroidism may experience depression and apathy.
abirb.com/test
CON: Metabolism
abirb.com/test
27. Which adoption studies about the influence of genetics on the development of
psychiatric disorders were described by Knowles? Select all that apply.
1. Studies in which children whose biological parents had a psychiatric
disorder were
abirb.com/test
raised by adoptive parents who did not have a psychiatric disorder
2. Studies in which children whose biological parents did not have a psychiatric disorder
were raised by adoptive parents who had a psychiatric disorder
abirb.com/test
3. Studies in which children were raised together by biological parents
who had a
psychiatric disorder
4. Studies in which children whose biological parents had a psychiatric disorder were
raised by adoptive parents who also had a psychiatric disorder abirb.com/test
5. Studies in which children whose biological parents had a psychiatric disorder were
raised by biological relatives who had a psychiatric disorder
abirb.com/test
ANS: 1, 2
Chapter: Chapter 3, Concepts of Psychobiology
Objective: Discuss the implications of psychobiological conceptsabirb.com/test
for the practice of
psychiatric and mental health nursing.
Page: 44
Heading: Genetics
abirb.com/test
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
Concept: Evidence-Based Practice
abirb.com/test
Difficulty: Difficult
abirb.com/test
abirb.com/test
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Chapter 3 - ETB
abirb.com/test
1.
2.
3.
4.
5.
Feedback
This is correct. Knowles described four types of adoption studies about the influence
abirb.com/test
of genetics on the development of psychiatric disorders. They
include studies of (1)
children whose biological parents had a psychiatric disorder who were raised by
adoptive parents who did not have a psychiatric disorder, (2) children whose
biological parents did not have a psychiatric disorder who abirb.com/test
were raised by adoptive
parents who had a psychiatric disorder, (3) adoptive and biological relatives of
adopted children who developed a psychiatric disorder, and (4) monozygotic twins
who were raised apart by different adoptive parents.
abirb.com/test
This is correct. Knowles described four types of adoption studies about the influence
of genetics on the development of psychiatric disorders. They include studies of (1)
children whose biological parents had a psychiatric disorder who were raised by
abirb.com/test
adoptive parents who did not have a psychiatric disorder, (2)
children whose
biological parents did not have a psychiatric disorder who were raised by adoptive
parents who had a psychiatric disorder, (3) adoptive and biological relatives of
adopted children who developed a psychiatric disorder, and (4) monozygotic twins
abirb.com/test
who were raised apart by different adoptive parents.
This is incorrect. This statement does not describe a study about adoption and the
influence of genetics and the development of psychiatric disorders developed by
abirb.com/test
Knowles.
This is incorrect. This statement does not describe one of the studies developed by
Knowles regarding adoption and the development of psychiatric disorders.
This is incorrect. This statement does not describe one of the
four types of studies
abirb.com/test
developed by Knowles regarding adoption and the development of psychiatric
disorders.
CON: Evidence Based-Practice
abirb.com/test
abirb.com/test
28. Which concepts are essential to psychiatric-mental health nursing practice? Select all
that apply.
1. Evidence-based outcomes
abirb.com/test
2. Holistic nursing practice
3. Integration of biological knowledge
4. Psychosocial adaptation and physical functioning
5. Diagnostic criteria for psychiatric disorders
abirb.com/test
ANS: 1, 3, 4
Chapter: Chapter 3, Concepts of Psychobiology
Objective: Discuss the implications of psychobiological conceptsabirb.com/test
for the practice of
psychiatric and mental health nursing.
Page: 48
Heading: Implications for Nursing
abirb.com/test
Nursing Process: Implementation
abirb.com/test
abirb.com/test
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Chapter 3 - ETB
abirb.com/test
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
abirb.com/test
Concept: Nursing Care Delivery Systems ; Evidence-Based Practice
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
abirb.com/test
This is correct. Integrating biological and behavioral concepts into psychiatricmental health nursing practice is essential for nurses to meet the complex needs of
clients with mental illness. Historical review of psychiatric practice reveals that
abirb.com/test
emphasis has been placed on treatment approaches focused on the biological
sciences. Psychiatric-mental health nurses must integrate knowledge of the
biological sciences and have an understanding of the relationship between
psychosocial adaptation and physical functioning. Psychobiological
abirb.com/testperspectives
must be incorporated into nursing practice, education, and research to attain the
evidence-based outcomes necessary for the delivery of competent care.
This is incorrect. It is not necessary to integrate holistic nursing practice into
abirb.com/test
psychiatric-mental health nursing practice.
This is correct. Integrating biological and behavioral concepts into psychiatricmental health nursing practice is essential for nurses to meet the complex needs of
clients with mental illness. Historical review of psychiatricabirb.com/test
practice reveals that
emphasis has been placed on treatment approaches focused on the biological
sciences. Psychiatric-mental health nurses must integrate knowledge of the
biological sciences and have an understanding of the relationship
between
abirb.com/test
psychosocial adaptation and physical functioning. Psychobiological perspectives
must be incorporated into nursing practice, education, and research to attain the
evidence-based outcomes necessary for the delivery of competent care.
abirb.com/test
This is correct. Integrating biological and behavioral concepts
into psychiatricmental health nursing practice is essential for nurses to meet the complex needs of
clients with mental illness. Historical review of psychiatric practice reveals that
emphasis has been placed on treatment approaches focusedabirb.com/test
on the biological
sciences. Psychiatric-mental health nurses must integrate knowledge of the
biological sciences and have an understanding of the relationship between
psychosocial adaptation and physical functioning. Psychobiological perspectives
must be incorporated into nursing practice, education, and abirb.com/test
research to attain the
evidence-based outcomes necessary for the delivery of competent care.
This is incorrect. Diagnostic criteria for psychiatric disorders is not a concept
essential for the nurse practicing in the psychiatric-mental abirb.com/test
health arena.
CON: Nursing Care Delivery Systems ;Evidence-Based Practice
abirb.com/test
29. Stress and its effect on the immune system are associated with which concepts?
Select all that apply.
abirb.com/test
1. Physical illness
abirb.com/test
abirb.com/test
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Chapter 3 - ETB
abirb.com/test
2. Severity of depression
3. Insomnia
4. Cognition
5. Schizophrenia
abirb.com/test
ANS: 1, 2, 5
Chapter: Chapter 3, Concepts of Psychobiology
abirb.com/test
Objective: Recognize theorized influences in the development of psychiatric disorders,
including brain physiology, genetics, endocrine function, immune system, and
psychosocial and environmental factors.
abirb.com/test
Page: 47
Heading: Implications of the Immune System in Psychiatric Illness
Integrated Processes: Nursing Process
Nursing Process: Assessment
abirb.com/test
Client Need: Physiological Integrity
Cognitive Level: Comprehension [Understanding]
Concept: Stress; Immunity
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
abirb.com/test
This is correct. Studies have correlated a decrease in lymphocyte
function with
periods of grief, bereavement, and depression, associating the degree of altered
immunity with severity of the depression. A number of research studies have been
conducted attempting to correlate the onset of schizophrenia to abnormalities of the
abirb.com/test
immune system. Evidence exists to support a correlation between psychosocial stress
and the onset of illness. Research is still required to determine the specific processes
involved in stress-induced modulation of the immune system.
abirb.com/test
This is correct. Studies have correlated a decrease in lymphocyte
function with
periods of grief, bereavement, and depression, associating the degree of altered
immunity with severity of the depression. A number of research studies have been
conducted attempting to correlate the onset of schizophrenia
to abnormalities of the
abirb.com/test
immune system. Evidence exists to support a correlation between psychosocial stress
and the onset of illness. Research is still required to determine the specific processes
involved in stress-induced modulation of the immune system.
abirb.com/test
This is incorrect. Evidence does not suggest a correlation between
insomnia and its
effect on the immune system.
This is incorrect. There is no correlation between an alteration in the immune system
and cognitive function.
abirb.com/test
This is correct. Studies have correlated a decrease in lymphocyte function with
periods of grief, bereavement, and depression, associating the degree of altered
immunity with severity of the depression. A number of research studies have been
abirb.com/test
conducted attempting to correlate the onset of schizophrenia
to abnormalities of the
immune system. Evidence exists to support a correlation between psychosocial stress
and the onset of illness. Research is still required to determine the specific processes
involved in stress-induced modulation of the immune system.
abirb.com/test
abirb.com/test
abirb.com/test
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Chapter 3 - ETB
abirb.com/test
CON: Stress; Immunity
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
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Chapter 4 - ETB
abirb.com/test
Chapter 4. Psychopharmacology
abirb.com/test
MULTIPLE CHOICE
abirb.com/test
1. When used in combination with anxiolytic medication, alcohol leads to ____ effects
abirb.com/test
and caffeine leads to ____ effects.
1. Increased; increased
2. Increased; decreased
3. Decreased; decreased
abirb.com/test
4. Decreased; increased
ANS: 2
abirb.com/test
Chapter: Chapter 4, Psychopharmacology
Objective: Describe indications, actions, contraindications, precautions, side effects, and
nursing implications for the following classifications of drugs: antianxiety agents,
antidepressants, mood-stabilizing agents, antipsychotics and agents
for the treatment of
abirb.com/test
tardive dyskinesia, antiparkinsonian agents, sedative-hypnotics, agents for attentiondeficit/hyperactivity disorder
Page: 60
abirb.com/test
Heading: Antianxiety Agents > Interactions
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Knowledge [Remembering]
abirb.com/test
Concept: Safety
Difficulty: Easy
1.
2.
3.
4.
abirb.com/test
Feedback
This is incorrect. Caffeine is a central nervous system (CNS) stimulant and inhibits
(decreases) their effects.
This is correct. Anxiolytic medications work by depressingabirb.com/test
certain CNS functions.
Alcohol is also a CNS depressant that potentiates (increases) effects of anxiolytics.
Caffeine is a CNS stimulant and inhibits (decreases) their effects.
This is incorrect. Alcohol is also a CNS depressant that potentiates (increases)
abirb.com/test
effects of anxiolytics.
This is incorrect. Alcohol is a CNS depressant that potentiates (increases) effects of
anxiolytics. Caffeine is a CNS stimulant and inhibits (decreases) their effects.
abirb.com/test
CON: Safety
abirb.com/test
abirb.com/test
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Chapter 4 - ETB
abirb.com/test
2. A patient was recently admitted to the inpatient unit after a suicide attempt. During
the hospitalization, the patient was placed on a tricyclic antidepressant. Which action
should the nurse implement to maintain the patient’s safety when the patient is
abirb.com/test
discharged?
1. Provide the patient with a 6-month supply of medication.
2. Provide a 1-week supply of medication to be refilled after visiting the provider.
abirb.com/test
3. Instruct increased fluid intake to counteract the medication’s side
effects.
4. Provide education on fluid restrictions to prevent side effects.
ANS: 2
abirb.com/test
Chapter: Chapter 4, Psychopharmacology
Objective: Describe indications, actions, contraindications, precautions, side effects, and
nursing implications for the following classifications of drugs: b. antidepressants.
abirb.com/test
Page: 64
Heading: Antidepressants > Safety Issues in Planning and Implementing Care; Table 4–
8
Integrated Processes: Nursing Process
abirb.com/test
Client Need: Physiological Integrity; Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Safety
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
This is incorrect. Suicide risk often increases as antidepressant
medication takes
abirb.com/test
effect and the patient’s level of depression and mood improve, and the patient should
be monitored more frequently than every 6 months.
This is correct. Suicide risk often increases as antidepressant medication takes effect
abirb.com/test
and the patient’s level of depression and mood improve. The
patient may then have
increased energy with which to implement a suicide plan. Providing a 1-week supply
to be refilled after visiting the provider may facilitate monitoring of the patient’s
overall level of depression.
abirb.com/test
This is incorrect. This would not be an intervention for safety, as the patient may
experience dry mouth from the medication.
This is incorrect. This would not be a valid intervention, as the medication may
abirb.com/test
cause dry mouth and there is no indication for a fluid restriction.
CON: Safety
abirb.com/test
3. Which statement best describes how the perspective on psychopharmacological use of
abirb.com/test
phenothiazines has historically changed?
1. Phenothiazines were originally used as a preoperative medication and found to
improve the client’s anxiety.
abirb.com/test
2. Phenothiazines were originally used for infection control and found
to improve a
client’s treatment compliance.
abirb.com/test
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Chapter 4 - ETB
abirb.com/test
3. Phenothiazines were originally used for postoperative care and found to improve the
client’s ability to recover from anesthesia.
4. Phenothiazines were originally used for diabetics to control their appetite and blood
abirb.com/test
sugars.
ANS: 1
abirb.com/test
Chapter: Chapter 4, Psychopharmacology
Objective: Discuss historical perspectives related to psychopharmacology
Page: 54
Heading: Introduction
abirb.com/test
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Comprehension [Understanding}
abirb.com/test
Concept: Evidence-Based Practice
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/test
This is correct. Dr. Henri Laborit (1914 to 1995) found that the clients benefited
from the administration of phenothiazines prior to surgery, and this foretold of a
psychotropic use.
abirb.com/test
This is incorrect. There is no indication that this medication
would have improved
the likelihood of a client’s adherence to a medical treatment plan.
This is incorrect. There is no stated historical indication that the medication was
given postoperatively nor of the client’s ability to recover quickly
from anesthesia.
abirb.com/test
This is incorrect. There is no historical indication that this classification of
medications was used to treat diabetes.
CON: Evidence-Based Practice
abirb.com/test
abirb.com/test
4. A patient was recently admitted to the inpatient unit after a suicide attempt and has
not responded to SSRIs or tricyclic antidepressants. The patient asks the nurse, “I heard
about MAOIs (monoamine oxidase inhibitors). Why can’t they be added to what I am on
abirb.com/test
now? Wouldn’t adding one help?” Which is the most appropriate nursing response?
1. “Electroconvulsive therapy (ECT) is your best option at this point.”
2. “Combined use can lead to a life-threatening condition called a hypertensive crisis.”
3. “There is no reason why an MAOI couldn’t be added to your therapy.”
abirb.com/test
4. “They can’t be used together because their mechanisms of action are very different.”
ANS: 2
abirb.com/test
Chapter: Chapter 4, Psychopharmacology
Objective: Describe indications, actions, contraindications, precautions, side effects, and
nursing implications for the following classifications of drugs: b. antidepressants.
abirb.com/test
Page: 64 & 65
Heading: Antidepressants > Other Atypical Antidepressants; Tables 4–6 & 4–7
abirb.com/test
abirb.com/test
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Chapter 4 - ETB
abirb.com/test
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Analysis [Analyzing]
abirb.com/test
Concept: Safety
Difficulty: Moderate
1.
2.
3.
4.
abirb.com/test
Feedback
This is incorrect. Antidepressants can be safely taken while a patient receives ECT
treatments.
This is correct. Concomitant use with MAOIs results in a potentially
life-threatening
abirb.com/test
hypertensive crisis. Antidepressants can be safely taken while a patient receives ECT
treatments.
This is incorrect. This is outside the scope of nursing practice. The nurse could have
abirb.com/test
guided the patient to speak to the provider.
This is incorrect. This does not explain the dangers of combining these medications
and is an ambiguous answer that does not provide therapeutic communication.
abirb.com/test
CON: Safety
abirb.com/test
5. A patient began taking lithium for the treatment of bipolar disorder approximately 1
month ago and asks why he has gained 12 pounds since then. Which is the most
appropriate nursing response?
abirb.com/test
1. “It is surprising that you have gained; weight loss is the typical pattern when taking
lithium.”
2. “Your weight gain is more likely related to food intake and decreased activity than
abirb.com/test
medication.”
3. “Weight gain is a common but troubling side effect. Let’s talk about some strategies
for safely improving your nutrition and exercise habits.”
4. “There’s not much you can do about the weight gain. It’s better
than being
abirb.com/test
emotionally unstable though.”
ANS: 3
abirb.com/test
Chapter: Chapter 4, Psychopharmacology
Objective: Describe indications, actions, contraindications, precautions, side effects, and
nursing implications for the following classifications of drugs: c. mood-stabilizing
agents.
abirb.com/test
Page: 70
Heading: Mood-Stabilizing Agents > Planning and Implementing Care > Lithium
Maintenance; Table 4–10
abirb.com/test
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Analysis [Analyzing]
abirb.com/test
Concept: Safety
Difficulty: Moderate
abirb.com/test
abirb.com/test
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Chapter 4 - ETB
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. Weight gain is a common side effect of lithium.
abirb.com/test
This is incorrect. Weight gain is a common side effect of lithium, so it may not be
due to diet or activity level.
This is correct. Weight gain is a common side effect of lithium. It may be helpful to
discuss low-calorie diets while stressing the importance ofabirb.com/test
not making significant
changes in sodium intake because this has an impact on serum blood levels of
lithium.
This is incorrect. This is nontherapeutic communication and
does not address the
abirb.com/test
patient’s concerns of weight gain.
CON: Safety
abirb.com/test
6. The nurse is assessing a patient who has a diagnosis of schizophrenia
and takes an
abirb.com/test
antipsychotic agent daily. Which finding requires further nursing assessment?
1. Respirations of 22 breaths/minute
2. Weight gain of 8 pounds in 2 months
abirb.com/test
3. Oral temperature of 101°F
4. Complaints of dry mouth
ANS: 3
abirb.com/test
Chapter: Chapter 4, Psychopharmacology
Objective: Describe indications, actions, contraindications, precautions, side effects, and
nursing implications for the following classifications of drugs: d. antipsychotics.
abirb.com/test
Page: 72 & 73
Heading: Antipsychotic Agents > Issues in Antipsychotic Maintenance Therapy >
Clozaril and the Risk for Agranulocytosis; Tables 4–11 & 4–12
Integrated Processes: Nursing Process
abirb.com/test
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Analysis [Analyzing]
Concept: Safety
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
This is incorrect. A respiration rate of 22 breaths a minute abirb.com/test
is within a normal range.
This is incorrect. Antipsychotic medications can cause weight gain.
This is correct. An elevated body temperature is a sign of an infectious process.
Clients taking antipsychotic medications may acquire agranulocytosis,
which is
abirb.com/test
characterized by a significant decrease in the white blood cell (WBC) count and
reduced immunity. .
This is incorrect. Dry mouth is a common side effect of antipsychotics, and the nurse
abirb.com/test
can recommend hard candies and sips of water.
abirb.com/test
abirb.com/test
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Chapter 4 - ETB
abirb.com/test
CON: Safety
abirb.com/test
7. A patient who is older with chronic schizophrenia takes an antipsychotic and
propranolol, a beta-adrenergic blocking agent, for hypertension. Given the combined
abirb.com/test
side effects of these drugs, which patient teaching should the nurse
provide?
1. “Make sure you concentrate on taking slow, deep, cleansing breaths.”
2. “Watch your diet and try to engage in some regular physical activity.”
3. “Rise slowly when you change position from lying to sitting orabirb.com/test
sitting to standing.”
4. “Wear sunscreen and try to avoid midday sun exposure.”
ANS: 3
abirb.com/test
Chapter: Chapter 4, Psychopharmacology
Objective: Describe indications, actions, contraindications, precautions, side effects, and
nursing implications for the following classifications of drugs: d. antipsychotics.
Page: 72 & 73
abirb.com/test
Heading: How Do Psychotropics Work; Tables 4–11 & 4–12
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
abirb.com/test
Cognitive Level: Analysis [Analyzing]
Concept: Safety
Difficulty: Difficult
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. This would be a relaxation technique, perhaps for anxiety.
This is incorrect. Antipsychotics often cause weight gain, but there is no correlation
abirb.com/test
between these two medications specifically and weight gain.
This is correct. Propanol and antipsychotic medication reduce blood pressure. Due to
the hypotensive properties of each, patients can develop orthostatic hypotension
when combined.
abirb.com/test
This is incorrect. Antipsychotics can cause photosensitivity, but this response does
not address the more pressing issue of orthostatic hypotension.
CON: Safety
abirb.com/test
abirb.com/test
8. A patient with depression and substance abuse has an interrupted sleep pattern. The
patient demands a sedative. Which teaching should the nurse provide about the rationale
for the use of nonpharmacological interventions instead?
abirb.com/test
1. “Sedative-hypnotics are potentially addictive and gradually lose their effectiveness as
one builds up tolerance to them.”
2. “Sedative-hypnotics work best in combination with other techniques, such as guided
abirb.com/test
imagery.”
abirb.com/test
abirb.com/test
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Chapter 4 - ETB
abirb.com/test
3. “Sedative-hypnotics are not permitted for use in patients with substance abuse
disorders.”
4. “Sedative-hypnotics are not as effective as the antidepressant medications for treating
abirb.com/test
sleep disturbances.”
ANS: 1
abirb.com/test
Chapter: Chapter 4, Psychopharmacology
Objective: Describe indications, actions, contraindications, precautions, side effects, and
nursing implications for the following classifications of drugs: f. sedative-hypnotics.
Page: 74
abirb.com/test
Heading: Sedative-Hypnotics > Contraindications/Precautions; Table 4–14
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
abirb.com/test
Cognitive Level: Knowledge [Remembering]
Concept: Safety
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is correct. Sedative-hypnotics are potentially addictive and should be used with
caution by patients with a history of substance use disorders, as tolerance can easily
abirb.com/test
develop.
This is incorrect. This does not address the overall issue of the addictive properties
of sedative-hypnotics and substance abuse disorders.
This is incorrect. This is not therapeutic communication and
does not explain the
abirb.com/test
rationale of the addictive properties of these medications.
This is incorrect. There is no correlation between sedative-hypnotics and
antidepressant medications for sleep disturbances.
abirb.com/test
CON: Safety
abirb.com/test
9. Which statement about tricyclic antidepressant medications is accurate?
1. Strong or aged cheese should not be eaten while taking them.
abirb.com/test
2. Their full therapeutic potential may not be reached until 4 weeks.
3. They may cause hypomania or recent-memory impairment.
4. They should not be given with antianxiety agents.
abirb.com/test
ANS: 2
Chapter: Chapter 4, Psychopharmacology
Objective: Describe indications, actions, contraindications, precautions, side effects, and
abirb.com/test
nursing implications for the following classifications of drugs: b. antidepressants.
Page: 66
Heading: How Do Psychotropics Work; Table 4–8
abirb.com/test
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
abirb.com/test
abirb.com/test
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Chapter 4 - ETB
abirb.com/test
Cognitive Level: Knowledge [Remembering]
Concept: Safety
Difficulty: Easy
1.
2.
3.
4.
abirb.com/test
Feedback
This is incorrect. Individuals taking MAOIs should not ingest aged cheese or other
foods high in tyramine, as a hypertensive crisis can occur. abirb.com/test
This is correct. It may take several weeks for tricyclic medications to reach their full
therapeutic effect.
This is incorrect. Antidepressants can precipitate acute mania
in clients diagnosed
abirb.com/test
with bipolar disorder.
This is incorrect. Antianxiety medications are not contraindicated for clients taking
tricyclic antidepressants.
abirb.com/test
CON: Safety
abirb.com/test
10. A patient was admitted with a chronic level of major depression. The patient was
started on an MAOI orally daily during this hospitalization. The nurse’s discharge
abirb.com/test
teaching should include which of the following?
1. “Continue taking medication as prescribed. You will continue to see improvement
over the next few days.”
2. “You will not need to follow up with outpatient psychotherapy,
as you and the social
abirb.com/test
worker have completed your therapy.”
3. “You may be able to discontinue the medication within 6 months to 1 year but only
under a doctor’s supervision. However, there is a chance of recurring episodes.”
4. “You should avoid foods with tyramine, including beer, beans,abirb.com/test
processed meats, and
red wine.”
ANS: 4
abirb.com/test
Chapter: Chapter 4, Psychopharmacology
Objective: Describe indications, actions, contraindications, precautions, side effects, and
nursing implications for the following classifications of drugs: b. antidepressants.
abirb.com/test
Page: 66
Heading: Antidepressants; Table 4–8
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Pharmacological and Parenteral
Therapies
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Safety
Difficulty: Moderate
abirb.com/test
1.
2.
Feedback
This is incorrect. This is nontherapeutic communication, as there is no indication
abirb.com/test
that this medication is fast acting in days.
This is incorrect. A patient with chronic moderate depression should maintain
abirb.com/test
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Chapter 4 - ETB
abirb.com/test
3.
4.
follow-up appointments on a regular basis.
This is incorrect. There is no indication that the patient may stop the medication
without first discussing it with the prescriber.
abirb.com/test
This is correct. Clients taking MAOIs should avoid foods with tyramine, including
beer, beans, processed meats, and red wine, to prevent a hypertensive crisis.
CON: Safety
abirb.com/test
abirb.com/test
11. In the treatment of anxiety disorders, benzodiazepines (e.g., Ativan, Xanax) are
indicated for ____ use and have ____ abuse potential.
1. Short-term; high
abirb.com/test
2. Long-term; high
3. Short-term; low
4. Long-term; low
abirb.com/test
ANS: 1
Chapter: Chapter 4, Psychopharmacology
Objective: Describe indications, actions, contraindications, precautions, side effects, and
nursing implications for the following classifications of drugs: a.abirb.com/test
antianxiety agents.
Page: 60
Heading: Antianxiety Agents > Background Assessment Data > Action
Integrated Processes: Nursing Process
abirb.com/test
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Knowledge [Remembering]
Concept: Safety
abirb.com/test
Difficulty: Easy
1.
2.
3.
4.
Feedback
This is correct. Benzodiazepines are indicated for short-term
treatment of anxiety
abirb.com/test
due to their addictive properties and subsequent increased risk for abuse.
This is incorrect. Benzodiazepines have addictive properties and should not be given
long term.
abirb.com/test
This is incorrect. Although benzodiazepines should be a short-term medication, they
have addictive properties.
This is incorrect. Benzodiazepines should not be given for long-term use due to their
abirb.com/test
highly addictive properties.
CON: Safety
abirb.com/test
12. Which medication requires periodic blood-level monitoring?
abirb.com/test
1. Eskalith (lithium carbonate)
2. Haldol (haloperidol)
abirb.com/test
abirb.com/test
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Chapter 4 - ETB
abirb.com/test
3. Xanax (benzodiazepine)
4. Paxil (paroxetine)
abirb.com/test
ANS: 4
Chapter: Chapter 4, Psychopharmacology
Objective: Describe indications, actions, contraindications, precautions, side effects, and
nursing implications for the following classifications of drugs: b.abirb.com/test
antidepressants.
Page: 70
Heading: Mood-Stabilizing Agents > Background Assessment Data; Table 4–10
Integrated Processes: Nursing Process
abirb.com/test
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Comprehension [Understanding]
Concept: Safety
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
This is incorrect. Serum lithium levels are monitored regularly
to ensure a
abirb.com/test
therapeutic range is maintained.
This is incorrect. Haldol is not generally monitored for therapeutic blood ranges.
This is incorrect. Xanax generally is not monitored for a therapeutic blood range.
abirb.com/test
This is correct. Blood-level monitoring is usually performed
for patients taking
paroxetine.
CON: Safety
abirb.com/test
abirb.com/test
13. As part of discharge teaching, which guideline regarding lithium
therapy will the
nurse plan to include?
1. Avoid excessive use of decaffeinated beverages.
2. Maintain a consistently low intake of sodium.
abirb.com/test
3. Consume at least 2500 mL of fluid daily.
4. Monitor blood sugar levels twice daily.
abirb.com/test
ANS: 4
Chapter: Chapter 4, Psychopharmacology
Objective: Describe indications, actions, contraindications, precautions, side effects, and
nursing implications for the following classifications of drugs: c.abirb.com/test
mood-stabilizing
agents.
Page: 70
Heading: Mood-Stabilizing Agents > Interactions; Table 4–10
abirb.com/test
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Safety
Difficulty: Moderate
abirb.com/test
abirb.com/test
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Chapter 4 - ETB
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. Caffeine, a stimulant, should be limited inabirb.com/test
patients with mania, not
decaffeinated beverages.
This is incorrect. Adequate sodium intake is necessary to prevent lithium toxicity.
This is correct. Adequate fluid intake is necessary to prevent lithium toxicity.
This is incorrect. There is no indication that lithium affectsabirb.com/test
blood sugar levels.
CON: Safety
abirb.com/test
14. A patient with schizophrenia has recently begun a new medication, clozapine
(Clozaril). Which is a fatal side effect that should be included in abirb.com/test
the teaching plan?
1. Agranulocytosis
2. Akathisia
3. Dystonia
abirb.com/test
4. Akinesia
ANS: 1
abirb.com/test
Chapter: Chapter 4, Psychopharmacology
Objective: Describe indications, actions, contraindications, precautions, side effects, and
nursing implications for the following classifications of drugs: d. antipsychotics.
Page: 73
abirb.com/test
Heading: Antipsychotic Agents > Safety Issues in Planning and Implementing Care >
Clozaril and the Risk for Agranulocytosis; Table 4–12
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Reduction of Risk Potentialabirb.com/test
Cognitive Level: Comprehension [Understanding]
Concept: Safety
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is correct. Agranulocytosis is a potentially fatal disorder in which the patient’s
abirb.com/test
WBC count drops to extremely low levels, placing the patient at great risk for
infections.
This is incorrect. Akathisia is characterized by a feeling of inner restlessness and a
abirb.com/test
compelling need to be in constant motion.
This is incorrect. Dystonia is characterized by persistent or intermittent muscle
contractions causing abnormal, often repetitive, movements, postures, or both.
This is incorrect. Akinesia refers to a loss of standard motor
functions or slowness
abirb.com/test
that causes impaired movement of muscles.
CON: Safety
abirb.com/test
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 4 - ETB
abirb.com/test
15. A patient with schizophrenia recently began a new medication, clozapine (Clozaril).
Which signs and symptoms of a potentially fatal side effect will the nurse include in the
abirb.com/test
teaching plan?
1. Blurred vision and muscular weakness
2. Sore throat, fever, and malaise
abirb.com/test
3. Tremor, shuffling gait, and rigidity
4. Fine tremor, tinnitus, and nausea
ANS: 2
abirb.com/test
Chapter: Chapter 4, Psychopharmacology
Objective: Describe indications, actions, contraindications, precautions, side effects, and
nursing implications for the following classifications of drugs: d. antipsychotics.
abirb.com/test
Page: 72
Heading: Antipsychotic Agents > Safety Issues in Planning and Implementing Care >
Clozaril and the Risk for Agranulocytosis
Integrated Processes: Teaching and Learning
abirb.com/test
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Safety
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
This is incorrect. Blurred vision and muscular weakness are
signs of extrapyramidal
abirb.com/test
side effects that are not fatal.
This is correct. The symptoms of infection indicate that the patient has a low WBC
count (below 3500/mm3), which indicates that the body’s ability to fight infection is
abirb.com/test
significantly decreased. Agranulocytosis is a potentially fatal
disorder in which the
patient’s WBC drops to extremely low levels, placing the patient at great risk for
infections.
This is incorrect. These are pseudoparkinsonism symptoms,
which are generally not
abirb.com/test
fatal.
This is incorrect. These are not fatal side effects of the medication.
CON: Safety
abirb.com/test
abirb.com/test
16. A client with schizophrenia recently began a new medication, clozapine (Clozaril).
Which blood cell counts reveal a potentially fatal side effect of this medication?
1. WBCs greater than 3,000/mm3; granulocytes greater than 1,500/mm3
abirb.com/test
2. WBCs less than 3,000/mm3; granulocytes greater than 1,500/mm3
3. WBCs greater than 3,000/mm3; granulocytes less than 1,500/mm3
4. WBCs less than 3,000/mm3; granulocytes less than 1,500/mm3
abirb.com/test
ANS: 4
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 4 - ETB
abirb.com/test
Chapter: Chapter 4, Psychopharmacology
Objective: Describe indications, actions, contraindications, precautions, side effects, and
nursing implications for the following classifications of drugs: d. antipsychotics.
abirb.com/test
Page: 72
Heading: Antipsychotic Agents > Safety Issues in Planning and Implementing Care >
Clozaril and the Risk for Agranulocytosis
abirb.com/test
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Analysis [Analyzing]
Concept: Safety
abirb.com/test
Difficulty: Difficult
1.
2.
3.
4.
Feedback
abirb.com/test
This is incorrect. This reflects a normal WBC count and does
not indicate
agranulocytosis.
This is incorrect. Although the WBC count is low, the granulocytes are not, so this
does not indicate a state of agranulocytosis.
abirb.com/test
This is incorrect. Although the granulocytes are low, the WBC count is not, so this
does not indicate a state of agranulocytosis.
This is correct. A WBC count of less than 3000/mm3 and granulocytes less than
abirb.com/test
1500/mm3 reflect a low WBC count and indicate that the body’s
ability to fight
infection is significantly decreased. Agranulocytosis is a potentially fatal disorder in
which the client’s WBC count drops to extremely low levels, placing the client at
great risk for infections.
abirb.com/test
CON: Safety
abirb.com/test
17. A psychiatrist prescribes an MAOI for a patient. When teaching the patient about the
effects of tyramine, which foods will the nurse caution the patientabirb.com/test
to avoid?
1. Pepperoni pizza and red wine
2. Bagels with cream cheese and tea
3. Apple pie and coffee
abirb.com/test
4. Potato chips and diet cola
ANS: 1
Chapter: Chapter 4, Psychopharmacology
abirb.com/test
Objective: Describe indications, actions, contraindications, precautions, side effects, and
nursing implications for the following classifications of drugs: b. antidepressants.
Page: 65
abirb.com/test
Heading: How Do Psychotropics Work; Table 4–7
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Reduction of Risk Potential
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Safety
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 4 - ETB
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/test
This is correct. A hypertensive crisis can occur if products containing tyramine are
consumed while taking MAOIs. Examples of foods high in tyramine include aged
cheeses, red wines, and smoked or processed meats.
abirb.com/test
This is incorrect. A hypertensive crisis can occur if products
containing tyramine are
consumed while taking MAOIs. These are not examples of foods with high tyramine
levels.
This is incorrect. A hypertensive crisis can occur if products
containing tyramine are
abirb.com/test
consumed while taking MAOIs. These do not contain high levels of tyramine.
This is incorrect. These foods are not contraindicated for a patient on MAOIs, as
they are not high in tyramine levels.
abirb.com/test
CON: Safety
abirb.com/test
18. A patient has been diagnosed with major depressive disorder and is prescribed
imipramine (Tofranil). Which information specifically related to this class of
abirb.com/test
antidepressants will the nurse plan to include in patient and family
education?
1. The medication may cause dry mouth.
2. The medication may cause nausea.
3. The medication should not be discontinued abruptly.
abirb.com/test
4. The medication may cause photosensitivity.
ANS: 4
abirb.com/test
Chapter: Chapter 4, Psychopharmacology
Objective: Describe indications, actions, contraindications, precautions, side effects, and
nursing implications for the following classifications of drugs: b. antidepressants.
Page: 66
abirb.com/test
Heading: Antidepressants > Safety Issues in Planning and Implementing Care; Table 4–
8
Integrated Processes: Nursing Process
abirb.com/test
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Comprehension [Understanding]
Concept: Safety
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. This is a common side effect of many other medications.
abirb.com/test
This is incorrect. Many other medications have this side effect, not just tricyclic
antidepressants.
This is incorrect. This is a common side effect of the other medications, not specific
abirb.com/test
to tricyclic antidepressants.
This is correct. Tricyclic antidepressants may cause photosensitivity, but other types
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 4 - ETB
abirb.com/test
of antidepressants would not.
CON: Safety
abirb.com/test
abirb.com/test
19. Which information suggests caution is necessary when prescribing
a benzodiazepine
to an anxious client?
1. The client has a history of alcohol dependence.
2. The client has a history of diabetes mellitus.
abirb.com/test
3. The client has a history of schizophrenia.
4. The client has a history of hypertension.
abirb.com/test
ANS: 1
Chapter: Chapter 4, Psychopharmacology
Objective: Describe indications, actions, contraindications, precautions, side effects, and
nursing implications for the following classifications of drugs: a.abirb.com/test
antianxiety agents.
Page: 60
Heading: Antianxiety Agents > Action
Integrated Processes: Nursing Process
abirb.com/test
Client Need: Physiological Integrity: Pharmacological and Parenteral
Therapies
Cognitive Level: Analysis [Analyzing]
Concept: Safety
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is correct. Benzodiazepines have a high potential for tolerance as well as
abirb.com/test
physiological and psychological addiction with long-term use.
Clients with a history
of substance use disorders should use them cautiously.
This is incorrect. There is no indication that that this would affect the client’s blood
sugar levels.
abirb.com/test
This is incorrect. There is no indication that a client with schizophrenia would have
any issues with this medication.
This is incorrect. This medication has no indication that it would cause harm to the
abirb.com/test
client with hypertension.
CON: Safety
abirb.com/test
20. Which medication is most likely to be prescribed for the extrapyramidal side effects
abirb.com/test
of antipsychotic medications?
1. Diazepam (Valium)
2. Amitriptyline (Elavil)
abirb.com/test
3. Benztropine (Cogentin)
4. Methylphenidate (Ritalin)
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 4 - ETB
abirb.com/test
ANS: 3
Chapter: Chapter 4, Psychopharmacology
abirb.com/test
Objective: Describe indications, actions, contraindications, precautions, side effects, and
nursing implications for the following classifications of drugs: e. antiparkinsonian
agents.
abirb.com/test
Page: 73
Heading: Antipsychotic Agents > Safety Issues in Planning and Implementing Care >
Extrapyramidal Side Effects; Table 4–12
Integrated Processes: Nursing Process
abirb.com/test
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Knowledge [Remembering]
Concept: Safety
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
This is incorrect. Diazepam (Valium) is an anxiolytic and would
not improve a
abirb.com/test
client’s reaction to extrapyramidal side effects.
This is incorrect. Amitriptyline (Elavil) is a tricyclic antidepressant, which is not
indicated for extrapyramidal side effects.
abirb.com/test
This is correct. Benztropine (Cogentin) is an anticholinergic
agent used to prevent
and/or treat extrapyramidal side effects.
This is incorrect. Methylphenidate is a CNS stimulant and not used for
extrapyramidal side effects.
abirb.com/test
CON: Safety
abirb.com/test
21. The nurse is assessing a patient in the community health clinic who complains of
having “the flu for over a week.” The patient reports the diagnosis
of bipolar disorder
abirb.com/test
and compliance with the maintenance dosage of lithium carbonate. Upon further
assessment the nurse finds that the patient has been coughing, a runny nose, chest
congestion, blurred vision, fever of 100.9°F, and “ringing in their ears.” What situation
abirb.com/test
does the nurse anticipate?
1. Ingestion of high foods high in tyramine
2. Noncompliance with therapy
3. Tolerance to the lithium
abirb.com/test
4. Lithium toxicity
ANS: 4
abirb.com/test
Chapter: Chapter 4, Psychopharmacology
Objective: Describe indications, actions, contraindications, precautions, side effects, and
nursing implications for the following classifications of drugs: c. mood-stabilizing
abirb.com/test
agents.
Page: 70
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 4 - ETB
abirb.com/test
Heading: Mood-Stabilizing Agents > Planning and Implementing Care > Lithium
Maintenance; Table 4–10
Integrated Processes: Nursing Process
abirb.com/test
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Analysis [Analyzing]
Concept: Safety
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
This is incorrect. These are not signs of neuroleptic malignant
syndrome.
abirb.com/test
This is incorrect. These are not signs of noncompliance with lithium therapy.
This is incorrect. This is not indicative of a tolerance to lithium carbonate.
This is correct. Vomiting, diarrhea, blurred vision, tinnitus, tremors, and sedation are
abirb.com/test
some symptoms of lithium toxicity. Lithium toxicity occurs
with a serum lithium
level over 1.2 mEq/L.
CON: Safety
abirb.com/test
abirb.com/test
22. The nurse is preparing a teaching plan for the parent of a child
diagnosed with
attention deficit-hyperactivity disorder. The parent voices concern over the child’s poor
appetite and inability to gain weight. Which of the following interventions would be the
most appropriate to address the parent’s concerns?
abirb.com/test
1. Administer the child’s medication immediately after meals.
2. Administer the child’s medication at bedtime.
3. Skip a dose of the medication when the child does not eat.
abirb.com/test
4. Assure the parent that the child will eat when hungry.
ANS: 1
Chapter: Chapter 4, Psychopharmacology
abirb.com/test
Objective: Describe indications, actions, contraindications, precautions, side effects, and
nursing implications for the following classifications of drugs: g. agents for attentiondeficit/hyperactivity disorder.
abirb.com/test
Page: 80
Heading: Agents for Attention-Deficit/Hyperactivity Disorder (ADHD) >
Planning/Implementation
Integrated Processes: Nursing Process
abirb.com/test
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Application [Applying]
Concept: Safety
abirb.com/test
Difficulty: Moderate
1.
Feedback
This is correct. Anorexia and weight loss are side effects ofabirb.com/test
stimulant medications.
Stimulants should be administered immediately after meals, and weight should be
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 4 - ETB
abirb.com/test
2.
3.
4.
monitored at least once a week.
This is incorrect. This would not address the issue of poor appetite.
This is incorrect. This is not an appropriate intervention, asabirb.com/test
this would encourage
nonadherence to the medication regimen.
This is incorrect. This suggests a behavior, not a side effect of the medication.
CON: Safety
abirb.com/test
abirb.com/test
23. A patient is experiencing a psychotic episode. The nurse finds that the patient has
allergies to penicillin, prochlorperazine (Compazine), and bee stings. Which
antipsychotic medication is contraindicated for this patient?
abirb.com/test
1. Haloperidol (Haldol)
2. Clozapine (Clozaril)
3. Risperidone (Risperdal)
4. Thioridazine (Mellaril)
abirb.com/test
ANS: 4
Chapter: Chapter 4, Psychopharmacology
abirb.com/test
Objective: Describe indications, actions, contraindications, precautions,
side effects, and
nursing implications for the following classifications of drugs: d. antipsychotics.
Page: 72
Heading: Antipsychotic Agents > Background Assessment Data;abirb.com/test
Table 4–11
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
Cognitive Level: Analysis [Analyzing]
abirb.com/test
Concept: Safety
Difficulty: Difficult
1.
2.
3.
4.
Feedback
abirb.com/test
This is incorrect. First generation antipsychotics do not have a cross-sensitivity with
phenothiazines.
This is incorrect. Atypical antipsychotics do not have a cross-sensitivity with
abirb.com/test
phenothiazines.
This is incorrect. Typical antipsychotics do not have a cross-sensitivity with
phenothiazines.
abirb.com/test
This is correct. Thioridazine (Mellaril) is contraindicated for
patients with a known
allergy to phenothiazines, as there is potential cross-sensitivity among
phenothiazines. Prochlorperazine (Compazine) and thioridazine (Mellaril) are
phenothiazines.
abirb.com/test
CON: Safety
abirb.com/test
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 4 - ETB
abirb.com/test
24. A physician prescribes an additional medication for a patient taking an antipsychotic
agent. The medication is to be administered “prn for extrapyramidal symptoms.” Which
is the most appropriate nursing assessment to determine when to give this medication?
abirb.com/test
1. WBCs <3000/mm3
2. Tremors and a shuffling gait
3. Dry mouth
abirb.com/test
4. Generalized seizures
ANS: 2
Chapter: Chapter 4, Psychopharmacology
abirb.com/test
Objective: Describe indications, actions, contraindications, precautions, side effects, and
nursing implications for the following classifications of drugs: d. antipsychotics.
Page: 73
abirb.com/test
Heading: Antipsychotic Agents > Safety Issues in Planning and Implementing
Care >
Extrapyramidal Side Effects; Table 4–12; Box 4–2
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Pharmacological and Parenteral
Therapies
abirb.com/test
Cognitive Level: Analysis [Analyzing]
Concept: Safety
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. A WBC count less than 3,000/mm3 indicates agranulocytosis, not
extrapyramidal symptoms.
abirb.com/test
This is correct. Tremors and a shuffling gait are extrapyramidal symptoms. Other
extrapyramidal symptoms are acute dystonias (muscle spasms) that can be lifethreatening, Parkinson-like symptoms, and tardive dyskinesia (later-onset
abirb.com/test
involuntary movement disorders primarily in the tongue, lips,
and jaw that may also
involve other movement disturbances). These can be permanent even after the drug
is discontinued.
This is incorrect. Dry mouth is a common side effect with abirb.com/test
many psychotropic
medications.
This is incorrect. Seizures are a symptom of neuroleptic malignant syndrome.
CON: Safety
abirb.com/test
abirb.com/test
25. A patient is diagnosed with anxiety disorder. Which medication would the nurse
expect to be prescribed?
1. Chlorpromazine (Thorazine)
abirb.com/test
2. Clozapine (Clozaril)
3. Diazepam (Valium)
4. Methylphenidate (Ritalin)
abirb.com/test
ANS: 3
abirb.com/test
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PMHN, 10e
Chapter 4 - ETB
abirb.com/test
Chapter: Chapter 4, Psychopharmacology
Objective: Describe indications, actions, contraindications, precautions, side effects, and
nursing implications for the following classifications of drugs: a. antianxiety agents.
abirb.com/test
Page: 59
Heading: Antianxiety Agents
Integrated Processes: Nursing Process
abirb.com/test
Client Need: Physiological Integrity: Pharmacological and Parenteral
Therapies
Cognitive Level: Knowledge [Remembering]
Concept: Stress
Difficulty: Easy
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. Chlorpromazine (Thorazine) is an antipsychotic medication used to
abirb.com/test
treat symptoms of schizophrenia and psychosis.
This is incorrect. Clozapine (Clozaril) is an antipsychotic medication used to treat
symptoms of schizophrenia and psychosis.
This is correct. Diazepam (Valium) is a benzodiazepine used
to treat anxiety.
abirb.com/test
This is incorrect. Methylphenidate (Ritalin) is a stimulant medication used to treat
attention disorders.
abirb.com/test
CON: Stress
abirb.com/test
MULTIPLE RESPONSE
abirb.com/test
26. The nurse is preparing to assess a patient before the physician prescribes a regimen
of psychopharmacological therapy. Which components will the nurse assess? Select all
that apply.
abirb.com/test
1. Medical history
2. Physical examination findings
3. Ethnocultural characteristics
abirb.com/test
4. Current medication
5. Signs of tardive dyskinesia
ANS: 1, 2, 3, 4
abirb.com/test
Chapter: Chapter 4, Psychopharmacology
Objective: Apply the steps of the nursing process to the administration of psychotropic
medications.
abirb.com/test
Page: 56
Heading: Table 4–1
Integrated Processes: Nursing Process
Client Need: Physiological Integrity: Reduction of Risk Potentialabirb.com/test
Cognitive Level: Comprehension [Understanding]
abirb.com/test
abirb.com/test
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Chapter 4 - ETB
abirb.com/test
Concept: Safety
Difficulty: Easy
abirb.com/test
1.
2.
3.
4.
5.
Feedback
This is correct. Medical history must be assessed before a regimen of
psychopharmacological therapy is prescribed for possible issues related to
abirb.com/test
comorbidity.
This is correct. Physical examination findings must be assessed before a regimen of
psychopharmacological therapy is prescribed to obtain baseline data in anticipation
of possible side effects of the mediations.
abirb.com/test
This is correct. Ethnocultural characteristics must be assessed before a regimen of
psychopharmacological therapy is prescribed to anticipate issues with adherence to
the regimen.
abirb.com/test
This is correct. Current medications must be assessed before
a regimen of
psychopharmacological therapy is prescribed to diminish risks of medication
interactions.
This is incorrect. This would not be a preassessment, as it is
a side effect that may
abirb.com/test
result from antipsychotic therapy months to years later.
CON: Safety
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
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Chapter 5 - ETB
abirb.com/test
Chapter 5. Ethical and Legal Issues
abirb.com/test
MULTIPLE CHOICE
abirb.com/test
1. A nursing student asked the charge nurse on the psychiatric unit why she chose
psychiatric-mental health nursing. The charge nurse replied, “Mentally
ill clients need
abirb.com/test
special care. If I were in that position, I’d want a caring nurse also.” The charge nurse’s
choice reflects which ethical framework?
1. Kantianism
abirb.com/test
2. Christian ethics
3. Ethical egoism
4. Utilitarianism
abirb.com/test
ANS: 2
Chapter: Chapter 5, Ethical and Legal Issues
Objective: Discuss ethical theories including utilitarianism, Kantianism, Christian ethics,
abirb.com/test
natural law theories, and ethical egoism.
Page: 89
Heading: Theoretical Perspectives > Christian Ethics
Integrated Processes: Caring
abirb.com/test
Client Need: Safe and Effective Care Environment > Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Ethics
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/test
This is incorrect. Kantianism states that decisions should be
based on moral law and
that actions are bound by a sense of moral duty.
This is correct. The charge nurse is operating from a Christian ethics framework. A
basic principle in Christian ethics is to “do unto others as you
would have them do
abirb.com/test
unto you.”
This is incorrect. Ethical egoism promotes the idea that what is right is good for the
individual.
This is incorrect. Utilitarianism holds that decisions shouldabirb.com/test
be made with a focus on
the end result being happiness.
CON: Ethics
abirb.com/test
abirb.com/test
2. Which response by a nursing applicant during a hiring interview
indicates that the
applicant operates from an ethical egoism framework?
abirb.com/test
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Chapter 5 - ETB
abirb.com/test
1. “I would want to be treated in a caring manner if I were mentally ill.”
2. “This job will pay the bills, and the workload is light enough for me.”
3. “I will be happy caring for the mentally ill. Lifting clients hurts my back.”
abirb.com/test
4. “It is my duty in life to be a psychiatric-mental health nurse because
it’s the right
thing to do.”
ANS: 2
abirb.com/test
Chapter: Chapter 5, Ethical and Legal Issues
Objective: Discuss ethical theories including utilitarianism, Kantianism, Christian ethics,
natural law theories, and ethical egoism.
abirb.com/test
Page: 89
Heading: Theoretical Perspectives > Ethical Egoism
Integrated Processes: Nursing Process: Evaluation
Client Need: Safe and Effective Care Environment > Management
of Care
abirb.com/test
Cognitive Level: Analysis [Analyzing]
Concept: Ethics
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. A basic principle in Christian ethics is to “do unto others as you
abirb.com/test
would have them do unto you.”
This is correct. An ethical egoism framework promotes the idea that decisions are
based on what is good for the individual and may not take the needs of others into
account.
abirb.com/test
This is incorrect. Utilitarianism holds that decisions should be made with a focus on
the end result being happiness.
This is incorrect. Kantianism states that decisions should be based on moral law and
abirb.com/test
that actions are bound by a sense of moral duty.
CON: Ethics
abirb.com/test
3. Without authorization, a nurse administers an extra dose of narcotic tranquilizer to an
abirb.com/test
agitated client. The nurse’s coworker observes this action but does
nothing for fear of
repercussion. What is the ethical interpretation of the coworker’s lack of involvement?
1. Taking no action is still considered an action by the coworker.
2. Taking no action is releasing the coworker from ethical responsibility.
abirb.com/test
3. Taking no action is advised when potential adverse consequences are foreseen.
4. Taking no action is acceptable, because the coworker is a bystander.
ANS: 1
Chapter: Chapter 5, Ethical and Legal Issues
Objective: Define ethical dilemma.
Page: 89
Heading: Ethical Dilemmas
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
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Chapter 5 - ETB
abirb.com/test
Integrated Processes: Communication and Documentation
Client Need: Safe and Effective Care Environment > Management of Care
Cognitive Level: Analysis [Analyzing]
abirb.com/test
Concept: Legal
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/test
This is correct. The coworker’s lack of involvement can be interpreted as an action
taken.
This is incorrect. Taking no action does not release the coworker from ethical
abirb.com/test
responsibility.
This is incorrect. Even when potential adverse consequences are foreseen, taking no
action is not advised.
This is incorrect. It is not acceptable, when the coworker isabirb.com/test
a bystander, to take no
action when ethical principles are neglected.
CON: Legal
abirb.com/test
abirb.com/test
4. Group therapy is strongly encouraged, but not mandatory, on an
inpatient psychiatric
unit. The unit manager’s policy is that clients can make a choice about whether to attend
group therapy. Which ethical principle does the unit manager’s policy preserve?
1. Justice
abirb.com/test
2. Autonomy
3. Veracity
4. Beneficence
abirb.com/test
ANS: 2
Chapter: Chapter 5, Ethical and Legal Issues
Objective: Discuss the ethical principles of autonomy, beneficence,
nonmaleficence,
abirb.com/test
justice, and veracity.
Page: 89
Heading: Ethical Principles > Autonomy
abirb.com/test
Integrated Processes: Nursing Process: Implementation
Client Need: Safe and Effective Care Environment > Management of Care
Cognitive Level: Application [Applying]
Concept: Ethics
abirb.com/test
Difficulty: Easy
1.
2.
Feedback
abirb.com/test
This is incorrect. The ethical principle of justice suggests that
all resources
(including health-care services) ought to be distributed equally to all people.
This is correct. The unit manager’s policy represents the ethical principle of
autonomy, which presumes individuals are capable of making
independent decisions
abirb.com/test
for themselves. All health-care workers must respect such decisions.
abirb.com/test
abirb.com/test
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Chapter 5 - ETB
abirb.com/test
3.
4.
This is incorrect. The ethical principle of veracity refers to one’s duty to always be
truthful.
This is incorrect. Beneficence refers to one’s duty to benefit or promote the good of
abirb.com/test
others.
CON: Ethics
abirb.com/test
5. Which is an example of an intentional tort?
abirb.com/test
1. A nurse fails to assess a client with rigid muscles and an elevated temperature.
2. A nurse physically places a client in restraints without the client’s consent.
3. A nurse makes a medication error and does not report the incident.
abirb.com/test
4. A nurse gives confidential client information to an unauthorized
person.
ANS: 2
Chapter: Chapter 5, Ethical and Legal Issues
abirb.com/test
Objective: Identify behaviors relevant to the psychiatric-mental health setting for which
specific malpractice action could be taken.
Page: 94
abirb.com/test
Heading: Civil Law > Torts
Integrated Processes: Nursing Process: Assessment
Client Need: Safe and Effective Care Environment > Management of Care
Cognitive Level: Analysis [Analyzing]
abirb.com/test
Concept: Legal
Difficulty: Moderate
1.
2.
3.
4.
abirb.com/test
Feedback
This is incorrect. The nurse failing to assess a client’s temperature is an act of
negligence or malpractice, which is an unintentional tort.
This is correct. A tort is a violation of civil law in which anabirb.com/test
individual has been
wronged, and this can be intentional or unintentional. By physically touching the
client while applying restraints without consent, the nurse committed an intentional
tort. Malpractice and negligence action are examples of unintentional torts.
This is incorrect. This is an example of nonmaleficence. abirb.com/test
This is incorrect. This sharing of client information is a Health Insurance Portability
and Accountability Act (HIPAA) violation.
abirb.com/test
CON: Legal
abirb.com/test
6. An involuntarily committed client is verbally abusive to the staff and repeatedly
threatens to sue. The client records the full names and phone numbers of the staff.
Which nursing action is most appropriate to decrease the possibility
of a lawsuit?
abirb.com/test
1. Verbally redirect the client and limit one-on-one interaction.
abirb.com/test
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Chapter 5 - ETB
abirb.com/test
2. Involve the hospital’s security division.
3. Inform the client that hospital policy prohibits documenting personal staff
information.
4. Continue professional attempts to establish a positive workingabirb.com/test
relationship.
ANS: 4
Chapter: Chapter 5, Ethical and Legal Issues
abirb.com/test
Objective: Identify behaviors relevant to the psychiatric-mental health setting for which
specific malpractice action could be taken.
Page: 102
abirb.com/test
Heading: Nursing Liability > Avoiding Liability > Box 5–3. Patient
Self-Determination
Act – Patient Rights
Integrated Processes: Nursing Process: Implementation
Client Need: Safe and Effective Care Environment > Management
of Care
abirb.com/test
Cognitive Level: Analysis [Analyzing]
Concept: Legal
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. The client may perceive limited one-on-one interaction as a barrier
abirb.com/test
to a positive working relationship.
This is incorrect. The involuntarily committed client has the right to assert
grievances if rights are infringed.
This is incorrect. The involuntarily committed client has the
right to assert
abirb.com/test
grievances if rights are infringed, and the client can document the staff’s
information.
This is correct. The priority nursing action is to continue professional attempts to
establish a positive working relationship with the client. abirb.com/test
CON: Legal
abirb.com/test
7. Which statement should the nurse identify as correct regarding a client’s right to
abirb.com/test
refuse treatment?
1. Clients can refuse pharmacological but not psychological treatment.
2. Clients can refuse any type of psychiatric treatment at any time.
3. The only treatment a client can refuse is electroconvulsive therapy
(ECT).
abirb.com/test
4. Professionals can override treatment refusal if the client is actively suicidal.
ANS: 4
abirb.com/test
Chapter: Chapter 5, Ethical and Legal Issues
Objective: Identify behaviors relevant to the psychiatric-mental health setting for which
specific malpractice action could be taken.
Page: 94
abirb.com/test
Heading: Legal Issues in Psychiatric/Mental Health Nursing > Informed Consent
abirb.com/test
abirb.com/test
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Chapter 5 - ETB
abirb.com/test
Integrated Processes: Nursing Process: Assessment
Client Need: Safe and Effective Care Environment > Management of Care
Cognitive Level: Comprehension [Understanding]
abirb.com/test
Concept: Legal
Difficulty: Easy
1.
2.
3.
4.
Feedback
abirb.com/test
This is incorrect. Clients can refuse both pharmacological and psychological
treatment.
This is incorrect. In most cases, a client can refuse any type of psychiatric treatment,
abirb.com/test
unless the client is suicidal or homicidal due to the serious risk to self or others.
This is incorrect. A client can refuse most treatments, except in the case of suicidal
or homicidal thoughts due to the risk of harm to self or others.
abirb.com/test
This is correct. A client has the right to refuse any treatments
unless he or she is
determined to have suicidal or homicidal intent, as there is a serious risk of harm to
self or others in that case. Health-care professionals can override treatment refusal to
keep the client and/or others safe from harm.
abirb.com/test
CON: Legal
abirb.com/test
8. Which client should a nurse identify as a potential candidate for involuntary
commitment?
abirb.com/test
1. A client living under a bridge in a cardboard box.
2. A client verbalizing intent to commit suicide.
3. A homeless client refusing to bathe.
abirb.com/test
4. A client who eats waste out of a garbage can.
abirb.com/test
ANS: 2
Chapter: Chapter 5, Ethical and Legal Issues
Objective: Discuss legal issues relevant to psychiatric-mental health nursing.
abirb.com/test
Page: 99
Heading: Hospitalization > Involuntary Commitment
Integrated Processes: Nursing Process: Assessment
Client Need: Safe and Effective Care Environment > Management
of Care
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Legal
Difficulty: Easy
abirb.com/test
1.
2.
Feedback
This is incorrect. The client living under a bridge is not a danger to self or others and
therefore is not a candidate for involuntary commitment. abirb.com/test
This is correct. The client verbalizing intent to commit suicide is eligible for
abirb.com/test
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Chapter 5 - ETB
abirb.com/test
3.
4.
involuntary commitment. The suicidal client who refuses treatment is a danger to
self and requires emergency treatment.
This is incorrect. The client who is refusing to bathe is not a danger to self or others
abirb.com/test
and therefore is not a candidate for involuntary commitment.
This is incorrect. The client who is eating from a garbage can is not a danger to self
or others and therefore is not a candidate for involuntary commitment.
abirb.com/test
CON: Legal
abirb.com/test
9. A client diagnosed with schizophrenia refuses to take medication, citing the right of
autonomy. Under which circumstance would a nurse have the right to medicate the
abirb.com/test
client?
1. The client makes inappropriate sexual innuendos to a staff member.
2. The client repeatedly demands constant attention from the nurse.
3. The client physically attacks another client during group therapy.
abirb.com/test
4. The client refuses to bathe or attend to personal hygiene.
ANS: 3
abirb.com/test
Chapter: Chapter 5, Ethical and Legal Issues
Objective: Discuss legal issues relevant to psychiatric-mental health nursing.
Page: 91
Heading: Ethical/Legal Issues in Psychiatric/Mental Health Nursing
> The Right to
abirb.com/test
Refuse Treatment (Including Medication)
Integrated Processes: Nursing Process: Implementation
Client Need: Safe and Effective Care Environment > Management of Care
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Legal
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. While the client is acting inappropriately, they are not a harm to
self or others and therefore cannot be forced to take medication.
abirb.com/test
This is incorrect. The client demanding constant attention is
not a risk of harm to self
or others and therefore cannot be forced to take medication.
This is correct. The nurse may legally medicate a client against his or her wishes if
the client physically attacks another client, as he or she poses
a significant risk of
abirb.com/test
harm to others. The client’s refusal to accept treatment can be challenged because
the client is endangering the safety of others.
This is incorrect. The client is not a threat of harm to self or others when personal
hygiene is neglected and therefore cannot be forced to takeabirb.com/test
medication.
CON: Moderate
abirb.com/test
abirb.com/test
abirb.com/test
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Chapter 5 - ETB
abirb.com/test
10. A psychiatric-mental health nurse working on an inpatient unit receives a call asking
if an individual has been a client in the facility. Which nursing response reflects
abirb.com/test
appropriate legal and ethical obligations?
1. Refuse to give any information to the caller and cite confidentiality.
2. Refuse to give any information to the caller and hang up.
3. Affirm only that the person has been seen at the facility.
abirb.com/test
4. Suggest the caller contact the client’s psychiatrist.
ANS: 1
abirb.com/test
Chapter: Chapter 5, Ethical and Legal Issues
Objective: Identify behaviors relevant to the psychiatric-mental health setting for which
specific malpractice action could be taken.
Page: 94
abirb.com/test
Heading: Legal Issues in Psychiatric/Mental Health Nursing > Confidentiality and Right
to Privacy
Integrated Processes: Nursing Process: Implementation
abirb.com/test
Client Need: Safe and Effective Care Environment > Management of Care
Cognitive Level: Application [Applying]
Concept: Legal
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is correct. The nurse is legally and ethically obligated to refuse to give any
abirb.com/test
information to the caller.
This is incorrect. The nurse is obligated to protect the client’s confidentiality and
should identify this as the reason for refusing to give information rather than hanging
abirb.com/test
up.
This is incorrect. Admission to a facility is considered privileged information and
should not be disclosed.
This is incorrect. The psychiatrist cannot provide information,
and the fact that the
abirb.com/test
client is seeing a psychiatrist is privileged information and should not be disclosed.
CON: Legal
abirb.com/test
11. A client requests information on several medications to makeabirb.com/test
an informed choice
about management of depression. A nurse should provide this information to facilitate
which ethical principle?
1. Autonomy
abirb.com/test
2. Beneficence
3. Nonmaleficence
4. Justice
abirb.com/test
ANS: 1
abirb.com/test
abirb.com/test
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Chapter 5 - ETB
abirb.com/test
Chapter: Chapter 5, Ethical and Legal Issues
Objective: Discuss the ethical principles of autonomy, beneficence, nonmaleficence,
justice, and veracity.
abirb.com/test
Page: 89
Heading: Ethical Principles > Autonomy
Integrated Processes: Nursing Process: Implementation
Client Need: Safe and Effective Care Environment > Management
of Care
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Ethics
Difficulty: Easy
abirb.com/test
1.
2.
3.
4.
Feedback
This is correct. The nurse is following the ethical principle of autonomy by
providing the client with information so the client can make
his or her own choice
abirb.com/test
about managing depression. A client who is capable of making independent choices
should be permitted to do so. A legal guardian or representative would be asked to
give consent for a client who is incapable of making informed decisions.
abirb.com/test
This is incorrect. Beneficence refers to one’s duty to benefit or promote the good of
others.
This is incorrect. Nonmaleficence is the requirement that health-care providers do no
harm to their clients, either intentionally or unintentionally.abirb.com/test
This is incorrect. Justice suggests that all resources (including health-care services)
ought to be distributed equally to all people.
abirb.com/test
CON: Ethics
abirb.com/test
12. A psychiatrist working on an inpatient unit refuses to treat clients who do not have
health insurance coverage and prematurely discharges clients whose health insurance
benefits have expired. The nurse recognizes the psychiatrist is violating
which ethical
abirb.com/test
principle?
1. Autonomy
2. Beneficence
abirb.com/test
3. Nonmaleficence
4. Justice
ANS: 4
abirb.com/test
Chapter: Chapter 5, Ethical and Legal Issues
Objective: Discuss the ethical principles of autonomy, beneficence, nonmaleficence,
justice, and veracity.
abirb.com/test
Page: 90
Heading: Ethical Principles > Justice
Integrated Processes: Nursing Process: Evaluation
Client Need: Safe and Effective Care Environment > Management
of Care
abirb.com/test
Cognitive Level: Application [Applying]
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 5 - ETB
abirb.com/test
Concept: Ethics
Difficulty: Moderate
1.
2.
3.
4.
abirb.com/test
Feedback
This is incorrect. The ethical principle of autonomy presumes individuals are capable
of making independent decisions for themselves.
This is incorrect. Beneficence refers to one’s duty to benefit
or promote the good of
abirb.com/test
others.
This is incorrect. Nonmaleficence is the requirement that health-care providers do no
harm to their clients, either intentionally or unintentionally.
abirb.com/test
This is correct. The psychiatrist has violated the ethical principle of justice, which
requires individuals to be treated equally regardless of race, sex, marital status,
medical diagnosis, social standing, economic level, or religious beliefs.
abirb.com/test
CON: Ethics
abirb.com/test
13. Which situation contradicts the ethical principle of veracity?
1. A nurse provides a client with outpatient resources to benefit recovery.
abirb.com/test for a client’s
2. A nurse refuses to give information to a physician who is not responsible
care.
3. A nurse tricks a client into seclusion by asking the client to carry linen to the
seclusion room.
abirb.com/test
4. A nurse treats all clients equally, regardless of the acuity of their illness.
ANS: 3
abirb.com/test
Chapter: Chapter 5, Ethical and Legal Issues
Objective: Discuss the ethical principles of autonomy, beneficence, nonmaleficence,
justice, and veracity.
Page: 90
abirb.com/test
Heading: Ethical Principles > Veracity
Integrated Processes: Nursing Process: Implementation
Client Need: Safe and Effective Care Environment > Management of Care
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Ethics
Difficulty: Moderate
abirb.com/test
1.
2.
3.
Feedback
This is incorrect. Providing a client with resources to benefit recovery demonstrates
the principles of justice and autonomy.
abirb.com/test
This is incorrect. A nurse refusing to provide information to
a physician not
responsible for a client’s care is acting appropriately to protect the client’s privacy.
This is correct. Tricking a client into seclusion has violated the ethical principle of
veracity. The principle of veracity refers to one’s duty to always
be truthful and not
abirb.com/test
intentionally deceive or mislead clients.
abirb.com/test
abirb.com/test
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Chapter 5 - ETB
abirb.com/test
4.
This is incorrect. Treating all clients equally demonstrates the principle of justice.
CON: Ethics
abirb.com/test
14. A client who will be receiving ECT must provide informed consent.
Which situation
abirb.com/test
should cause a nurse to question the validity of the informed consent?
1. The client is demonstrating symptoms of paranoia.
2. The client is 87 years old.
abirb.com/test
3. The client is not oriented to person, date, or time.
4. The client asks the spouse’s opinion.
ANS: 3
abirb.com/test
Chapter: Chapter 5, Ethical and Legal Issues
Objective: Identify behaviors relevant to the psychiatric-mental health setting for which
specific malpractice action could be taken.
abirb.com/test
Page: 97
Heading: Informed Consent > Competency
Integrated Processes: Nursing Process: Assessment
abirb.com/test
Client Need: Safe and Effective Care Environment > Management
of Care
Cognitive Level: Application [Applying]
Concept: Legal
Difficulty: Easy
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. The client who is paranoid is not necessarily unable to cognitively
abirb.com/test
understand the risks and benefits of the procedure.
This is incorrect. Age is not a determinant for the ability to provide informed
consent. The client should be cognitively able to understand the risks and benefits of
a procedure.
abirb.com/test
This is correct. The nurse should question the validity of informed consent when the
client is not oriented, demonstrated by incorrectly reporting a spouse’s name, date,
and time of day. This indicates that this client is disoriented and may not be
abirb.com/test
competent to make informed choices.
This is incorrect. The client who requests the opinion of their spouse is still able to
make an informed decision and understand risks and benefits.
abirb.com/test
CON: Legal
abirb.com/test
15. A client diagnosed with schizophrenia receives fluphenazine decanoate (Prolixin
Decanoate) from a home health nurse. The client refuses the medication during one
regularly scheduled home visit. Which nursing intervention is ethically
appropriate?
abirb.com/test
1. Allow the client to decline the medication and document the refusal.
abirb.com/test
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Chapter 5 - ETB
abirb.com/test
2. Tell the client that hospitalization will be needed if the medication is refused.
3. Arrange with a relative to add medication to the client’s morning orange juice.
4. Call for help to hold the client down while the injection is administered.
abirb.com/test
ANS: 1
Chapter: Chapter 5, Ethical and Legal Issues
Objective: Discuss the ethical principles of autonomy, beneficence,
nonmaleficence,
abirb.com/test
justice, and veracity.
Page: 89
Heading: Ethical Principles > Autonomy
abirb.com/test
Integrated Processes: Nursing Process: Implementation
Client Need: Safe and Effective Care Environment > Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Ethics
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/test
This is correct. It is ethically and legally appropriate for the nurse to allow the client
to refuse the medication and to provide accurate documentation. The client’s right to
refuse treatment should be upheld unless the refusal puts the client or others at risk
abirb.com/test
of harm.
This is incorrect. The threat to hospitalize the client is an example of violating the
principle of veracity.
This is incorrect. Adding the medication to the client’s orange
juice without their
abirb.com/test
knowledge would violate the principle of autonomy.
This is incorrect. Holding the client down to give the injection would be an
intentional tort by the nurse and violates the client’s rights.
abirb.com/test
CON: Ethics
abirb.com/test
16. Which situation exemplifies both assault and battery?
1. The nurse becomes angry, calls the client offensive names, and withholds treatment.
abirb.com/test
2. The nurse threatens to “tie down” the client and does so against
the client’s wishes.
3. The nurse hides the client’s clothes and medicates the client to prevent elopement.
4. The nurse restrains the client without just cause and communicates this to family.
abirb.com/test
ANS: 2
Chapter: Chapter 5, Ethical and Legal Issues
Objective: Identify behaviors relevant to the psychiatric-mental health setting for which
abirb.com/test
specific malpractice action could be taken.
Page: 101
Heading: Types of Lawsuits that Occur in Psychiatric Nursing
Integrated Processes: Nursing Process: Implementation
abirb.com/test
Client Need: Safe and Effective Care Environment > Management of Care
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 5 - ETB
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Legal
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. The nurse becoming angry and withholding treatment does not
include touching the person without consent.
abirb.com/test
This is correct. The nurse has committed the acts of both assault and battery. Assault
refers to an action that results in fear and apprehension that the person will be
touched without consent. Battery is the touching of another person without consent.
abirb.com/test
This is incorrect. The nurse hiding clothes and medicating the client does not include
the person being touched without consent.
This is incorrect. The nurse restraining the client without just cause is battery but
abirb.com/test
does not include the fear and intimidation required to qualify
as assault.
CON: Legal
abirb.com/test
17. A geriatric client is confused and wandering in and out of every door. Which
scenario reflects the least restrictive alternative for this client? abirb.com/test
1. Place the client in seclusion.
2. Place the client in a geriatric chair that has a tray.
3. Place the client in soft Posey restraints.
abirb.com/test
4. Place a monitoring bracelet on the client’s ankle.
ANS: 4
abirb.com/test
Chapter: Chapter 5, Ethical and Legal Issues
Objective: Discuss legal issues relevant to psychiatric-mental health nursing.
Page: 92
Heading: The Right to the Least-Restrictive Treatment Alternative
abirb.com/test
Integrated Processes: Nursing Process: Implementation
Client Need: Safe and Effective Care Environment > Management of Care
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Legal
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/test
This is incorrect. Seclusion is not justified because the client is not a harm to self or
others. Placing the client in seclusion is a restrictive intervention.
This is incorrect. A geriatric chair with a tray is restrictive and is perceived as a
abirb.com/test
restraint. This client is not a harm to self or others and therefore
does not need to be
restrained in any manner.
This is incorrect. A Posey restraint is a restrictive treatment; the client is not a harm
to self or others and does not warrant such intervention. abirb.com/test
This is correct. The least restrictive alternative is to place a monitoring bracelet on
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 5 - ETB
abirb.com/test
the client’s ankle. The ankle bracelet allows the client freedom of movement.
CON: Legal
abirb.com/test
18. A man calls the psychiatric unit to speak to his sister. The nurse
connects him to the
abirb.com/test
community phone and the sister is summoned. The nurse later realizes that the brother
was not on the client’s approved call list. What law has the nurse broken?
1. National Alliance for the Mentally Ill (NAMI)
abirb.com/test
2. Tarasoff Ruling
3. Health Insurance Portability and Accountability Act (HIPAA)
4. Good Samaritan law
abirb.com/test
ANS: 3
Chapter: Chapter 5, Ethical and Legal Issues
Objective: Identify behaviors relevant to the psychiatric-mental health setting for which
abirb.com/test
specific malpractice action could be taken.
Page: 94
Heading: Confidentiality and Right to Privacy > HIPAA
abirb.com/test
Integrated Processes: Nursing Process: Evaluation
Client Need: Safe and Effective Care Environment > Management of Care
Cognitive Level: Application [Applying]
Concept: Legal
abirb.com/test
Difficulty: Easy
1.
2.
3.
4.
Feedback
abirb.com/test
This is incorrect. NAMI is an organization that works to improve
the lives of the
mentally ill.
This is incorrect. The Tarasoff Ruling indicates that a mental health professional has
a duty to a client and individual(s) whom the client may threaten.
abirb.com/test
This is correct. The nurse violated HIPAA by revealing that the client had been
admitted to the psychiatric unit. Under HIPAA, the nurse may not provide any
information without proper consent from the client.
abirb.com/test
This is incorrect. The Good Samaritan law protects those who
work to give
reasonable assistance to someone injured or otherwise in danger.
CON: Legal
abirb.com/test
19. An inpatient client, whom the treatment team has determinedabirb.com/test
to be a danger to self,
gives notice of intent to leave the hospital. What information should the nurse recognize
as having an impact on the treatment team’s next action?
1. State law determines the length of time a psychiatric facility can
hold a client.
abirb.com/test
2. Federal law determines if the client is competent enough to be discharged.
abirb.com/test
abirb.com/test
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Chapter 5 - ETB
abirb.com/test
3. The client’s family will be involved to determine if discharge is possible.
4. Hospital policies will determine treatment team actions.
abirb.com/test
ANS: 1
Chapter: Chapter 5, Ethical and Legal Issues
Objective: Discuss legal issues relevant to psychiatric-mental health nursing.
Page: 99
abirb.com/test
Heading: Hospitalization > Emergency Commitments
Integrated Processes: Nursing Process: Analysis
Client Need: Safe and Effective Care Environment
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Legal
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is correct. Most states commonly cite that, in an emergency, a client who is
dangerous to self or others may be involuntarily hospitalized.
abirb.com/test
This is incorrect. It is state–not federal–law that determines what actions can be
taken when a client is determined to be a danger to themself.
This is incorrect. The family is not included to determine if the client can be
abirb.com/test
discharged since the client is a danger to themself.
This is incorrect. Hospital policy may guide a portion of the actions; however, state
standards will be utilized to determine whether a client can remain hospitalized.
abirb.com/test
CON: Legal
abirb.com/test
20. A client is concerned that information given to the nurse remains confidential.
Which is the nurse’s best response?
1. “Your information is confidential and will be kept just between
us.”
abirb.com/test
2. “I will share the information with staff members only with your approval.”
3. “If the information impacts your care, I will need to share it with the treatment team.”
4. “You can make the decision whether your physician needs this information and
abirb.com/test
whether it can be shared.”
ANS: 3
Chapter: Chapter 5, Ethical and Legal Issues
abirb.com/test
Objective: Discuss legal issues relevant to psychiatric-mental health nursing.
Page: 95
Heading: Legal Issues in Psychiatric/Mental Health Nursing > Confidentiality and Right
abirb.com/test
to Privacy > HIPAA
Integrated Processes: Nursing Process: Implementation
Client Need: Safe and Effective Care Environment > Management of Care
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Legal
abirb.com/test
abirb.com/test
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Chapter 5 - ETB
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
This is incorrect. Any information pertinent to the client’s abirb.com/test
care will be shared with
staff members. Clients give implied consent to share information pertinent to their
care among the care staff.
This is incorrect. The nurse will need to share any information
pertinent to the
abirb.com/test
client’s care with other members of the care team, and the client gives implied
consent for this when in the facility.
This is correct. Basic to the psychiatric client’s hospitalization is his or her right to
abirb.com/test
confidentiality and privacy. When admitted to an inpatient psychiatric facility, a
client gives implied consent for information to be shared with health-care workers
specifically involved in the client’s care.
abirb.com/test
This is incorrect. The client does not decide what information
is to be shared with
the physician and what is not. The nurse will share information with the care staff,
including the physician.
abirb.com/test
CON: Legal
abirb.com/test
21. The nursing staff is discussing the concept of competency. The nurse recognizes
which information about competency as true?
1. Competency is determined with a client’s compliance with treatment.
abirb.com/test
2. Refusing medication can initiate an incompetency hearing, leading to forced
medications.
3. A competent client has the ability to make reasonable judgments and decisions for
abirb.com/test
themself.
4. Competency is a medical determination made by the client’s physician.
ANS: 3
abirb.com/test
Chapter: Chapter 5, Ethical and Legal Issues
Objective: Discuss legal issues relevant to psychiatric-mental health nursing.
Page: 95
abirb.com/test
Heading: Legal Issues in Psychiatric/Mental Health Nursing > Informed
Consent
Integrated Processes: Nursing Process: Assessment
Client Need: Safe and Effective Care Environment > Management of Care
Cognitive Level: Comprehension [Understanding]
abirb.com/test
Concept: Legal
Difficulty: Moderate
1.
2.
abirb.com/test
Feedback
This is incorrect. Competency is not determined with a client’s compliance to
treatment; rather, it is based on the client’s ability to make judgments and decisions.
This is incorrect. Refusing medication is not justification for
a competency hearing
abirb.com/test
or determination and does not lead to forced medication unless the client is a harm to
abirb.com/test
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Chapter 5 - ETB
abirb.com/test
3.
4.
self or others.
This is correct. A competent individual whose cognition is not impaired to an extent
that interferes with decision-making has the right to make judgments and decisions.
abirb.com/test
This is incorrect. A physician, with the assistance of the courts, will determine a
client’s competency.
CON: Legal
abirb.com/test
abirb.com/test
22. A nursing instructor is lecturing on the provisions of the nurse practice act. Which
student statement indicates a need for further instruction?
1. “The nurse practice act provides a list of definitions of important terms, including the
abirb.com/test
definition of nursing.”
2. “The nurse practice act lists education requirements for licensure and reciprocity.”
3. “The nurse practice act contains detailed statements that describe the scope of practice
for registered nurses.”
abirb.com/test
4. “The nurse practice act lists the general authority and powers of the state board of
nursing.”
abirb.com/test
ANS: 3
Chapter: Chapter 5, Ethical and Legal Issues
Objective: Discuss legal issues relevant to psychiatric-mental health nursing.
Page: 93
abirb.com/test
Heading: Nurse Practice Acts
Integrated Processes: Nursing Process: Assessment
Client Need: Safe and Effective Care Environment > Management of Care
abirb.com/test
Cognitive Level: Comprehension [Understanding]
Concept: Legal
Difficulty: Easy
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. The nurse practice act of each state provides definitions, including
the definition of nursing.
abirb.com/test
This is incorrect. Nurse practice acts do provide educational
requirements for
licensure and reciprocity.
This is correct. This student’s statement indicates a need for further instruction. Each
state’s nurse practice act contains broad statements that describe
the scope of
abirb.com/test
practice for various levels of nursing (APN, RN, LPN).
This is incorrect. The nurse practice act does provide general authority and powers
of the state board of nursing.
abirb.com/test
CON: Legal
abirb.com/test
abirb.com/test
abirb.com/test
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Chapter 5 - ETB
abirb.com/test
23. Which description of a common law is accurate?
1. A common law would be invoked to deal with a nurse who threatens a client with
restraints without justification.
abirb.com/test
2. A common law would be invoked to deal with a nurse who touches
a client without
the client’s consent.
3. A common law would be invoked to deal with a hospital employee who steals drugs,
hospital equipment, or both.
abirb.com/test
4. A common law would be invoked to deal with a nurse who refuses to provide care for
a specific client.
ANS: 4
Chapter: Chapter 5, Ethical and Legal Issues
Objective: Differentiate between civil and criminal law.
Page: 93
Heading: Types of Law > Common Law
Integrated Processes: Nursing Process: Assessment
Cognitive Level: Comprehension [Understanding]
Concept: Legal
Difficulty: Moderate
1.
2.
3.
4.
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
Feedback
This is incorrect. This is an example of a nurse’s action that would be addressed with
civil law.
This is incorrect. Battery is governed by civil law rather than
common law.
abirb.com/test
This is incorrect. The hospital employee who steals would be addressed under
criminal law.
This is correct. Common laws apply to a body of principles that evolve from court
abirb.com/test
decisions resolving various controversies. Common laws may
vary from state to
state.
CON: Legal
abirb.com/test
24. Which of the following nursing interventions would best helpabirb.com/test
a client who is
physically restrained cope with the experience?
1. Administer a tranquilizing medication before applying the restraints.
2. Talk to the client at brief, but regular, intervals while the clientabirb.com/test
is restrained.
3. Leave the client alone most of the time to decrease stimuli.
4. Check on the client infrequently to meet documentation requirements.
abirb.com/test
ANS: 2
Chapter: Chapter 5, Ethical and Legal Issues
Objective: Discuss legal issues relevant to psychiatric-mental health nursing.
Page: 98
abirb.com/test
Heading: Legal Issues in Psychiatric/Mental Health Nursing > Restraints and Seclusion
abirb.com/test
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Chapter 5 - ETB
abirb.com/test
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Legal
Difficulty: Moderate
1.
2.
3.
4.
abirb.com/test
Feedback
abirb.com/test
This is incorrect. Tranquilizing medication is a form of restraint and does not assist
the client to recognize the intervention as therapeutic.
This is correct. Connecting with the client by maintaining communication while the
abirb.com/test
client is physically restrained will help the client recognize this intervention as a
therapeutic treatment versus a punishment.
This is incorrect. Leaving the client alone while restrained is inappropriate care, as
abirb.com/test
the client should be assessed and monitored often, as frequently
as every 15 minutes
during the period of restraint.
This is incorrect. The client must be assessed frequently during restraint, as often as
every 15 minutes, and the nurse should provide regular contact
to assist the client.
abirb.com/test
CON: Legal
abirb.com/test
25. There is one bed available on an inpatient psychiatric unit. For which individual
should the nurse advocate emergency commitment to that bed? abirb.com/test
1. An individual who is persistently mentally ill and was evicted from an apartment
2. An individual treated in the emergency department for generalized anxiety disorder
3. An individual who is delusional and has a plan to kill his spouse and children
abirb.com/test
4. An individual who rates mood 4/10 and is participating in a no-harm
safety plan
ANS: 3
Chapter: Chapter 5, Ethical and Legal Issues
abirb.com/test
Objective: Discuss legal issues relevant to psychiatric-mental health nursing.
Page: 99
Heading: Hospitalization > Involuntary Commitment
abirb.com/test
Integrated Processes: Nursing Process: Assessment
Client Need: Safe and Effective Care Environment > Management of Care
Cognitive Level: Application [Applying]
Concept: Legal
abirb.com/test
Difficulty: Moderate
1.
2.
3.
Feedback
This is incorrect. This client, while lacking housing, is not abirb.com/test
a danger to self or others
and therefore does not require involuntary or emergency commitment.
This is incorrect. The client treated in the ER for generalized anxiety disorder is not
a threat to self or others and does not require involuntary orabirb.com/test
emergency commitment.
This is correct. The criteria for involuntary emergency commitment include danger
abirb.com/test
abirb.com/test
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Chapter 5 - ETB
abirb.com/test
4.
to self and/or others. The client who is delusional and has a plan to kill his spouse
and children meets the criterion of posing a danger to others.
This is incorrect. The client who rates their mood as 4/10 and is participating in a noabirb.com/test
harm plan is not considered a threat to self or others and does
not need emergency or
involuntary commitment.
CON: Legal
abirb.com/test
abirb.com/test
26. What is the legal significance of a nurse’s action when the nurse threatens to restrain
a client physically?
1. The nurse can be charged with assault.
abirb.com/test
2. The nurse can be charged with negligence.
3. The nurse can be charged with malpractice.
4. The nurse can be charged with beneficence.
abirb.com/test
ANS: 1
abirb.com/test
Chapter: Chapter 5, Ethical and Legal Issues
Objective: Identify behaviors relevant to the psychiatric-mental health setting for which
specific malpractice action could be taken.
Page: 101
abirb.com/test
Heading: Types of Lawsuits That Occur in Psychiatric Nursing
Integrated Processes: Nursing Process: Implementation
Client Need: Safe and Effective Care Environment > Management of Care
abirb.com/test
Cognitive Level: Comprehension [Understanding]
Concept: Legal
Difficulty: Easy
abirb.com/test
1.
2.
3.
4.
Feedback
This is correct. Threatening to physically restrain a client constitutes assault. Assault
is an act that results in a person’s genuine fear and apprehension that he or she will
abirb.com/test
be touched without consent.
This is incorrect. Negligence is the failure to provide reasonable and prudent care to
others.
This is incorrect. Malpractice is the conduct of a professional
that does not meet
abirb.com/test
professional competence.
This is incorrect. Beneficence is the duty to benefit or promote the good of others.
abirb.com/test
CON: Legal
abirb.com/test
27. Which nursing intervention constitutes false imprisonment?
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 5 - ETB
abirb.com/test
1. The nurse seeks a physician’s order after restraining a combative client who states,
“No one can stop me from leaving.”
2. The nurse institutes seclusion of a client who has been consistently seeking the
abirb.com/test
attention of the nurses much of the day.
3. The nurse runs after an involuntarily admitted psychotic client who runs off the unit
and then agrees to return.
4. The nurse calls the security team to prevent an involuntarily admitted
client from
abirb.com/test
leaving.
ANS: 2
abirb.com/test
Chapter: Chapter 5, Ethical and Legal Issues
Objective: Identify behaviors relevant to the psychiatric-mental health setting for which
specific malpractice action could be taken.
Page: 102
abirb.com/test
Heading: Types of Lawsuits That Occur in Psychiatric Nursing > Restraints and
Seclusion
Integrated Processes: Nursing Process: Implementation
abirb.com/test
Client Need: Safe and Effective Care Environment > Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Legal
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. This act by the nurse provides authorization for the restraint and
abirb.com/test
does not constitute false imprisonment.
This is correct. Secluding the client is false imprisonment. False imprisonment is the
deliberate and unauthorized commitment of a person within fixed limits by the use
of verbal or physical means. Seclusion should only be usedabirb.com/test
in an emergency to
prevent harm after the least restrictive means have been unsuccessfully attempted.
This is incorrect. The nurse who runs after a client who has been involuntarily
committed is seeking to protect the client. Clients are involuntarily
committed if they
abirb.com/test
are a risk of harm to self or others.
This is incorrect. Since the client is involuntarily committed, the client was seen as a
danger to self or others; therefore, asking security to prevent the client from leaving
protects the client and others and is not false imprisonment.abirb.com/test
CON: Legal
abirb.com/test
abirb.com/test
28. Which of the following is indicative of serious critical thinking
about how
individuals should treat others?
1. Values
2. Rights
abirb.com/test
3. Morals
abirb.com/test
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PMHN, 10e
Chapter 5 - ETB
abirb.com/test
4. Ethics
ANS: 3
abirb.com/test
Chapter: Chapter 5, Ethics and Legal Issues
Objective: Differentiate among ethics, morals, values, and rights.
Page: 88
Heading: Core Concepts
abirb.com/test
Integrated Processes: Nursing Process
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Knowledge [Remembering]
abirb.com/test
Concept: Ethics
Difficulty: Easy
1.
2.
3.
4.
Feedback
abirb.com/test
This is incorrect. Values are personal beliefs about what is important and desirable.
This is incorrect. A right is defined as “a valid, legally recognized claim or
entitlement, encompassing both freedom from government interference or
abirb.com/test
discriminatory treatment, and an entitlement to a benefit or service.”
This is correct. Moral behavior is defined as conduct that results from serious
critical thinking about how individuals ought to treat others. Moral behavior reflects
the way a person interprets basic respect for other persons,abirb.com/test
such as the respect for
autonomy, freedom, justice, honesty, and confidentiality.
This is incorrect. Ethics is a branch of philosophy that deals with systematic
approaches to distinguishing right behavior from wrong behavior.
abirb.com/test
CON: Ethics
abirb.com/test
29. The psychiatric-mental health nurse is teaching a client about the side effects of
amlodipine besylate (Norvasc). The nurse’s action is within the nurse’s
scope of practice
abirb.com/test
in the state. Which type of law defines nursing scope of practice?
1. Common law
2. Statutory law
abirb.com/test
3. Criminal law
4. Civil law
abirb.com/test
ANS: 2
Chapter: Chapter 5, Ethics and Legal Issues
Objective: Define statutory law and common law.
abirb.com/test
Page: 93
Heading: Types of Law: Statutory Law
Integrated Processes: Nursing Process: Implementation
Client Need: Safe and Effective Care Environment: Managementabirb.com/test
of Care
Cognitive Level: Application [Applying]
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 5 - ETB
abirb.com/test
Concept: Legal
Difficulty: Moderate
1.
2.
3.
4.
abirb.com/test
Feedback
This is incorrect. Common laws are derived from decisions made in previous cases
and apply to a body of principles that evolve from court decisions resolving various
controversies. Each state’s nurse practice act is a statutory abirb.com/test
law that defines nursing
scope of practice in that state.
This is correct. Each state’s nurse practice act is a statutory law that defines nursing
scope of practice in that state. A statutory law is a law that has been enacted by a
abirb.com/test
legislative body, such as a county or city council, state legislature, or the U.S.
Congress.
This is incorrect. Criminal law provides protection from conduct deemed injurious to
abirb.com/test
the public welfare. It provides for punishment of those found
to have engaged in
such conduct, which commonly includes imprisonment, parole conditions, a loss of
privilege (e.g., a license), a fine, or any combination of these. Each state’s nurse
practice act is a statutory law that defines nursing scope ofabirb.com/test
practice in that state.
This is incorrect. Civil law protects the private and property rights of individuals and
businesses. Each state’s nurse practice act is a statutory law that defines nursing
scope of practice in that state.
abirb.com/test
CON: Legal
abirb.com/test
30. The nursing supervisor reassigned the psychiatric-mental health nurse to the surgical
intensive care unit (SICU) 4 hours into his shift. The nurse is observing an actively
abirb.com/test
suicidal client who requires one-to-one observation. The charge nurse
informs the nurse
there is no other staff member available to take over the one-to-one observation. The
nurse does not feel qualified to care for clients in the SICU. Which of the following
represents the nurse’s situation?
abirb.com/test
1. Conflict between personal beliefs
2. Violation of the standard of nursing care
3. Ethical dilemma
abirb.com/test
4. Breach of duty
ANS: 3
Chapter: Chapter 5, Ethics and Legal Issues
abirb.com/test
Objective: Describe ethical issues relevant to psychiatric-mental health nursing.
Page: 91
Heading: Ethical Dilemmas
abirb.com/test
Integrated Processes: Nursing Process: Evaluation
Client Need: Safe and Effective Care Environment > Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Ethics
abirb.com/test
Difficulty: Difficult
abirb.com/test
abirb.com/test
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Chapter 5 - ETB
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. The nurse’s situation represents an ethical dilemma. An ethical
dilemma in nursing is a situation that requires the nurse to abirb.com/test
make a choice between
two equally unfavorable alternatives. Values are personal beliefs about what is
important and desirable.
This is incorrect. The nurse’s situation represents an ethicalabirb.com/test
dilemma. An ethical
dilemma in nursing is a situation that requires the nurse to make a choice between
two equally unfavorable alternatives. Standards of nursing practice developed by the
American Nurses Association provide guidelines for nursing performance. They are
abirb.com/test
the rules or definition of what it means to provide competent care.
This is correct. The nurse’s situation represents an ethical dilemma. An ethical
dilemma in nursing is a situation that requires the nurse to make a choice between
abirb.com/test
two equally unfavorable alternatives. The individual who must
make the choice
experiences conscious conflict regarding the decision.
This is incorrect. The nurse’s situation represents an ethical dilemma. An ethical
dilemma in nursing is a situation that requires the nurse to abirb.com/test
make a choice between
two equally unfavorable alternatives. A breach of duty is nursing care that is not
consistent with the recognized standard of care.
CON: Ethics
abirb.com/test
abirb.com/test
MULTIPLE RESPONSE
abirb.com/test
31. After disturbing the peace, an aggressive, disoriented, unkempt, homeless individual
is escorted to an emergency department by police. The client threatens suicide. Which
criteria enable a physician to consider involuntary commitment? abirb.com/test
Select all that apply.
1. The client is a danger to others.
2. The client is homeless.
3. The client is disruptive to the community.
4. The client is gravely disabled and unable to meet basic needs. abirb.com/test
5. The client is suicidal.
abirb.com/test
ANS: 1, 4, 5
Chapter: Chapter 5, Ethical and Legal Issues
Objective: Discuss legal issues relevant to psychiatric-mental health nursing.
abirb.com/test
Page: 100
Heading: Involuntary Commitment > The Mentally Ill Person in Need of Treatment
Integrated Processes: Nursing Process: Analysis
Client Need: Safe and Effective Care Environment > Management
of Care
abirb.com/test
Cognitive Level: Analysis
abirb.com/test
abirb.com/test
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Chapter 5 - ETB
abirb.com/test
Concept: Legal
Difficulty: Moderate
1.
2.
3.
4.
5.
abirb.com/test
Feedback
This is correct. The physician could consider involuntary commitment when a client
is dangerous to others.
This is incorrect. Even though the client is homeless, the individual
is not necessarily
abirb.com/test
a harm to self or others and cannot be involuntarily committed based on
homelessness.
This is incorrect. Being disruptive to the community does not demonstrate a threat to
abirb.com/test
self or others and is not grounds for involuntary commitment.
This is correct. The physician could consider involuntary commitment when a client
is gravely disabled.
abirb.com/test when a client
This is correct. The physician could consider involuntary commitment
is suicidal.
CON: Legal
abirb.com/test
32. Which elements must be proven for a plaintiff to prevail in a abirb.com/test
nursing malpractice
suit? Select all that apply.
1. Breach of duty
2. Battery
abirb.com/test
3. Assault
4. Injury to client
5. Negligence
abirb.com/test
6. Duty to client existed
ANS: 1, 4, 6
Chapter: Chapter 5, Ethical and Legal Issues
abirb.com/test
Objective: Differentiate between malpractice and negligence.
Page: 101
Heading: Nursing Liability > Malpractice and Negligence
abirb.com/test
Client Need: Safe and Effective Care Management > Management
of Care
Cognitive Level: Analysis [Analyzing]
Concept: Legal
Difficulty: Moderate
abirb.com/test
1.
2.
Feedback
This is correct. Malpractice is a specialized form of negligence caused only by
abirb.com/test
professionals. Breach of duty is one of the four elements that
must be proven for a
plaintiff to prevail in a nursing malpractice claim.
This is incorrect. Malpractice is a specialized form of negligence caused only by
professionals. Battery is not one of the four elements that must
be proven for a
abirb.com/test
plaintiff to prevail in a nursing malpractice claim. Battery is the unconsented
abirb.com/test
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PMHN, 10e
Chapter 5 - ETB
abirb.com/test
3.
4.
5
6.
touching of another person.
This is incorrect. Malpractice is a specialized form of negligence caused only by
professionals. Assault is not one of the four elements that must be proven for a
plaintiff to prevail in a nursing malpractice claim. Assault abirb.com/test
is an act that results in a
person’s genuine fear and apprehension that he or she will be touched without
consent.
This is correct. Malpractice is a specialized form of negligence
caused only by
abirb.com/test
professionals. Injury to the client is one of the four elements that must be proven for
a plaintiff to prevail in a nursing malpractice claim.
This is incorrect. Negligence has been defined as the failure to exercise the standard
abirb.com/test
of care that a reasonably prudent person would have exercised in a similar situation;
any conduct that falls below the legal standard established to protect others against
unreasonable risk of harm, except for conduct that is intentionally, wantonly, or
abirb.com/test
willfully disregardful of others’ rights (Garner, 2014). Malpractice
is a specialized
form of negligence caused only by professionals. Negligence is not one of the four
elements that must be proven for a plaintiff to prevail in a nursing malpractice claim.
This is correct. Malpractice is a specialized form of negligence
caused only by
abirb.com/test
professionals. Duty to client existed is one of the four elements that must be proven
for a plaintiff to prevail in a nursing malpractice claim.
CON: Legal
abirb.com/test
abirb.com/test
33. The psychiatric-mental health nurse is obtaining informed consent for a client who is
scheduled for ECT the following morning. Which major elements must be
addressed when obtaining informed consent? Select all that apply.
abirb.com/test
1. Client signature and date
2. Physician order
3. Lack of coercion
4. Unimpaired cognition
abirb.com/test
5. Necessity for treatment
6. Client knowledge of the procedure
abirb.com/test
ANS: 3, 4, 6
Chapter: Chapter 5, Ethical and Legal Issues
Objective: Discuss legal issues relevant to psychiatric-mental health nursing.
Page: 97
abirb.com/test
Heading: Legal Issues in Psychiatric/Mental Health Nursing > Informed Consent
Integrated Processes: Nursing Process: Assessment
Client Need: Safe and Effective Care Environment > Management of Care
abirb.com/test
Cognitive Level: Analysis [Analyzing]
Concept: Legal
Difficulty: Moderate
abirb.com/test
Feedback
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 5 - ETB
abirb.com/test
1.
2.
3.
4.
5.
6.
This is incorrect. The client will sign and date the informed consent when the major
elements for informed consent have been addressed. The three major elements that
must be addressed when obtaining informed consent are knowledge, competency,
abirb.com/test
and free will.
This is incorrect. A physician order for ECT is required before informed consent is
obtained. The three major elements that must be addressed when obtaining informed
consent are knowledge, competency, and free will.
abirb.com/test
This is correct. Informed consent requires the client to give consent voluntarily and
without coercion from others. The three major elements that must be addressed when
obtaining informed consent are knowledge, competency, and free will.
abirb.com/test
This is correct. The client’s cognition must not be impaired to an extent that would
interfere with decision-making. The three major elements that must be addressed
when obtaining informed consent are knowledge, competency, and free will.
abirb.com/test
This is incorrect. Informed consent is obtained after the physician
determines the
necessity for treatment and provides an order. The three major elements that must be
addressed when obtaining informed consent are knowledge, competency, and free
will.
abirb.com/test
This is correct. The client must have received adequate information on which to base
his or her decision. The three major elements that must be addressed when obtaining
informed consent are knowledge, competency, and free will.
abirb.com/test
CON: Legal
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 6 - ETB
abirb.com/test
Chapter 6. Relationship Development
abirb.com/test
MULTIPLE CHOICE
abirb.com/test
1. What is the most essential task for a nurse prior to forming a therapeutic relationship
with a client?
abirb.com/test
1. Clarify personal attitudes, values, and beliefs.
2. Obtain thorough assessment data.
3. Determine the client’s length of stay.
abirb.com/test
4. Establish personal goals for the interaction.
ANS: 1
Chapter: Chapter 7, Relationship Development
abirb.com/test
Objective: Discuss the importance of self-awareness in the nurse-client relationship.
Page: 110
Heading: Role of the Psychiatric-Mental Health Nurse > Gaining Self-Awareness
abirb.com/test
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Comprehension [Understanding]
Concept: Patient-Centered Care
abirb.com/test
Difficulty: Easy
1.
2.
3.
4.
Feedback
abirb.com/test
This is correct. The most essential task for a nurse to accomplish prior to forming a
therapeutic relationship with a client is to clarify personal attitudes, values, and
beliefs. Understanding one’s own attitudes, values, and beliefs is called selfabirb.com/test
awareness.
This is incorrect. The thorough assessment would occur after the nurse is able to
clarify personal attitudes, etc.
This is incorrect. This would not be a component of the therapeutic
relationship.
abirb.com/test
This is incorrect. This would occur after the nurse is able to self-reflect as
preparation for the relationship to begin.
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
2. A hungry, homeless client, diagnosed with schizophrenia, refuses to participate in an
admission interview. The nurse postpones the admission interview, verbally assures
safety, and provides the client with a warm meal. Which of the following does the
abirb.com/test
nurse’s action demonstrate?
1. Sympathy
abirb.com/test
abirb.com/test
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Chapter 6 - ETB
abirb.com/test
2. Trust
3. Veracity
4. Manipulation
abirb.com/test
ANS: 2
Chapter: Chapter 7, Relationship Development
Objective: Discuss the dynamics of a therapeutic nurse-client relationship.
abirb.com/test
Page: 113
Heading: Conditions Essential to Development of a Therapeutic Relationship
Integrated Processes: Caring
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. Sympathy implies taking on the other’s needs and problems as if
abirb.com/test
they were your own and becoming emotionally involved to the point of losing your
objectivity.
This is correct. The nurse is promoting trust, which implies a feeling of confidence
abirb.com/test
that a person is reliable and sincere and has integrity and veracity.
Trustworthiness is
demonstrated through nursing interventions that convey a sense of warmth and
caring to the client.
This is incorrect. Veracity is the ethical principle of truth. abirb.com/test
This is incorrect. Manipulation would imply that a boundary has been overstepped.
CON: Patient-Centered Care
abirb.com/test
3. Which is the nurse’s best action when a client demonstrates transference?
abirb.com/test
1. Promote safety and immediately terminate the relationship with the client.
2. Encourage the client to ignore these thoughts and feelings.
3. Immediately reassign the client to another staff member.
abirb.com/test
4. Help the client clarify the meaning of the nurse-client relationship.
ANS: 4
Chapter: Chapter 7, Relationship Development
abirb.com/test
Objective: Discuss the dynamics of a therapeutic nurse-client relationship.
Page: 115
Heading: Phases of a Therapeutic Nurse-Client Relationship > The Working Phase >
abirb.com/test
Transference
Integrated Processes: Caring
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Patient-Centered Care
abirb.com/test
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Chapter 6 - ETB
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
This is incorrect. Immediately terminating the relationshipabirb.com/test
does not promote client
safety. The purpose of termination involves bringing a therapeutic closure to the
relationship.
This is incorrect. The nurse’s goal is to guide clients toward
independence by
abirb.com/test
teaching them to assume responsibility for their own behaviors, feelings, and
thoughts.
This is incorrect. Reassigning the client implies the nurse does not demonstrate
abirb.com/test
acceptance of the client, which is necessary for a therapeutic nurse-client
relationship.
This is correct. Transference occurs when the client unconsciously displaces feelings
abirb.com/test
formed toward a person from the past toward the nurse. The
nurse should respond by
assisting the client separate the past from the present and clarify the meaning of the
nurse-client relationship, based on the current situation.
abirb.com/test
CON: Patient-Centered Care
abirb.com/test
4. Which of the following is the priority nursing action during the orientation
(introductory) phase of the nurse-client relationship?
1. Acknowledge the client’s actions and generate alternative behaviors.
abirb.com/test
2. Establish rapport and develop mutually agreeable treatment goals.
3. Attempt to find alternative placement for the client.
4. Explore how thoughts and feelings may adversely impact nursing care.
abirb.com/test
ANS: 2
Chapter: Chapter 7, Relationship Development
Objective: Describe the phases of relationship development and the
tasks associated
abirb.com/test
with each phase.
Page: 116
Heading: Phases of a Therapeutic Nurse-Client Relationship > The Orientation
abirb.com/test
(Introductory) Phase
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Patient-Centered Care
Difficulty: Moderate
1.
2.
abirb.com/test
Feedback
This is incorrect. This would be a component of the working phase.
This is correct. The priority nursing action during the orientation phase of the nurseclient relationship should be to establish rapport and develop
treatment goals.
abirb.com/test
Rapport implies feelings on the part of both the nurse and the client based on
abirb.com/test
abirb.com/test
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Chapter 6 - ETB
abirb.com/test
3.
4.
respect, acceptance, a sense of trust, and a nonjudgmental attitude.
This is incorrect. Although this is a component of the orienting phase, it is not a
priority.
abirb.com/test
This is incorrect. This would be an appropriate intervention during the working
phase if the nurse discovers countertransference.
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
5. Which outcome does the nurse expect during the working phase of the nurse-client
relationship?
1. The client gains insight and incorporates alternative behaviors.
abirb.com/test
2. The client and nurse establish rapport and mutually develop treatment
goals.
3. The client explores feelings related to reentering the community.
4. The client explores personal strengths and weaknesses that impact behaviors.
abirb.com/test
ANS: 1
Chapter: Chapter 7, Relationship Development
Objective: Describe the phases of relationship development and the tasks associated
abirb.com/test
with each phase.
Page: 116
Heading: Phases of a Therapeutic Nurse-Client Relationship > The Working Phase
Integrated Processes: Nursing Process: Evaluation
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
abirb.com/test
Difficulty: Easy
1.
2.
3.
4.
Feedback
This is correct. The nurse expects the client will gain insight
and incorporate
abirb.com/test
alternative behaviors during the working phase of the nurse-client relationship. The
client may also overcome resistance, develop problem-solving skills, and continually
evaluate progress toward goals.
abirb.com/test
This is incorrect. Establishing rapport and developing treatment
goals occurs during
the orientation (introductory) phase of the nurse-client relationship.
This is incorrect. This occurs during the termination phase of the nurse-client
relationship.
abirb.com/test
This is incorrect. Exploring personal strengths and weaknesses occurs during the
orientation (introductory) phase of the nurse-client relationship.
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
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Chapter 6 - ETB
abirb.com/test
6. Which of the following is the nurse’s primary goal during the preinteraction phase of
the nurse-client relationship?
1. Evaluate goal attainment.
abirb.com/test
2. Formulate a contract for intervention.
3. Explore self-perceptions.
4. Promote client change.
abirb.com/test
ANS: 3
Chapter: Chapter 7, Relationship Development
Objective: Describe the phases of relationship development and the tasks associated
abirb.com/test
with each phase.
Page: 115
Heading: Phases of a Therapeutic Nurse-Client Relationship > The Preinteraction Phase
Integrated Processes: Nursing Process: Planning
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
abirb.com/test
Difficulty: Easy
1.
2.
3.
4.
Feedback
abirb.com/test
This is incorrect. This is the nurse’s goal during the termination
phase of the nurseclient relationship.
This is incorrect. This is the nurse’s goal during the orientation (introductory) phase
of the nurse-client relationship.
abirb.com/test
This is correct. The nurse’s primary goal of the preinteraction phase is to explore
self-perceptions. The nurse should be aware of preconceptions that may affect the
nurse’s ability to care for individual clients.
abirb.com/test
This is incorrect. This is the nurse’s goal during the working
phase of the nurseclient relationship.
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
7. Which phase of the nurse-client relationship begins when the nurse
and client first
meet and is characterized by an agreement to continue meeting and working on setting
client-centered goals?
1. Preinteraction
abirb.com/test
2. Orientation
3. Working
4. Termination
abirb.com/test
ANS: 2
Chapter: Chapter 7, Relationship Development
Objective: Describe the phases of relationship development and the
tasks associated
abirb.com/test
with each phase.
abirb.com/test
abirb.com/test
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Chapter 6 - ETB
abirb.com/test
Page: 114
Heading: Phases of a Therapeutic Nurse-Client Relationship > The Orientation
(Introductory) Phase
abirb.com/test
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Comprehension [Understanding]
Concept: Patient-Centered Care
abirb.com/test
Difficulty: Easy
1.
2.
3.
4.
Feedback
abirb.com/test
This is incorrect. The preinteraction phase involves preparation for the first
encounter with the client.
This is correct. The orientation phase is when the individuals first meet and is
abirb.com/test
characterized by an agreement to continue to meet and work
on setting clientcentered goals.
This is incorrect. The therapeutic work of the relationship is accomplished during the
working phase. This occurs during the orientation phase. abirb.com/test
This is incorrect. The termination phase involves bringing a therapeutic conclusion
to the relationship.
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
8. Which client statement does the nurse recognize as the client’s typical response to
stress most often experienced in the working phase of the nurse-client relationship?
1. “I can’t bear the thought of leaving here and failing.”
abirb.com/test
2. “You remind me of one of my parents. I might have a hard time
working with you.”
3. “I can’t tell my spouse how I feel; he wouldn’t listen anyway.”
4. “I’m not sure that I can count on you to protect my confidentiality.”
abirb.com/test
ANS: 3
Chapter: Chapter 7, Relationship Development
Objective: Describe the phases of relationship development and the tasks associated
abirb.com/test
with each phase.
Page: 116
Heading: Phases of a Therapeutic Nurse-Client Relationship > The Working Phase
Integrated Processes: Nursing Process: Assessment
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
abirb.com/test
Difficulty: Moderate
1.
Feedback
This is incorrect. This statement may be verbalization of anxiety
during the
abirb.com/test
termination phase of the relationship. Termination can be difficult for both the client
abirb.com/test
abirb.com/test
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Chapter 6 - ETB
abirb.com/test
2.
3.
4.
and nurse. The main task involves bringing a therapeutic conclusion to the
relationship.
This is incorrect. This is an example of transference during the orientation phase of
abirb.com/test
the relationship. Transference can interfere with the therapeutic
interaction when the
feelings expressed include anger and hostility. Anger toward the nurse can be
manifested by uncooperativeness and resistance to therapy.
This is correct. The client’s statement reflects resistance toabirb.com/test
change, which is a
common behavior in the working phase of the nurse-client relationship. The working
phase includes overcoming resistant behaviors on the part of the client as the level of
anxiety rises in response to discussion of painful issues.
abirb.com/test
This is incorrect. This can be an example of transference during the working phase
of the relationship, where the client is suspicious of the nurse’s actions.
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
9. A client has made the decision to leave her alcoholic spouse and reports feeling very
depressed. Which of the following statements by the nurse represents sympathy?
1. “You are feeling very depressed. I felt the same way when I decided to leave my
abirb.com/test
spouse.”
2. “I can understand you are feeling depressed. It was a difficult decision. I’ll sit with
you.”
3. “You seem depressed. It was a difficult decision to make. Would
you like to talk
abirb.com/test
about it?”
4. “I know this is a difficult time for you. Would you like medication for anxiety?”
abirb.com/test
ANS: 1
Chapter: Chapter 7, Relationship Development
Objective: Identify and discuss essential conditions for a therapeutic relationship to
occur.
abirb.com/test
Page: 114
Heading: Conditions Essential to Development of a Therapeutic Relationship > Empathy
Integrated Processes: Nursing Process: Implementation
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
abirb.com/test
1.
2.
Feedback
This is correct. The nurse’s nontherapeutic statement conveys sympathy, which is
often confused with empathy. Sympathy implies the nurse abirb.com/test
“shares” what the client is
feeling and experiences a need to alleviate distress. The nurse demonstrates empathy
by “accurately perceiving or understanding” what the client is feeling and by
encouraging the client to explore these feelings.
abirb.com/test
This is incorrect. This therapeutic statement conveys empathy. The nurse
abirb.com/test
abirb.com/test
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Chapter 6 - ETB
abirb.com/test
3.
4.
demonstrates empathy by “accurately perceiving or understanding” what the client is
feeling .
This is incorrect. This statement conveys empathy. The nurse demonstrates empathy
abirb.com/test
by “accurately perceiving or understanding” what the client
is feeling and by
encouraging the client to explore these feelings. .
This is incorrect. This statement implies empathy but is nontherapeutic with the
suggestion of a medication rather than attempting a resolution
to the issue.
abirb.com/test
CON: Patient-Centered Care
abirb.com/test
10. A parent who has learned that her child was killed in a tragic car accident states, “I
abirb.com/test
can’t bear to go on with my life.” Which nursing statement conveys
empathy?
1. “This situation is very sad, but time is a great healer.”
2. “You are sad, but you must be strong for your other children.”
3. “Once you cry it all out, things will seem so much better.”
abirb.com/test
4. “It must be horrible to lose a child; I’ll stay with you until your spouse arrives.”
ANS: 4
abirb.com/test
Chapter: Chapter 7, Relationship Development
Objective: Identify and discuss essential conditions for a therapeutic relationship to
occur.
Page: 114
abirb.com/test
Heading: Conditions Essential to Development of a Therapeutic Relationship > Empathy
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. This response does not convey empathy or acknowledge the
client’s feelings.
This is incorrect. This response does not acknowledge the abirb.com/test
client’s feelings and
demonstrates the nontherapeutic technique of advice giving.
This is incorrect. This response demonstrates the nontherapeutic technique of advice
giving.
abirb.com/test
This is correct. The nurse’s response conveys empathy to the client. Empathy is the
ability to see the situation from the client’s point of view. Empathy is one of the
most important characteristics of the therapeutic relationship.
abirb.com/test
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
abirb.com/test
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Chapter 6 - ETB
abirb.com/test
11. A nurse discovers that their newly assigned client is their sibling. What would be the
most appropriate step in this nurse-client relationship?
1. Notify the charge nurse of the need to withdraw from the care of the client.
2. Notify the other clients in the unit that the nurse and client areabirb.com/test
related.
3. Notify the client that they do not need to exchange gifts for the holidays this year.
4. Continue with the care and do not acknowledge the relationship.
abirb.com/test
ANS: 1
Chapter: Chapter 7, Relationship Development
Objective: Identify and discuss essential conditions for a therapeutic relationship to
abirb.com/test
occur.
Page: 117
Heading: Boundaries in the Nurse-Patient Relationship. Integrated Processes: Nursing
Process: Evaluation
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Comprehension [Understanding]
Concept: Patient-Centered Care
abirb.com/test
Difficulty: Easy
1.
2.
3.
4.
Feedback
This is correct. This may present as a violation of personalabirb.com/test
vs. professional
boundaries. If the nurse is unable to accomplish a separation, the nurse should
withdraw from the nurse-client relationship.
This is incorrect. This may present a sign of potential favoritism
and a lack of
abirb.com/test
professional boundaries.
This is incorrect. This is incorrect. This would violate the professional boundaries of
nurse-client relationships.
abirb.com/test
This is incorrect. This is incorrect. There may be subtle cues
of a violation of
professional boundaries, as this would be considered keeping a secret with the client.
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
12. Which task is the nurse’s priority during the working phase of
a therapeutic
relationship?
1. Establishing a contract for intervention
2. Examining feelings about working with the client
abirb.com/test
3. Establishing a plan for continuing aftercare
4. Promoting the client’s insight and perception of reality
abirb.com/test
ANS: 4
Chapter: Chapter 7, Relationship Development
Objective: Identify and discuss essential conditions for a therapeutic relationship to
occur.
abirb.com/test
Page: 116
abirb.com/test
abirb.com/test
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Chapter 6 - ETB
abirb.com/test
Heading: Phases of a Therapeutic Nurse-Client Relationship > The Working Phase
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Easy
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. Establishing a contract for intervention occurs during the
orientation phase.
abirb.com/test
This is incorrect. Examining feelings about working with a client occurs during the
preinteraction phase.
This is incorrect. Establishing a plan for aftercare occurs during the termination
abirb.com/test
phase.
This is correct. The nurse’s priority during the working phase of a therapeutic
relationship is to promote the client’s insight and perception of reality.
abirb.com/test
CON: Patient-Centered Care
abirb.com/test
13. When asked to play a game, a client diagnosed with paranoid schizophrenia becomes
agitated. The client states, “Do you want to be my girlfriend?” Which nursing response
is best?
abirb.com/test
1. “You are upset now. It would be best if you go to your room until you feel better.”
2. “Remember, we have a professional relationship. Are you feeling uncomfortable?”
3. “We have discussed this before. I am not allowed to date clients.”
4. “I think you should discuss your fantasies with your therapist.”abirb.com/test
ANS: 2
Chapter: Chapter 7, Relationship Development
abirb.com/test
Objective: Identify and discuss essential conditions for a therapeutic relationship to
occur.
Page: 116
abirb.com/test
Heading: Phases of a Therapeutic Nurse-Client Relationship > The
Working Phase
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
abirb.com/test
Concept: Patient-Centered Care
Difficulty: Moderate
1.
2.
abirb.com/test
Feedback
This is incorrect. This does not address the inappropriate statement nor address what
is troubling the client.
This is correct. This is the nurse’s best response, as it promotes
the client’s insight
abirb.com/test
and perception of reality by confirming appropriate roles in the nurse-client
abirb.com/test
abirb.com/test
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Chapter 6 - ETB
abirb.com/test
3.
4.
relationship and identifying what is troubling the client.
This is incorrect. This does not address the client’s statement and opens the
possibility for more inappropriate behavior.
abirb.com/test
This is incorrect. This does not address the statement and does not provide insight to
the inappropriate nature of the client’s behavior.
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
14. A nurse moving out of state speaks to a client about the need to work with a new
nurse. The client states, “I’m not well enough to switch to a different nurse.” Which of
the following does the nurse recognize the client is demonstrating?
abirb.com/test
1. Manipulation to receive secondary gain
2. The defense mechanism of denial
3. Difficulty terminating the relationship
4. Use of “splitting” to remain dependent on the nurse
abirb.com/test
ANS: 3
Chapter: Chapter 7, Relationship Development
abirb.com/test
Objective: Discuss the dynamics of a therapeutic nurse-client relationship.
Page: 117
Heading: Phases of a Therapeutic Nurse-Client Relationship > The Termination Phase
Integrated Processes: Nursing Process: Assessment
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
This is incorrect. This does not describe a secondary gain via
manipulation. There is
abirb.com/test
no secondary gain in this statement.
This is incorrect. This is not an example of denial. Denial would involve the client’s
inability to realize that the nurse was leaving.
abirb.com/test
This is correct. The client is demonstrating feelings of sadness
and loss in response
to the end to the relationship with the nurse. Behaviors to delay termination may
become evident. Termination should begin in the orientation phase to minimize the
client’s feelings of loss when the nurse-client relationship ends.
abirb.com/test
This is incorrect. The client is not attempting to create a divide among staff
members.
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
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Chapter 6 - ETB
abirb.com/test
15. Which of the nursing actions described by Peplau demonstrates the nurse’s role as a
resource person?
1. Balances a safe therapeutic environment to increase the client’s sense of belonging
abirb.com/test
2. Conducts a group on the unit to discuss common feelings about
mental illness
3. Administers medications and watches for signs of “cheeking”
4. Provides information using language the client can understand
abirb.com/test
ANS: 4
Chapter: Chapter 7, Relationship Development
Objective: Identify and discuss essential conditions for a therapeutic relationship to
abirb.com/test
occur.
Page: 109
Heading: Role of the Psychiatric Nurse > The Resource Person
Integrated Processes: Nursing Process: Implementation
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Comprehension [Understanding]
Concept: Patient-Centered Care
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/test
This is incorrect. This is an example of the role of surrogate.
This is incorrect. This is an example of the counselor with “interpersonal
techniques.”
This is incorrect. This is an example of the technical expertabirb.com/test
that uses clinical skills to
perform interventions that are in the best interest of the client
This is correct. Peplau described the nurse as “a resource person who provides
specific answers to questions usually formulated with relation to a larger problem.”
abirb.com/test
CON: Patient-Centered Care
abirb.com/test
16. Which nursing intervention described by Peplau demonstrates the nurse’s role as a
surrogate?
1. Functions as a nurturing parent to build a trusting relationship abirb.com/test
2. Plays cards with a small group of clients on the inpatient unit
3. Discusses the client’s childhood events that affect personality development
4. Creates a safe social environment within the milieu
abirb.com/test
ANS: 1
Chapter: Chapter 7, Relationship Development
abirb.com/test
Objective: Identify and discuss essential conditions for a therapeutic
relationship to
occur.
Page: 109
Heading: Role of the Psychiatric Nurse > The Surrogate
abirb.com/test
Integrated Processes: Nursing Process: Evaluation
abirb.com/test
abirb.com/test
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Chapter 6 - ETB
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Easy
1.
2.
3.
4.
abirb.com/test
Feedback
This is correct. Peplau identified that a client may incur theabirb.com/test
role of infant or child if
he or she perceives the nurse as a mother surrogate when acutely ill.
This is incorrect. This is an example of a counselor with interpersonal skills.
This is incorrect. This is an example of the interpersonal skills of the counselor role.
abirb.com/test
This is incorrect. This is an example of the resource role, where the nurse provides
answers in language that the client can understand related to the client’s health care.
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
17. Which of the following is the nurse’s most therapeutic statement when the client and
nurse move from the orientation stage to the working stage of the therapeutic
relationship?
1. “I want to assure you that I will maintain your confidentiality.”abirb.com/test
2. “A long-term goal for someone your age would be to develop better job skills.”
3. “Which problems that we identified would you like for us to address first?”
4. “I think we need to focus on your relationship issues first.” abirb.com/test
ANS: 3
Chapter: Chapter 7, Relationship Development
abirb.com/test
Objective: Describe the phases of relationship development and the
tasks associated
with each phase.
Page: 116
Heading: Phases of a Therapeutic Nurse-Client Relationship > The
Working Phase
abirb.com/test
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Patient-Centered Care
Difficulty: Moderate
1.
2.
3.
Feedback
abirb.com/test
This is incorrect. This statement does not indicate the nurse and client are moving on
a continuum from the orientation to the working phase of the nurse-client therapeutic
relationship by addressing the client’s identified goals of client’s behavioral change.
This is incorrect. This statement is nontherapeutic and mayabirb.com/test
be perceived as advice
giving.
This is correct. This is a therapeutic statement as it represents moving on a
continuum from the orientation to working phase of the nurse-client
abirb.com/testrelationship.
The nurse and client are doing the therapeutic work of promoting the client’s
abirb.com/test
abirb.com/test
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Chapter 6 - ETB
abirb.com/test
4.
behavioral change by addressing the client’s identified goals.
This is incorrect. This is not a therapeutic relationship as it is not a mutually attained
goal for client-centered care.
abirb.com/test
CON: Patient-Centered Care
abirb.com/test
18. Which of the following is the main goal of the working phase of the nurse-client
therapeutic relationship?
abirb.com/test
1. Role-play to improve interaction with others.
2. Resolve the client’s problems.
3. Use therapeutic communication to clarify perceptions.
abirb.com/test
4. Help the client access outpatient treatment.
ANS: 2
Chapter: Chapter 7, Relationship Development
abirb.com/test
Objective: Identify and discuss essential conditions for a therapeutic relationship to
occur.
Page: 116
abirb.com/test
Heading: Phases of a Therapeutic Nurse-Client Relationship > The
Working Phase
Integrated Processes: Nursing Process: Evaluation
Client Need: Psychosocial Integrity
Cognitive Level: Comprehension [Understanding]
abirb.com/test
Concept: Patient-Centered Care
Difficulty: Easy
1.
2.
3.
4.
abirb.com/test
Feedback
This is incorrect. This may be the nurse’s goal after self-reflection during the
preinteraction phase.
This is correct. The goal of the working phase of the nurse-client
therapeutic
abirb.com/test
relationship is to resolve client problems by promoting behavioral change.
This is incorrect. This is an intervention during the entire relationship.
This is incorrect. This may be a goal of the termination phase.
abirb.com/test
CON: Patient-Centered Care
abirb.com/test
19. Which client statement indicates to the nurse that the client may be experiencing a
transference reaction?
1. “I need a real nurse. You are young enough to be my daughter,abirb.com/test
and I don’t want to tell
you about my personal life.”
2. “I deserve more than I am getting here. Do you know who I am and what I do? Let me
talk to your supervisor.”
abirb.com/test
abirb.com/test
abirb.com/test
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Chapter 6 - ETB
abirb.com/test
3. “I don’t seem to be able to relate to people. I would rather stay in my room and be by
myself.”
4. “My mother is the source of my problems. She has always told me what to do and
abirb.com/test
what to say.”
ANS: 1
Chapter: Chapter 7, Relationship Development
abirb.com/test
Objective: Discuss the dynamics of a therapeutic nurse-client relationship.
Page: 117
Heading: Phases of a Therapeutic Nurse-Client Relationship > Transference
abirb.com/test
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/test
This is correct. Transference occurs when a client unconsciously displaces or
“transfers” to the nurse feelings formed toward a person from the past.
This is incorrect. This is not an example of transferring personal feelings toward
abirb.com/test
another individual.
This is incorrect. This is an isolation behavior, not a transference of feelings toward
another individual.
This is incorrect. This is a displacement of blame, not a transfer
of feelings aimed at
abirb.com/test
another individual.
CON: Patient-Centered Care
abirb.com/test
20. Which nursing action demonstrates the role of the teacher in abirb.com/test
the therapeutic milieu?
1. The nurse implements a self-affirmation exercise during a one-on-one client
interaction.
2. The nurse conducts a group meeting to present common side effects of psychiatric
abirb.com/test
medications.
3. The nurse introduces the concept of fair play while playing cards with a group of
clients.
4. The nurse models adaptive and effective coping mechanisms with
clients on the
abirb.com/test
psychiatric unit.
ANS: 2
abirb.com/test
Chapter: Chapter 7, Relationship Development
Objective: Identify and discuss essential conditions for a therapeutic relationship to
occur.
Page: 109
abirb.com/test
Heading: Role of the Psychiatric Nurse > The Teacher
abirb.com/test
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Chapter 6 - ETB
abirb.com/test
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1.
2.
3.
4.
abirb.com/test
Feedback
abirb.com/test
This is incorrect. This would be an example of the role of a counselor, as the nurse
assists the client to adapt to changes with “interpersonal techniques.”
This is correct. While in the role of teacher, the nurse identifies learning needs and
abirb.com/test
provides information required by the client or family to improve the client’s health.
This is incorrect. The nurse is displaying the role of counselor with adaptive
techniques for difficulties or changes in life experiences.
abirb.com/test
This is incorrect. This is the role of counselor, where the nurse
helps “the client
remember and understand what is happening in the present situation, so that the
experience can be integrated with, rather than dissociated from, other experiences in
life” (Peplau, 1991).
abirb.com/test
CON: Patient-Centered Care
abirb.com/test
21. Which client statement indicates to the nurse that termination of the therapeutic
nurse-client relationship has been successful?
abirb.com/test
1. “I know I can count on you for continued support.”
2. “I am looking forward to discharge, but I am surprised that we will no longer work
together.”
abirb.com/test
3. “Reviewing the changes that have happened during our time together
has helped me
put things in perspective.”
4. “I don’t know how comfortable I will feel when talking to someone else.”
abirb.com/test
ANS: 3
Chapter: Chapter 7, Relationship Development
Objective: Discuss the dynamics of a therapeutic nurse-client relationship.
abirb.com/test
Page: 117
Heading: Phases of a Therapeutic Nurse-Client Relationship > The Termination Phase
Integrated Processes: Nursing Process: Evaluation
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Moderate
abirb.com/test
1.
2.
Feedback
This is incorrect. This statement shows that the client has not progressed toward the
end of the relationship.
abirb.com/test
This is incorrect. Termination begins in the orientation phase to minimize feelings of
abirb.com/test
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Chapter 6 - ETB
abirb.com/test
3.
4.
loss when the nurse-client relationship ends. The statement does not indicate the
client feels progress has been made toward attainment of mutually set goals.
Bringing a therapeutic conclusion to the relationship occurs when the client
abirb.com/test
experiences growth.
This is correct. The statement indicates the client feels progress has been made
toward attainment of mutually set goals. Bringing a therapeutic conclusion to the
relationship occurs when the client experiences growth. Termination
abirb.com/test begins in the
orientation phase to minimize feelings of loss when the nurse-client relationship
ends.
This is incorrect. This is not a statement of the client’s successful progression toward
abirb.com/test
the end of the relationship.
CON: Patient-Centered Care
abirb.com/test
22. Which of the following indicates that the nurse understands self-disclosure
is
abirb.com/test
appropriate in a therapeutic nurse-client relationship?
1. The information may benefit the nurse and client.
2. There is a duty to warn.
abirb.com/test
3. The nurse feels emotionally indebted toward the client.
4. The information may benefit the client.
ANS: 4
abirb.com/test
Chapter: Chapter 7, Relationship Development
Objective: Identify goals of the nurse-client relationship.
Page: 117
abirb.com/test
Heading: Boundaries in the Nurse-Client Relationship > Self-Disclosure
Integrated Processes: Nursing Process: Evaluation
Client Need: Psychosocial Integrity
Cognitive Level: Comprehension [Understanding]
abirb.com/test
Concept: Patient-Centered Care
Difficulty: Easy
1.
2.
3.
4.
abirb.com/test
Feedback
This is incorrect. Self-disclosure on the part of the nurse may be appropriate when
the information may therapeutically benefit the client and not meet the nurse’s
needs.
abirb.com/test
This is incorrect. This would indicate a danger to self or others, not self-disclosure
on the part of the nurse.
This is incorrect. This would not benefit the client and may harm the relationship
abirb.com/test
between the nurse and client with violation of the professional
boundary.
This is correct. The nurse’s use of self-disclosure is appropriate when the nurse
determines the information may therapeutically benefit the client. Self-disclosure
should never be used to meet the nurse’s needs.
abirb.com/test
abirb.com/test
abirb.com/test
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Chapter 6 - ETB
abirb.com/test
CON: Patient-Centered Care
abirb.com/test
23. The nurse has realized that growing up in an alcoholic family may affect his or her
ability to care for an individual client. This task is part of what phase of the therapeutic
nurse-client relationship?
abirb.com/test
1. Preinteraction phase
2. Orientation phase
3. Working phase
abirb.com/test
4. Termination phase
ANS: 1
Chapter: Chapter 7, Relationship Development
abirb.com/test
Objective: Describe the relevance of a therapeutic nurse-client relationship.
Page: 116
Heading: Phases of a Therapeutic Nurse-Patient Relationship.
abirb.com/test
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
Cognitive Level: Comprehension [Understanding]
Core concept: Patient-Centered Care
abirb.com/test
Difficulty: Easy
1.
2.
3.
4.
Feedback
abirb.com/test
This is correct. Examining one’s feelings, fear, and anxieties about working with a
particular client is a component of the preinteraction phase.
This is incorrect. During the orientation phase, the nurse and client become
acquainted. Examples of tasks in this phase would include abirb.com/test
exploring feelings of both
the client and nurse and formulating nursing diagnoses.
This is incorrect. The working phase has tasks that include maintaining trust and
rapport established during the orientation phase and promoting
the client’s insight
abirb.com/test
and perception of reality.
This is incorrect. The tasks for termination phase include feelings about termination
of the relationship being recognized and explored. The client learns that the feelings
of sadness and loss are acceptable at the time of separation.abirb.com/test
CON: Patient-Centered Care
abirb.com/test
24. A client who was discharged 2 weeks ago sends a thank-you card to the psychiatricabirb.com/test
mental health nurse and finds season tickets to the city’s professional
football team.
Which of the following must the nurse consider when deciding whether to keep the
tickets?
1. Material boundaries
abirb.com/test
2. Personal boundaries
abirb.com/test
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Chapter 6 - ETB
abirb.com/test
3. Social boundaries
4. Professional boundaries
abirb.com/test
ANS: 4
Chapter: Chapter 7, Relationship Development
Objective: Identify and discuss essential conditions for a therapeutic relationship to
occur.
abirb.com/test
Page: 117
Heading: Boundaries in the Nurse-Client Relationship
Integrated Processes: Nursing Process: Evaluation
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
Core concept: Patient-Centered Care
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. Material boundaries are physical property that can be seen, such as
abirb.com/test
fences that border land.
This is incorrect. Personal boundaries are boundaries that individuals define for
themselves. They include physical distance and emotional boundaries.
This is incorrect. Social boundaries are established within abirb.com/test
a culture and define how
individuals are expected to behave in social situations. The nurse’s relationship with
the client is a professional relationship.
This is correct. Professional boundaries limit and outline expectations
for
abirb.com/test
appropriate professional relationships with clients. Individuals who are receiving
care may feel indebted toward health-care providers and give a gift. The nurse
should decide whether to accept a gift based on what gift giving means to the client,
abirb.com/test
as well as to institutional policy, the American Nurses Association
(ANA) Code of
Ethics for Nurses, and the ANA Scope and Standards of Practice.
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
25. The psychiatric-mental health nurse is counseling a client whose
infant recently died
from sudden infant death syndrome. Which nursing response demonstrates empathy?
1. “It must have been frightening when you realized something was wrong.”
2. “Tell me how you and your spouse have been doing since the abirb.com/test
funeral.”
3. “Let me help you understand the different stages of the grieving process.”
4. “Have you had feelings of hurting yourself or someone else lately?”
abirb.com/test
ANS: 1
Chapter: Chapter 7, Relationship Development
Objective: Discuss the dynamics of a therapeutic nurse-client relationship.
Page: 115
abirb.com/test
Heading: Conditions Essential to Development of a Therapeutic Relationship > Empathy
abirb.com/test
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Chapter 6 - ETB
abirb.com/test
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
Core concept: Patient-Centered Care
Difficulty: Moderate
1.
2.
3.
4.
abirb.com/test
Feedback
abirb.com/test
This is correct. This statement demonstrates empathy. With empathy, the nurse can
accurately perceive and comprehend the meaning and relevance of the client’s
thoughts and feelings. The nurse must also be able to communicate this perception to
abirb.com/test
the client by attempting to translate words and behaviors into feelings.
This is incorrect. This statement does not encourage the client to express her own
feelings.
abirb.com/test
This is incorrect. This statement is an example of client teaching.
This is incorrect. This statement demonstrates the nurse’s assessment of risk to self
or others.
abirb.com/test
CON: Patient-Centered Care
abirb.com/test
26. The nurse is providing care to the client during the detoxification process and does
so without emotion. The nurse does not recognize the client’s perception of the care as
cold and judgmental. Which quadrant of the Johari window would
this be considered?
abirb.com/test
1. Open self
2. Unknowing self
3. Private self
abirb.com/test
4. Unknown self
ANS: 2
Chapter: Chapter 7, Relationship Development
abirb.com/test
Objective: Identify and discuss essential conditions for a therapeutic relationship to
occur.
Page: 113
Heading: Conditions Essential to Development of a Therapeutic abirb.com/test
Relationship > Trust
Integrated Processes: Nursing Process: Evaluation
Client Need: Psychosocial Integrity
Cognitive Level: Comprehension [Understanding]
abirb.com/test
Core concept: Patient-Centered Care
Difficulty: Easy
1.
2.
abirb.com/test
Feedback
This is incorrect. The open or public self represents the part of the self that is public,
of which both the individual and others are aware.
This is correct. The unknowing self represents the part of the
self that is known to
abirb.com/test
others but remains hidden from the awareness of the individual.
abirb.com/test
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Chapter 6 - ETB
abirb.com/test
3.
4.
This is incorrect. The private self represents the part of the self that is known to the
individual but which the individual deliberately and consciously conceals from
others.
This is incorrect. The unknown self is unknown to both theabirb.com/test
individual and others.
CON: Patient-Centered Care
abirb.com/test
MULTIPLE RESPONSE
abirb.com/test
abirb.com/test
27. The nurse-client therapeutic relationship includes which of the
following
characteristics? Select all that apply.
1. Meeting the psychological needs of the nurse and the client
2. Ensuring therapeutic termination
abirb.com/test
3. Promoting client insight into problematic behavior
4. Collaborating to set appropriate goals
5. Meeting the holistic needs of the client
abirb.com/test
ANS: 2, 3, 4, 5
Chapter: Chapter 7, Relationship Development
Objective: Identify and discuss essential conditions for a therapeutic
relationship to
abirb.com/test
occur.
Page: 113
Heading: Phases of a Therapeutic Nurse-Client Relationship
abirb.com/test
Integrated Processes: Nursing Process: Evaluation
Client Need: Psychosocial Integrity
Cognitive Level: Comprehension [Understanding]
Concept: Patient-Centered Care
abirb.com/test
Difficulty: Easy
1.
2.
3.
4.
5.
Feedback
abirb.com/test
This is incorrect. The nurse’s psychological needs should not
be addressed within
the nurse-client relationship.
This is correct. Ensuring therapeutic termination is a characteristic of the nurse-client
therapeutic relationship.
abirb.com/test
This is correct. Promoting client insight into problematic behavior is a characteristic
of the nurse-client therapeutic relationship.
This is correct. Collaborating to set appropriate goals is a characteristic of the nurseabirb.com/test
client therapeutic relationship.
This is correct. Meeting the holistic needs of the client is a characteristic of the
nurse-client therapeutic relationship.
abirb.com/test
CON: Patient-Centered Care
abirb.com/test
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Chapter 6 - ETB
abirb.com/test
abirb.com/test
28. Which of the following can the psychiatric-mental health nurse
utilize to best
increase self-awareness? Select all that apply.
1. Values clarification
2. The Johari window
abirb.com/test
3. Concrete thinking
4. Positive regard
5. Personal boundaries
abirb.com/test
ANS: 1, 2
Chapter: Chapter 7, Relationship Development
Objective: Discuss the importance of self-awareness in the nurse-client
relationship.
abirb.com/test
Page: 113
Heading: Dynamics of a Therapeutic Nurse-Client Relationship
Integrated Processes: Nursing Process: Assessment
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Comprehension [Understanding]
Core concept: Patient-Centered Care
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
5.
Feedback
This is correct. Self-awareness requires that an individual recognize and accept what
abirb.com/test
he or she values and learn to accept the uniqueness of and differences in others.
Values clarification is one process by which an individual may gain self-awareness.
This is correct. The Johari window, presented in Figure 7–1, is a representation of
abirb.com/test
the self and a tool that can be used to increase self-awareness.
This is incorrect. This does not describe self-awareness. The nurse would realize that
many psychiatric clients experience concrete thinking and would use interventions to
develop trustworthiness.
abirb.com/test
This is incorrect. Positive regard refers to belief in the dignity and worth of an
individual regardless of his or her unacceptable behavior.
This is incorrect. A boundary indicates a border that determines the extent of
abirb.com/test
acceptable limits that individuals define for themselves. They
include physical
distance boundaries and emotional boundaries.
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
29. Which of the following indicate that the integrity of the nurse-client
relationship may
be in jeopardy? Select all that apply.
1. Requesting to be reassigned to a particular client
2. Informing the client that a behavior is unacceptable
abirb.com/test
3. Touching and hugging the client
abirb.com/test
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Chapter 6 - ETB
abirb.com/test
4. Expressing sympathy for the client
5. Contacting the client after discharge
abirb.com/test
ANS: 1, 5
Chapter: Chapter 7. Relationship Development
Objective: Identify and discuss essential conditions for a therapeutic relationship to
occur.
abirb.com/test
Page: 118
Heading: Boundaries in the Nurse-Client Relationship
Integrated Processes: Nursing Process: Evaluation
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
Core concept: Patient-Centered Care
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
5.
Feedback
This is correct. Boundary crossing can threaten the integrity of the nurse-client
abirb.com/test
relationship. Requesting to be reassigned to a particular client is a warning sign that
professional boundaries are at risk.
This is incorrect. This is an example of the therapeutic strategy of setting limits.
abirb.com/test
This is incorrect. Touching or hugging can be beneficial when
it is implemented
with therapeutic intent and client consent.
This is incorrect. Sympathy is evident when the nurse “shares” what the client is
feeling and experiences a need to alleviate distress. Expressing
sympathy does not
abirb.com/test
jeopardize professional boundaries.
This is correct. Contacting the client after discharge indicates a violation of
professional boundaries. The nurse should conclude the nurse-client relationship
prior to the client’s discharge during the termination phase.abirb.com/test
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
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Chapter 7 - ETB
abirb.com/test
Chapter 7. Therapeutic Communication
abirb.com/test
MULTIPLE CHOICE
abirb.com/test
1. Which therapeutic communication technique is being used in this nurse-client
interaction?
abirb.com/test
Client: “When I get angry, I get into a fistfight with my partner or I take it out on the
kids.”
Nurse: “I notice that you are smiling as you talk about this physical violence.”
abirb.com/test
1. Encouraging comparison
2. Exploring
3. Formulating a plan of action
4. Making observations
abirb.com/test
ANS: 4
Chapter: Chapter 7 Therapeutic Communication
abirb.com/test
Objective: Describe therapeutic and nontherapeutic verbal communication
techniques.
Page: 126
Heading: Therapeutic Communication Techniques > Table 7–2 Therapeutic
Communication Techniques
abirb.com/test
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Communication
Difficulty: Moderate
1.
2.
3.
abirb.com/test
Feedback
This is incorrect. The nurse is using the therapeutic communication technique of
making observations by noting that the client smiles when talking about physical
violence. The technique of making observations encourages the client to compare
abirb.com/test
personal perceptions with those of the nurse. Encouraging comparison is a
therapeutic technique that involves asking the client to compare similarities and
differences in ideas, experiences, or interpersonal relationships.
abirb.com/test
This is incorrect. The nurse is using the therapeutic communication
technique of
making observations by noting that the client smiles when talking about physical
violence. The technique of making observations encourages the client to compare
personal perceptions with those of the nurse.
abirb.com/test
This is incorrect. The nurse is using the therapeutic communication technique of
making observations by noting that the client smiles when talking about physical
violence. The technique of making observations encourages the client to compare
personal perceptions with those of the nurse. Formulating aabirb.com/test
plan assists the client in
making a plan to prevent anger or anxiety from escalating.
abirb.com/test
abirb.com/test
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Chapter 7 - ETB
abirb.com/test
4.
This is correct. The nurse is using the therapeutic communication technique of
making observations by noting that the client smiles when talking about physical
violence. The technique of making observations encourages the client to compare
abirb.com/test
personal perceptions with those of the nurse.
CON: Communication
abirb.com/test
2. Which therapeutic communication technique is being used in this nurse-client
abirb.com/test
interaction?
Client: “My father spanked me often.”
Nurse: “Your father was a harsh disciplinarian.”
1. Restating
abirb.com/test
2. Offering general leads
3. Focusing
4. Accepting
abirb.com/test
ANS: 1
Chapter: Chapter 7 Therapeutic Communication
abirb.com/test techniques.
Objective: Describe therapeutic and nontherapeutic verbal communication
Page: 126
Heading: Therapeutic Communication Techniques > Table 7–2 Therapeutic
Communication Techniques
abirb.com/test
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Communication
Difficulty: Moderate
1.
2.
3.
Feedback
abirb.com/test
This is correct. The nurse is using the therapeutic communication technique of
restating. Restating involves repeating the main idea of what the client has said. The
nurse uses this technique to communicate that the client’s statement has been heard
abirb.com/test
and understood.
This is incorrect. The nurse is using the therapeutic communication technique of
restating. Restating involves repeating the main idea of what the client has said. The
nurse uses this technique to communicate that the client’s statement
abirb.com/testhas been heard
and understood. Offering general leads to the client encourages the client to
continue.
This is incorrect. The nurse is using the therapeutic communication technique of
abirb.com/test
restating. Restating involves repeating the main idea of what
the client has said. The
nurse uses this technique to communicate that the client’s statement has been heard
and understood. Focusing is when the nurse notices a single idea or even a single
word and works especially well with a client who is moving
rapidly from one
abirb.com/test
thought to another. Focusing is not therapeutic with a client who is very anxious.
abirb.com/test
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Chapter 7 - ETB
abirb.com/test
4.
This is incorrect. The nurse is using the therapeutic communication technique of
restating. Restating involves repeating the main idea of what the client has said. The
nurse uses this technique to communicate that the client’s statement has been heard
and understood. Accepting conveys an attitude of receptionabirb.com/test
and regard.
CON: Communication
abirb.com/test
3. Which therapeutic communication technique is being used in this nurse-client
abirb.com/test
interaction?
Client: “When I am anxious, the only thing that calms me down is alcohol.”
Nurse: “Other than drinking, what alternatives have you explored to decrease anxiety?”
1. Reflecting
abirb.com/test
2. Making observations
3. Formulating a plan of action
4. Giving recognition
abirb.com/test
ANS: 3
Chapter: Chapter 7 Therapeutic Communication
abirb.com/test techniques.
Objective: Describe therapeutic and nontherapeutic verbal communication
Page: 126
Heading: Therapeutic Communication Techniques > Table 7–2 Therapeutic
Communication Techniques
abirb.com/test
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Communication
Difficulty: Moderate
1.
2.
3.
Feedback
abirb.com/test
This is incorrect. The nurse is using the therapeutic communication technique of
formulating a plan of action to help the client explore alternatives to drinking
alcohol. The use of this technique, rather than direct confrontation regarding the
client’s poor coping choice, may serve to prevent anger or abirb.com/test
anxiety from escalating.
Reflecting involves referring questions and feelings back to the client so that they
may be recognized and accepted and so that the client may recognize that his or her
point of view has value.
abirb.com/test
This is incorrect. The nurse is using the therapeutic communication technique of
formulating a plan of action to help the client explore alternatives to drinking
alcohol. The use of this technique, rather than direct confrontation regarding the
client’s poor coping choice, may serve to prevent anger or abirb.com/test
anxiety from escalating.
Making observations involves verbalizing what is observed or perceived and
encourages the client to recognize specific behaviors and compare perceptions with
the nurse.
abirb.com/test
This is correct. The nurse is using the therapeutic communication technique of
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 7 - ETB
abirb.com/test
4.
formulating a plan of action to help the client explore alternatives to drinking
alcohol. The use of this technique, rather than direct confrontation regarding the
client’s poor coping choice, may serve to prevent anger or anxiety from escalating.
abirb.com/test
This is incorrect. The nurse is using the therapeutic communication
technique of
formulating a plan of action to help the client explore alternatives to drinking
alcohol. The use of this technique, rather than direct confrontation regarding the
client’s poor coping choice, may serve to prevent anger or abirb.com/test
anxiety from escalating.
Giving recognition is acknowledging and indicating the client’s awareness.
CON: Communication
abirb.com/test
4. The nurse is interviewing a newly admitted psychiatric client. abirb.com/test
Which nursing
statement is an example of offering a general lead?
1. “Do you know why you are here?”
2. “Are you feeling depressed or anxious?”
abirb.com/test
3. “Yes, I see. Go on.”
4. “Can you chronologically order the events that led to your admission?”
abirb.com/test
ANS: 3
Chapter: Chapter 7 Therapeutic Communication
Objective: Describe therapeutic and nontherapeutic verbal communication techniques.
Page: 126
abirb.com/test
Heading: Therapeutic Communication Techniques > Table 7–2 Therapeutic
Communication Techniques
Integrated Processes: Nursing Process: Implementation
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. The question “Do you know why you are here?” is not an example
abirb.com/test
of offering a general lead. Offering a general lead encourages
the client to continue
sharing information with minimal input from the nurse.
This is incorrect. The question “Are you feeling depressed or anxious?” is not an
example of offering a general lead. Offering a general leadabirb.com/test
encourages the client to
continue sharing information with minimal input from the nurse.
This is correct. The nurse’s statement is an example of the therapeutic
communication technique of a general lead. Offering a general lead encourages the
abirb.com/test
client to continue sharing information.
This is incorrect. The question “Can you chronologically order the events that led to
your admission?” is not an example of offering a general lead. Offering a general
lead encourages the client to continue sharing information abirb.com/test
with minimal input from
the nurse.
abirb.com/test
abirb.com/test
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abirb.com/test
CON: Communication
abirb.com/test
5. A nurse states to a client, “Things will look better tomorrow after a good night’s
sleep.” This is an example of which communication technique? abirb.com/test
1. The nontherapeutic technique of “giving advice”
2. The therapeutic technique of “formulating a plan of action”
3. The therapeutic technique of “presenting reality”
4. The nontherapeutic technique of “giving false reassurance” abirb.com/test
ANS: 4
Chapter: Chapter 7 Therapeutic Communication
abirb.com/test
Objective: Describe therapeutic and nontherapeutic verbal communication techniques.
Page: 129
Heading: Nontherapeutic Communication Techniques > Table 7–3 Nontherapeutic
abirb.com/test
Communication Techniques
Integrated Processes: Caring
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Communication
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. The nurse’s statement is an example of the nontherapeutic
technique of giving false reassurance. Giving false reassurance indicates to the client
abirb.com/test
that there is no cause for anxiety, thereby devaluing the client’s
feelings. Giving
advice is the nontherapeutic technique of telling the client what to do or how to
behave and implies that the nurse knows what is best and that the client is incapable
of any self-direction.
abirb.com/test
This is incorrect. The nurse’s statement is an example of the nontherapeutic
technique of giving false reassurance. Giving false reassurance indicates to the client
that there is no cause for anxiety, thereby devaluing the client’s feelings.
Formulating a plan of action encourages a client to identifyabirb.com/test
a plan for behavior
change.
This is incorrect. The nurse’s statement is an example of the nontherapeutic
technique of giving false reassurance. Giving false reassurance
indicates to the client
abirb.com/test
that there is no cause for anxiety, thereby devaluing the client’s feelings. Presenting
reality is the therapeutic technique used to define reality when a client has a
misperception of the environment.
This is correct. The nurse’s statement is an example of the abirb.com/test
nontherapeutic technique
of giving false reassurance. Giving false reassurance indicates to the client that there
is no cause for anxiety, thereby devaluing the client’s feelings.
abirb.com/test
CON: Communication
abirb.com/test
abirb.com/test
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Chapter 7 - ETB
abirb.com/test
abirb.com/test
6. A client diagnosed with posttraumatic stress disorder is admitted
to an inpatient
psychiatric unit for evaluation and medication stabilization. Which utterance made by
the nurse is an example of a broad opening?
1. “What occurred prior to the traumatic event, and when did youabirb.com/test
go to the emergency
department?”
2. “What would you like to talk about?”
3. “I notice you seem uncomfortable discussing this.”
abirb.com/test
4. “How can we help you feel safe during your stay here?”
ANS: 2
Chapter: Chapter 7 Therapeutic Communication
abirb.com/test
Objective: Describe therapeutic and nontherapeutic verbal communication techniques.
Page: 126
Heading: Therapeutic Communication Techniques > Table 7–2 Therapeutic
abirb.com/test
Communication Techniques
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Communication
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. The nurse’s question “What occurred prior to the traumatic event,
and when did you go to the emergency department?” is an example of the
therapeutic communication technique of placing the event abirb.com/test
in time or sequence.
Using a broad opening allows the client to take the initiative in introducing the topic
and emphasizes the importance of the client’s role in the interaction.
This is correct. The nurse’s question “What would you likeabirb.com/test
to talk about?” is an
example of the therapeutic communication technique of giving broad openings.
Using a broad opening allows the client to take the initiative in introducing the topic
and emphasizes the importance of the client’s role in the interaction.
This is incorrect. The nurse’s statement “I notice you seemabirb.com/test
uncomfortable discussing
this” is an example of the therapeutic communication technique of making
observations. Using a broad opening allows the client to take the initiative in
introducing the topic and emphasizes the importance of theabirb.com/test
client’s role in the
interaction.
This is incorrect. The nurse’s question “How can we help you feel safe during your
stay here?” is an example of the therapeutic communication technique of
formulating a plan of action. Using a broad opening allowsabirb.com/test
the client to take the
initiative in introducing the topic and emphasizes the importance of the client’s role
in the interaction.
abirb.com/test
CON: Communication
abirb.com/test
abirb.com/test
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Chapter 7 - ETB
abirb.com/test
7. A nurse is assessing a client diagnosed with schizophrenia for abirb.com/test
the presence of
hallucinations. Which therapeutic communication technique used by the nurse is an
example of making observations?
1. “You appear to be talking to someone I do not see.”
abirb.com/test
2. “Please describe what you are seeing.”
3. “Why do you continually look in the corner of this room?”
4. “If you hum a tune, the voices may not be so distracting.”
abirb.com/test
ANS: 1
Chapter: Chapter 7 Therapeutic Communication
Objective: Describe therapeutic and nontherapeutic verbal communication
abirb.com/test techniques.
Page: 126
Heading: Therapeutic Communication Techniques > Table 7–2 Therapeutic
Communication Techniques
abirb.com/test
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Communication
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/test
This is correct. The nurse is making an observation when stating, “You appear to be
talking to someone I do not see.” Making observations involves verbalizing what is
observed or perceived. This encourages the client to recognize specific behaviors
abirb.com/test
and make comparisons with the nurse’s perceptions.
This is incorrect. The statement “Please describe what you are seeing” is an example
of offering general leads.
This is incorrect. The question “Why do you continually look
in the corner of this
abirb.com/test
room?” is an example of the nontherapeutic technique of requesting an explanation,
which can be intimidating.
This is incorrect. The statement “If you hum a tune, the voices may not be so
distracting” is an example of the nontherapeutic technique abirb.com/test
of giving advice.
CON: Communication
abirb.com/test
8. A nurse maintains an uncrossed arm and leg posture. This nonverbal behavior is
abirb.com/test
reflective of which letter of the SOLER acronym for active listening?
1. S
2. O
3. L
abirb.com/test
4. E
abirb.com/test
abirb.com/test
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Chapter 7 - ETB
abirb.com/test
ANS: 2
Chapter: Chapter 7 Therapeutic Communication
Objective: Identify components of nonverbal expression.
Page: 131
Heading: Active Listening
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Easy
1.
2.
3.
4.
abirb.com/test
abirb.com/test
abirb.com/test
Feedback
This is incorrect. The S in the acronym SOLER stands for abirb.com/test
sitting squarely facing the
client.
This is correct. The nurse’s uncrossed arm and leg posture is nonverbal behavior that
reflects the O in the active-listening acronym SOLER. The acronym SOLER
abirb.com/test
includes sitting squarely facing the client (S), open posture when interacting with the
client (O), leaning forward toward the client (L), establishing eye contact (E), and
relaxing (R).
This is incorrect. The L in the acronym SOLER stands for abirb.com/test
leaning forward toward
the client.
This is incorrect. The E in the acronym SOLER stands for establishing eye contact
(E).
abirb.com/test
CON: Communication
abirb.com/test
9. Which action by the nurse, who is first meeting a client, would likely send a
nonverbal message that is inappropriate for the therapeutic relationship?
abirb.com/test
1. The nurse provides eye contact intermittently during the meeting.
2. The nurse is dressed in business casual attire; a tattoo is visible.
3. The nurse offers a handshake during initial interaction with the client.
4. The nurse gives a client a strong hug at the end of the meeting.abirb.com/test
ANS: 4
Chapter: Chapter 7 Therapeutic Communication
Objective: Identify components of nonverbal communication.
Page: 125
Heading: Nonverbal Communication
Integrated Processes: Caring
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Moderate
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
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Chapter 7 - ETB
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. The nurse who provides intermittent eye contact is demonstrating
abirb.com/test
interest in the client.
This is incorrect. The nurse is presenting oneself in a professional manner. Many
dress codes allow visible tattoos. While these may be perceived differently by
individuals, tattoos are generally acceptable.
abirb.com/test
This is incorrect. Offering a handshake during the first meeting demonstrates a
socially polite behavior that is accepting of the client.
This is correct. A strong hug is typically a gesture that demonstrates
an attraction or
abirb.com/test
attachment to another person and is inappropriate for establishing a therapeutic
relationship.
CON: Communication
abirb.com/test
abirb.com/test
10. After assertiveness training, a formerly passive client appropriately confronts a peer
in group therapy. The group leader states, “I’m so proud of you for being assertive. You
are so good!” Which communication technique has the leader employed?
abirb.com/test
1. Giving approval
2. Interpreting
3. Presenting reality
4. Making observations
abirb.com/test
ANS: 1
Chapter: Chapter 7 Therapeutic Communication
abirb.com/test techniques.
Objective: Describe therapeutic and nontherapeutic verbal communication
Page: 128
Heading: Nontherapeutic Communication Techniques > Table 7–3 Nontherapeutic
Communication Techniques
abirb.com/test
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Communication
Difficulty: Moderate
1.
2.
Feedback
abirb.com/test
This is correct. The group leader has employed the nontherapeutic technique of
giving approval. Giving approval implies that the nurse has the right to pass
judgment on whether the client’s ideas or behaviors are “good” or “bad.” This
abirb.com/test
creates a conditional acceptance of the client.
This is incorrect. The group leader has employed the nontherapeutic technique of
giving approval. Giving approval implies that the nurse has the right to pass
judgment on whether the client’s ideas or behaviors are “good”
or “bad.” This
abirb.com/test
creates a conditional acceptance of the client. Interpreting is a nontherapeutic
abirb.com/test
abirb.com/test
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Chapter 7 - ETB
abirb.com/test
3.
4.
technique in which the therapist seeks to make conscious that which is unconscious,
telling the client the meaning of his or her experience.
This is incorrect. The group leader has employed the nontherapeutic technique of
giving approval. Giving approval implies that the nurse hasabirb.com/test
the right to pass
judgment on whether the client’s ideas or behaviors are “good” or “bad.” This
creates a conditional acceptance of the client. Presenting reality is the therapeutic
technique used to define reality when a client has a misperception
of the
abirb.com/test
environment.
This is incorrect. The group leader has employed the nontherapeutic technique of
giving approval. Giving approval implies that the nurse has the right to pass
abirb.com/test
judgment on whether the client’s ideas or behaviors are “good” or “bad.” This
creates a conditional acceptance of the client. Making observations involves
verbalizing what is observed or perceived and encourages the client to recognize
specific behaviors and compare perceptions with the nurse.abirb.com/test
CON: Communication
abirb.com/test
11. What is the purpose of a nurse providing appropriate feedback?
abirb.com/test
1. To provide the client with good advice
2. To advise the client on appropriate behaviors
3. To evaluate the client’s behavior
4. To give the client critical information
abirb.com/test
ANS: 4
Chapter: Chapter 7 Therapeutic Communication
Objective: Discuss therapeutic feedback.
Page: 131
Heading: Feedback
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Comprehension [Understanding]
Concept: Communication
Difficulty: Easy
1.
2.
3.
4.
abirb.com/test
abirb.com/test
abirb.com/test
Feedback
This is incorrect. The purpose of providing appropriate feedback
is to give the client
abirb.com/test
critical information. Feedback should not be used to give advice.
This is incorrect. The purpose of providing appropriate feedback is to give the client
critical information. Feedback should not be used to evaluate behaviors.
abirb.com/test
This is incorrect. The purpose of providing appropriate feedback
is to give the client
critical information. Feedback should not be used to evaluate behaviors.
This is correct. The purpose of providing appropriate feedback is to give the client
critical information. Feedback should not be used to give advice
or evaluate
abirb.com/test
behaviors.
abirb.com/test
abirb.com/test
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Chapter 7 - ETB
abirb.com/test
CON: Communication
abirb.com/test
12. The nurse is providing therapeutic feedback to a client who exhibited an angry
outburst in a group setting. Which is appropriate for the nurse to abirb.com/test
say to the client?
1. “Why do you continue to alienate your peers by your angry outbursts?”
2. “You accomplish nothing when you lose your temper like that.”
3. “Showing your anger in that manner is very childish and insensitive.”
abirb.com/test
4. “During group, you raised your voice, yelled at a peer, and slammed
the door.”
ANS: 4
Chapter: Chapter 7 Therapeutic Communication
Objective: Discuss therapeutic feedback.
Page: 131
Heading: Feedback
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Moderate
1.
2.
3.
4.
abirb.com/test
abirb.com/test
abirb.com/test
Feedback
abirb.com/test
This is incorrect. This feedback does not help the client consider how to modify
behavior. This approach will likely put the client in a defensive position and is not a
therapeutic response.
abirb.com/testjudgment. The
This is incorrect. This feedback is nontherapeutic and demonstrates
nurse is not allowing the client the opportunity to consider how to modify his or her
behavior.
This is incorrect. This is a judgmental response that does not
provide the client the
abirb.com/test
opportunity to modify his or her behavior. This response is likely to alienate the
client or put the client in a defensive position, which is not therapeutic.
This is correct. The nurse is providing appropriate feedback when stating, “During
abirb.com/test
group, you raised your voice, yelled at a peer, and slammed
the door.” Giving
appropriate feedback involves helping the client consider a modification of behavior.
Feedback should give information to the client about how he or she is perceived by
others. Feedback should not be evaluative or used to give advice.
abirb.com/test
CON: Communication
abirb.com/test
13. A client diagnosed with dependent personality disorder states, “Do you think I
should move out of my parents’ house and get a job?” Which nursing
response is most
abirb.com/test
appropriate?
abirb.com/test
abirb.com/test
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Chapter 7 - ETB
abirb.com/test
1. “It would be best to do that to increase independence.”
2. “Why would you want to leave a secure home?”
3. “Let’s discuss and explore all of your options.”
4. “I’m afraid you would feel very guilty leaving your parents.”
abirb.com/test
ANS: 3
Chapter: Chapter 7 Therapeutic Communication
abirb.com/test
Objective: Describe therapeutic and nontherapeutic verbal communication techniques.
Page: 126
Heading: Therapeutic Communication Techniques > Table 7–2 Therapeutic
abirb.com/test
Communication Techniques
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Communication
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. The statement “It would be best to do that to increase
independence,” is an example of the nontherapeutic technique of advice giving.
abirb.com/test
This is incorrect. The question “Why would you want to leave
a secure home?” is an
example of the nontherapeutic technique of requesting an explanation, which can be
intimidating.
This is correct. The most appropriate response by the nurseabirb.com/test
is, “Let’s discuss and
explore all of your options.” In this example, the nurse is encouraging the client to
formulate ideas and decide independently the appropriate course of action.
This is incorrect. The statement “I’m afraid you would feel very guilty leaving your
abirb.com/test
parents” is an example of the nontherapeutic technique of giving
advice and implies
that the nurse knows what is best and that the client is incapable of any selfdirection.
abirb.com/test
CON: Communication
abirb.com/test
14. Why is it important for the nurse to demonstrate active listening during a client
interaction?
1. The client will be able to understand the nurse’s instructions better.
abirb.com/test
2. The client will feel a sense of trust and acceptance by the nurse.
3. The client will change his or her behavior if active listening is used.
4. The client will be able to provide feedback to the nurse for improvement.
abirb.com/test
ANS: 2
Chapter: Chapter 7 Therapeutic Communication
Objective: Describe active listening.
Page: 131
abirb.com/test
abirb.com/test
abirb.com/test
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Chapter 7 - ETB
abirb.com/test
Heading: Active Listening
Integrated Processes: Nursing Process: Planning
Client Need: Psychosocial Integrity
Cognitive Level: Comprehension [Understanding]
Concept: Patient-Centered Care
Difficulty: Moderate
abirb.com/test
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. Active listening does not necessarily improve the client’s ability to
understand or follow the nurse’s instructions.
abirb.com/test
This is correct. Active listening conveys acceptance of the client and helps to
develop trust between the nurse and client.
This is incorrect. Active listening is a part of motivational interviewing but it is not
the entire process that would assist in changing the client’sabirb.com/test
behavior.
This is incorrect. Active listening does not allow for the client to give the nurse
feedback for improvement. A process recording is used for this purpose.
abirb.com/test
CON: Patient-Centered Care
abirb.com/test
15. A mother rescues two of her four children from a house fire. In an emergency
department, she cries, “I should have gone back in to get them. I should have died, not
them.” Which of the following responses by the nurse is an example
of reflection?
abirb.com/test
1. “The smoke was too thick. You couldn’t have gone back in.”
2. “You’re feeling guilty because you weren’t able to save your children.”
3. “Focus on the fact that you could have lost all four of your children.”
abirb.com/test
4. “It’s best if you try not to think about what happened. Try to move
on.”
ANS: 2
Chapter: Chapter 7 Therapeutic Communication
abirb.com/test
Objective: Describe therapeutic and nontherapeutic verbal communication techniques.
Page: 126
Heading: Therapeutic Communication Techniques > Table 7–2 Therapeutic
abirb.com/test
Communication Techniques
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Communication
Difficulty: Moderate
1.
abirb.com/test
Feedback
This is incorrect. The response “The smoke was too thick. You couldn’t have gone
back in” utilizes the nontherapeutic communication technique of disagreeing, which
implies inaccuracy and provokes the need for the client to abirb.com/test
be defensive.
abirb.com/test
abirb.com/test
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Chapter 7 - ETB
abirb.com/test
2.
3.
4.
This is correct. The best response by the nurse is, “You’re feeling guilty because you
weren’t able to save your children.” This response utilizes the therapeutic
communication technique of reflection, which identifies a client’s emotional
abirb.com/test
response and reflects these feelings back to the client so that
they may be recognized
and accepted.
This is incorrect. The response “Focus on the fact that you could have lost all four of
your children” utilizes the nontherapeutic communication technique
abirb.com/testof giving
advice, which implies that the nurse knows what is best and discourages independent
thinking.
This is incorrect. The response “It’s best if you try not to think about what happened.
abirb.com/test
Try to move on” utilizes the nontherapeutic communication technique of giving
advice, which implies that the nurse knows what is best and discourages independent
thinking.
abirb.com/test
CON: Communication
abirb.com/test
16. A newly admitted client diagnosed with obsessive-compulsive disorder (OCD)
washes her hands continually. This behavior prevents her from attending unit activities.
abirb.com/test
Which nursing statement made to the client best addresses this situation?
1. “Everyone diagnosed with OCD needs to control their ritualistic behaviors.”
2. “It is important for you to discontinue these ritualistic behaviors.”
3. “Why are you asking for help if you won’t participate in unit therapy?”
abirb.com/test
4. “Let’s figure out a way for you to attend unit activities and still wash your hands.”
ANS: 4
abirb.com/test
Chapter: Chapter 7 Therapeutic Communication
Objective: Describe therapeutic and nontherapeutic verbal communication techniques.
Page: 126
Heading: Therapeutic Communication Techniques > Table 7–2 Therapeutic
abirb.com/test
Communication Techniques
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Moderate
abirb.com/test
1.
2.
3.
Feedback
This is incorrect. The statement “Everyone diagnosed with OCD needs to control
their ritualistic behaviors” reflects the nontherapeutic communication technique of
abirb.com/test
giving advice.
This is incorrect. The statement “It is important for you to discontinue these
ritualistic behaviors” is an example of the nontherapeutic technique of giving advice.
This is incorrect. The question “Why are you asking for help
if you won’t participate
abirb.com/test
in unit therapy?” is an example of the nontherapeutic technique of requesting an
abirb.com/test
abirb.com/test
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Chapter 7 - ETB
abirb.com/test
4.
explanation, which can be intimidating.
This is correct. The most appropriate statement by the nurse is, “Let’s figure out a
way for you to attend unit activities and still wash your hands.” This statement
abirb.com/test
reflects the therapeutic communication technique of formulating
a plan of action.
The nurse attempts to work with the client to develop a plan without damaging the
therapeutic relationship or increasing the client’s anxiety.
abirb.com/test
CON: Communication
abirb.com/test
17. Which example of a therapeutic communication technique would be most effective
in the planning phase of the nursing process?
1. “We’ve discussed past coping skills. Let’s see if these coping abirb.com/test
skills can be effective
now.”
2. “Please tell me in your own words what brought you to the hospital.”
3. “This new approach worked for you. Keep it up.”
abirb.com/test
4. “I noticed that you seem to be responding to voices that I do not hear.”
ANS: 1
abirb.com/test
Chapter: Chapter 7 Therapeutic Communication
Objective: Describe therapeutic and nontherapeutic verbal communication techniques.
Page: 126
Heading: Therapeutic Communication Techniques > Table 7–2 Therapeutic
abirb.com/test
Communication Techniques
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is correct. The nurse’s statement “We’ve discussed past coping skills. Let’s see
if these coping skills can be effective now” is an example of the therapeutic
abirb.com/test
communication technique of formulating a plan of action. This
technique can help
the client plan in advance to deal with a stressful situation, which may prevent anger
and/or anxiety from escalating to an unmanageable level.
This is incorrect. The nurse’s statement “Please tell me in your
own words what
abirb.com/test
brought you to the hospital” is an example of the therapeutic communication
technique of exploring. This technique is not most effective during the planning
phase.
abirb.com/test
This is incorrect. The nurse’s statement “This new approach
worked for you. Keep it
up” is an example of the nontherapeutic communication technique of giving advice.
This is incorrect. The nurse’s statement “I noticed that you seem to be responding to
voices that I do not hear” is an example of the therapeutic communication
technique
abirb.com/test
of presenting reality. This technique can help the client who has a misperception of
abirb.com/test
abirb.com/test
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abirb.com/test
the environment but is not especially effective during the planning phase.
CON: Communication
abirb.com/test
18. A client tells the nurse, “I feel like my mother does not want abirb.com/test
me to return home after
I leave the hospital.” Which nursing response is therapeutic?
1. “It’s quite common for clients to feel that way after a lengthy hospitalization.”
2. “Why don’t you talk to your mother? You may find out she doesn’t feel that way.”
abirb.com/test
3. “Your mother seems like an understanding person. I’ll help you approach her.”
4. “You feel that your mother does not want you to come back home?”
ANS: 4
abirb.com/test
Chapter: Chapter 7 Therapeutic Communication
Objective: Describe therapeutic and nontherapeutic verbal communication techniques.
Page: 126
abirb.com/test
Heading: Therapeutic Communication Techniques > Table 7–2 Therapeutic
Communication Techniques
Integrated Processes: Caring
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. The nurse’s statement “It’s quite common for clients to feel that
abirb.com/test
way after a lengthy hospitalization” is an example of the nontherapeutic
communication technique of belittling or minimizing feelings.
This is incorrect. The nurse’s question “Why don’t you talk to your mother? You
may find out she doesn’t feel that way” is an example of the
nontherapeutic
abirb.com/test
communication technique of giving advice.
This is incorrect. The nurse’s statement “Your mother seems like an understanding
person. I’ll help you approach her” is an example of the nontherapeutic
abirb.com/test
communication technique of giving false reassurance.
This is correct. The nurse’s question “You feel that your mother does not want you
to come back home?” is an example of the therapeutic communication technique of
restating. Restating is the repeating of the main idea the client
has verbalized and lets
abirb.com/test
the client know whether the statement has been understood and gives him or her the
chance to continue or clarify if necessary.
CON: Communication
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
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abirb.com/test
19. Which feature distinguishes motivational interviewing from other therapeutic
techniques?
1. Motivational interviewing establishes a contract for change.
abirb.com/test
2. Motivational interviewing is the only patient-centered communication
strategy.
3. Motivational interviewing allows the nurse to inform the client’s choices.
4. Motivational interviewing focuses on what the client wants.
abirb.com/test
ANS: 4
Chapter: Chapter 7 Therapeutic Communication
Objective: Describe motivational interviewing as a communication strategy.
abirb.com/test
Page: 131
Heading: Motivational Interviewing
Integrated Processes: Nursing Process: Intervention
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Comprehension [Understanding]
Concept: Communication
Difficulty: Easy
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. Motivational interviewing does not use a contract for change in and
of itself, it focuses on the client’s motivation to change. abirb.com/test
This is incorrect. Motivational interviewing is one of several patient-centered
approaches.
This is incorrect. Motivational interviewing does not rely on
the nurse informing the
abirb.com/test
client of his/her choices; it focuses on the client’s choices.
This is correct. Motivational interviewing promotes behavior change by focusing on
what the client wants.
abirb.com/test
CON: Communication
abirb.com/test
20. Which nursing statement is a good example of the therapeutic communication
technique of giving recognition?
1. “You did not attend group today. Can we talk about that?” abirb.com/test
2. “I’ll sit with you until it is time for your family session.”
3. “I noticed you are wearing a new dress and have washed your hair.”
4. “I’m happy that you are now taking your medications. They will
really help.”
abirb.com/test
ANS: 3
Chapter: Chapter 7 Therapeutic Communication
abirb.com/test
Objective: Describe therapeutic and nontherapeutic verbal communication
techniques.
Page: 126
Heading: Therapeutic Communication Techniques > Table 7–2 Therapeutic
Communication Techniques
abirb.com/test
Integrated Processes: Nursing Process: Implementation
abirb.com/test
abirb.com/test
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abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Easy
1.
2.
3.
4.
abirb.com/test
Feedback
This is incorrect. The nurse’s question “You did not attendabirb.com/test
group today. Can we talk
about that?” is an example of the therapeutic communication techniques of making
observations and exploring.
This is incorrect. The nurse’s statement “I’ll sit with you until it is time for your
abirb.com/test
family session” is an example of the therapeutic communication technique of
offering self.
This is correct. This statement is an example of the therapeutic communication
abirb.com/test
technique of giving recognition. Giving recognition acknowledges
and indicates
awareness. This technique is more appropriate than complimenting the client, which
reflects the nurse’s judgment.
This is incorrect. The nurse’s statement “I’m happy that you
are now taking your
abirb.com/test
medications. They will really help” is an example of the nontherapeutic
communication technique of giving approval.
CON: Communication
abirb.com/test
abirb.com/test
21. A client is trying to explore and solve a problem. Which nursing statement is an
example of verbalizing the implied?
1. “You seem to be motivated to change your behavior.”
2. “How will these changes affect your family relationships?” abirb.com/test
3. “Why don’t you make a list of the behaviors you need to change?”
4. “The team recommends that you make only one behavioral change at a time.”
abirb.com/test
ANS: 1
Chapter: Chapter 7 Therapeutic Communication
Objective: Describe therapeutic and nontherapeutic verbal communication techniques.
abirb.com/test
Page: 127
Heading: Therapeutic Communication Techniques > Table 7–2 Therapeutic
Communication Techniques
Integrated Processes: Nursing Process: Implementation
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Communication
abirb.com/test
Difficulty: Moderate
Feedback
abirb.com/test
abirb.com/test
abirb.com/test
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Chapter 7 - ETB
abirb.com/test
1.
2.
3.
4.
This is correct. This is an example of the therapeutic communication technique of
verbalizing the implied. Verbalizing the implied puts into words what the client has
only implied or said indirectly.
abirb.com/test
This is incorrect. The nurse’s question “How will these changes
affect your family
relationships?” is an example of the therapeutic communication technique of
reflecting.
This is incorrect. The nurse’s question “Why don’t you make
a list of the behaviors
abirb.com/test
you need to change?” is not an example of verbalizing the implied. Verbalizing the
implied puts into words what the client has only implied or said indirectly.
This is incorrect. The nurse’s statement “The team recommends that you make only
abirb.com/test
one behavioral change at a time” is an example of the nontherapeutic communication
technique of giving advice.
CON: Communication
abirb.com/test
abirb.com/test
22. The nurse says to a newly admitted client, “Tell me more about what led up to your
hospitalization.” What is the purpose of this therapeutic communication technique?
1. To reframe the client’s thoughts about mental health treatment
abirb.com/test
2. To put the client at ease
3. To explore a subject, idea, experience, or relationship
4. To communicate that the nurse is listening to the conversation
abirb.com/test
ANS: 3
Chapter: Chapter 7 Therapeutic Communication
Objective: Describe therapeutic and nontherapeutic verbal communication techniques.
abirb.com/test
Page: 127
Heading: Therapeutic Communication Techniques > Table 7–2 Therapeutic
Communication Techniques
Integrated Processes: Nursing Process: Implementation
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Communication
abirb.com/test
Difficulty: Moderate
1.
2.
Feedback
This is incorrect. The nurse’s statement is an example of the
therapeutic
abirb.com/test
communication technique of exploring. The purpose of exploring is not to reframe
the client’s thoughts about mental health treatment.
This is incorrect. The nurse’s statement is an example of the therapeutic
abirb.com/test
communication technique of exploring. The purpose of exploring
is to facilitate the
client’s understanding of events. It is not meant to put the client at ease.
abirb.com/test
abirb.com/test
abirb.com/test
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Chapter 7 - ETB
abirb.com/test
3.
4.
This is correct. This is an example of the therapeutic communication technique of
exploring. The purpose of exploring is to delve further into the subject, idea,
experience, or relationship. This technique is especially helpful with clients who
tend to remain on a superficial level of communication. abirb.com/test
This is incorrect. The nurse’s statement is an example of the therapeutic
communication technique of exploring. The purpose of exploring is not to
communicate that the nurse is listening to the conversation.abirb.com/test
CON: Communication
abirb.com/test
23. A student nurse tells the instructor, “I’m concerned that when a client asks me for
abirb.com/test
advice, I won’t have a good solution.” Which would be the nursing
instructor’s best
response?
1. “It’s scary to feel put on the spot by a client. Nurses don’t always have the answers.”
2. “Remember, clients, not nurses, are responsible for their own choices and decisions.”
abirb.com/test
3. “Just keep the client’s best interests in mind and do the best that you can.”
4. “Set a goal to continue to work on this aspect of your practice.”
abirb.com/test
ANS: 2
Chapter: Chapter 7 Therapeutic Communication
Objective: Describe therapeutic and nontherapeutic verbal communication techniques.
Page: 127
abirb.com/test
Heading: Nontherapeutic Communication Techniques > Table 7–3 Nontherapeutic
Communication Techniques
Integrated Processes: Teaching and Learning
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. The instructor’s statement “It’s scary to feel put on the spot by a
abirb.com/test explain why
client. Nurses don’t always have the answers” does not appropriately
nurses should not use the nontherapeutic communication technique of advice giving.
This is correct. The instructor’s statement “Remember, clients, not nurses, are
responsible for their own choices and decisions” provides the
best rationale for
abirb.com/test
advising students not to use advice giving. Advice giving is a nontherapeutic
communication technique in which the nurse tells the client what to do or how to
behave, and it implies the nurse knows what is best and that the client is incapable of
abirb.com/test
any self-direction.
This is incorrect. The instructor’s statement “Just keep the client’s best interests in
mind and do the best that you can” does not explain that nurses should not use the
nontherapeutic communication technique of advice giving.abirb.com/test
This is incorrect. The instructor’s statement “Set a goal to continue to work on this
abirb.com/test
abirb.com/test
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Chapter 7 - ETB
abirb.com/test
aspect of your practice” does not explain that nurses should not use the
nontherapeutic communication technique of advice giving.
abirb.com/test
CON: Communication
abirb.com/test
24. A student nurse is learning about the appropriate use of touch when communicating
with clients diagnosed with psychiatric disorders. Which statement made by the
instructor best provides information about this aspect of therapeutic communication?
abirb.com/test
1. “Touch carries a different meaning for different individuals.”
2. “Touch is often used when deescalating volatile client situations.”
3. “Touch is used to convey interest and warmth.”
4. “Touch is best combined with empathy when dealing with anxious
clients.”
abirb.com/test
ANS: 1
Chapter: Chapter 7 Therapeutic Communication
Objective: Identify components of nonverbal expression.
Page: 124
Heading: Nonverbal Communication > Touch
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Moderate
1.
2.
3.
4.
abirb.com/test
abirb.com/test
abirb.com/test
Feedback
This is correct. Touch can elicit both negative and positiveabirb.com/test
reactions, depending on
the people involved and the circumstances of the interaction.
This is incorrect. The instructor’s statement “Touch is often used when deescalating
volatile client situations” is not accurate. Touch can elicit both
negative and positive
abirb.com/test
reactions.
This is incorrect. The instructor’s statement “Touch is used to convey interest and
warmth” is technically true, but it is not the purpose of touch when communicating
abirb.com/test
with clients.
This is incorrect. The instructor’s statement “Touch is best combined with empathy
when dealing with anxious clients” is not necessarily true. Touch can elicit both
negative and positive reactions, depending on the people involved
and the
abirb.com/test
circumstances of the interaction.
CON: Communication
abirb.com/test
25. Which nursing statement is a good example of the therapeuticabirb.com/test
communication
technique of focusing?
abirb.com/test
abirb.com/test
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Chapter 7 - ETB
abirb.com/test
1. “Describe one of the best things that happened to you this week.”
2. “I’m having a difficult time understanding what you mean.”
3. “Your counseling session is in 30 minutes. I’ll stay with you until then.”
abirb.com/test
4. “You mentioned your relationship with your father. Let’s discuss
that further.”
ANS: 4
Chapter: Chapter 7 Therapeutic Communication
abirb.com/test
Objective: Describe therapeutic and nontherapeutic verbal communication techniques.
Page: 126
Heading: Therapeutic Communication Techniques > Table 7–2 Therapeutic
abirb.com/test
Communication Techniques
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Communication
Difficulty: Easy
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. The statement “Describe one of the best things that happened to
you this week” is not an example of the therapeutic communication technique of
abirb.com/test
focusing.
This is incorrect. The statement “I’m having a difficult time understanding what you
mean” is an example of the therapeutic communication technique of seeking
clarification and validation.
abirb.com/test
This is incorrect. The statement “Your counseling session is in 30 minutes. I’ll stay
with you until then” is an example of the therapeutic communication technique of
offering self.
abirb.com/test
This is correct. The statement “You mentioned your relationship
with your father.
Let’s discuss that further” is an example of the therapeutic communication technique
of focusing. Focusing takes notice of a single idea or even a single word and works
especially well with a client who is moving rapidly from one
thought to another.
abirb.com/test
CON: Communication
abirb.com/test
26. A client begins fasting at 10 p.m. for a blood test the next morning. The morning of
the test, the client finds out that it has been canceled. The client uses
profanity with the
abirb.com/test
nurse and states, “You are incompetent!” Which is the nurse’s best response?
1. “Do you believe that I caused your blood test to be canceled?”
2. “I see that you are upset, but I feel uncomfortable when you swear at me.”
abirb.com/test
3. “Have you ever thought about ways to express anger appropriately?”
4. “I’ll give you some space. Let me know if you need anything.”
ANS: 2
Chapter: Chapter 7 Therapeutic Communication
abirb.com/test
abirb.com/test
abirb.com/test
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Chapter 7 - ETB
abirb.com/test
Objective: Discuss therapeutic feedback.
Page: 124
Heading: Feedback
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Moderate
1.
2.
3.
4.
abirb.com/test
abirb.com/test
Feedback
abirb.com/test
This is incorrect. Feedback needs to be directed at a behavior the client can modify.
This is correct. The feedback is specific and focuses on a behavior the client can
modify.
This is incorrect. The feedback needs to focus on a specificabirb.com/test
behavior. The feedback
also needs to be descriptive rather than evaluative. This statement does not
specifically address the swearing, which the client can modify.
This is incorrect. This statement is not specific and does not
address a behavior the
abirb.com/test
client can modify.
CON: Communication
abirb.com/test
27. During a nurse-client interaction, which nursing statement may
belittle the client’s
abirb.com/test
feelings and concerns?
1. “Don’t worry. Everything will be alright.”
2. “You appear uptight.”
abirb.com/test
3. “I notice you have bitten your nails to the quick.”
4. “You are jumping to conclusions.”
ANS: 1
abirb.com/test
Chapter: Chapter 7 Therapeutic Communication
Objective: Describe therapeutic and nontherapeutic verbal communication techniques.
Page: 127
abirb.com/test
Heading: Nontherapeutic Communication Techniques > Table 7–3
Nontherapeutic
Communication Techniques
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Easy
abirb.com/test
Feedback
abirb.com/test
abirb.com/test
abirb.com/test
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Chapter 7 - ETB
abirb.com/test
1.
2.
3.
4.
This is correct. The nursing statement “Don’t worry. Everything will be alright” is
an example of the nontherapeutic communication block of belittling feelings.
Belittling feelings occurs when the nurse misjudges the degree of the client’s
abirb.com/test
discomfort, suggesting a lack of empathy and understanding.
This is incorrect. The nursing statement “You appear uptight” is not an example of
the nontherapeutic communication block of belittling feelings. Belittling feelings
occurs when the nurse misjudges the degree of the client’sabirb.com/test
discomfort, suggesting a
lack of empathy and understanding.
This is incorrect. The nursing statement “I notice you have bitten your nails to the
quick” is an example of the therapeutic communication technique of making
abirb.com/test
observations.
This is incorrect. The nursing statement “You are jumping to conclusions” is not an
example of the nontherapeutic communication block of belittling feelings. Belittling
feelings occurs when the nurse misjudges the degree of theabirb.com/test
client’s discomfort,
suggesting a lack of empathy and understanding.
CON: Communication
abirb.com/test
abirb.com/test
28. A client on an inpatient psychiatric unit tells the nurse, “I should
have died, because
I am totally worthless.” To encourage the client to continue talking about feelings,
which should be the nurse’s initial response?
1. “How would your family feel if you died?”
abirb.com/test
2. “You feel worthless now, but that can change with time.”
3. “You’ve been feeling sad and alone for some time now?”
4. “It is great that you have come in for help.”
abirb.com/test
ANS: 3
Chapter: Chapter 7 Therapeutic Communication
Objective: Describe therapeutic and nontherapeutic verbal communication
techniques.
abirb.com/test
Page: 126
Heading: Therapeutic Communication Techniques > Table 7–2 Therapeutic
Communication Techniques
abirb.com/test
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Communication
abirb.com/test
Difficulty: Moderate
1.
2.
Feedback
abirb.com/test
This is incorrect. The question “How would your family feel
if you died?” is an
example of the nontherapeutic communication technique of probing.
This is incorrect. The statement “You feel worthless now, but that can change with
time” is an example of the nontherapeutic communication abirb.com/test
technique of belittling or
minimizing feelings.
abirb.com/test
abirb.com/test
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Chapter 7 - ETB
abirb.com/test
3.
4.
This is correct. The question “You’ve been feeling sad and alone for some time
now?” is an example of the therapeutic communication technique of reflection.
When reflection is used, questions and feelings are referred back to the client so that
abirb.com/test
they may be recognized and accepted.
This is incorrect. The statement “It is great that you have come in for help” is an
example of the nontherapeutic communication technique of giving approval.
abirb.com/test
CON: Communication
abirb.com/test
29. Which nursing response is an example of the nontherapeutic communication
technique of requesting an explanation?
abirb.com/test
1. “Can you tell me why you said that?”
2. “Keep your chin up. I’ll explain the procedure to you.”
3. “There is always an explanation for both good and bad behaviors.”
4. “Are you not understanding the explanation I provided?”
abirb.com/test
ANS: 1
Chapter: Chapter 7 Therapeutic Communication
abirb.com/test techniques.
Objective: Describe therapeutic and nontherapeutic verbal communication
Page: 127
Heading: Nontherapeutic Communication Techniques > Table 7–3 Nontherapeutic
Communication Techniques
abirb.com/test
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Communication
Difficulty: Easy
1.
2.
3.
4.
Feedback
abirb.com/test
This is correct. The question “Can you tell me why you said that?” is an example of
the nontherapeutic communication technique of requesting an explanation.
Requesting an explanation is when the client is asked to provide the reason for
thoughts, feelings, behaviors, and events. Asking “why” a abirb.com/test
client did something or
feels a certain way can be intimidating and implies that the client must defend his or
her behavior or feelings.
This is incorrect. The statement “Keep your chin up” is an abirb.com/test
example of the
nontherapeutic communication technique of making stereotyped comments. When
the nurse uses meaningless expressions, it encourages a similar response from the
client.
abirb.com/test
This is incorrect. The statement “There is always an explanation
for both good and
bad behaviors” is an example of the nontherapeutic communication technique of
approving or disapproving, as it implies that the nurse has the right to pass judgment
on the client’s behaviors as “good” or “bad”.
abirb.com/test
This is incorrect. The question “Are you not understanding the explanation I
abirb.com/test
abirb.com/test
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Chapter 7 - ETB
abirb.com/test
provided?” is not an example of the nontherapeutic communication block of
requesting an explanation.
CON: Communication
abirb.com/test
abirb.com/test
30. A client states, “You won’t believe what my husband said to me during visiting
hours. He has no right treating me that way.” Which nursing response would best assess
the situation that occurred?
abirb.com/test
1. “Does your husband treat you like this very often?”
2. “What do you think is your role in this relationship?”
3. “Why do you think he behaved like that?”
4. “Describe what happened during your time with your husband.”
abirb.com/test
ANS: 4
Chapter: Chapter 7 Therapeutic Communication
abirb.com/test
Objective: Describe therapeutic and nontherapeutic verbal communication techniques.
Page: 126
Heading: Therapeutic Communication Techniques > Table 7–2 Therapeutic
abirb.com/test
Communication Techniques
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Communication
Difficulty: Moderate
1.
2.
3.
4.
abirb.com/test
Feedback
This is incorrect. The nurse’s question “Does your husband treat you like this very
often?” is more similar to the nontherapeutic communication technique of probing.
The client may not want to answer this question.
abirb.com/test
This is incorrect. The nurse’s question “What do you think is your role in this
relationship?” is more similar to the nontherapeutic communication technique of
probing. The client may not want to answer this question.
This is incorrect. The nurse’s question “Why do you think abirb.com/test
he behaved like that?” is
an example of the nontherapeutic communication technique of requesting an
explanation.
This is correct. The nurse’s response “Describe what happened
during your time
abirb.com/test
with your husband” is an example of the therapeutic communication technique of
exploring and is especially helpful with clients who tend to remain on a superficial
level of communication. The purpose of using exploring is to delve further into the
abirb.com/test
subject, idea, experience, or relationship.
CON: Communication
abirb.com/test
abirb.com/test
abirb.com/test
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Chapter 7 - ETB
abirb.com/test
31. Which statement reflects the therapeutic communication technique the nurse should
use when communicating with a client who is experiencing auditory hallucinations?
abirb.com/test
1. “My sister has the same diagnosis as you, and she also hears voices.”
2. “I understand that the voices seem real to you, but I do not hear any voices.”
3. “Why not turn up the radio so that the voices are muted.”
4. “I wouldn’t worry about these voices. The medication will make
them disappear.”
abirb.com/test
ANS: 2
Chapter: Chapter 7 Therapeutic Communication
abirb.com/test
Objective: Describe therapeutic and nontherapeutic verbal communication
techniques.
Page: 126
Heading: Therapeutic Communication Techniques > Table 7–2 Therapeutic
Communication Techniques
abirb.com/test
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Comprehension [Understanding]
abirb.com/test
Concept: Communication
Difficulty: Moderate
1.
2.
3.
4.
abirb.com/test
Feedback
This is incorrect. The nurse’s statement “My sister has the same diagnosis as you
and she also hears voices” does not present reality, which should be used when the
client has a misperception of the environment.
abirb.com/test
This is correct. The nurse’s statement “I understand that the voices seem real to you,
but I do not hear any voices” is an example of presenting reality, which should be
used when the client has a misperception of the environment. Presenting reality is
when the nurse defines or indicates the nurse’s perception abirb.com/test
of the situation for the
client.
This is incorrect. The nurse’s statement “Why not turn up the radio so that the voices
are muted” is an example of giving advice, which is a nontherapeutic
abirb.com/test
communication technique and does not present reality.
This is incorrect. The nurse’s statement “I wouldn’t worry about these voices. The
medication will make them disappear” does not present reality, which should be
abirb.com/test
used when the client has a misperception of the environment.
CON: Communication
abirb.com/test
32. Which nursing response is the best example of the therapeutic communication
abirb.com/test
technique of offering self?
1. “I think it would be great if you talked about that problem during our next group
session.”
2. “Would you like me to accompany you to your electroconvulsive
therapy treatment?”
abirb.com/test
3. “I notice that you are offering help to other peers in the milieu.”
abirb.com/test
abirb.com/test
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Chapter 7 - ETB
abirb.com/test
4. “After discharge, would you like to meet me for lunch to review your outpatient
progress?”
abirb.com/test
ANS: 2
Chapter: Chapter 7 Therapeutic Communication
Objective: Describe therapeutic and nontherapeutic verbal communication techniques.
Page: 126
abirb.com/test
Heading: Therapeutic Communication Techniques > Table 7–2 Therapeutic
Communication Techniques
Integrated Processes: Nursing Process: Implementation
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. The statement “I think it would be great if you talked about that
abirb.com/test
problem during our next group session” is an example of the nontherapeutic
communication technique of giving advice.
This is correct. The question “Would you like me to accompany you to your
abirb.com/test
electroconvulsive therapy treatment?” is the best example of
the therapeutic
communication technique of offering self. Offering self makes the nurse available on
an unconditional basis, increasing the client’s feelings of self-worth. When using the
technique of offering self, the nurse must maintain professional
boundaries.
abirb.com/test
This is incorrect. The statement “I notice that you are offering help to other peers in
the milieu” is an example of the therapeutic communication technique of making
observations.
This is incorrect. The question “After discharge, would youabirb.com/test
like to meet me for
lunch to review your outpatient progress?” is not an example of the therapeutic
communication technique of offering self. Offering self makes the nurse available on
an unconditional basis. In this example, the nurse is askingabirb.com/test
to review the client’s
progress.
CON: Communication
abirb.com/test
33. Which of the following best represents a patient-centered approach
that promotes a
abirb.com/test
change in behavior?
1. Process recordings
2. Providing guidance
abirb.com/test
3. Motivational interviewing
4. Therapeutic communication
ANS: 3
Chapter: Chapter 7 Therapeutic Communication
abirb.com/test
abirb.com/test
abirb.com/test
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Chapter 7 - ETB
abirb.com/test
Objective: Describe motivational interviewing as a communication strategy.
Page: 131
Heading: Motivational Interviewing
abirb.com/test
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
Cognitive Level: Comprehension [Understanding]
Concept: Communication
abirb.com/test
Difficulty: Easy
1.
2.
3.
4.
Feedback
abirb.com/test
This is incorrect. Process recordings are used as a tool by the nurse to improve
interpersonal communication techniques.
This is incorrect. Providing guidance, while an important part of the therapeutic
abirb.com/test
relationship, does not necessarily promote a change in behavior.
This is correct. Motivational interviewing is an evidence-based, patient-centered
style of communication that promotes behavior change by guiding clients to explore
their motivation to change and the advantages and disadvantages
to their decisions.
abirb.com/test
This is incorrect. Therapeutic communication is the foundation of a therapeutic
client-nurse relationship; however, it does not necessarily promote a change in
behavior. Therapeutic communication is a set of “procedures” used to enhance a
abirb.com/test
therapeutic relationship.
CON: Communication
abirb.com/test
34. Which statement reflects the model of transactional communication?
1. Individuals use nonverbal body language to communicate. abirb.com/test
2. Individuals simultaneously perceive each other.
3. Individuals use touch as a means of social communication.
4. Individuals use facial expressions to convey feelings.
abirb.com/test
ANS: 2
Chapter: Chapter 7 Therapeutic Communication
Objective: Discuss the transactional model of communication.
Page: 122
Heading: What Is Communication?
Integrated Processes: Nursing Process: Assessment
Client Needs: Psychosocial Integrity
Cognitive Level: Comprehension [Understanding]
Concept: Communication
Difficulty: Moderate
1.
abirb.com/test
abirb.com/test
abirb.com/test
Feedback
This is incorrect. In the transactional model of communication,
both participants
abirb.com/test
simultaneously perceive each other, listen to each other, and are mutually involved
abirb.com/test
abirb.com/test
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Chapter 7 - ETB
abirb.com/test
2.
3.
4.
in creating meaning in a relationship. Nonverbal communication is only one way in
which individuals can communicate.
This is correct. Interpersonal communication is a transaction between the sender and
the receiver. In the transactional model of communication,abirb.com/test
both participants
simultaneously perceive each other, listen to each other, and are mutually involved
in creating meaning in a relationship.
This is incorrect. In the transactional model of communication,
both participants
abirb.com/test
simultaneously perceive each other, listen to each other, and are mutually involved
in creating meaning in a relationship. Touch is one example of nonverbal
communication.
abirb.com/test
This is incorrect. In the transactional model of communication, both participants
simultaneously perceive each other, listen to each other, and are mutually involved
in creating meaning in a relationship. The use of facial expressions to convey
abirb.com/test
feelings is one example of communication.
CON: Communication
abirb.com/test
35. The nurse observes a client sitting alone and crying after a group therapy session.
abirb.com/test
The nurse sits in the chair nearest to the client and states, “I see you
are crying. I’d like
to sit with you for a few minutes.” Which communication technique is the nurse using?
1. Making an observation
2. Offering a general lead
abirb.com/test
3. Presenting reality
4. Silence
abirb.com/test
ANS: 1
Chapter: Chapter 7 Therapeutic Communication
Objective: Describe therapeutic and nontherapeutic verbal communication techniques.
Page: 126
abirb.com/test
Heading: Therapeutic Communication Techniques > Table 7–2 Therapeutic
Communication Techniques
Integrated Processes: Nursing Process: Implementation
abirb.com/test
Client Needs: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
Concept: Communication
Difficulty: Moderate
abirb.com/test
1.
2.
3.
Feedback
This is correct. The nurse is using the therapeutic technique of making an
abirb.com/test
observation by verbalizing and acknowledging that the client
is crying. This assists
the client to recognize feelings and behaviors.
This is incorrect. Offering a general lead is used during a therapeutic conversation to
encourage the client to continue. This is not an example ofabirb.com/test
offering a general lead.
This is incorrect. The nurse presents reality when a client has a misperception of the
abirb.com/test
abirb.com/test
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Chapter 7 - ETB
abirb.com/test
4.
environment. This is not an example of presenting reality.
This is incorrect. The nurse uses silence to give the client the opportunity to collect
and organize thoughts, to think through a point, or to consider introducing a topic of
greater concern than the one being discussed. The nurse is abirb.com/test
not demonstrating silence.
CON: Communication
abirb.com/test
36. A client tells the nurse, “I have nothing left to enjoy in life. My children are grown
abirb.com/test
and married.” The nurse replies, “I’m sure you are looking forward to having
grandchildren.” Which communication technique is this considered?
1. Giving advice
abirb.com/test
2. Reflecting
3. Using denial
4. Verbalizing the implied
abirb.com/test
ANS: 3
Chapter: Chapter 7 Therapeutic Communication
Objective: Describe therapeutic and nontherapeutic verbal communication techniques.
abirb.com/test
Page: 127
Heading: Nontherapeutic Communication Techniques > Table 7–3 Nontherapeutic
Communication Techniques
Integrated Processes: Nursing Process: Implementation
abirb.com/test
Client Needs: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
Concept: Communication
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
This is incorrect. The nurse is using the nontherapeutic communication
technique of
abirb.com/test
denial. Giving advice is the nontherapeutic technique of telling the client what to do
or how to behave and implies that the nurse knows what is best and that the client is
incapable of any self-direction.
abirb.com/test
This is incorrect. The nurse is using the nontherapeutic communication
technique of
denial. Reflecting is the therapeutic communication technique in which the nurse
refers questions and feelings back to the client so they may be recognized and
accepted.
abirb.com/test
This is correct. The nurse is using the nontherapeutic communication technique of
denial. Denying that a problem exists blocks discussion with the client and avoids
helping the client identify and explore areas of difficulty.
abirb.com/test
This is incorrect. The nurse is using the nontherapeutic communication
technique of
denial. Verbalizing the implied is the therapeutic communication technique in which
the nurse puts into words what the client has only implied or said indirectly and
clarifies that which is implicit rather than explicit.
abirb.com/test
abirb.com/test
abirb.com/test
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Chapter 7 - ETB
abirb.com/test
CON: Communication
abirb.com/test
MULTIPLE RESPONSE
abirb.com/test
37. Which individuals are communicating a message? Select all that apply.
1. A parent spanking her child for playing with matches
abirb.com/test
2. A teenager isolating himself and playing loud music
3. A biker sporting an eagle tattoo on a bicep
4. A teenager writing, “No one understands me”
5. A parent checking for new e-mail on a regular basis
abirb.com/test
ANS: 1, 2, 3, 4
Chapter: Chapter 7 Therapeutic Communication
Objective: Discuss the transactional model of communication.
Page: 122
Heading: What Is Communication?
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Easy
1.
2.
3.
4.
5.
abirb.com/test
abirb.com/test
abirb.com/test
Feedback
abirb.com/test
This is correct. Spanking is a way of communicating a message.
Approximately 70%
to 90% of communication is nonverbal.
This is correct. Isolating oneself is a way of communicating a message.
Approximately 70% to 90% of communication is nonverbal.
abirb.com/test
This is correct. Getting a tattoo is a way of communicating a message.
Approximately 70% to 90% of communication is nonverbal.
This is correct. Writing is a way of communicating a message to others.
abirb.com/test
Approximately 70% to 90% of communication is nonverbal.
This is incorrect. Communication is a transaction between a sender and a receiver in
which both participants simultaneously perceive each other, listen to each other, and
are mutually involved in creating meaning in a relationship.
Checking e-mail does
abirb.com/test
not involve an interaction between a sender and a receiver.
CON: Communication
abirb.com/test
38. Which preexisting conditions influence the outcome of communication?
abirb.com/test Select all
that apply.
abirb.com/test
abirb.com/test
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Chapter 7 - ETB
abirb.com/test
1. Gender
2. Distance
3. Eye contact
4. Values
5. Paralanguage
abirb.com/test
ANS: 1, 2, 4
abirb.com/test
Chapter: Chapter 7 Therapeutic Communication
Objective: Identify types of preexisting conditions that influence the outcome of the
communication process.
abirb.com/test
Page: 123
Heading: The Impact of Preexisting Conditions
Integrated Processes: Nursing Process: Evaluation
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Knowledge [Remembering]
Concept: Communication
Difficulty: Easy
abirb.com/test
1.
2.
3.
4.
5.
Feedback
This is correct. Gender is a preexisting condition that influences the manner in which
abirb.com/test
individuals communicate. Most cultures have gender signals
that are recognized as
either masculine or feminine and provide a basis for distinguishing between
members of each gender.
This is correct. Territoriality, density, and distance are aspects
of the preexisting
abirb.com/test
condition of the environment in which the transaction takes place.
This is incorrect. Eye contact is a type of nonverbal communication.
This is correct. Values, attitudes, and beliefs are preexisting conditions that impact
abirb.com/test
communication. One’s value system may be communicated
with behaviors that are
more symbolic in nature.
This is incorrect. Paralanguage is a type of nonverbal communication.
abirb.com/test
CON: Communication
abirb.com/test
39. Which nursing statements demonstrate useful feedback? Select all that apply.
1. “Hitting the wall yesterday was not the best way to express your anger.”
2. “The hospital has a support group on Tuesdays for those who want
to quit smoking.”
abirb.com/test
3. “It appears you want to sit near the nurses’ station when the morning meeting starts.”
4. “Your behavior has been unacceptable since you were admitted to this unit.”
5. “I noticed you participated in group more this afternoon than this morning.”
abirb.com/test
ANS: 2, 3, 5
Chapter: Chapter 7 Therapeutic Communication
Objective: Discuss therapeutic feedback.
Page: 131
abirb.com/test
abirb.com/test
abirb.com/test
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Chapter 7 - ETB
abirb.com/test
Heading: Feedback
Integrated Processes: Nursing Process: Implementation
Client Needs: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
Concept: Communication
Difficulty: Moderate
abirb.com/test
abirb.com/test
1.
2.
3.
4.
5.
Feedback
This is incorrect. This is an example of delayed-response feedback, which is not
useful to the client. Feedback is most useful when given at the earliest appropriate
abirb.com/test
opportunity following the specific behavior.
This is correct. Feedback is useful when it encourages self-sufficiency and imparts
information rather than offering advice.
This is correct. Useful feedback should be directed towardabirb.com/test
a behavior the client has
the capacity to modify. In this situation, the nurse can explore the reason the client
sits near the nurse’s station and assist the client to modify the behavior when
appropriate.
abirb.com/test
This is incorrect. Useful feedback should be specific rather than general.
This is correct. Useful feedback should be directed toward behavior that the client
has the capacity to modify and is specific. This statement is directed toward a
abirb.com/test
specific behavior the client can modify (participating in group).
CON: Communication
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
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Chapter 8 - ETB
abirb.com/test
Chapter 8. The Nursing Process in Psychiatric-Mental Health Nursing
abirb.com/test
MULTIPLE CHOICE
abirb.com/test
1. Which data-gathering technique is employed during the assessment phase of the nursing
process?
abirb.com/test
1. Asking the client to rate mood after administering an antidepressant
2. Asking the client to verbalize understanding of previously explained unit rules
3. Asking the client to describe any thoughts of self-harm
abirb.com/test
4. Asking the client if the group on assertiveness skills was helpful
ANS: 3
Chapter: Chapter 8, The Nursing Process in Psychiatric-Mental Health
Nursing
abirb.com/test
Objective: Identify six steps of the nursing process and describe nursing actions associated
with each.
Page: 139
abirb.com/test
Heading: The Nursing Process > Standards of Practice > Standard
1. Assessment
Integrated Processes: Nursing Process: Assessment
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Communication
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. The client is asked to rate mood during the evaluation phase of the
nursing process.
abirb.com/test
This is incorrect. The client is asked to verbalize understanding
of previously
explained unit rules during the evaluation phase of the nursing process.
This is correct. The nurse should ask the client to describe any thoughts of self-harm
during the assessment phase of the nursing process. Assessment
involves collecting
abirb.com/test
and analyzing data about the client that may include the following dimensions:
physical, psychological, sociocultural, spiritual, cognitive, developmental, economic,
lifestyle, and functional abilities.
abirb.com/test
This is incorrect. The client is asked if the group on assertiveness
skills was helpful
during the evaluation phase of the nursing process.
CON: Communication
abirb.com/test
2. Which statement is most accurate regarding the assessment of abirb.com/test
clients diagnosed with
psychiatric problems?
abirb.com/test
abirb.com/test
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Chapter 8 - ETB
abirb.com/test
1. Medical history is of little significance and can be eliminated from the nursing
assessment.
2. Assessment provides a holistic view of the client, including biopsychosocial aspects.
abirb.com/test
3. Comprehensive assessments can be performed only by advanced
practice nurses.
4. Psychosocial evaluations are gained by subjective reports rather than objective
observations.
abirb.com/test
ANS: 2
Chapter: Chapter 8, The Nursing Process in Psychiatric-Mental Health Nursing
Objective: Apply the six steps of the nursing process in caring for a client within the
abirb.com/test
psychiatric setting.
Page: 140
Heading: The Nursing Process> Standards of Practice > Standard 1. Assessment
Integrated Processes: Nursing Process: Assessment
abirb.com/test
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Comprehension [Understanding]
Concept: Patient-Centered Care
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/test
This is incorrect. A client’s medical history is significant and
should be part of the
nursing assessment.
This is correct. Assessment of clients diagnosed with psychiatric problems provides
a holistic view of the client. A thorough assessment involves
collecting and
abirb.com/test
analyzing data from the client, significant others, and health-care providers that may
include the following dimensions: physical, psychological, sociocultural, spiritual,
cognitive, developmental, economic, lifestyle, and functional abilities.
abirb.com/test
This is incorrect. All registered nurses can perform comprehensive
client
assessments.
This is incorrect. Psychosocial evaluations are gained by both subjective reports and
objective observations.
abirb.com/test
CON: Patient-Centered Care
abirb.com/test
3. Which nursing diagnosis is correctly formulated?
1. Schizophrenia related to (R/T) biochemical alterations as evidenced
by (AEB) altered
abirb.com/test
thought
2. Self-care deficit: hygiene R/T altered thought AEB disheveled appearance
3. Depressed mood R/T multiple life stressors
4. Developmental disability R/T early-onset schizophrenia AEB abirb.com/test
hallucinations
ANS: 2
Chapter: Chapter 8, The Nursing Process in Psychiatric-Mental Health
Nursing
abirb.com/test
Objective: Apply the six steps of the nursing process in caring for a client within the
abirb.com/test
abirb.com/test
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Chapter 8 - ETB
abirb.com/test
psychiatric setting.
Page: 147
Heading: The Nursing Process > Appendix F, Assigning NANDA Nursing Diagnoses to
abirb.com/test
Client Behaviors
Integrated Processes: Nursing Process: Analysis
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Patient-Centered Care
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. The nursing diagnosis should describe the unhealthy response
(inference).
abirb.com/test
This is correct. The correctly written diagnosis is “Self-care
deficit: hygiene R/T
altered thought AEB disheveled appearance.” This nursing diagnosis describes the
unhealthy response (inference), the contributing factors, and the data that support the
inference.
abirb.com/test
This is incorrect. The nursing diagnosis should describe the data that support the
inference.
This is incorrect. The nursing diagnosis should describe the unhealthy response
abirb.com/test
(inference), the contributing factors, and the data that support
the inference.
CON: Patient-Centered Care
abirb.com/test
4. Which is a correctly stated client outcome?
abirb.com/test
1. Client will feel happier by discharge.
2. Client will demonstrate two relaxation techniques.
3. Client will verbalize triggers to anger by end of session.
4. Client will initiate interaction with one peer during free time within
2 days.
abirb.com/test
ANS: 4
Chapter: Chapter 8, The Nursing Process in Psychiatric-Mental Health Nursing
Objective: Apply the six steps of the nursing process in caring forabirb.com/test
a client within the
psychiatric setting.
Page: 147
Heading: The Nursing Process > Standards of Practice >Standardabirb.com/test
3. Outcomes Identification
Integrated Processes: Nursing Process: Planning
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Comprehension [Understanding]
abirb.com/test
Concept: Patient-Centered Care
Difficulty: Easy
1.
Feedback
This is incorrect. This client outcome is not measurable.
abirb.com/test
abirb.com/test
abirb.com/test
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Chapter 8 - ETB
abirb.com/test
2.
3.
4.
This is incorrect. This client outcome does not include a time frame.
This is incorrect. This client outcome is not realistic.
This is correct. Outcomes should be measurable, realistic, client-focused goals that
abirb.com/test
include a time frame.
CON: Patient-Centered Care
abirb.com/test
5. Which statement regarding nursing interventions is accurate?
abirb.com/test
1. Nursing interventions are independent of the treatment team’s goals.
2. Nursing interventions are directed solely by written physician orders.
3. Nursing interventions occur independently but align with overall treatment team goals.
abirb.com/test
4. Nursing interventions are standardized by policies and procedures
with client input.
ANS: 3
Chapter: Chapter 8, The Nursing Process in Psychiatric-Mental Health
Nursing
abirb.com/test
Objective: Identify six steps of the nursing process and describe nursing actions associated
with each.
Page: 148
abirb.com/test
Heading: The Nursing Process > Standards of Practice > Standard
4. Planning
Integrated Processes: Nursing Process: Implementation
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Comprehension [Understanding]
abirb.com/test
Concept: Patient-Centered Care
Difficulty: Moderate
1.
2.
3.
4.
abirb.com/test
Feedback
This is incorrect. Nursing interventions occur independently but are also in concert
with overall treatment goals. They should be developed and implemented in
collaboration with other health-care professionals involvedabirb.com/test
in the client’s care.
This is incorrect. Nursing interventions are not directed by physician orders. Nursing
interventions should be developed and implemented in collaboration with other
health-care professionals involved in the client’s care.
This is correct. Nursing interventions occur independently abirb.com/test
but are also in concert
with overall treatment goals. Nursing interventions should be developed and
implemented in collaboration with other health-care professionals involved in the
client’s care.
abirb.com/test
This is incorrect. Nursing interventions are not standardized by policies and
procedures. Nurses formulate nursing interventions designed to meet each client’s
individual needs. Nursing interventions should be developed and implemented in
collaboration with other health-care professionals involvedabirb.com/test
in the client’s care.
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 8 - ETB
abirb.com/test
6. Which function is exclusive to the advanced practice psychiatric-mental health nurse’s
scope of practice?
1. Teaching about the side effects of neuroleptic medications abirb.com/test
2. Using psychotherapy to improve mental health status
3. Using milieu therapy to structure a therapeutic environment
4. Providing case management to coordinate continuity of healthabirb.com/test
services
ANS: 2
Chapter: Chapter 8, The Nursing Process in Psychiatric-Mental Health Nursing
abirb.com/test
Objective: Define and discuss the use of case management and critical
pathways of care in
the clinical setting.
Page: 148
Heading: The Nursing Process > Standards of Practice > Standard
5. Implementation >
abirb.com/test
Standard 5C. Consultation
Integrated Processes: Nursing Process: Implementation
Client Need: Safe and Effective Care Environment: Management of Care
abirb.com/test
Cognitive Level: Comprehension [Understanding]
Concept: Professionalism
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. It is within the scope of practice of a registered psychiatric-mental
health nurse generalist to provide education.
abirb.com/test
This is correct. The advanced practice psychiatric-mental health nurse is authorized
to use psychotherapy to improve mental health. This includes individual, couples,
group, and family psychotherapy.
abirb.com/test
This is incorrect. It is within the scope of practice of a registered
psychiatric-mental
health nurse generalist to provide milieu therapy.
This is incorrect. It is within the scope of practice of a registered psychiatric-mental
health nurse generalist to provide case management.
abirb.com/test
CON: Professionalism
abirb.com/test
7. A nurse charts, “Verbalizes understanding of the side effects of Prozac.” This is an
example of which category of focus charting?
abirb.com/test
1. Data
2. Problem
3. Action
abirb.com/test
4. Response
ANS: 4
Chapter: Chapter 8, The Nursing Process in Psychiatric-Mental Health
Nursing
abirb.com/test
Objective: Document client care that validates use of the nursing process.
abirb.com/test
abirb.com/test
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Chapter 8 - ETB
abirb.com/test
Page: 156
Heading: Documentation of the Nursing Process > Focus Charting
Integrated Processes: Communication and Documentation
Client Need: Safe and Effective Care Environment: Managementabirb.com/test
of Care
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Easy
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. Data is information supporting the stated focus or pertinent
abirb.com/test
observations about the client.
This is incorrect. Problem is not a category of focus charting.
This is incorrect. Action addresses immediate or future nursing actions that address
the focus and evaluation of the present care plan along withabirb.com/test
any changes required.
This is correct. “Verbalizes understanding of the side effects of Prozac” is an
example of the response category of response in focus charting. The response is a
description of the client’s reaction to any part of medical orabirb.com/test
nursing care.
CON: Communication
abirb.com/test
8. The nurse should recognize which acronym as representing problem-oriented recording?
1. SOAPIE
abirb.com/test
2. SOLER
3. DAR
4. PQRST
abirb.com/test
ANS: 1
Chapter: Chapter 8, The Nursing Process in Psychiatric-Mental Health Nursing
Objective: Document client care that validates use of the nursingabirb.com/test
process.
Page: 155
Heading: Documentation of the Nursing Process > Problem-Oriented Recording
Integrated Processes: Communication and Documentation
Client Need: Safe and Effective Care Environment: Managementabirb.com/test
of Care
Cognitive Level: Comprehension [Understanding]
Concept: Communication
Difficulty: Easy
abirb.com/test
1.
2.
Feedback
This is correct. The acronym SOAPIE represents problem-oriented charting, which
abirb.com/test
reflects the subjective, objective, assessment, plan, implementation,
and evaluation
format. This type of charting identifies nursing diagnoses (client problems) on a
written plan of care with appropriate nursing interventions described for each.
This is incorrect. The acronym SOLER represents sit squarely,
open posture, lean
abirb.com/test
toward the client, eye contact, and relax. SOLER refers to how the nurse should use
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 8 - ETB
abirb.com/test
3.
4.
body language to facilitate therapeutic communication.
This is incorrect. The acronym DAR refers to the data, action, and response format
used in focus charting. The acronym SOAPIE represents problem-oriented charting,
which reflects the subjective, objective, assessment, plan, abirb.com/test
implementation, and
evaluation format. This type of charting identifies nursing diagnoses (client
problems) on a written plan of care with appropriate nursing interventions described
for each.
abirb.com/test
This is incorrect. The acronym PQRST is for the assessment of pain.
CON: Communication
abirb.com/test
abirb.com/test
9. Which tool would be appropriate for a nurse to use when assessing
mental acuity prior to
and immediately following electroconvulsive therapy (ECT)?
1. CIWA scale
2. GGT
abirb.com/test
3. MMSE
4. CAPS scale
abirb.com/test
ANS: 3
Chapter: Chapter 8, The Nursing Process in Psychiatric-Mental Health Nursing
Objective: Apply the six steps of the nursing process in caring for a client within the
psychiatric setting.
abirb.com/test
Page: 140
Heading: The Nursing Process > Standards of Practice > Standard 1. Assessment
Integrated Processes: Nursing Process: Assessment
Client Need: Safe and Effective Care Environment: Managementabirb.com/test
of Care
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. The CIWA scale, or Clinical Institute Withdrawal Assessment
abirb.com/test
scale, is used to assess alcohol withdrawal.
This is incorrect. The GGT test is used to assess gamma-glutamyl transferase levels,
which may be an indication of alcoholism.
This is correct. The MMSE, or Mini-Mental Status Examination,
would be the
abirb.com/test
appropriate tool to use to assess the mental acuity of a client prior to and
immediately following ECT.
This is incorrect. The CAPS scale is a clinician-administered scale for posttraumatic
abirb.com/test
stress disorder (PTSD) and is used to assess signs and symptoms
of PTSD.
CON: Cognition
abirb.com/test
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 8 - ETB
abirb.com/test
10. What is being assessed when a nurse asks a client to identify name, date, residential
address, and situation?
abirb.com/test
1. Mood
2. Perception
3. Orientation
4. Affect
abirb.com/test
ANS: 3
Chapter: Chapter 8, The Nursing Process in Psychiatric-Mental Health Nursing
Objective: Apply the six steps of the nursing process in caring forabirb.com/test
a client within the
psychiatric setting.
Page: 140
Heading: The Nursing Process > Standards of Practice > Standard
1. Assessment
abirb.com/test
Integrated Processes: Nursing Process: Assessment
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Comprehension [Understanding]
abirb.com/test
Concept: Cognition
Difficulty: Easy
1.
2.
3.
4.
abirb.com/test
Feedback
This is incorrect. Mood is assessed with parameters such as happiness, sadness,
despair, and elation.
This is incorrect. Perception is assessed by identifying the abirb.com/test
client’s understanding or
description of a stressor, illness, or experience.
This is correct. The nurse is assessing the client’s orientation by asking the client to
identify name, date, residential address, and situation. Assessment of the client’s
orientation to reality is part of a mental status evaluation. abirb.com/test
This is incorrect. Affect is assessed along with mood using parameters such as
euphoria, suspiciousness, apathy, and anger.
abirb.com/test
CON: Cognition
abirb.com/test
11. Which provides the basis for selecting nursing interventions to achieve outcomes for
which the nurse is accountable?
1. Physician diagnosis
abirb.com/test
2. Nursing diagnosis
3. Critical pathways
4. Case management
abirb.com/test
ANS: 2
Chapter: Chapter 8, The Nursing Process in Psychiatric-Mental Health Nursing
Objective: Identify six steps of the nursing process and describe abirb.com/test
nursing actions associated
with each.
abirb.com/test
abirb.com/test
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Chapter 8 - ETB
abirb.com/test
Page: 140
Heading: Core Concept
Integrated Processes: Nursing Process: Assessment
Client Need: Safe and Effective Care Environment: Managementabirb.com/test
of Care
Cognitive Level: Comprehension [Understanding]
Concept: Patient-Centered Care
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. Physician diagnoses are not the basis for independent nursing
abirb.com/test
interventions.
This is correct. Nursing diagnoses are the basis for independent nursing
interventions.
abirb.com/test
This is incorrect. Critical pathways are abbreviated care plans
that provide guidelines
for goal achievement.
This is incorrect. Case management serves to decrease fragmented care and keeps
the cost of services contained.
abirb.com/test
CON: Patient-Centered Care
abirb.com/test
12. A nurse on an inpatient psychiatric unit implements care by scheduling client activities,
interacting with clients, and maintaining a safe therapeutic environment.
These actions
abirb.com/test
reflect which role of the nurse?
1. Health teacher
2. Case manager
abirb.com/test
3. Milieu manager
4. Psychotherapist
ANS: 3
abirb.com/test
Chapter: Chapter 8, The Nursing Process in Psychiatric-Mental Health Nursing
Objective: Apply the six steps of the nursing process in caring for a client within the
psychiatric setting.
abirb.com/test
Page: 156
Heading: The Nursing Process > Standards of Practice > Standard 5. Implementation >
Standard 5F. Milieu Therapy
Integrated Processes: Nursing Process: Implementation
abirb.com/test
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Comprehension [Understanding]
Concept: Safety
abirb.com/test
Difficulty: Difficult
1.
Feedback
This is incorrect. The role of health teacher involves promoting
health and a safe
abirb.com/test
environment.
abirb.com/test
abirb.com/test
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Chapter 8 - ETB
abirb.com/test
2.
3.
4.
This is incorrect. The role of the case manager is to organize client care so that
outcomes are achieved.
This is correct. The nurse’s actions represent the nurse’s role of milieu manager. The
abirb.com/test
milieu manager implements care by scheduling client activities,
interacting with
clients, and maintaining a safe therapeutic environment.
This is incorrect. The role of psychotherapist involves conducting individual,
couples, group, and family counseling.
abirb.com/test
CON: Safety
abirb.com/test
13. The following outcome was developed for a client: “Client will list five personal
abirb.com/test
strengths by the end of day 1.” Which nursing diagnostic statement
most likely generated
this outcome?
1. Altered self-esteem R/T years of emotional abuse AEB self-deprecating statements
2. Self-care deficit R/T altered thought processes AEB soiled clothing
and poor hygiene
abirb.com/test
3. Disturbed body image R/T major depressive disorder AEB mood rating of 2/10
4. Risk for disturbed self-concept R/T hopelessness AEB suicide attempt
abirb.com/test
ANS: 1
Chapter: Chapter 8, The Nursing Process in Psychiatric-Mental Health Nursing
Objective: Apply the six steps of the nursing process in caring for a client within the
psychiatric setting.
abirb.com/test
Page: 157
Heading: The Nursing Process > Standards of Practice > Standard 6. Evaluation
Integrated Processes: Nursing Process: Analysis
Client Need: Safe and Effective Care Environment: Managementabirb.com/test
of Care
Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is correct. The nursing diagnostic statement “Altered self-esteem R/T years of
abirb.com/test
emotional abuse AEB self-deprecating statements” most likely
generated the
outcome of “the client will list five personal strengths by the end of day 1.”
This is incorrect. The self-care deficit nursing diagnosis does not relate to the need to
identify personal strengths; rather, it would address an outcome
of proper hygiene
abirb.com/test
and cleanliness.
This is incorrect. The disturbed body image does not relate to an outcome to identify
5 strengths by the end of the day.
abirb.com/test
This is incorrect. The “risk for disturbed self-concept” nursing
diagnosis is
incorrectly written. The correct nursing diagnostic statement is “Altered self-esteem
R/T years of emotional abuse AEB self-deprecating statements” and most likely
generated the outcome of “the client will list five personal abirb.com/test
strengths by the end of
day 1.”
abirb.com/test
abirb.com/test
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Chapter 8 - ETB
abirb.com/test
CON: Patient-Centered Care
abirb.com/test
14. Which is the correct manner to prioritize nursing diagnoses?
1. By the established goal of care
abirb.com/test
2. By the life-threatening potential
3. By the physician’s priority of care
4. By the client’s preference
abirb.com/test
ANS: 2
Chapter: Chapter 8, The Nursing Process in Psychiatric-Mental Health Nursing
Objective: Apply the six steps of the nursing process in caring forabirb.com/test
a client within the
psychiatric setting.
Page: 152
Heading: Applying the Nursing Process in the Psychiatric Setting
abirb.com/test
Integrated Processes: Nursing Process: Analysis
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Comprehension [Understanding]
Concept: Patient-Centered Care
abirb.com/test
Difficulty: Easy
1.
2.
3.
4.
Feedback
abirb.com/test
This is incorrect. The established goal of care does not reflect the life-threatening
potential appropriate to prioritizing nursing care.
This is correct. The nurse should prioritize nursing diagnoses related to lifethreatening potential. Safety is always the nurse’s priority.abirb.com/test
This is incorrect. The physician’s priority of care does not always reflect safety or
life-threatening potential and is not used to address independent nursing care.
This is incorrect. The client’s preference does not necessarily
address safety or lifeabirb.com/test
threatening potential and therefore is not used to prioritize care.
CON: Patient-Centered Care
abirb.com/test
15. A client has a nursing diagnosis of “Insomnia R/T paranoid thinking
AEB midnight
abirb.com/test
awakenings, difficulty falling asleep, and daytime napping.” Which is a correctly written
and appropriate outcome for this client’s problem?
1. The client will avoid daytime napping and attend all groups.
abirb.com/test
2. The client will exercise as needed before bedtime.
3. The client will sleep 7 uninterrupted hours by day 4 of hospitalization.
4. The client’s sleep habits will improve during hospitalization.
abirb.com/test
ANS: 3
abirb.com/test
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Chapter 8 - ETB
abirb.com/test
Chapter: Chapter 8, The Nursing Process in Psychiatric-Mental Health Nursing
Objective: Apply the six steps of the nursing process in caring for a client within the
psychiatric setting.
abirb.com/test
Page: 145
Heading: The Nursing Process > Standards of Practice > Standard 3. Outcomes
Identification
Integrated Processes: Nursing Process: Planning
abirb.com/test
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Communication
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
This is incorrect. The outcome to avoid daytime napping and
attend all groups is not
abirb.com/test
realistic or measurable.
This is incorrect. The outcome to exercise as needed before bedtime is not
measurable or focused on the client’s needs to improve sleep.
abirb.com/test
This is correct. The outcome “The client will sleep 7 uninterrupted hours by day 4 of
hospitalization” is accurately written and is an appropriate outcome. Outcomes
should be measurable, realistic, client-focused goals that include a time frame.
abirb.com/test
Appropriate nursing interventions are guided by client outcomes.
This is incorrect. The outcome for the client to improve sleep during the
hospitalization is not measurable.
abirb.com/test
CON: Communication
abirb.com/test
16. The following North American Nursing Diagnosis Association (NANDA) nursing
diagnostic stem was developed for a client on an inpatient unit: “Risk for injury.”
Which assessment data most likely led to the development of thisabirb.com/test
problem statement?
1. The client is receiving ECT and is diagnosed with parkinsonism.
2. The client has a history of four suicide attempts in adolescence.
3. The client expresses hopelessness and helplessness and isolates self.
abirb.com/test
4. The client has disorganized thought processes and delusional thinking.
ANS: 1
Chapter: Chapter 8, The Nursing Process in Psychiatric-Mental Health
Nursing
abirb.com/test
Objective: Apply the six steps of the nursing process in caring for a client within the
psychiatric setting.
Page: 145
abirb.com/test
Heading: The Nursing Process > Standards of Practice > Standard
2. Diagnosis
Integrated Processes: Nursing Process: Analysis
Client Need: Physiological
Cognitive Level: Analysis [Analyzing]
abirb.com/test
Concept: Patient-Centered Care
abirb.com/test
abirb.com/test
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Chapter 8 - ETB
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
This is correct. The assessment data identifying the client’sabirb.com/test
confusion due to ECT
therapy and potential for falls related to parkinsonism would lead to the problem
statement “risk for injury.”
This is incorrect. A history of suicide would lead to the development
abirb.com/test of the nursing
diagnosis “risk for suicide.”
This is incorrect. The nursing diagnosis “risk for suicide” is appropriate for the client
who is isolating and expressing hopelessness and helplessness.
abirb.com/test
This is incorrect. The nursing diagnosis “altered thought processes” is appropriate
for the client with disorganized thought processes and delusional thinking.
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
17. A student nurse asks an instructor which resource is best to use when developing nursing
outcomes for clients. Which reply most accurately answers the student’s question?
1. “Use the Nursing Interventions Classification (NIC) as a reference for nursing outcomes.”
2. “Use the NANDA resource to identify appropriate outcomes.”abirb.com/test
3. “Use the Nursing Outcomes Classification (NOC) as a reference for nursing outcomes.”
4. “Copy your standard outcomes from a nursing care plan textbook.”
abirb.com/test
ANS: 3
Chapter: Chapter 8, The Nursing Process in Psychiatric-Mental Health Nursing
Objective: Use the NANDA resource to identify appropriate outcomes.
abirb.com/test
Page: 147
Heading: The Nursing Process > Standards of Practice > Standard 3. Outcomes
Identification
Integrated Processes: Nursing Process: Planning
abirb.com/test
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Comprehension [Understanding]
Concept: Patient-Centered Care
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
This is incorrect. Using the Nursing Interventions Classification
(NIC) would
abirb.com/test
provide interventions appropriate for clients.
This is incorrect. NANDA is a resource for identifying approved nursing diagnoses.
This is correct. The instructor’s reply “Use the Nursing Outcomes Classification
abirb.com/test
(NOC) as a reference for nursing outcomes” best answers the student’s question. The
NOC is a comprehensive, standardized classification of client outcomes developed
to evaluate the effects of nursing interventions.
abirb.com/test
This is incorrect. Standard outcomes from a nursing care plan
do not provide
specific outcomes for nursing diagnoses.
abirb.com/test
abirb.com/test
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Chapter 8 - ETB
abirb.com/test
CON: Patient-Centered Care
abirb.com/test
18. A client diagnosed with schizophrenia is exhibiting nonverbal behaviors indicating that
the client is hearing things that others do not. Which nursing diagnosis
accurately reflects
abirb.com/test
this client’s problem?
1. Altered thought processes
2. Altered sensory perception
abirb.com/test
3. Ineffective coping
4. Chronic confusion
ANS: 2
abirb.com/test
Chapter: Chapter 8, The Nursing Process in Psychiatric-Mental Health Nursing
Objective: Apply the six steps of the nursing process in caring for a client within the
psychiatric setting.
abirb.com/test
Page: 146
Heading: The Nursing Process > Standards of Practice > Standard 2. Diagnosis
Integrated Processes: Nursing Process: Assessment
Client Need: Safe and Effective Care Environment: Managementabirb.com/test
of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. Delusional thinking, confusion, and disorientation are associated
with the nursing diagnosis “altered thought processes.” Theabirb.com/test
nursing diagnosis
“altered sensory perception” accurately reflects the client’s symptoms of hearing
things that others do not. A nursing diagnosis describes a client’s condition and
facilitates the prescription of interventions.
abirb.com/test
This is correct. The nursing diagnosis “altered sensory perception” accurately
reflects the client’s symptoms of hearing things that others do not. A nursing
diagnosis describes a client’s condition and facilitates the prescription of
abirb.com/test
interventions.
This is incorrect. The nursing diagnosis of ineffective coping is associated with an
inability to assess stressors, choose appropriate responses, or use available resources.
This is incorrect. The nursing diagnosis of chronic confusion
is a decreased ability
abirb.com/test
for intellectual thought or to interpret environmental stimuli.
CON: Patient-Centered Care
abirb.com/test
19. Which best reflects the reason clients are now called “health-care
consumers?”
abirb.com/test
1. Healthcare is a for-profit industry and the term “consumers” best reflects this industry.
abirb.com/test
abirb.com/test
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Chapter 8 - ETB
abirb.com/test
2. The term “health-care consumer” reflects the extensive choices available to individuals.
3. “Health-care consumer” echoes the collaborative relationship between nurses and clients.
4. The term “health-care consumer” reflects client protections available within the industry.
abirb.com/test
ANS: 3
Chapter: Chapter 8, The Nursing Process in Psychiatric-Mental Health Nursing
Objective: Identify six steps of the nursing process, and describeabirb.com/test
nursing actions associated
with each.
Page: 139
Heading: The Nursing Process > Standards of practice
abirb.com/test
Integrated Processes: Nursing Process: Evaluation
Client Need: Teaching and Learning
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/test
This is incorrect. Not all aspects of health care are a for-profit industry.
This is incorrect. The term “consumer” does not reflect the many choices a client
seeking healthcare may have; in some cases, consumers do not have a great deal of
abirb.com/test
choices.
This is correct. The relationship between nurses and clients has become a more
collaborative, client-centered approach.
This is incorrect. The term does not reflect protections available
to clients seeking
abirb.com/test
healthcare.
CON: Patient-Centered Care
abirb.com/test
20. Which should the nurse perform to maximize client educationabirb.com/test
prior to discharge
teaching?
1. Assess the client’s readiness to learn.
2. Identify the priority nursing diagnosis.
abirb.com/test
3. Provide routine antidepressant medication.
4. Begin the teaching as soon as possible.
ANS: 1
abirb.com/test
Chapter: Chapter 8, The Nursing Process in Psychiatric-Mental Health Nursing
Objective: Apply the six steps of the nursing process in caring for a client within the
psychiatric setting.
abirb.com/test
Page: 146
Heading: The Nursing Process > Standards of Practice > Standard 1. Assessment
Integrated Processes: Nursing Process: Assessment
Client Need: Safe and Effective Care Environment: Managementabirb.com/test
of Care
Cognitive Level: Application [Applying]
abirb.com/test
abirb.com/test
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Townsend
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Chapter 8 - ETB
abirb.com/test
Concept: Patient-Centered Care
Difficulty: Easy
1.
2.
3.
4.
abirb.com/test
Feedback
This is correct. Assessment is the first step of the nursing process and should be
done prior to implementing any intervention.
This is incorrect. Determining the priority nursing diagnosis
does not assist the nurse
abirb.com/test
to know if the client is ready to learn and benefit from discharge teaching.
This is incorrect. Providing routine antidepressant medication does not allow the
nurse to determine readiness for learning.
abirb.com/test
This is incorrect. Beginning the teaching as early as possible benefits the client but
does not ensure readiness to learn, which is important to ensuring effective teaching.
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
21. During the implementation phase of the nursing process, a nurse is teaching an adult
client who is experiencing depression and has a cochlear implant about medications. Which
modification in the teaching plan would be best for this client?
abirb.com/test
1. Using repetition
2. Speaking face-to-face
3. Employing the use of sign language
4. Providing large-print materials
abirb.com/test
ANS: 2
Chapter: Chapter 8, The Nursing Process in Psychiatric-Mental Health Nursing
Objective: Apply the six steps of the nursing process in caring forabirb.com/test
a client within the
psychiatric setting.
Page: 156
Heading: The Nursing Process > Standards of Practice > Standard
5. Implementation
abirb.com/test
Integrated Processes: Nursing Process: Implementation
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Patient-Centered Care
Difficulty: Easy
1.
2.
3.
Feedback
abirb.com/test
This is incorrect. Repetition does not promote the best therapeutic environment for
the client who may have an alteration in hearing capabilities.
This is correct. Speaking face-to-face is the best way to provide a therapeutic and
abirb.com/test
collaborative care environment for the client with alterations
in hearing.
This is incorrect. The client with a cochlear implant has the ability to hear, though
potentially altered, and does not demonstrate the need for an alternate language to
communicate with the client. The nurse should seek the most
therapeutic and
abirb.com/test
collaborative environment for the client.
abirb.com/test
abirb.com/test
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Chapter 8 - ETB
abirb.com/test
4.
This is incorrect. Large-print materials are used for clients who have an alteration in
vision, not hearing, and would not be appropriate for this client situation.
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
22. A client who slept 6 hours the previous night reports it to the assigned psychiatricmental health nurse. Which should be the initial nursing action to address this situation?
1. Provide warm milk and a back rub.
abirb.com/test
2. Give a sleep medication.
3. Hold a relaxation group before bedtime.
4. Review the client’s normal sleep pattern.
abirb.com/test
ANS: 4
Chapter: Chapter 8, The Nursing Process in Psychiatric-Mental Health Nursing
Objective: Apply the six steps of the nursing process in caring for a client within the
abirb.com/test
psychiatric setting.
Page: 140
Heading: The Nursing Process > Standards of Practice > Standard 1. Assessment
abirb.com/test
Integrated Processes: Nursing Process: Assessment
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/test
This is incorrect. The nurse should initially determine the client’s
normal sleep
patterns to evaluate whether a problem exists. Providing warm milk and a back rub
are nursing interventions and occur after the assessment phase.
This is incorrect. The nurse should initially determine the client’s
normal sleep
abirb.com/test
patterns to evaluate whether a problem exists. Administering a sleep medication is a
nursing intervention and occurs after the assessment phase.
This is incorrect. The nurse should initially determine the client’s normal sleep
abirb.com/test
patterns to evaluate whether a problem exists. Holding a relaxation
group before
bedtime is a nursing intervention and occurs after the assessment phase.
This is correct. The nurse should initially determine the client’s normal sleep
patterns to evaluate whether a problem exists. During the assessment
abirb.com/test phase of the
nursing process, the nurse collects comprehensive health data pertinent to the
client’s health or situation.
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 8 - ETB
abirb.com/test
23. A nursing instructor overhears a student say, “That family seems to disagree more than
agree. The family seems to be dysfunctional.” To further assess the family’s situation, which
would be an appropriate reply by the instructor?
abirb.com/test
1. “Families who disagree can be a challenge to the treatment team.”
2. “You seem critical of the family. Do you believe that you are unable to help them?”
3. “Let’s bring the family in for an educational session to improve their communication.”
4. “What appears to trigger family disagreements?”
abirb.com/test
ANS: 4
Chapter: Chapter 8, The Nursing Process in Psychiatric-Mental Health Nursing
Objective: Apply the six steps of the nursing process in caring forabirb.com/test
a client within the
psychiatric setting.
Page: 140
Heading: The Nursing Process > Standards of Practice > Standard
1. Assessment
abirb.com/test
Integrated Processes: Nursing Process: Assessment
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Patient-Centered Care
Difficulty: Moderate
1.
2.
3.
4.
abirb.com/test
Feedback
This is incorrect. Prior to intervening with this family, the nurse should gather
further information about the cause of family conflicts. Indicating challenges related
to treatment does not thoroughly assess the situation before coming to conclusions
abirb.com/test
about the family.
This is incorrect. Prior to intervening with this family, the nurse should gather
further information about the cause of family conflicts. This response addressing the
abirb.com/test
student’s approach does not demonstrate further assessment
of the family and their
needs.
This is incorrect. Prior to intervening with this family, the nurse should gather
further information about the cause of family conflicts. Bringing
the client and
abirb.com/test
family in for an educational session without further assessment does not thoroughly
assess the family’s needs.
This is correct. Prior to intervening with this family, the nurse should gather further
information about the cause of family conflicts. Gathering abirb.com/test
information is part of the
assessment phase of the nursing process, during which the nurse collects
comprehensive health data that are pertinent to the client’s health or situation.
abirb.com/test
CON: Patient-Centered Care
abirb.com/test
24. Which nursing response best represents the evaluation phase of the nursing process?
1. “If I were in your situation, I would not repeat a behavior that has caused problems.”
2. “What do you think needs changing, and what do you want to abirb.com/test
do differently?”
3. “What exactly will it take to carry out your plan, and what else do you need to do?”
abirb.com/test
abirb.com/test
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Chapter 8 - ETB
abirb.com/test
4. “It sounds like you’re saying this new approach is working for you.”
ANS: 4
abirb.com/test
Chapter: Chapter 8, The Nursing Process in Psychiatric-Mental Health
Nursing
Objective: Apply the six steps of the nursing process in caring for a client within the
psychiatric setting.
Page: 157
abirb.com/test
Heading: The Nursing Process > Standards of Practice > Standard 6. Evaluation
Integrated Processes: Nursing Process: Evaluation
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. The nursing response “If I were in your situation, I would not
repeat a behavior that has caused problems” represents an implementation.
abirb.com/test
This is incorrect. This nursing response represents assessment.
This is incorrect. The nursing response “What exactly will it take to carry out your
plan, and what else do you need to do?” represents an implementation.
abirb.com/test
This is correct. The nurse’s statement “It sounds like you’re
saying this new
approach is working for you” best represents the evaluation phase of the nursing
process. During the evaluation phase of the nursing process, the nurse and the client
evaluate progress toward attainment of the expected outcomes.
abirb.com/test
CON: Communication
abirb.com/test
25. A client diagnosed with major depressive disorder states, “Why should I keep trying to
get a job? I mess up everything I do.” Which correctly written nursing
diagnosis best
abirb.com/test
reflects the content and mood themes in this client’s statement?
1. Hopelessness R/T poor job performance AEB client’s unemployment
2. Risk for impaired adjustment R/T inadequate social skills AEB isolation
abirb.com/test
3. Altered role performance R/T the fear of failure AEB not seeking
employment
4. Chronic low self-esteem R/T major depressive disorder AEB self-hatred
ANS: 3
abirb.com/test
Chapter: Chapter 8, The Nursing Process in Psychiatric-Mental Health Nursing
Objective: Apply the six steps of the nursing process in caring for a client within the
psychiatric setting.
abirb.com/test
Page: 141
Heading: The Nursing Process > Standards of Practice > Standard 2. Diagnosis
Integrated Processes: Nursing Process: Analysis
Client Need: Safe and Effective Care Environment: Managementabirb.com/test
of Care
Cognitive Level: Analysis [Analyzing]
abirb.com/test
abirb.com/test
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Chapter 8 - ETB
abirb.com/test
Concept: Patient-Centered Care
Difficulty: Moderate
1.
2.
3.
4.
abirb.com/test
Feedback
This is incorrect. Hopelessness is not evidenced by unemployment. The client is not
demonstrating hopelessness.
This is incorrect. Isolation is not demonstrated by the clientabirb.com/test
in this situation.
This is correct. This client’s statement indicates role performance is altered because
fear of failure prevents seeking employment. The nursing diagnosis “Altered role
performance R/T the fear of failure AEB not seeking employment” best reflects the
abirb.com/test
content and mood themes in this client’s statement.
This is incorrect. No evidence of self-hatred is demonstrated by the client.
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
26. During an intake interview, which question would best assist the nurse to gather data
about the client’s judgment?
1. “What brought you to the hospital? Do you know what day and season it is now?”
2. “On a scale of 1 to 10, how would you rate your stress level?”abirb.com/test
3. “What does the phrase ‘a rolling stone gathers no moss’ mean to you?”
4. “If you found a stamped, addressed envelope in the street, what would you do?”
abirb.com/test
ANS: 4
Chapter: Chapter 8, The Nursing Process in Psychiatric-Mental Health Nursing
Objective: Apply the six steps of the nursing process in caring for a client within the
abirb.com/test
psychiatric setting.
Page: 140
Heading: The Nursing Process > Standards of Practice > Standard 1. Assessment
Integrated Processes: Nursing Process: Assessment
abirb.com/test
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
This is incorrect. This questioning assesses the client’s orientation.
abirb.com/test
This is incorrect. This questioning does not assess the client’s judgment; it assesses
the client’s perception of his or her stress.
This is incorrect. This question assesses the client’s ability for abstract thinking.
abirb.com/test
This is correct. The best assessment question is “If you found a stamped, addressed
envelope in the street, what would you do?” Presenting a situation that requires the
client to make a judgment call allows the nurse to assess appropriate judgment based
abirb.com/test
on the client’s action choice.
abirb.com/test
abirb.com/test
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Chapter 8 - ETB
abirb.com/test
CON: Patient-Centered Care
abirb.com/test
27. An adolescent client has problems expressing anger appropriately. Which nursing
statement would encourage the client to set realistic goals?
1. “What do you think needs to change about how you express anger?”
abirb.com/test
2. “How did you feel after attending the anger management session?”
3. “On a scale of 1 to 10, please rate your current level of anger.”
4. “What bothers you about the actions of others when you get angry?”
abirb.com/test
ANS: 1
Chapter: Chapter 8, The Nursing Process in Psychiatric-Mental Health Nursing
Objective: Apply the six steps of the nursing process in caring forabirb.com/test
a client within the
psychiatric setting.
Page: 148
Heading: The Nursing Process > Standards of Practice > Standard 4. Planning
abirb.com/test
Integrated Processes: Nursing Process: Planning
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
abirb.com/test
Difficulty:
1.
2.
3.
4.
Feedback
abirb.com/test
This is correct. The nurse’s question “What do you think needs to change about how
you express anger?” encourages the client to set realistic goals. The nurse is assisting
the client to formulate a plan of action. In the planning phase of the nursing process,
abirb.com/test
the nurse works with the client to identify expected outcomes
for a plan
individualized to the client or to the situation.
This is incorrect. This question evaluates the client after an intervention has been
applied and does not relate to goal setting.
abirb.com/test
This is incorrect. This question assesses the client’s condition and does not address
goal- setting.
This is incorrect. This question is an approach to assessment and does not address
abirb.com/test
goal setting.
CON: Patient-Centered Care
abirb.com/test
28. The nurse interviewed a client who was uncooperative, answered questions with
abirb.com/test
minimal responses, and rarely made eye contact. Which is the most
complete documentation
of baseline data obtained during the interview?
1. “Appears uncooperative. Exhibits characteristics of depression.”
2. “Maintains poor eye contact throughout interview process. Unable
to answer interview
abirb.com/test
questions due to depression.”
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 8 - ETB
abirb.com/test
3. “States ‘I don’t need to be here’ when discussing admission status. Maintains minimal
eye contact and offers little data related to triggers for admission.”
4. “Unwilling to respond openly during interview.”
abirb.com/test
ANS: 3
Chapter: Chapter 8, The Nursing Process in Psychiatric-Mental Health Nursing
Objective: Document client care that validates use of the nursingabirb.com/test
process.
Page: 153
Heading: Documentation of the Nursing Process
Integrated Processes: Communication and Documentation
Client Need: Safe and Effective Care Environment: Managementabirb.com/test
of Care
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. All charting entries to the client’s legal record should be objective
abirb.com/test
and based on assessed data. Implications and generalizations should be avoided.
“Appears uncooperative” is a general statement. Documentation occurs in the
implementation phase of the nursing process.
abirb.com/test
This is incorrect. All charting entries to the client’s legal record
should be objective
and based on assessed data. Implications and generalizations should be avoided.
“Unable to answer interview questions due to depression” implies that the nurse
knows the cause of the client’s behavior. Documentation occurs
in the
abirb.com/test
implementation phase of the nursing process.
This is correct. All charting entries to the client’s legal record should be objective
and based on assessed data. Implications and generalizations should be avoided. This
statement contains objective data. Documentation occurs inabirb.com/test
the implementation
phase of the nursing process.
This is incorrect. All charting entries to the client’s legal record should be objective
and based on assessed data. Implications and generalizations
should be avoided.
abirb.com/test
“Unwilling to respond openly during interview” implies that the nurse knows the
underlying reason for the client’s behavior. Documentation occurs in the
implementation phase of the nursing process.
abirb.com/test
CON: Communication
abirb.com/test
29. A client is assigned the nursing diagnosis of impaired social interaction R/T
sociocultural differences AEB client stating, “Although I’d like to, I don’t join in because I
abirb.com/test
don’t speak the language so good.” Which correctly written outcome
addresses this client’s
problem?
1. The client will collaborate with nursing staff to set specific goals by day 3.
2. The client will participate in one group activity of choice by day
2.
abirb.com/test
3. The client will express a desire to interact with others.
abirb.com/test
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Chapter 8 - ETB
abirb.com/test
4. The client will become increasingly independent by discharge.
ANS: 2
abirb.com/test
Chapter: Chapter 8, The Nursing Process in Psychiatric-Mental Health
Nursing
Objective: Apply the six steps of the nursing process in caring for a client within the
psychiatric setting.
Page: 147
abirb.com/test
Heading: The Nursing Process > Standards of Practice > Standard 3. Outcomes
Identification
Integrated Processes: Nursing Process: Planning
Client Need: Safe and Effective Care Environment: Managementabirb.com/test
of Care
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. This outcome is not directly related to the client’s situation. In the
abirb.com/test
planning phase of the nursing process, the nurse works with the client to identify
expected outcomes for a plan individualized to the client’s need or to the situation.
This is correct. This outcome is directly related to the client’s situation where he/she
abirb.com/test
is not participating due to language difficulty.
This is incorrect. This outcome is not directly related to the client’s situation. The
client did not indicate a lack of desire to interact with others.
This is incorrect. This outcome is not directly related to theabirb.com/test
client’s situation. In the
planning phase of the nursing process, the nurse works with the client to identify
expected outcomes for a plan individualized to the client’s need or to the situation.
Increasing independence does not address the impaired social interaction.
abirb.com/test
CON: Communication
abirb.com/test
30. The following clients are seen in the emergency department. The psychiatric unit has
one remaining bed. Which client should the triage nurse expect to be admitted?
abirb.com/test
1. The client who is experiencing tremors and has a need for medication
adjustment.
2. The client who is experiencing anxiety and a sad mood after separation from spouse.
3. The client who is a single parent and hears voices stating, “Kill your infant.”
4. The client who argued with her partner and inflicted a superficial
cut on her arm.
abirb.com/test
ANS: 3
Chapter: Chapter 8, The Nursing Process in Psychiatric-Mental Health Nursing
Objective: Apply the six steps of the nursing process in caring forabirb.com/test
a client within the
psychiatric setting.
Page: 140
Heading: The Nursing Process > Standards of Practice > Standard
1. Assessment
abirb.com/test
Integrated Processes: Nursing Process: Assessment
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 8 - ETB
abirb.com/test
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
abirb.com/test
Difficulty: Easy
1.
2.
3.
4.
Feedback
This is incorrect. Safety of self and others is always a priority.
This client is not
abirb.com/test
demonstrating a life-threatening situation or risk to self or others.
This is incorrect. Safety of self and others is always a priority. Anxiety and a sad
mood after separating from a spouse is an expected reaction to the situation. The
abirb.com/test
client is not demonstrating a risk to self or others.
This is correct. The nurse’s assessment indicates this client is at the greatest risk due
to stating an intent to “kill her infant.” Safety of self and others is always a priority.
abirb.com/test
In the assessment phase of the nursing process, the nurse collects
comprehensive
health data that are pertinent to the client’s health or situation.
This is incorrect. Safety of self and others is always a priority. The assessment does
not demonstrate the client is a risk to self or others and therefore
does not need to be
abirb.com/test
admitted for care.
CON: Patient-Centered Care
abirb.com/test
MULTIPLE RESPONSE
abirb.com/test
abirb.com/testof psychiatric31. Which of the following nursing interventions fall within the standards
mental health clinical nursing practice for a nurse generalist? Select all that apply.
1. Assist clients to perform activities of daily living.
2. Act as a consultant to provide services for clients and effect system
change.
abirb.com/test
3. Encourage clients to discuss triggers for relapse.
4. Use prescriptive authority in accordance with state and federal laws.
5. Educate families about signs and symptoms of alcohol dependence and withdrawal.
abirb.com/test
ANS: 1, 3, 5
Chapter: Chapter 8, The Nursing Process in Psychiatric-Mental Health Nursing
Objective: Identify six steps of the nursing process and describe abirb.com/test
nursing actions associated
with each.
Page: 139
Heading: The Nursing Process > Standards of Practice
abirb.com/test
Integrated Processes: Nursing Process: Implementation
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Professionalism
abirb.com/test
Difficulty: Moderate
abirb.com/test
abirb.com/test
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Chapter 8 - ETB
abirb.com/test
1.
2.
3.
4.
5.
Feedback
This is correct. Assisting clients to perform activities of daily living falls within the
abirb.com/test
standards of psychiatric-mental health clinical nursing practice
for a nurse generalist.
This is incorrect. This does not fall within the standards of psychiatric-mental health
clinical nursing practice for a nurse generalist. The nurse generalist does not act as a
consultant.
abirb.com/test
This is correct. Assisting clients to discuss triggers, are nursing interventions that fall
within the standards of psychiatric-mental health clinical nursing practice for a nurse
generalist.
abirb.com/test
This is incorrect. This does not fall within the standards of psychiatric-mental health
clinical nursing practice for a nurse generalist. A nurse generalist does not have
prescriptive authority.
This is correct. Educating families is a nursing interventionabirb.com/test
that falls within the
standards of psychiatric-mental health clinical nursing practice for a nurse generalist.
CON: Professionalism
abirb.com/test
abirb.com/test
32. Which of the following are characteristics of accurately developed
client outcomes?
Select all that apply.
1. Client outcomes are formulated by each nurse, independent of other team members.
2. Client outcomes are not restricted by time frames.
abirb.com/test
3. Client outcomes are specific and measurable.
4. Client outcomes are realistically based on client capability.
5. Client outcomes are formally approved by the psychiatrist and the nurse practitioner.
abirb.com/test
ANS: 3, 4
Chapter: Chapter 8, The Nursing Process in Psychiatric-Mental Health Nursing
Objective: Identify six steps of the nursing process and describe abirb.com/test
nursing actions associated
with each.
Page: 147
Heading: The Nursing Process > Standards of Practice > Standard 3. Outcomes
abirb.com/test
Identification
Integrated Processes: Nursing Process: Planning
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Comprehension
abirb.com/test
Concept: Patient-Centered Care
Difficulty: Moderate
1.
2.
abirb.com/test
Feedback
This is incorrect. Outcomes are most effective when formulated cooperatively by the
interdisciplinary team members, client, and significant others.
This is incorrect. Outcomes should be derived from the diagnosis
and should include
abirb.com/test
a time estimate for attainment.
abirb.com/test
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Chapter 8 - ETB
abirb.com/test
3.
4.
5.
This is correct. Client outcomes should be specific and measurable.
This is correct. Client outcomes should be realistically based on client capability.
This is incorrect. The psychiatrist does not formulate outcomes independent of other
abirb.com/test
interdisciplinary team members. Outcomes are most effective when formulated
cooperatively by the interdisciplinary team members, client, and significant others.
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
33. After a comprehensive assessment, correctly written nursing diagnoses developed for
psychiatric clients may include which of the following components? Select all that apply.
1. Medical judgments related to the psychiatric disorder
abirb.com/test
2. Unmet client needs present at the moment
3. Supporting data that validate the diagnosis
4. Outcomes that will be targets for nursing interventions
5. Statements of client problems of a functional nature
abirb.com/test
ANS: 2, 3, 5
Chapter: Chapter 8, The Nursing Process in Psychiatric-Mental Health Nursing
Objective: Apply the six steps of the nursing process in caring forabirb.com/test
a client within the
psychiatric setting.
Page: 141
Heading: The Nursing Process > Standards of Practice > Standard
2. Diagnosis
abirb.com/test
Integrated Processes: Nursing Process: Analysis
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
abirb.com/test
Concept: Patient-Centered Care
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
abirb.com/test
This is incorrect. Medical judgments are not part of the nursing diagnosis.
This is correct. A nursing diagnosis is a statement of a client’s functional problem.
An actual nursing diagnosis must include related to (R/T) and as evidenced by
abirb.com/test
(AEB) statements. Unmet needs may be included in developing
a nursing diagnosis.
This is correct. A nursing diagnosis is a statement of a client’s functional problem.
An actual nursing diagnosis must include R/T and as AEB statements. Supporting
data to validate the nursing diagnosis is part of the evidence
in the nursing diagnosis.
abirb.com/test
This is incorrect. Outcomes that will be targets for nursing interventions are not
included. A nursing diagnosis is a statement of a client’s functional problem. An
actual nursing diagnosis must include R/T and AEB statements.
abirb.com/test
This is correct. A nursing diagnosis is a statement of a client’s functional problem.
An actual nursing diagnosis must include related R/T and AEB statements.
Statements of a client’s functional problems are a part of the nursing diagnosis.
abirb.com/test
CON: Patient-Centered Care
abirb.com/test
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PMHN, 10e
Chapter 8 - ETB
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
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Chapter 9 - ETB
abirb.com/test
Chapter 9. Therapeutic Groups
abirb.com/test
MULTIPLE CHOICE
abirb.com/test
1. During a therapeutic group, a client talks about personal accomplishments in an effort
to gain attention. Which group role, assumed by this client, should
the nurse identify?
abirb.com/test
1. Task role of gatekeeper
2. Individual role of recognition seeker
3. Maintenance role of dominator
abirb.com/test
4. Task role of elaborator
ANS: 2
Chapter: Chapter 10, Therapeutic Groups
abirb.com/test
Objective: Identify various roles that members assume within a group.
Page: 168
Heading: Table 9–2, Member Roles Within Groups
abirb.com/test
Integrated Processes: Nursing Process: Evaluation
Client Need: Psychosocial Integrity
Cognitive Level: Knowledge [Remembering]Concept: Patient-Centered Care
Difficulty: Easy
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. The gatekeeper encourages acceptance of and participation by all
abirb.com/test
members of the group.
This is correct. The client is assuming the individual role of the recognition seeker.
Other individual roles include the aggressor, the blocker, the dominator, the help
abirb.com/test
seeker, the monopolizer, and the seducer.
This is incorrect. The dominator manipulates others to gain control and behaves in
an authoritarian manner.
This is incorrect. The elaborator expands upon and explains
group plans and ideas.
abirb.com/test
CON: Patient-Centered Care
abirb.com/test
2. During a therapeutic group, two clients engage in an angry verbal exchange. The
nurse leader interrupts the exchange and excuses both of the clients
from the group. The
abirb.com/test
nurse has demonstrated which leadership style?
1. Autocratic
2. Democratic
abirb.com/test
3. Laissez-faire
4. Bureaucratic
abirb.com/test
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Chapter 9 - ETB
abirb.com/test
ANS: 1
Chapter: Chapter 10, Therapeutic Groups
abirb.com/test
Objective: Identify various leadership styles in groups.
Page: 167
Heading: Leadership Styles > Autocratic; Table 9–1, Leadership Styles—Similarities
and Differences
abirb.com/test
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Patient-Centered Care
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/test
This is correct. The nurse is demonstrating an autocratic leadership style. An
autocratic leadership style may be useful in certain situations that require structure
and limit setting.
abirb.com/test
This is incorrect. Democratic leaders focus on the members of the group and groupselected goals.
This is incorrect. Laissez-faire leaders provide no direction to group members.
abirb.com/test
This is incorrect. This not bureaucratic leadership, which is
not mentioned in this
chapter.
CON: Patient-Centered Care
abirb.com/test
3. During a therapeutic group, which nursing action demonstratesabirb.com/test
a laissez-faire
leadership style?
1. The nurse mandates that all group members reveal an embarrassing personal situation.
2. The nurse asks for a show of hands to determine group topic preference.
abirb.com/test
3. The nurse sits silently as the group members stray from the assigned topic.
4. The nurse shuffles through papers to determine the facility policy on length of group.
abirb.com/test
ANS: 3
Chapter: Chapter 10, Therapeutic Groups
Objective: Identify various leadership styles in groups.
Page: 167
abirb.com/test
Heading: Leadership Styles > Democratic; Table 10–1, Leadership Styles—Similarities
and Differences
Integrated Processes: Nursing Process: Implementation
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
abirb.com/test
abirb.com/test
abirb.com/test
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Chapter 9 - ETB
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. This is an example of autocratic leadership. This form of leadership
can stifle individual creativity and decrease individual motivation.
abirb.com/test
This is incorrect. This is an example of a democratic leadership style, where the
members engage in group problem-solving.
This is correct. The nurse leader who sits silently and allows group members to stray
abirb.com/test
from the assigned topic is demonstrating a laissez-faire leadership
style. The nurse
leader provides no direction for the group. Group members often become frustrated
and confused in reaction to a laissez-faire leadership style.
This is incorrect. This is not described as a leadership styleabirb.com/test
in this chapter.
CON: Patient-Centered Care
abirb.com/test
4. During a community meeting, a nurse encourages clients to present unit problems and
discuss possible solutions. Which type of leadership style is the nurse
demonstrating?
abirb.com/test
1. Democratic
2. Autocratic
3. Laissez-faire
abirb.com/test
4. Energized
ANS: 1
Chapter: Chapter 10, Therapeutic Groups
abirb.com/test
Objective: Identify various leadership styles in groups.
Page: 167
Heading: Leadership Styles > Democratic; Table 10–1, Leadership Styles—Similarities
abirb.com/test
and Differences
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Patient-Centered Care
Difficulty: Moderate
1.
2.
3.
4.
abirb.com/test
Feedback
This is correct. The nurse is demonstrating a democratic leadership style.
Democratic leaders share information with group members, promote decisionmaking by the members of the group, and provide guidance
and expertise as needed.
abirb.com/test
This is incorrect. Autocratic leadership increases productivity but often reduces
morale and motivation due to lack of member input and creativity.
This is incorrect. The laissez-faire nurse leader provides no direction for the group.
abirb.com/test
This is incorrect. Although the nurse is energizing the group, this is a task role, not a
leadership style.
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
abirb.com/test
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Chapter 9 - ETB
abirb.com/test
5. Which situation should a nurse identify as an example of an autocratic leadership
abirb.com/test
style?
1. The president of a club asks members to form research committees.
2. The unit manager completes the work schedule without input from staff members.
3. During a community meeting, a nurse listens as clients generate
solutions.
abirb.com/test
4. The student nurses’ association advertises for candidates for president.
ANS: 2
abirb.com/test
Chapter: Chapter 10, Therapeutic Groups
Objective: Identify various leadership styles in groups.
Page: 167
Heading: Leadership Styles > Autocratic; Table 10–1, Leadership
Styles—Similarities
abirb.com/test
and Differences
Integrated Processes: Nursing Process: Assessment
Client Need: Environment Psychosocial Integrity
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Difficult
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. This is a characteristic of a democratic leadership style, where the
leader asks members to engage in group problem-solving.
abirb.com/test
This is correct. The nurse leader who mandates decisions without consulting the
group is demonstrating an autocratic leadership style. Autocratic leadership increases
productivity but often reduces morale and motivation due to lack of members’ input
abirb.com/test
and creativity.
This is incorrect. By having the members generate solutions to a problem, this is a
democratic leadership style.
This is incorrect. There does not appear to be any mention abirb.com/test
of a leader in this group;
rather, the group is focused on a task to be completed.
CON: Patient-Centered Care
abirb.com/test
6. The young parents of a child in preschool are attending a parenting
group. Many of
abirb.com/test
the participants have older children and are able to influence the young parents about the
expected norms for communication and behavior. What has this group provided this
young couple?
abirb.com/test
1. Task completion
2. Governance
3. Normative influence
4. Information sharing
abirb.com/test
abirb.com/test
abirb.com/test
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Chapter 9 - ETB
abirb.com/test
ANS: 3
Chapter: Chapter 10, Therapeutic Groups
Objective: Discuss eight functions of a group.
Page: 163
Heading: Functions of A Group
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1.
2.
3.
4.
abirb.com/test
abirb.com/test
abirb.com/test
Feedback
This is incorrect. Task completion occurs when group members provide assistance in
endeavors that are beyond the capacity of one individual (or
couple in this case),
abirb.com/test
when results can be achieved more effectively as a team.
This is incorrect. Groups that provide oversight functions and direction of activities,
often within the context of a larger group organization, are providing governance.
abirb.com/test
This is correct. Per Sampson and Marthas (1990), this function relates to the ways in
which groups enforce the established norms. As groups members interact, they
influence each other about expected norms for communication and behavior.
This is incorrect. Although the older parents may provide abirb.com/test
information to the
younger parents, there is more occurring than providing information to the younger
parents.
abirb.com/test
CON: Patient-Centered Care
abirb.com/test
7. A man diagnosed with alcohol dependence experiences his first relapse. During his
Alcoholics Anonymous (AA) meeting, another group member states, “I relapsed three
times but now have been sober for 15 years.” Which of Yalom’s abirb.com/test
curative group factors
does this illustrate?
1. Imparting of information
2. Instillation of hope
abirb.com/test
3. Catharsis
4. Universality
ANS: 2
Chapter: Chapter 10, Therapeutic Groups
Objective: Discuss therapeutic factors that occur in groups.
Page: 165
Heading: Therapeutic factors
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
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Chapter 9 - ETB
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/test
This is incorrect. Had the other group member imparted advice
or suggestions to the
speaker, this would be imparting of information.
This is correct. This is an example of the curative group factor of instillation of hope.
This occurs when members observe the progress of others abirb.com/test
in the group with similar
problems and begin to believe that personal problems can also be resolved.
This is incorrect. Catharsis, or open expression of feelings, occurs when group
members are able to express both positive and negative feelings—perhaps feelings
abirb.com/test
that have never been expressed before—in a nonthreatening atmosphere.
This is incorrect. Through universality, individuals come to realize that they are not
alone in the problems, thoughts, and feelings they are experiencing.
abirb.com/test
CON: Patient-Centered Care
abirb.com/test
8. During a group discussion, members freely interact with each other. Which member
statement is an example of Yalom’s curative group factor of imparting information?
abirb.com/test
1. “I found a Web site explaining the different types of brain tumors
and their
treatment.”
2. “My brother also had a brain tumor and now is completely cured.”
3. “I understand your fear and will be by your side during this time.”
abirb.com/test
4. “My mother was also diagnosed with cancer of the brain.”
ANS: 1
Chapter: Chapter 10, Therapeutic Groups
Objective: Discuss therapeutic factors that occur in groups.
Page: 165
Heading: Therapeutic Factors
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1.
2.
3.
abirb.com/test
abirb.com/test
abirb.com/test
Feedback
abirb.com/test
This is correct. Yalom’s curative group factor of imparting information involves
members sharing knowledge gained through formal instruction as well as sharing
information and suggestions.
This is incorrect. This would be an example of instillation abirb.com/test
of hope. By observing the
progress of others in the group with similar problems, a group member garners hope
that his/her problems can be resolved.
This is incorrect. This would be an example of universality,
which relieves anxiety
abirb.com/test
by the support and understanding of others in the group.
abirb.com/test
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Chapter 9 - ETB
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4.
This is incorrect. This would be an example of universality, where the individuals
come to realize that they are not alone in the problems they are experiencing.
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
9. Prayer group members at a local Baptist church are meeting with a poor, homeless
family they are supporting. Which member statement is an example of Yalom’s curative
group factor of altruism?
abirb.com/test
1. “I’ll give you the name of a friend that rents inexpensive rooms.”
2. “The last time we helped a family, they got back on their feet and prospered.”
3. “I can give you all of my baby clothes for your little one.”
4. “I can appreciate your situation. I had to declare bankruptcy last
year.”
abirb.com/test
ANS: 3
Chapter: Chapter 10, Therapeutic Groups
Objective: Discuss therapeutic factors that occur in groups.
Page: 165
Heading: Therapeutic Factors
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Promoting Mental Health
Difficulty: Moderate
1.
2.
3.
4.
abirb.com/test
abirb.com/test
abirb.com/test
Feedback
This is incorrect. This statement is an example of impartingabirb.com/test
of information.
This is incorrect. This statement is an example of instillation of hope that their
problems will be resolved.
This is correct. Yalom’s curative group factor of altruism occurs
when group
abirb.com/test
members provide assistance and support to each other, creating a positive self-image
and promoting self-growth. Individuals increase self-esteem through mutual caring
and concern.
abirb.com/test
This is incorrect. This statement is an example of universality.
CON: Promoting Mental Health
abirb.com/test
10. During an inpatient educational group, a client shouts out, “This information is
worthless. Nothing you have said can help me.” These statementsabirb.com/test
indicate to the nurse
leader that the client is assuming which group role?
1. Aggressor
2. Initiator
abirb.com/test
3. Gatekeeper
abirb.com/test
abirb.com/test
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4. Blocker
ANS: 1
abirb.com/test
Chapter: Chapter 10, Therapeutic Groups
Objective: Identify various roles that members assume within a group.
Page: 167
Heading: Table 10–2 Member Roles Within Groups
abirb.com/test
Integrated Processes: Nursing Process: Evaluation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Patient-Centered Care
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/test
This is correct. The client is assuming the group role of the aggressor. The aggressor
expresses negativism and hostility toward others in the group or to the group leader
and may use sarcasm in an effort to degrade the status of others.
abirb.com/test
This is incorrect. The initiator outlines the task for the group and proposes methods
for solution.
This is incorrect. The gatekeeper encourages acceptance of and participation by all
abirb.com/test
members of the group.
This is incorrect. The blocker resists group efforts and demonstrates rigid and
sometimes irrational behaviors that impede group progress.
abirb.com/test
CON: Patient-Centered Care
abirb.com/test
11. A nurse believes that the members of a parenting group are in the initial (orientation)
phase of group development. Which group behaviors would support this assumption?
1. The group members manage conflict within the group.
abirb.com/test
2. The group members use denial as part of the grief response.
3. The group members compliment the leader and compete for the role of recorder.
4. The group members initially trust one another and the leader.
abirb.com/test
ANS: 3
Chapter: Chapter 10, Therapeutic Groups
Objective: Describe the phases of group development.
abirb.com/test
Page: 165
Heading: Phases of Group Development > Phase I. Initial or Orientation Phase
Integrated Processes: Nursing Process: Evaluation
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
abirb.com/test
abirb.com/test
abirb.com/test
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1.
2.
3.
4.
Feedback
This is incorrect. Conflict often occurs during the middle (working) phase.
This is incorrect. Members may express grief during the termination phase of the
abirb.com/test
group.
This is correct. In the initial (orientation) phase of group development, members
often compliment the leader and compete for the role of recorder. Power struggles
abirb.com/test
may occur as members compete for their position in the group.
Members in this
phase have not yet established trust and have a fear of not being accepted.
This is incorrect. Initial trust occurs during the middle (working) phase.
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
12. During a group session, which client statement demonstrates that the group has
progressed to the middle (working) phase of group development?
1. “It’s hard for me to tell my story when I’m not sure about the reactions
of others.”
abirb.com/test
2. “I think Joe’s Antabuse suggestion is a good one and might work for me.”
3. “My situation is very complex, and I need professional, not peer, advice.”
4. “I am really upset that you expect me to solve my own problems.”
abirb.com/test
ANS: 2
Chapter: Chapter 10, Therapeutic Groups
Objective: Describe the phases of group development.
abirb.com/test
Page: 166
Heading: Phases of Group Development > Phase II. Middle or Working Phase
Integrated Processes: Nursing Process: Evaluation
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. This statement indicates that the group is in the initial (orientation)
abirb.com/test
phase of group development.
This is correct. This statement reflects that the group is in the working phase of
group development, during which members begin to look to each other instead of to
the leader for guidance. Group members in the working phase
begin to accept
abirb.com/test
criticism from each other and use it constructively to foster change.
This is incorrect. This statement indicates that the group is in the initial (orientation)
phase of group development.
abirb.com/test
This is incorrect. This statement indicates that the group is in the initial (orientation)
phase of group development.
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
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abirb.com/test
13. Which nurse group leader activity is most important in the final (termination) phase
abirb.com/test
of group development?
1. The group leader establishes the rules that will govern the group after discharge.
2. The group leader encourages members to rely on each other for problem-solving.
3. The group leader presents and discusses the concept of group termination.
abirb.com/test
4. The group leader helps the members to process feelings of loss.
ANS: 4
abirb.com/test
Chapter: Chapter 10, Therapeutic Groups
Objective: Describe the phases of group development.
Page: 166
Heading: Phases of Group Development > Phase III. Final or Termination
abirb.com/testPhase
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Patient-Centered Care
Difficulty: Moderate
1.
2.
3.
4.
abirb.com/test
Feedback
This is incorrect. This is the role of the leader during the initiation or orientation
phase of the group.
This is incorrect. This is the role of the leader during the working
phase of the group.
abirb.com/test
This is incorrect. Although this is a beginning component of the termination phase, it
is not the most important nurse intervention.
This is correct. The most important nurse intervention in the final (termination)
phase of group development is for the group leader to helpabirb.com/test
members process feelings
of loss. The leader should encourage the members to review the goals and discuss
outcomes, provide feedback to each other about progress, and reminisce about what
has occurred.
abirb.com/test
CON: Patient-Centered Care
abirb.com/test
14. The nurse is providing information on self-help groups like Alcoholics Anonymous
(AA) to a client. Which client statement indicates that learning has
occurred?
abirb.com/test
1. “There is little research to support AA’s effectiveness.”
2. “Self-help groups used to be the treatment of choice, but their popularity is waning.”
3. “These groups have no external regulation, so clients need to be cautious.”
abirb.com/test
4. “Members themselves run the group, with leadership usually rotating
among the
members.”
ANS: 4
Chapter: Chapter 10, Therapeutic Groups
abirb.com/test
abirb.com/test
abirb.com/test
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Objective: Identify various types of groups.
Page: 164
Heading: Types of Groups > Self-Help Groups
Integrated Processes: Nursing Process: Evaluation
Client Need: Health Promotion and Maintenance
Cognitive Level: Application [Applying]
Concept: Addiction and Behaviors
Difficulty: Easy
1.
2.
3.
4.
abirb.com/test
abirb.com/test
Feedback
abirb.com/test
This is incorrect. Self-help groups have grown in number and credibility in recent
years.
This is incorrect. Self-help groups have become a valuable source of referral for
abirb.com/test
clients with specific problems. The nurse may find it necessary
to attend several
meetings of a particular group to assess its effectiveness of purpose and
appropriateness for patient referral.
This is incorrect. Although they are run by members, nurses
must be knowledgeable
abirb.com/test
about the purposes of the groups, membership, leadership, benefits, and problems
that might threaten the success of the group before making referrals for a specific
group. The nurse may attend meetings to assess the group’s effectiveness for their
abirb.com/test
particular clients.
This is correct. The statement “members themselves run the group, with leadership
usually rotating among the members” reflects that the student understands self-help
groups. Self-help groups allow members to talk about feelings
and reduce feelings of
abirb.com/test
isolation while receiving support from others undergoing similar experiences.
CON: Addiction and Behaviors
abirb.com/test
15. Which group function should the nurse utilize to help an extremely
withdrawn,
abirb.com/test
paranoid client increase feelings of security?
1. Socialization
2. Support
abirb.com/test
3. Empowerment
4. Governance
ANS: 2
Chapter: Chapter 10, Therapeutic Groups
Objective: Discuss eight functions of a group.
Page: 164
Heading: Types of Groups > Supportive/Therapeutic Groups
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
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Chapter 9 - ETB
abirb.com/test
Difficulty: Easy
1.
2.
3.
4.
Feedback
This is incorrect. At this point, the client would not benefitabirb.com/test
from teaching social
norms of the community or group.
This is correct. The group function of support would help an extremely withdrawn,
paranoid client increase feelings of security. Support assists
group members in
abirb.com/test
gaining a feeling of security from group involvement.
This is incorrect. At this time, support to improve existing conditions for
empowerment is not a priority.
abirb.com/test
This is incorrect. The client does not need strategic planning at this time.
CON: Patient-Centered Care
abirb.com/test
16. When planning group therapy, the nurse identifies which configuration
as most
abirb.com/test
optimal for a therapeutic group?
1. Open-ended membership, circle of chairs, group size of 5 to 10 members
2. Open-ended membership, chairs around a table, group size of 10 to 15 members
abirb.com/test
3. Closed membership, circle of chairs, group size of 5 to 10 members
4. Closed membership, chairs around a table, group size of 10 to 15 members
ANS: 3
Chapter: Chapter 10, Therapeutic Groups
Objective: Describe physical conditions that influence groups.
Page: 164
Heading: Physical Conditions That Influence Group Dynamics
Integrated Processes: Nursing Process: Planning
Client Need: Care Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Easy
1.
2.
3.
4.
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
Feedback
This is incorrect. Although arranging the chairs in a circle fosters interactions among
group members, an open membership may prohibit comfort. The focus of
therapeutic groups is on relationships within the group andabirb.com/test
the interactions among
group members.
This is incorrect. The table would provide a barrier to communication, and the larger
group would limit interactions among group members.
abirb.com/test
This is correct. Arranging the chairs in a circle fosters interactions among group
members. The focus of therapeutic groups is on relationships within the group and
the interactions among group members. Additional conditions for a therapeutic
group are closed membership and a group size of 5 to 10 members.
abirb.com/test
This is incorrect. A closed membership with circle seating would facilitate
abirb.com/test
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Chapter 9 - ETB
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communication, but the larger size would limit interactions among all participants.
CON: Patient-Centered Care
abirb.com/test
17. During the sixth week of a 10-week parenting skills group, a abirb.com/test
nurse observes as
several members get into a heated dispute about spanking. Group members decide to
create a pros-and-cons poster on the use of physical discipline. At this time, what is the
role of the group leader?
abirb.com/test
1. To referee the debate
2. To adamantly oppose physical discipline measures
3. To redirect the group to a less controversial topic
4. To encourage the group to solve the problem collectively
abirb.com/test
ANS: 4
Chapter: Chapter 10, Therapeutic Groups
abirb.com/test
Objective: Identify various roles that members assume within a group.
Page: 167
Heading: Supportive/Therapeutic Groups; Table 10–1, Leadership Styles—Similarities
abirb.com/test
and Differences
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Patient-Centered Care
Difficulty: Easy
1.
2.
3.
4.
abirb.com/test
Feedback
This is incorrect. This would encourage heated discussions and may prohibit a
resolution to the problem.
This is incorrect. This is an autocratic leadership style thatabirb.com/test
may prohibit everyone’s
input and collective problem-solving abilities.
This is incorrect. This may not facilitate problem-solving of the issue and may
further divide the group.
abirb.com/test
This is correct. The role of the group leader at this time is to
encourage the group to
solve the problem collectively. This represents a democratic leadership style, which
encourages members to cooperatively solve group issues.
abirb.com/test
CON: Patient-Centered Care
abirb.com/test
18. A 10-week, prenuptial counseling group composed of five couples is terminating. At
the last group meeting, a nurse notices that the two most faithful and participative
couples are absent. When considering concepts of group development,
which might
abirb.com/test
explain their behavior?
abirb.com/test
abirb.com/test
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1. They are feeling abandoned with the termination.
2. They did not think any new material would be covered at the last session.
3. They were angry with the leader for not extending the length of the group.
abirb.com/test
4. They were bored with the material covered in the group.
ANS: 1
Chapter: Chapter 10, Therapeutic Groups
abirb.com/test
Objective: Describe the phases of group development.
Page: 166
Heading: Phases of Group Development > Phase III. Final or Termination Phase
abirb.com/test
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/test
This is correct. The clients’ absence from the final group meeting may indicate that
they are experiencing problems with termination. The termination phase of group
development may elicit feelings of abandonment and anger. Successful termination
abirb.com/test
may help members develop skills to cope with future unrelated
losses.
This is incorrect. There is no indication that the clients feel this way.
This is incorrect. Although the clients may feel loss, there is no indication that they
felt this way.
abirb.com/test
This is incorrect. There is no indication that the clients were “bored’ with the
material, as they were faithfully attending until the termination phase.
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
19. An experienced psychiatric-mental health registered nurse has taken a new position
leading groups in a day treatment program. Which group is this nurse most qualified to
lead?
abirb.com/test
1. Psychodrama group
2. Psychotherapy group
3. Parenting group
4. Family therapy group
abirb.com/test
ANS: 3
Chapter: Chapter 10, Therapeutic Groups
Objective: Describe the role of the nurse in group therapy.
Page: 168
Heading: The Role of the Nurse in Therapeutic Groups
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
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Chapter 9 - ETB
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Professionalism
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. Psychodrama group therapy must be facilitated by a qualified
leader who has an advanced degree in psychology, social work,
nursing, or
abirb.com/test
medicine.
This is incorrect. Psychotherapy group therapy must be facilitated by a qualified
leader who has an advanced degree in psychology, social work, nursing, or
abirb.com/test
medicine.
This is correct. A psychiatric-mental health registered nurse is qualified to lead a
parenting group, which would be classified as either a teaching group or therapeutic
abirb.com/test
group. Psychodrama, psychotherapy, and family therapy groups
must be facilitated
by qualified leaders who have advanced degrees in psychology, social work,
nursing, or medicine.
This is incorrect. Family group therapy must be facilitated abirb.com/test
by a qualified leader who
has an advanced degree in psychology, social work, nursing, or medicine.
CON: Professionalism
abirb.com/test
20. The master’s-prepared nurse with specialized training is serving
as a group leader,
abirb.com/test
where the client becomes an “actor” in a life-situation scenario. This scenario provides
the client a safe atmosphere to work through unresolved conflicts. What is this type of
therapeutic group?
abirb.com/test
1. Psychodrama
2. Teaching
3. Self-Help
4. Parenting
abirb.com/test
ANS: 1
Chapter: Chapter 10, Therapeutic Groups
abirb.com/test
Objective: Discuss psychodrama as a specialized form of group therapy.
Page: 167
Heading: Psychodrama
Integrated Processes: Teaching/Learning
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Comprehension [Understanding]
Concept: Patient-Centered Care
abirb.com/test
Difficulty: Moderate
1.
Feedback
This is correct. The master’s-prepared nurse with specialized
training may serve as a
abirb.com/test
leader in a psychodrama group, where the client acts in a scenario to find a safer,
abirb.com/test
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Chapter 9 - ETB
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2.
3.
4.
less-threatening atmosphere than a real situation in which to express and work
through unresolved conflicts.
This is incorrect. Although there is some teaching in this type of group, the key
abirb.com/test
words are specialized training and master’s-prepared nurse.
This is incorrect. Although the client is developing self-help skills during this group,
the client is using drama to work through the scenario to learn (or develop) new
coping skills.
abirb.com/test
This is incorrect The key words for this question are specialized training and
master’s- prepared nurse. A parenting group can be taught by a nurse without the
specialized training needed for psychodrama.
abirb.com/test
CON: Patient-Centered Care
abirb.com/test
MULTIPLE RESPONSE
abirb.com/test
21. Which of the following client behaviors would lead the nurse to evaluate a member
abirb.com/test
as assuming a maintenance group role? Select all that apply.
1. A client decreases conflict within the group by encouraging compromise.
2. A client offers recognition and acceptance of others.
3. A client outlines the task and proposes solutions.
abirb.com/test
4. A client listens attentively to group interaction.
5. A client uses the group to gain sympathy from others.
abirb.com/test
ANS: 1, 2, 4
Chapter: Chapter 10, Therapeutic Groups
Objective: Identify various roles that members assume within a group.
Page: 168
abirb.com/test
Heading: Table 10–2, Member Roles Within Groups
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is correct. The client who offers recognition and acceptance of others is
assuming a maintenance group role.
abirb.com/test
This is correct. The client who offers recognition and acceptance
of others is
assuming a maintenance group role.
This is incorrect. This client, who outlines the tasks and proposes solutions, is
assuming the role of initiator.
abirb.com/test
This is correct. The client who offers recognition and acceptance of others is
abirb.com/test
abirb.com/test
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Chapter 9 - ETB
abirb.com/test
5.
assuming a maintenance group role.
This is incorrect. Clients who decrease conflict within the group, offer recognition
and acceptance of others, and listen attentively to group interaction are assuming a
abirb.com/test
maintenance group role.
CON: Patient-Centered Care
abirb.com/test
22. Which of the following behavioral skills should a nurse implement when leading a
abirb.com/test
group that is functioning in the orientation phase of group development? Select all that
apply.
1. Encouraging members to provide feedback to each other about individual progress
abirb.com/test
2. Ensuring that rules established by the group do not interfere with
goal fulfillment
3. Working with group members to establish rules that will govern the group
4. Emphasizing the need for and importance of confidentiality within the group
5. Helping the members to resolve conflicts and foster cohesiveness within the group
abirb.com/test
ANS: 2, 3, 4
Chapter: Chapter 10, Therapeutic Groups
abirb.com/test
Objective: Describe the phases of group development.
Page: 165
Heading: Phases of Group Development > Phase I. Initial or Orientation Phase
Integrated Processes: Nursing Process: Implementation
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
This is incorrect. Encouraging members to provide feedback
occurs during the final
abirb.com/test
(termination) phase.
This is correct. During the orientation phase of group development, members need to
establish trust and cohesion to move into the working phase of group development.
abirb.com/test
This is correct. During the orientation phase of group development,
members need to
establish trust and cohesion to move into the working phase of group development.
This is correct. During the orientation phase of group development, members need to
establish trust and cohesion to move into the working phase
of group development.
abirb.com/test
This is incorrect. Helping group members resolve conflicts and fostering
cohesiveness occurs during the middle (working) phase.
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 10 - ETB
abirb.com/test
Chapter 10. Intervention With Families
abirb.com/test
MULTIPLE CHOICE
abirb.com/test
1. A fatherless, 11-year-old African American girl lives with her grandmother after the
death of her mother. Her older stepbrother is very involved in herabirb.com/test
life. How should the
community health nurse view this family constellation, and why?
1. Abnormal; the grandmother should be concerned with issues other than childrearing.
2. Abnormal; a two-parent household is the most advantageous arrangement.
abirb.com/test
3. Normal; this is an example of a cultural variation that exists in the family life cycle.
4. Normal; older adults make better parenting figures due to life experiences.
abirb.com/test
ANS: 3
Chapter: Chapter 10, Intervention With Families
Objective: Describe major variations to the American middle-class family life cycle.
Page: 177
abirb.com/test
Heading: Major Variations > Cultural Variations
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Family Dynamics
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. This statement does not consider that each household has different
and successful dynamics.
abirb.com/test
This is incorrect. This is an assumption that the child will not
have adequate
parenting with a grandparent and older brother.
This is correct. The family constellation is normal. Cultural differences and specific
events may lead to variety in family constellations.
abirb.com/test
This is incorrect. This is an assumption that older adults have adequate parenting
skills due to life experiences.
CON: Family Dynamics
abirb.com/test
abirb.com/test
2. In defiance of parental wishes, a teenager succumbs to peer pressure and gets a tattoo.
According to Bowen’s family systems theory, how should the community health nurse
interpret the teenager’s action?
abirb.com/test
1. The teenager is attempting to differentiate self.
abirb.com/test
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Chapter 10 - ETB
abirb.com/test
2. The teenager is triangulating self.
3. The teenager is cutting self off emotionally.
4. The teenager is exhibiting antisocial traits.
abirb.com/test
ANS: 1
Chapter: Chapter 10, Intervention With Families
abirb.com/test
Objective: Identify stages of family development.
Page: 181
Heading: Therapeutic Modalities with Families > Major Concepts > Differentiation of
Self
abirb.com/test
Integrated Processes: Nursing Process: Analysis
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Family Dynamics
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/test
This is correct. The teenager is attempting the normal task of adolescence of
differentiating himself or herself. The teenager is taking on some of the cultural
values of peers and is beginning to develop a unique identity.
This is incorrect. Triangulation occurs when a relationshipabirb.com/test
between two people is
dysfunctional, so a third person is brought into the relationship to help stabilize it.
This is incorrect. Emotional cutoff describes differentiation of the self from the
perception of the child.
abirb.com/test
This is incorrect. This is not an example of antisocial traits but an example of the
teenager attempting to develop a unique identity.
CON: Family Dynamics
abirb.com/test
abirb.com/test
3. A home health nurse is visiting an Asian family. A married couple, their three
children, and the maternal grandparents all live in the home. How should the nurse
interpret the presence of the grandparents in the home?
abirb.com/test
1. The parents have diffuse boundaries and have allowed the grandparental subsystem to
be present.
2. The grandparental subsystem is not successfully managing separation from the
parental subsystem.
abirb.com/test
3. Extended family living arrangements are common in some cultures.
4. The nuclear family living arrangement is the preferred environment for child-rearing.
abirb.com/test
ANS: 3
Chapter: Chapter 10, Intervention With Families
Objective: Describe major variations to the American middle-class family life cycle.
abirb.com/test
Page: 183
Heading: Major Variations> Extended Family
abirb.com/test
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Chapter 10 - ETB
abirb.com/test
Integrated Processes: Nursing Process: Analysis
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Family Dynamics
Difficulty: Moderate
1.
2.
3.
4.
abirb.com/test
abirb.com/test
Feedback
This is incorrect. In some U.S. subcultures, it is not uncommon to find several
generations living together. There is no inherent issue with the presence of the
grandparental system.
abirb.com/test
This is incorrect. In some U.S. subcultures, it is not uncommon to find several
generations living together. There is no indication that the presence of the
grandparental system is causing an issue.
abirb.com/test
This is correct. In some U.S. subcultures, such as in families
of Asian descent, it is
not uncommon to find several generations living together.
This is incorrect. It is not necessary for a child to be raised in a nuclear family living
arrangement.
abirb.com/test
CON: Family Dynamics
abirb.com/test
4. A depressed 21-year-old client has lived with his mother ever since the death of his
father 3 years ago. After the client received a college acceptance,abirb.com/test
the mother repeatedly
stated, “That’s wonderful. I’ll be fine all alone.” How would the nurse interpret the
mother’s statements?
1. The mother is withholding supportive messages.
abirb.com/test
2. The mother is expressing denigrating remarks.
3. The mother is communicating indirectly.
4. The mother is using double-bind communication.
abirb.com/test
ANS: 4
Chapter: Chapter 10, Intervention With Families
Objective: Describe behaviors that interfere with adaptive family functioning.
abirb.com/test
Page: 178
Heading: Family Functioning > Communication > Presenting Double-Bind Messages
Integrated Processes: Nursing Process: Analysis
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Moderate
abirb.com/test
1.
Feedback
This is incorrect. This statement is not an example of withholding supportive
abirb.com/test
messages. People may withhold supportive messages because
they themselves have
not been the recipients of reinforcement from significant others and have not learned
abirb.com/test
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Chapter 10 - ETB
abirb.com/test
2.
3.
4.
how to provide support to others.
This is incorrect. Denigrating remarks are messages conveying one is worthless or
unloved.
abirb.com/test
This is incorrect. This statement is an example of indirect communication in which
an individual who does not or cannot present a message to a receiver directly seeks
to communicate through a third person.
abirb.com/test
This is correct. The mother’s statement is an example of sending
a mixed message
through double-bind communication. Double-bind communication occurs when a
statement is made and is then succeeded by a contradictory statement.
abirb.com/test
CON: Communication
abirb.com/test
5. In a family that is in the life cycle stage “The Family With Adolescents,” which
changes must occur for the family to proceed developmentally?
1. Making adjustments within the marital system to meet the responsibilities
abirb.com/test of
parenthood
2. Establishing a new identity as a couple by realigning relationships with extended
family
abirb.com/test
3. Redefining the level of dependence so that adolescents are provided
with greater
autonomy
4. Reestablishing the bond of the dyadic marital relationship and eventual death of
parents
abirb.com/test
ANS: 3
Chapter: Chapter 10, Intervention With Families
abirb.com/test
Objective: Identify stages of family development.
Page: 181
Heading: Stages of Family Development > The Family With Adolescents; Table 11–1
Stages of the Family Life Cycle
abirb.com/test
Integrated Processes: Nursing Process: Analysis
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Family Dynamics
Difficulty: Moderate
1.
2.
3.
Feedback
abirb.com/test
This is incorrect. This would best be described as a task of the “Family With Young
Children.”
This is incorrect. This is among the tasks of “The Family Joined Through
abirb.com/test
Marriage/Union.”
This is correct. The task of “The Family With Adolescents” (stage IV of the family
life cycle) is to redefine the level of dependence so that adolescents are provided
with greater autonomy while parents remain responsive to abirb.com/test
teenagers’ dependency
needs.
abirb.com/test
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Chapter 10 - ETB
abirb.com/test
4.
This is incorrect. This is a task of the “Family With Children Leaving Home.”
CON: Family Dynamics
abirb.com/test
6. A clinic nurse is caring for a 40-year-old client who lives withabirb.com/test
his parents. One parent
continues to do the client’s laundry and provides spending money. Which family
dynamic does the nurse recognize in this situation?
1. Taking over
abirb.com/test
2. Communicating indirectly
3. Belittling feelings
4. Making assumptions
abirb.com/test
ANS: 1
Chapter: Chapter 10, Intervention With Families
Objective: Describe behaviors that interfere with adaptive familyabirb.com/test
functioning.
Page: 177
Heading: Family Functioning > Communication > Taking Over
Integrated Processes: Nursing Process: Assessment
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Family Dynamics
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is correct. This situation is an example of taking over, which occurs when a
family member fails to allow another member to develop aabirb.com/test
sense of responsibility
and self-worth. By doing the client’s laundry and managing finances, the parent is
fostering the client’s dependence.
This is incorrect. Communicating indirectly occurs when an
individual seeks to
abirb.com/test
communicate through a third person.
This is incorrect. Belittling feelings involves ignoring or minimizing another’s
feelings.
abirb.com/test
This is incorrect. This pertains to the behavior that the individual assumes to know
what another member is thinking or feeling without checking to make certain.
CON: Family Dynamics
abirb.com/test
abirb.com/test
7. A 30-year-old client seeking therapy states, “My parent cries when she is not included
in all my social activities and thinks of my friends as her own.” Which of the following
indicates the nurse’s description of this family’s boundaries?
abirb.com/test
1. The boundaries are rigid.
2. The boundaries are restructured.
abirb.com/test
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Chapter 10 - ETB
abirb.com/test
3. The boundaries are enmeshed.
4. The boundaries are disengaged.
abirb.com/test
ANS: 3
Chapter: Chapter 10, Intervention With Families
Objective: Describe behaviors that interfere with adaptive family functioning.
abirb.com/test
Page: 185
Heading: Therapeutic Modalities With Families > Boundaries
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Family Dynamics
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. A rigid boundary is characterized by decreased communication and
lack of support and responsiveness.
abirb.com/test
This is incorrect. This describes a flexible boundary that may be an adaptation to the
changes of family dynamics.
This is correct. Families with enmeshed boundaries lack individuation and
experience exaggerated connectedness. The client’s parentabirb.com/test
is trying to prevent
independence by generating feelings of guilt.
This is incorrect. Families who demonstrate emotional disengagement do not appear
to be close.
abirb.com/test
CON: Family Dynamics
abirb.com/test
8. A nurse enters an inpatient room and finds the family disagreeing about the client’s
living arrangements after discharge. Which information should the
nurse provide when
abirb.com/test
teaching techniques to resolve family conflicts?
1. All family members should use past incidents to make their point.
2. One family member should act as a gatekeeper to avoid family confrontation.
abirb.com/test
3. One family member should act as a compromiser to preserve harmony in the family.
4. All family members should respect differing opinions and negotiate a compromise.
ANS: 4
abirb.com/test
Chapter: Chapter 10, Intervention With Families
Objective: Describe behaviors that interfere with adaptive family functioning.
Page: 177
abirb.com/test
Heading: Family Functioning > Communication > Handling Differences
Integrated Processes: Teaching and Learning
Client Need: Health Promotion and Maintenance
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Communication
abirb.com/test
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Chapter 10 - ETB
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/test
This is incorrect. This would only potentiate the conflict and distract from the
present conflict.
This is incorrect. This could be a form of triangulation and entangles the process of
abirb.com/test
conflict resolution.
This is incorrect. This can be a form of triangulation that deflects from the stressor.
This is correct. Members of a functional family understand that it is acceptable to
disagree and deal with differences in an open, nonthreatening
manner. Members are
abirb.com/test
willing to hear the other person’s position, they respect the other person’s right to
hold an opposing position, and they work to modify the expectations on both sides of
the issue to negotiate a workable solution.
abirb.com/test
CON: Communication
abirb.com/test
9. The nurse is using the nursing process to develop a teaching plan for a
multigenerational family household. Which statement best describes how a genogram
abirb.com/test
would facilitate a teaching plan?
1. The genogram would provide an overall picture of the life of the family over several
generations.
2. The genogram would provide influences for the development of
predictable
abirb.com/test
personality characteristics.
3. This provides a conceptual view of societal emotional support system for the family
during crises.
4. This provides guidelines for boundary setting with prevention abirb.com/test
of excessive
interference.
ANS: 1
abirb.com/test
Chapter: Chapter 10, Intervention With Families
Objective: Construct a family genogram.
Page: 182
abirb.com/test
Heading: Multigenerational Transmission Process > Genograms
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Family Dynamics
Difficulty: Moderate
abirb.com/test
1.
2.
Feedback
This is correct. This is the definition of the genogram, which offers a great deal of
information in a small amount of space and can be used as a teaching tool for the
abirb.com/test
family.
This is incorrect. This describes Bowen’s theory on sibling position, which suggests
abirb.com/test
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Chapter 10 - ETB
abirb.com/test
3.
4.
that birth order influences the development of predictable personality characteristics.
This is incorrect. This describes the societal concept of Bowen’s theory, which
views society as an emotional system.
abirb.com/test
This is incorrect. This would not define boundaries within the family dynamics.
Boundaries are defined as the level of participation and interaction among
subsystems.
abirb.com/test
CON: Family Dynamics
abirb.com/test
10. An instructor is teaching about differentiated parent and adult child relationships.
Students are instructed to give an example of a well-differentiated parent and adult child
abirb.com/test
relationship. Which student example meets the instructor requirement?
1. An adult child considers, but is not governed by, the advice of his or her parents.
2. An adult child appears to listen to, but ignores, the advice of his or her parents.
her parents.
3. An adult child respects and is governed by the wishes of his orabirb.com/test
4. An adult child never requests advice or feedback from his or her parents.
ANS: 1
abirb.com/test
Chapter: Chapter 10, Intervention With Families
Objective: Discuss characteristics of adaptive family functioning.
Page: 181
Heading: Therapeutic Modalities With Families > The Family asabirb.com/test
a System >
Differentiation of Self
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Family Dynamics
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is correct. A well-differentiated parent and adult child relationship is when an
adult child considers, but is not governed by, the advice of his or her parent.
abirb.com/test
Differentiation of self indicates an individual who manifests a clearly defined sense
of self.
This is incorrect. This suggests emotional cutoff, per Bowen, which is the result of
dysfunction within the family of origin.
abirb.com/test
This is incorrect There is no differentiation of self within the generations.
This is incorrect. This is an example of emotional cutoff, which is the result of
dysfunction within the family of origin.
abirb.com/test
CON: Family Dynamics
abirb.com/test
abirb.com/test
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Chapter 10 - ETB
abirb.com/test
11. During family counseling a spouse states, “Every time my partner and I discuss child
discipline, we get into shouting matches.” The nurse instructs the couple to shout at each
other for 2 weeks on Tuesdays and Thursdays for 30 minutes. Which intervention is the
abirb.com/test
nurse using?
1. Reframing
2. Restructuring the family
abirb.com/test
3. Expressive psychotherapy
4. Paradoxical intervention
ANS: 4
abirb.com/test
Chapter: Chapter 10, Intervention With Families
Objective: Apply the steps of the nursing process in therapeutic intervention with
families.
abirb.com/test
Page: 185
Heading: Goals and Techniques of Therapy > Paradoxical Intervention
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Family Dynamics
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. Reframing involves relabeling problematic behavior by viewing it
in a new, more positive light that emphasizes its good intention.
abirb.com/test
This is incorrect. Restructuring is an intervention in which the therapist establishes
an alliance or contract for therapy with the family to express feelings openly and
honestly. By becoming an actual part of the family, the therapist is able to
manipulate the system and facilitate the circumstances andabirb.com/test
experiences that can lead
to structural change.
This is incorrect. Expressive therapy enables family members to express their
feelings openly and honestly.
abirb.com/test
This is correct. In a paradoxical intervention, the therapist requests the family to
continue the maladaptive behavior. This removes control over the behavior from the
family to the therapist. Clients are made more aware of the defeating behavior, and
abirb.com/test
this can lead to behavioral change.
CON: Family Dynamics
abirb.com/test
12. During family counseling a child states, “I just want to surf like other kids. Mom
abirb.com/test
says it’s OK, but Dad says I’m too young.” The mother allows surfing when the father is
absent. In the structural model of family therapy, what family interactional pattern
should the nurse recognize?
abirb.com/test
1. Multigenerational transmission
2. Disengagement
abirb.com/test
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Chapter 10 - ETB
abirb.com/test
3. Mother–child subsystem
4. Emotional cutoff
abirb.com/test
ANS: 3
Chapter: Chapter 10, Intervention With Families
Objective: Discuss the essential components of family systems, structural, and strategic
abirb.com/test
therapies.
Page: 187
Heading: The Structural Mode l > Subsystems
Integrated Processes: Nursing Process: Assessment
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Family Dynamics
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
This is incorrect. Multigenerational transmission is the process
by which
abirb.com/test
interactional patterns are transferred from one generation to another.
This is incorrect. Disengagement refers to extreme separateness among family
members.
This is correct. Subsystems are smaller elements that makeabirb.com/test
up the larger family
system. The mother and child have formed a subsystem in which they have aligned
themselves against the father.
This is incorrect. Emotional cutoff describes differentiationabirb.com/test
of self from the
perception of the child.
CON: Family Dynamics
abirb.com/test
13. During family counseling, a husband tells his wife to spend more
time with the
abirb.com/test
family, and she responds by stating, “Okay, I’ll turn in my resignation tomorrow.” The
husband replies, “I knew it! You’ve always been a quitter!” How should the nurse
interpret the husband’s statement?
abirb.com/test
1. The husband is expressing an emotional cutoff.
2. The husband is expressing double-bind communication.
3. The husband is expressing indirect messages.
4. The husband is expressing avoidance behaviors.
abirb.com/test
ANS: 2
Chapter: Chapter 10, Intervention With Families
abirb.com/test
Objective: Describe behaviors that interfere with adaptive family functioning.
Page: 177
Heading: Family Functioning > Communication > Presenting Double-Bind Messages
abirb.com/test
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
abirb.com/test
abirb.com/test
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Chapter 10 - ETB
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Moderate
1.
2.
3.
4.
abirb.com/test
Feedback
This is incorrect. Emotional cutoff describes differentiation of self from the
abirb.com/test
perception of the child.
This is correct. The husband is expressing double-bind communication. Double-bind
communication occurs when a statement is made and is then succeeded by a
contradictory statement.
abirb.com/test
This is incorrect. The husband is expressing double-bind communication. Doublebind communication occurs when a statement is made and is then succeeded by a
contradictory statement. An indirect message is vague and incongruent.
This is incorrect. The statement maker avoids discussing itabirb.com/test
for fear that the other
person will withdraw love or approval or become angry in response to the
disagreement. Avoidance occurs when an individual fears loss of love, loss of
approval, or loss of control of his or her temper if a disagreement
is brought out into
abirb.com/test
the open.
CON: Communication
abirb.com/test
14. A couple has been married for 20 years. They argue constantly,
belittle feelings, and
abirb.com/test
continuously contradict each other. During a therapy session, the nurse documents
“marital schism.” Which of the following is the meaning of the nurse’s documentation?
1. The couple has a compatible marriage relationship.
abirb.com/test
2. The husband has a dominant relationship over the wife.
3. The couple has an enmeshed relationship.
4. The couple has an incompatible marriage relationship.
abirb.com/test
ANS: 4
Chapter: Chapter 10, Intervention With Families
Objective: Describe behaviors that interfere with adaptive family functioning.
abirb.com/test
Page: 184
Heading: The Strategic Model > Schism and Skew
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Family Dynamics
Difficulty: Moderate
abirb.com/test
1.
2.
3.
Feedback
This is incorrect. This is not a description of a compatible marital relationship.
This is incorrect. There is no indication that the husband isabirb.com/test
dominating.
This is incorrect. This couple does not have exaggerated connectedness.
abirb.com/test
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PMHN, 10e
Chapter 10 - ETB
abirb.com/test
4.
This is correct. A marital schism is a state of chronic disequilibrium and discord.
CON: Family Dynamics
abirb.com/test
abirb.com/test
15. A couple is in counseling related to their dysfunctional relationship.
Their child has
recently made a suicide gesture. The nurse should recognize that this might be an
example of which family system concept?
1. Triangulation
abirb.com/test
2. Pseudohostility
3. Double-bind communication
4. Pseudomutuality
abirb.com/test
ANS: 1
Chapter: Chapter 10, Intervention With Families
Objective: Describe behaviors that interfere with adaptive familyabirb.com/test
functioning.
Page: 181
Heading: Therapeutic Modalities With Families > The Family as a System > Triangles
Integrated Processes: Nursing Process: Analysis
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Family Dynamics
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is correct. Triangulation is a dysfunctional family dynamic that serves to relieve
anxiety through diversion rather than through resolution ofabirb.com/test
the issue. A third person
is brought into the relationship to help stabilize it. The couple is triangulating with
their daughter. The threatened daughter draws attention from her parents’
interpersonal conflicts by her own dysfunctional behavior.abirb.com/test
This is incorrect. Pseudohostility is a fixed and rigid style of relating in which an
individual’s facade is that of a state of chronic conflict and alienation among family
members. This relationship pattern allows family members to deny underlying fears
abirb.com/test
of tenderness and intimacy.
This is incorrect. Double-bind communication occurs when a statement is made and
is then succeeded by a contradictory statement.
This is incorrect. Pseudomutuality is characterized by a facade
of mutual regard.
abirb.com/test
Emotional investment is directed at maintaining the outward representation of
reciprocal fulfillment rather than the relationship itself.
CON: Family Dynamics
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 10 - ETB
abirb.com/test
16. An adolescent, his mother, and his soon-to-be stepfather have been in counseling
with the nurse. Which statement by the nurse fosters positive relationships within this
new family structure?
abirb.com/test
1. “Stepchildren should be consistently disciplined by only one parent.”
2. “It is most important to give your full attention to the child’s adjustment since it is
most difficult for them.”
3. “Keeping the lines of communication open between everyone abirb.com/test
in the family is
important in establishing healthy relationships.”
4. “Children need to decide who will be their disciplinarian because this new situation
will be stressful.”
abirb.com/test
ANS: 3
Chapter: Chapter 10, Intervention With Families
abirb.com/test with
Objective: Apply the steps of the nursing process in therapeutic intervention
families.
Page: 175
Heading: The Nursing Process – A Case Study > Expressive Functioning
>
abirb.com/test
Planning/Implementation
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. This negates the adjustment in the relationship of the family with
the roles of a family joined in marriage/union and the family with adolescents. There
abirb.com/test
is no sign of adjustment in their relationship.
This is incorrect. This negates the role of the family joined through marriage/union
and the tasks of establishing a new identity as a couple.
This is correct. A positive family climate is founded on trust
and reflected in open
abirb.com/test
communication. Open lines of communication are needed for newly forming
families to begin their relationship together and establish a new family structure.
This is incorrect. Although problems arise when the parents are unable to relinquish
abirb.com/test
control and allow the adolescent greater autonomy, the parents
must maintain certain
levels of responsibility and support for each other in this effort.
CON: Communication
abirb.com/test
abirb.com/test
17. A nursing instructor is teaching about the importance of healthy family-member
expectations for newly blended families. Which student statement indicates a need for
further instruction?
1. “Healthy family-member expectations should be flexible.” abirb.com/test
2. “Healthy family-member expectations should be conforming.”
abirb.com/test
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Chapter 10 - ETB
abirb.com/test
3. “Healthy family-member expectations should be individual.”
4. “Healthy family-member expectations should be realistic.”
abirb.com/test
ANS: 2
Chapter: Chapter 10, Intervention With Families
Objective: Describe behaviors that interfere with adaptive family functioning.
abirb.com/test
Page: 185
Heading: The Strategic Model
Integrated Processes: Nursing Process: Evaluation
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Comprehension [Understanding]
Concept: Family Dynamics
Difficulty: Easy
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. Flexibility is a characteristic of healthy family-member
expectations.
abirb.com/test
This is correct. Conforming is a behavior that interferes with adaptive functioning in
terms of family-member expectations.
This is incorrect. Individuality is a characteristic of healthy family-member
abirb.com/test
expectations.
This is incorrect. Realism is a characteristic of healthy family-member expectations.
CON: Family Dynamics
abirb.com/test
abirb.com/test
18. A client is angry because her spouse has forgotten their anniversary.
The following
week, the client is still unwilling to discuss this with her spouse because she is afraid she
will lose control. How should the nurse interpret this client’s means of coping with
anger?
abirb.com/test
1. Coping by attacking
2. Coping by surrendering
3. Coping by avoiding
abirb.com/test
4. Coping by belittling
ANS: 3
Chapter: Chapter 10, Intervention With Families
abirb.com/test
Objective: Describe behaviors that interfere with adaptive family functioning.
Page: 179
Heading: Handling Differences > Avoiding
abirb.com/test
Integrated Processes: Nursing Process: Evaluation
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
abirb.com/test
Concept: Communication
Difficulty: Moderate
abirb.com/test
abirb.com/test
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Chapter 10 - ETB
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. Attacking occurs when one person blames
the other with insulting
abirb.com/test
remarks and reminders of past transgressions.
This is incorrect. Surrendering occurs when an individual avoids expressing a
difference of opinion for fear of angering another person or of losing approval and
abirb.com/test
support.
This is correct. The client is avoiding discussing her spouse’s forgetting their
anniversary. When coping by avoidance, differences are never acknowledged
openly. The individual who disagrees avoids discussing it abirb.com/test
for fear that the other
person will withdraw love or approval or become angry in response to the
disagreement. Avoidance also occurs when an individual fears loss of control of his
or her temper.
abirb.com/test another’s
This is incorrect. Belittling feelings involves ignoring or minimizing
feelings.
CON: Family Dynamics
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 11 - ETB
abirb.com/test
Chapter 11. Milieu Therapy—The Therapeutic Community
abirb.com/test
MULTIPLE CHOICE
abirb.com/test
1. An angry client on an inpatient unit approaches a nurse, stating, “Someone took my
lunch! People need to respect others, and you need to do something
about this now!”
abirb.com/test
The nurse’s response should be guided by which basic assumption of milieu therapy?
1. Conflict should be avoided at all costs on inpatient psychiatric units.
2. Conflict should be resolved by the nursing staff.
abirb.com/test
3. Every interaction is an opportunity for therapeutic intervention.
4. Conflict resolution should be addressed only during group therapy.
ANS: 3
abirb.com/test
Chapter: Chapter 11, Milieu Therapy—The Therapeutic Community
Objective: Identify seven basic assumptions of a therapeutic community.
Page: 198
abirb.com/test
Heading: Basic Assumptions
Integrated Processes: Communication and Documentation
Nursing Process: Implementation
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. Avoiding conflict does not help the client heal.
abirb.com/test
This is incorrect. Clients should participate in conflict resolution.
This is correct. Every interaction is an opportunity for therapeutic intervention.
This incorrect. Conflict resolution should be addressed as the need arises.
abirb.com/test
CON: Patient-Centered Care
abirb.com/test
2. A client on an inpatient unit angrily states to a nurse, “Peter is not cleaning up after
himself in the community bathroom. You need to address this problem.” Which
response by the nurse is appropriate?
abirb.com/test
1. “I’ll talk to Peter and present your concerns.”
2. “Why are you overreacting to this issue?”
3. “You should bring this to the attention of your treatment team.”
abirb.com/test
4. “I can see that you are angry. Let’s discuss ways to approach Peter
with your
concerns.”
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 11 - ETB
abirb.com/test
ANS: 4
Chapter: Chapter 11, Milieu Therapy—The Therapeutic Community
abirb.com/test
Objective: Identify seven basic assumptions of a therapeutic community.
Page: 198
Heading: Basic Assumptions
Integrated Processes: Communication and Documentation
abirb.com/test
Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Patient-Centered Care
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/test
This is incorrect. The client should be encouraged to resolve conflict.
This is incorrect. This statement is not therapeutic.
This is incorrect. This statement does not help the client problem-solve
in the
abirb.com/test
moment.
This is correct. This is a therapeutic statement to the client.
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
3. A newly admitted client asks, “Why do we need a unit schedule? I’m not going to
these groups. I’m here to get some rest.” Which reply by the nurse is appropriate?
1. “Group therapy provides the opportunity to learn and practice new coping skills.”
abirb.com/test
2. “Group therapy is mandatory. All clients must attend.”
3. “Group therapy is optional. You can go if you find the topic helpful and interesting.”
4. “Group therapy is an economical way of providing therapy to many clients
concurrently.”
abirb.com/test
ANS: 1
Chapter: Chapter 11, Milieu Therapy—The Therapeutic Community
abirb.com/test
Objective: Discuss conditions that characterize a therapeutic community.
Page: 198
Heading: Conditions That Promote a Therapeutic Community
Integrated Processes: Communication and Documentation
abirb.com/test
Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Patient-Centered Care
Difficulty: Easy
1.
Feedback
abirb.com/test
This is correct. This statement is therapeutic to the client and explains why group
abirb.com/test
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PMHN, 10e
Chapter 11 - ETB
abirb.com/test
2.
3.
4.
therapy is important.
This is incorrect. This statement does not explain why group therapy is important.
This is incorrect. This statement does not set expectations for the client.
abirb.com/test
This is incorrect. This statement does not explain why group therapy is beneficial to
the client.
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
4. A client diagnosed with schizophrenia functions well and is bright, spontaneous, and
interactive during hospitalization but then decompensates after discharge. Which
statement is true regarding what the milieu provides that may be missing in the home
abirb.com/test
environment?
1. Peer pressure
2. Structured programming
3. Visitor restrictions
abirb.com/test
4. Mandated activities
ANS: 2
abirb.com/test
Chapter: Chapter 11, Milieu Therapy—The Therapeutic Community
Objective: Discuss conditions that characterize a therapeutic community.
Page: 198
Heading: Conditions That Promote a Therapeutic Community abirb.com/test
Integrated Processes: Caring
Nursing Process: Assessment
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. Peer pressure is not provided in the milieu.
This is correct. The therapeutic community provides a structured schedule of
abirb.com/test
activities in which interpersonal interaction and communication
with others are
emphasized. In the milieu, time is also devoted to personal problems and focus
groups. Structured programming is often missing in the home environment.
This is incorrect. Visitor restrictions are not part of the milieu.
abirb.com/test
This is incorrect. Mandated activities are not part of the milieu environment.
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
5. To promote self-reliance, how would a psychiatric-mental health
nurse best conduct
medication administration?
abirb.com/test
abirb.com/test
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Chapter 11 - ETB
abirb.com/test
1. Encourage clients to request their medications at the appropriate times.
2. Refuse to administer medications unless clients request them at the appropriate times.
3. Allow the clients to determine appropriate medication times.
abirb.com/test
4. Take medications to the clients’ bedsides at the appropriate times.
ANS: 1
Chapter: Chapter 11, Milieu Therapy—The Therapeutic Community
abirb.com/test
Objective: Describe the role of the nurse on the interdisciplinary treatment team.
Page: 199
Heading: The Role of the Nurse in Milieu Therapy
abirb.com/test
Integrated Processes: Nursing Process
Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Patient-Centered Care
Difficulty: Easy
abirb.com/test
1.
2.
3.
4.
Feedback
This is correct. This action promotes self-reliance in the client. Nurses are
responsible for the management of medication administration on inpatient
abirb.com/test
psychiatric units; however, nurses must work with clients to
foster independence and
provide experiences that would foster increased self-esteem.
This is incorrect. This action is not beneficial to the client. Nurses are responsible for
the management of medication administration on inpatientabirb.com/test
psychiatric units;
however, nurses must work with clients to foster independence and provide
experiences that would foster increased self-esteem.
This is incorrect. This action is not therapeutic to the client. Nurses are responsible
abirb.com/test
for the management of medication administration on inpatient
psychiatric units;
however, nurses must work with clients to foster independence and provide
experiences that would foster increased self-esteem.
This is incorrect. This action does not promote self-reliance
in the client. Nurses are
abirb.com/test
responsible for the management of medication administration on inpatient
psychiatric units; however, nurses must work with clients to foster independence and
provide experiences that would foster increased self-esteem.
abirb.com/test
CON: Patient-Centered Care
abirb.com/test
6. A nurse working on an inpatient psychiatric unit is assigned to conduct a 45-minute
education group. Which activity would the nurse identify as an appropriate group topic?
abirb.com/test
1. Dream analysis
2. Creative cooking
3. Paint by number
4. Stress management
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 11 - ETB
abirb.com/test
ANS: 4
Chapter: Chapter 11, Milieu Therapy—The Therapeutic Community
Objective: Identify the various therapies that may be included within the program of the
therapeutic community and the health-care workers that make upabirb.com/test
the interdisciplinary
treatment team.
Page: 198
Heading: The Program of the Therapeutic Community
abirb.com/test
Integrated Processes: Caring
Nursing Process: Planning
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Easy
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. Dream analysis is not an appropriate group topic.
This is incorrect. Creative cooking is not an appropriate group topic.
abirb.com/test
This is incorrect. Paint-by-number is not an appropriate group topic.
This is correct. The nurse should identify that teaching clients about stress
management is an appropriate education group topic. Nurses should be able to
abirb.com/test
perform the role of client teacher in the psychiatric area. Nurses
need to be able to
assess a client’s learning readiness. Other topics for education groups include
medical diagnoses, side effects of medications, and the importance of medication
compliance.
abirb.com/test
CON: Patient-Centered Care
abirb.com/test
7. Which statement made by the nursing student indicates an understanding regarding
the role of the social worker?
abirb.com/test
1. “The social worker can encourage a client to express their feelings through the use of
music.”
2. “My client has been eating drywall, so I have contacted the social worker to come
abirb.com/test
speak to them.”
3. “I have asked the social worker to organize a game of volleyball this weekend.”
4. “My client cannot afford medications when they are discharged, so the social worker
is arranging some assistance.”
abirb.com/test
ANS: 4
Chapter: Chapter 11, Milieu Therapy—The Therapeutic Community
abirb.com/test
Objective: Identify the various therapies that may be included within
the program of the
therapeutic community and the health-care workers that make up the interdisciplinary
treatment team.
Page: 200
abirb.com/test
Heading: Table 11-1 The Interdisciplinary Treatment Team in Psychiatry
abirb.com/test
abirb.com/test
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Chapter 11 - ETB
abirb.com/test
Integrated Processes: Communication and Documentation
Nursing Process: Evaluation
Client Need: Psychosocial Integrity
Cognitive Level: Evaluation [Evaluating]
Concept: Patient-Centered Care
Difficulty: Moderate
abirb.com/test
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. The music therapist encourages the expression of feelings through
music.
abirb.com/test
This is incorrect. The dietitian would be useful in assisting a client with pica.
This is incorrect. A recreational therapist organizes activities and sports.
This is correct. A social worker is concerned with a client’s social needs, such as
placement, financial support, and community requirements.abirb.com/test
CON: Patient-Centered Care
abirb.com/test
8. Which statement describes the development of trust between the nurse and client?
1. “You cannot draw a picture until you take your medication.” abirb.com/test
2. “I am sorry you are angry.”
3. “I am going to teach you how to change your dressing.”
4. “I will listen if you would like to tell me about your day.”
abirb.com/test
ANS: 4
Chapter: Chapter 11, Milieu Therapy—The Therapeutic Community
abirb.com/test
Objective: Describe the role of the nurse in establishing and maintaining
a therapeutic
milieu.
Page: 198
Heading: The Role of the Nurse in Milieu Therapy
abirb.com/test
Integrated Processes: Communication and Documentation
Nursing Process: Planning
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. This statement sets limits.
This is incorrect. This statement is an example of caring.
abirb.com/test
This is incorrect. This statement is educating the client.
This is correct. The nurse is telling the client they will listen to them, which, by
encouraging them to share their feelings, establishes trust.
abirb.com/test
CON: Communication
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 11 - ETB
abirb.com/test
abirb.com/test
9. A client has undergone psychological testing. With which member
of the
interdisciplinary team would a nurse collaborate to review these results?
1. Psychiatrist
2. Psychiatric social worker
abirb.com/test
3. Clinical psychologist
4. Clinical nurse specialist
abirb.com/test
ANS: 3
Chapter: Chapter 11, Milieu Therapy—The Therapeutic Community
Objective: Describe the role of the nurse on the interdisciplinary treatment team.
Page: 200
abirb.com/test
Heading: Table 11-1 The Interdisciplinary Team in Psychiatry
Integrated Processes: Communication and Documentation
Nursing Process: Implementation
abirb.com/test
Client Need: Safe and Effective Care Environment
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Easy
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. It would not be the most beneficial for the nurse to collaborate with
abirb.com/test
the psychiatrist.
This is incorrect. It would not be the most beneficial for the nurse to collaborate with
the psychiatric social worker.
abirb.com/test
This is correct. The nurse should collaborate with the clinical
psychologist. Clinical
psychologists can administer, interpret, and evaluate psychological tests to assist in
the diagnostic process.
This is incorrect. It would not be the most beneficial for theabirb.com/test
nurse to collaborate with
the clinical nurse specialist.
CON: Patient-Centered Care
abirb.com/test
10. Which dining arrangement would the nurse use to best promote
a sense of
abirb.com/test
community?
1. Arrange tables for two around the dining room
2. Allow clients to take their meals to their rooms
3. Set up rectangular tables in the shape of a large square aroundabirb.com/test
the room to seat
everyone
4. Arrange tables seating 5 or 6 clients around the dining room
abirb.com/test
ANS: 4
abirb.com/test
abirb.com/test
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Chapter 11 - ETB
abirb.com/test
Chapter: Chapter 11, Milieu Therapy—The Therapeutic Community
Objective: Discuss conditions that characterize a therapeutic community.
Page: 198
abirb.com/test
Heading: Conditions that Promote a Therapeutic Community>Involvement
Integrated Processes: Nursing Process
Nursing Process: Planning
Client Need: Physiological Integrity
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. Tables set for two do not promote a sense of community.
This is incorrect. Allowing the client to take their meals toabirb.com/test
their room promotes
isolation.
This is incorrect. One large table seating everyone does not promote conversation;
there are too many people to facilitate or hear a conversation.
abirb.com/test
This is correct. Small group seating arrangements are encouraged to promote a sense
of community and facilitate conversation.
CON: Communication
abirb.com/test
abirb.com/test
11. Which client would benefit most from working with a dietitian?
1. A client with anxiety
2. A client with schizophrenia
abirb.com/test
3. A client with pica
4. A client with bipolar disorder
ANS: 3
abirb.com/test
Chapter: Chapter 11, Milieu Therapy—The Therapeutic Community
Objective: Identify the various therapies that may be included in the program of the
therapeutic community and the health-care workers that make up the interdisciplinary
abirb.com/test
treatment team.
Page: 200
Heading: Table 11-1 The Interdisciplinary Treatment Team in Psychiatry
Integrated Processes: Communication and Documentation
abirb.com/test
Nursing Process: Implementation
Cognitive Level: Comprehension [Understanding]
Concept: Nutrition
abirb.com/test
Difficulty: Easy
1.
Feedback
This is incorrect. Although a client with schizophrenia would
benefit from a
abirb.com/test
dietitian’s guidance, a client with pica would benefit more.
abirb.com/test
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PMHN, 10e
Chapter 11 - ETB
abirb.com/test
2.
3.
4.
This is incorrect. Although a client with anxiety would benefit from a dietitian’s
guidance, a client with pica would benefit more.
This is correct. A client with pica craves unusual substances with no nutritional
abirb.com/test
value (such as clay or dirt) and would benefit from working
with a dietitian to
replace nutrients.
This is incorrect. A client with bipolar disorder would benefit from working with a
dietitian, but a client with pica would benefit more.
abirb.com/test
CON: Nutrition
abirb.com/test
12. The psychiatric-mental health nurse understands the goal of milieu therapy is which
abirb.com/test
of the following?
1. To structure the environment to ensure a therapeutic experience
2. To demand clients to be active participants in their therapy
3. To provide spontaneous opportunities for therapeutic interactions
abirb.com/test
4. To design a homelike atmosphere that encourages communication
ANS: 1
abirb.com/test
Chapter: Chapter 11, Milieu Therapy—The Therapeutic Community
Objective: Explain the goal of therapeutic community/milieu therapy.
Page: 197
Heading: Milieu, Defined
abirb.com/test
Integrated Processes: Nursing Process
Nursing Process: Assessment
Cognitive Level: Comprehension [Understanding]
abirb.com/test
Core concept: Patient-Centered Care
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/test
This is correct. The goal of milieu therapy is to manipulate the environment so that
all aspects of the client’s hospital experience are considered therapeutic.
This is incorrect. The milieu environment is not rigid or punitive, but supportive and
abirb.com/test
affirming.
This is incorrect. Activities are structured and scheduled, not spontaneous.
This is incorrect. Designing a homelike environment is not the goal of milieu
therapy.
abirb.com/test
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 11 - ETB
abirb.com/test
13. A client tells the nurse she is anxious and loudly demands the nurse give her
lorazepam right now. The nurse replies, “I understand you are having anxiety; however,
demanding medication in a loud voice is unacceptable behavior.” Which type of
abirb.com/test
intervention is the nurse implementing?
1. Establishing trust
2. Limit setting
3. Validating feelings
abirb.com/test
4. Client teaching
ANS: 2
abirb.com/test
Chapter: Chapter 11, Milieu Therapy—The Therapeutic Community
Objective: Describe the role of the nurse on the interdisciplinary treatment team.
Page: 198
Heading: The Role of the Nurse in Milieu Therapy
abirb.com/test
Integrated Processes: Communication and Documentation
Nursing Process: Implementation
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Patient-Centered Care
Difficulty: Moderate
1.
2.
3.
4.
abirb.com/test
Feedback
This is incorrect. The nurse telling the client a behavior is unacceptable is not
establishing trust.
This is correct. The nurse is responsible for setting limits on
unacceptable behavior
abirb.com/test
in the therapeutic milieu. This requires stating to the client in understandable
terminology which behaviors are not acceptable. All staff must be consistent in
setting limits.
abirb.com/test
This is incorrect. The nurse telling the client he or she understands
they are anxious
is validating their feelings; however, telling the client it is unacceptable to demand
medication in a loud voice is setting limits.
This is incorrect. The nurse is not teaching the client by informing
him or her that it
abirb.com/test
is unacceptable to demand medication in a loud voice.
CON: Patient-Centered Care
abirb.com/test
MULTIPLE RESPONSE
abirb.com/test
abirb.com/test
14. A nurse attends an interdisciplinary team meeting on an inpatient
unit. Which of the
following individuals are typically included as members of the interdisciplinary
treatment team in psychiatry? Select all that apply.
1. Respiratory therapist
abirb.com/test
2. Occupational therapist
abirb.com/test
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PMHN, 10e
Chapter 11 - ETB
abirb.com/test
3. Recreational therapist
4. Psychiatric social worker
5. Mental health technician
abirb.com/test
ANS: 2, 3, 4, 5
Chapter: Chapter 11, Milieu Therapy—The Therapeutic Community
Objective: Identify the various therapies that may be included within
the program of the
abirb.com/test
therapeutic community and the health-care workers that make up the interdisciplinary
treatment team.
Page: 198
abirb.com/test
Heading: The Program of Therapeutic Community
Integrated Processes: Communication and Documentation
Nursing Process: Implementation
Client Need: Safe and Effective Care Environment
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Easy
abirb.com/test
1.
2.
3.
4.
5.
Feedback
This is incorrect. The respiratory therapist is not typically part of the treatment team.
This is correct. The typical interdisciplinary treatment teamabirb.com/test
in a psychiatric inpatient
setting includes an occupational therapist. Other disciplines may be included based
on resources available in a particular hospital setting and individual client needs.
This is correct. The typical interdisciplinary treatment teamabirb.com/test
in a psychiatric inpatient
setting includes a recreational therapist. Other disciplines may be included based on
resources available in a particular hospital setting and individual client needs.
This is correct. The typical interdisciplinary treatment team in a psychiatric inpatient
abirb.com/test
setting includes a psychiatric social worker. Other disciplines
may be included based
on resources available in a particular hospital setting and individual client needs.
This is correct. The typical interdisciplinary treatment team in a psychiatric inpatient
setting includes a mental health technician. Other disciplines
may be included based
abirb.com/test
on resources available in a particular hospital setting and individual client needs.
CON: Patient-Centered Care
abirb.com/test
15. Which descriptors are true regarding a therapeutic community?
Select all that apply.
abirb.com/test
1. The unit schedule includes unlimited free time for personal reflection.
2. Unit responsibilities are assigned according to client capabilities.
3. A flexible schedule is determined by client needs.
abirb.com/test
4. The individual is the sole focus of therapy.
5. A democratic form of government exists.
ANS: 2, 5
abirb.com/test
Chapter: Chapter 11, Milieu Therapy—The Therapeutic Community
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 11 - ETB
abirb.com/test
Objective: Discuss conditions that characterize a therapeutic community.
Page: 198
Heading: Conditions That Promote a Therapeutic Community
abirb.com/test
Integrated Processes: Caring
Nursing Process: Implementation
Client Need: Safe and Effective Care Environment
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Patient-Centered Care
Difficulty: Easy
abirb.com/test
1.
2.
3.
4.
5.
Feedback
This is incorrect. Therapeutic communities are structured; unlimited free time is not
provided.
abirb.com/testare assigned
This is correct. In a therapeutic community, the unit responsibilities
according to client capability.
This is incorrect. Therapeutic communities are structured and do not typically have
flexible schedules.
abirb.com/test
This is incorrect. Therapeutic communities provide interventions that focus on
communication and relationship-development skills.
This is correct. In a therapeutic community, a democratic form of government exists.
abirb.com/test
CON: Patient-Centered Care
abirb.com/test
16. Which responsibilities describe those of the psychiatric-mental health nurse on the
interdisciplinary treatment team? Select all that apply.
abirb.com/test
1. Present educational programs for nursing staff.
2. Perform in-depth psychosocial history.
3. Develop one-to-one relationships with clients.
4. Manage the therapeutic milieu on a 24-hour basis.
abirb.com/test
5. Provide input during the development of the treatment plan.
ANS: 3, 4, 5
abirb.com/test
Chapter: Chapter 11, Milieu Therapy—The Therapeutic Community
Objective: Describe the role of the nurse on the interdisciplinary treatment team.
Page: 200
Heading: The Role of the Nurse in Milieu Therapy > Table 12–1abirb.com/test
Integrated Processes: Nursing Process
Nursing Process: Assessment
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Application [Applying]
Core concept: Patient-Centered Care
Difficulty: Moderate
abirb.com/test
Feedback
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 11 - ETB
abirb.com/test
1.
2.
3.
4.
5.
This is incorrect. The psychiatric clinical nurse specialist is responsible for
presenting educational programs for nursing staff.
This is incorrect. The psychiatric social worker is responsible for performing the inabirb.com/test
depth psychosocial history.
This is correct. The psychiatric-mental health nurse’s responsibilities on the
interdisciplinary treatment team include developing one-to-one relationships with
clients.
abirb.com/test
This is correct. The psychiatric-mental health nurse’s responsibilities on the
interdisciplinary treatment team include managing the therapeutic milieu on a 24hour basis.
abirb.com/test
This is correct. The psychiatric-mental health nurse’s responsibilities on the
interdisciplinary treatment team include providing input into interdisciplinary
treatment plans.
abirb.com/test
CON: Patient-Centered Care
abirb.com/test
17. Therapeutic community is based on which of Skinner’s assumptions? Select all that
apply.
abirb.com/test
1. Every interaction is an opportunity for therapeutic intervention.
2. Social interactions and group activities foster behavior change.
3. Peer pressure is a useful and powerful tool.
4. Inappropriate behaviors are dealt with as they occur.
abirb.com/test
5. Physical facilities enhance adaptive coping skills.
ANS: 1, 3, 4
abirb.com/test
Chapter: Chapter 11, Milieu Therapy—The Therapeutic Community
Objective: Identify seven basic assumptions of a therapeutic community.
Page: 197
Heading: Basic Assumptions
abirb.com/test
Integrated Processes: Communication and Documentation
Nursing Process: Assessment
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Comprehension [Understanding]
Core concept: Patient-Centered Care
Difficulty: Easy
abirb.com/test
1.
2.
3.
Feedback
This is correct. Skinner (1979) outlined seven basic assumptions on which a
therapeutic community is based on the assumption that every interaction is an
abirb.com/test
opportunity for therapeutic intervention.
This is incorrect. Skinner (1979) did not believe that social interactions and group
activities foster behavior change.
This is correct. Skinner (1979) outlined seven basic assumptions
on which a
abirb.com/test
therapeutic community is based on the assumption that peer pressure is a useful and
abirb.com/test
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PMHN, 10e
Chapter 11 - ETB
abirb.com/test
4.
5.
powerful tool.
This is correct. Skinner (1979) outlined seven basic assumptions on which a
therapeutic community is based on the assumption that inappropriate behaviors are
abirb.com/test
dealt with as they occur.
This is incorrect. Skinner (1979) did not believe physical facilities enhance adaptive
coping skills.
abirb.com/test
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 12 - ETB
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Chapter 12. Crisis Intervention
abirb.com/test
MULTIPLE CHOICE
abirb.com/test
1. A parent is concerned about her ability to perform in her new role. She is quite
abirb.com/test
anxious and refuses to leave the postpartum unit. To offer effective
client care, a nurse
should recognize which information about this type of crisis?
1. This type of crisis is precipitated by unexpected external stressors.
2. This type of crisis is precipitated by preexisting psychopathology.
abirb.com/test
3. This type of crisis is precipitated by an acute response to an external stressor.
4. This type of crisis is precipitated by normal life-cycle transitions that overwhelm the
client.
abirb.com/test
ANS: 4
Chapter: Chapter 12, Crisis Intervention
Objective: Identify types of crises that occur in people’s lives. abirb.com/test
Page: 210
Heading: Types of Crises > Class 2: Crises of Anticipated Life Transitions
Integrated Processes: Nursing Process: Planning
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Stress
Difficulty: Easy
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. The type of crisis precipitated by an unexpected external stressor
over which the individual has little or no control is known abirb.com/test
as a crisis resulting from
traumatic stress.
This is incorrect. Preexisting pathology can also precipitate a crisis.
This is incorrect. Dispositional crises reflect an acute response
to a situational
abirb.com/test
stressor.
This is correct. This type of crisis is precipitated by normal life-cycle transitions that
overwhelm the client. Reassurance and guidance should be provided as needed, and
abirb.com/test
the client should be referred to services that can provide assistance.
CON: Stress
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 12 - ETB
abirb.com/test
2. A wife brings her husband to an emergency department after an attempt to hang
himself. He is a full-time student and works 8 hours at night to support his family. He
states, “I can’t function any longer under all this stress.” Which type of crisis is the
abirb.com/test
client experiencing?
1. Maturational/developmental crisis
2. Psychiatric emergency crisis
abirb.com/test
3. Anticipated life-transition crisis
4. Traumatic stress crisis
ANS: 2
Chapter: Chapter 12, Crisis Intervention
Objective: Identify types of crises that occur in people’s lives.
Page: 211
Heading: Types of Crises > Class 6: Psychiatric Emergencies
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Stress
Difficulty: Moderate
1.
2.
3.
4.
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
Feedback
This is incorrect. A maturational/developmental crisis occurs in response to failed
attempts to master developmental tasks associated with transitions in the life cycle.
This is correct. The husband is experiencing a psychiatric emergency
abirb.com/test crisis.
Psychiatric emergencies occur when crisis situations result in severe impairment,
incompetence, or inability to assume personal responsibility.
This is incorrect. Anticipated life-transition crises are expected, even events over
abirb.com/test
which the individual may feel a lack of control.
This is incorrect. Crises resulting from traumatic stress are precipitated by an
unexpected external stressor over which the individual has little or no control, and
because of which he or she feels emotionally overwhelmedabirb.com/test
and defeated.
CON: Stress
abirb.com/test
3. A client comes to a psychiatric clinic, experiencing sudden extreme fatigue and
decreased sleep and appetite. The client works 12 hours a day and
rates anxiety as 8/10
abirb.com/test
on a numeric scale. Which long-term outcome is realistic to address the client’s crisis?
1. The client will develop adaptive behaviors by week 1.
2. The client will list five positive self-attributes by week 2.
abirb.com/test
3. The client will examine how childhood events led to this behavior by week 3.
4. The client will return to previous adaptive levels of functioning by week 6.
ANS: 4
Chapter: Chapter 12, Crisis Intervention
abirb.com/test
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 12 - ETB
abirb.com/test
Objective: Identify the role of the nurse in crisis intervention.
Page: 210
Heading: Phases of Crisis Intervention: The Role of the Nurse > Phase 2. Planning of
abirb.com/test
Therapeutic Interventions; Table 13-2, Care Plan for the Client Who Has Experienced a
Traumatic Event
Integrated Processes: Nursing Process: Planning
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Stress
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. This is neither a long-term nor measurable goal.
abirb.com/test
This is incorrect. Although this is client-centered, and measurable,
this is not a longterm goal.
This is incorrect. This may prove difficult to achieve in the short term of three
weeks.
abirb.com/test
This is correct. A realistic long-term outcome for this client would be to return to
previous adaptive levels of functioning. The nurse should work with the client to
develop attainable outcomes related to the client’s current situation. A correctly
abirb.com/test
written outcome is client centered, specific, measurable, and
realistic and contains a
time frame.
CON: Stress
abirb.com/test
abirb.com/test
4. The nurse is a volunteer for the American Red Cross and has visited
victims of a
tornado that occurred a month ago. Many of the area’s adult residents’ responses have
included sadness and an increase in alcohol use, while the children have separation
anxiety to the point of sleeping with their parents. Which is the correctly
written priority
abirb.com/test
nursing diagnosis for this population?
1. Ineffective community coping related to (R/T) natural disaster
2. Anxiety R/T fear of another disaster as evidenced by (AEB) inability to proceed with
abirb.com/test
cleanup
3. Risk for injury R/T hopelessness
4. Risk for low self-esteem R/T loss events
abirb.com/test
ANS: 1
Chapter: Chapter 12, Crisis Intervention
Objective:. Apply the nursing process to care for victims of disasters.
abirb.com/test
Page: 221
Heading: Application of the nursing process to disaster nursing
Integrated Processes: Nursing Process: Analysis
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
abirb.com/test
abirb.com/test
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Chapter 12 - ETB
abirb.com/test
Concept: Stress
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is correct. The priority nursing diagnosis is ineffective community coping, The
AEB factors of increased alcohol use and separation anxiety show that the
abirb.com/test
community has not been able to cope with the loss.
This is incorrect. Although the community may have anxiety, it does not appear to
be fear of another disaster (no verbalization of the community members); this is not
a priority nursing diagnosis.
abirb.com/test
This is incorrect. Although there may be a risk for injury this is not a priority at this
time. The clients do not verbalize hopelessness or injury potential.
This is incorrect. Nurses should prioritize diagnoses and outcomes based on the
potential safety risk to the client and/or others. A correctlyabirb.com/test
written nursing diagnosis
includes actual evidence if the problem is current and does not have evidence if the
situation is potential.
abirb.com/test
CON: Stress
abirb.com/test
5. The nurse is providing care to a client who has become emotionally labile with
paranoia after losing their career and home due to a motor vehicle accident. The nurse
recognizes that the client is at what phase of crisis development?abirb.com/test
1. Phase 1
2. Phase 2
3. Phase 3
abirb.com/test
4. Phase 4
ANS: 4
abirb.com/test
Chapter: Chapter 12, Crisis Intervention
Objective: Describe four phases in the development of a crisis.
Page: 213
Heading: Phases of Crisis Intervention: The Role of the Nurse Phase
4
abirb.com/test
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
abirb.com/test
Concept: Stress
Difficulty: Easy
1.
2.
Feedback
abirb.com/test
This incorrect. In phase 1, the individual is exposed to a precipitating crisis.
Symptoms include increased anxiety and the use of previously employed problemsolving techniques.
abirb.com/test
This is incorrect. In phase 2, previous problem-solving techniques
do not relieve the
stressor, which further increases anxiety. Coping techniques that have worked in the
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 12 - ETB
abirb.com/test
3.
4.
past are attempted, only to create feelings of helplessness when they are not
successful.
This is incorrect. In phase 3, all possible resources, both internal
and external, are
abirb.com/test
called on to resolve the problem and relieve the discomfort. New problem-solving
techniques may be used, and, if effectual, resolutions may occur at this phase, with
the client returning to a higher level, lower level, or the previous level of precrisis
abirb.com/test
functioning.
This is correct. In phase 4, if the resolution does not occur in previous phases,
Caplan states that the “tension mounts beyond a further threshold or its burden
increases over time to a breaking point. Major disorganization
of the individual with
abirb.com/test
drastic results often occurs” (p. 41). Anxiety may reach panic levels. Cognitive
functions are disordered, emotions are labile, and behavior may reflect the presence
of psychotic thinking.
abirb.com/test
CON: Stress
abirb.com/test
6. An involuntarily committed client, when offered a dinner tray, pushes it off the
bedside table onto the floor. Which is the nurse’s priority intervention?
abirb.com/test
1. Initiate forced-medication protocol.
2. Help the client to explore the source of anger.
3. Avoid reinforcement of the behavior.
4. Set firm limits on the behavior.
abirb.com/test
ANS: 4
Chapter: Chapter 12, Crisis Intervention
abirb.com/test
Objective: Describe the steps in crisis intervention
Page: 213
Heading: Phases of Crisis Intervention: The Role of the Nurse > Phase 3. Intervention;
Table 13–2, Care Plan for the Client Who Has Experienced a Traumatic
Event
abirb.com/test
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
abirb.com/test
Concept: Patient-Centered Care
Difficulty: Moderate
1.
2.
3.
Feedback
abirb.com/test
This is incorrect. The priority nursing intervention is to set firm limits on the client’s
behavior. The client’s behavior does not warrant forced medication because pushing
food onto the floor is not a direct safety concern.
abirb.com/test
This is incorrect. The priority nursing intervention is to set firm limits on the client’s
behavior. Exploring the source of anger may be appropriate after the client has
gained emotional control.
This is incorrect. The priority nursing intervention is to setabirb.com/test
firm limits on the client’s
behavior. Ignoring the behavior may further upset the client and does not reinforce
abirb.com/test
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Chapter 12 - ETB
abirb.com/test
4.
appropriate behavior.
This is correct. The priority nursing intervention is to set firm limits on the client’s
behavior.
abirb.com/test
CON: Patient-Centered Care
abirb.com/test
7. The rape crisis nurse has completed several counseling sessions with a client who was
nearly raped while jogging. Which client statement made at the final
session most
abirb.com/test
clearly suggests that the goals of crisis intervention have been met?
1. “You’ve really been helpful. Can I count on you for continued support?”
2. “I use the indoor track on campus and avoid going outside.”
abirb.com/test
3. “I’m really glad I didn’t go home. It would have been hard to come
back.”
4. “I carry mace when I jog. It makes me feel safe and secure.”
ANS: 4
abirb.com/test
Chapter: Chapter 12, Crisis Intervention
Objective: Discuss the goal of crisis intervention.
Page: 214
Heading: Phases of Crisis Intervention: The Role of the Nurse > abirb.com/test
Phase 4. Evaluation of
Crisis Resolution and Anticipatory Planning; Table 13–2, Care Plan for the Client Who
Has Experienced a Traumatic Event
Integrated Processes: Nursing Process: Evaluation
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
Concept: Stress
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
This is incorrect. During the termination phase of counseling,
the client would not
abirb.com/test
rely upon a return to the therapist.
This is incorrect. This does not address the issue of the risk for another assault
attempt.
abirb.com/test
This is incorrect. Although this may be a statement that would provide insight on
how the client feels, it is an insight, not an intervention.
This is correct. The client is describing a plan of action to deal with a potential crisis
abirb.com/test
similar to the one that precipitated this crisis. This statement
indicates that the client
has developed adaptive coping strategies and has achieved the goals of crisis
intervention.
CON: Stress
abirb.com/test
abirb.com/test
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Chapter 12 - ETB
abirb.com/test
8. A despondent client who recently lost her husband of 30 years tearfully states, “I’ll
feel a lot better if I sell my house and move away.” Which nursing reply is most
appropriate?
abirb.com/test
1. “I’m confident you know what’s best for you.”
2. “This may not be the best time for you to make such an important decision.”
3. “Your children will be terribly disappointed to lose their childhood home.”
abirb.com/test
4. “Tell me why you want to make this change.”
ANS: 2
Chapter: Chapter 12, Crisis Intervention
abirb.com/test
Objective: Identify the role of the nurse in crisis intervention.
Page: 213
Heading: Phases of Crisis Intervention: The Role of the Nurse > Phase 3. Intervention;
abirb.com/test
Table 13–2, Care Plan for the Client Who Has Experienced a Traumatic
Event
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Stress
Difficulty: Difficult
1.
2.
3.
4.
abirb.com/test
Feedback
This is incorrect. This does not provide guidance for problem-solving with the client.
This may be an impulsive decision due to a crisis.
This is correct. The nurse should guide the client through the
problem-solving
abirb.com/test
process. The nurse should help the individual confront the source of the problem,
encourage exploration of feelings about aspects of the crisis that cannot be changed,
and encourage the client to discuss changes he or she would like to make. The nurse
abirb.com/test
should also assist the client in determining whether changes
are realistic and if the
timing of those changes is appropriate. This encourages the client to think through
whether the decision is impulsive.
This is incorrect. This does not address the client’s needs nor
does it provide
abirb.com/test
guidance toward a decision.
This is incorrect. Although this uses a therapeutic response, it does not address the
need for guidance toward a less-impulsive decision.
abirb.com/test
CON: Stress
abirb.com/test
9. An inpatient client with a known history of violence suddenly begins to pace. Which
client behavior alerts the nurse to the client’s escalating anger and aggression?
abirb.com/test
1. The client requests their prn medications.
2. The client has a tense facial expression and body language.
3. The client refuses to eat all three meals for the day.
abirb.com/test
4. The client sits in group therapy with back to peers.
abirb.com/test
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Chapter 12 - ETB
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ANS: 2
Chapter: Chapter 12, Crisis Intervention
Objective: Identify the role of the nurse in crisis intervention.
abirb.com/test
Page: 212
Heading: Phases of Crisis Intervention: The Role of the Nurse > Phase 1. Assessment
Integrated Processes: Nursing Process: Assessment
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Stress
Difficulty: Difficult
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. The client is acknowledging the need for a prn medication to cope
abirb.com/test
with the anxiety/crisis.
This is correct. Tense facial expressions and body language may indicate that a
client’s anger is escalating. The nurse should conduct a thorough assessment of the
client’s past and current violent behaviors and develop interventions
abirb.com/test to deescalate
the client’s anger.
This is incorrect The client’s refusal to eat meals is not a sign of pending violence;
rather, it is a behavioral issue or response to a crisis.
This is incorrect. This is a nonaggressive behavior and notabirb.com/test
a sign of a pending
violent outburst.
CON: Stress
abirb.com/test
abirb.com/test
10. Which is the best nursing rationale for holding a debriefing session
with clients and
staff after clients have witnessed a peer being “taken down” after a violent outburst?
1. To reinforce unit rules with the client population
2. To create protocols for the future release of tensions associatedabirb.com/test
with anger
3. To process feelings and concerns related to the witnessed intervention
4. To discuss the client problems that led to inappropriate expressions of anger
abirb.com/test
ANS: 3
Chapter: Chapter 12, Crisis Intervention
Objective: Identify the role of the nurse in crisis intervention.
Page: 213
abirb.com/test
Heading: Phases of Crisis Intervention: The Role of the Nurse > Phase 3. Intervention
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Stress
Difficulty: Moderate
abirb.com/test
Feedback
abirb.com/test
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Chapter 12 - ETB
abirb.com/test
1.
2.
3.
4.
This is incorrect. This is a nontherapeutic communication and would potentiate loss
of communication within the client population.
This is incorrect. The protocols should be in place prior to abirb.com/test
a takedown incident and
developed by staff, not by the clients.
This is correct. The nursing rationale for facilitating a debriefing session with clients
and staff after clients have witnessed a peer being “taken down” after a violent
abirb.com/testintervention.
outburst is to process feelings and concerns related to the witnessed
This is incorrect. This statement would present a confidentiality issue and possibly
prohibit further discussion with the witnesses.
abirb.com/test
CON: Stress
abirb.com/test
MULTIPLE RESPONSE
abirb.com/test
11. Which of the following are most appropriate when performing a nursing assessment
with an individual in crisis? Select all that apply.
abirb.com/test
1. “Tell me, in your own words, what happened.”
2. “What coping methods have you used, and did they work?”
3. “Describe to me what your life was like before this happened.”
4. “Let’s focus on the current problem.”
abirb.com/test
5. “I’ll assist you in selecting functional coping strategies.”
ANS: 1, 2, 3
abirb.com/test
Chapter: Chapter 12, Crisis Intervention
Objective: Identify the role of the nurse in crisis intervention.
Page: 212
Heading: Phases of Crisis Intervention: The Role of the Nurse > abirb.com/test
Phase 1. Assessment
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Stress
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/test
This is correct. The nurse should first assess to gather information regarding the
precipitating stressor of the client’s current crisis.
This is correct. Assessing the client’s prior successful coping mechanisms may help
abirb.com/test
with the progression of the nursing care plan.
This is correct. This assessment would provide an opportunity to help the client find
a possible goal.
abirb.com/testregarding the
This is incorrect. The nurse should first assess to gather information
precipitating stressor of the client’s current crisis. This is a nursing intervention. This
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Chapter 12 - ETB
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5.
would negate any opportunity to discuss any prior coping mechanisms.
This is incorrect. The nurse should first assess to gather information regarding the
precipitating stressor of the client’s current crisis. This is aabirb.com/test
nursing intervention. This
would not be a nursing assessment but rather the development of a plan and goal.
CON: Stress
abirb.com/test
12. Which of the following interventions should the nurse utilizeabirb.com/test
when caring for an
inpatient client who is expressing anger inappropriately? Select all that apply.
1. Maintain a calm demeanor.
2. Clearly delineate the consequences of the behavior.
abirb.com/test
3. Use therapeutic touch to convey empathy.
4. Set firm limits on the behavior.
5. Teach the client to avoid “I” statements related to expression of feelings.
abirb.com/test
ANS: 1, 2, 4
Chapter: Chapter 12, Crisis Intervention
Objective: Identify the role of the nurse in crisis intervention.
abirb.com/test
Page: 213
Heading: Phases of Crisis Intervention: The Role of the Nurse > Phase 3. Intervention;
Table 13–2, Care Plan for the Client Who Has Experienced a Traumatic Event
Integrated Processes: Nursing Process: Implementation
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Stress
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
This is correct. Maintaining a calm demeanor reduces the client’s
anxiety and
abirb.com/test
encourages a sense of safety.
This is correct. Delineating consequences of behavior increases the client’s
awareness of the impact of actions and encourages the client to take responsibility
abirb.com/test
for feelings.
This is incorrect. The use of therapeutic touch may not be appropriate and could
escalate the client’s anger.
abirb.com/test
This is correct. Setting firm limits communicates which behaviors
are acceptable and
those that are not.
This is incorrect. “I” messages encourage the client to express feelings and take
responsibility for them.
abirb.com/test
CON: Stress
abirb.com/test
abirb.com/test
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Chapter 13 - ETB
abirb.com/test
Chapter 13. Assertiveness Training
abirb.com/test
MULTIPLE CHOICE
abirb.com/test
1. During a psychoeducational group on assertiveness training, a client asks, “Why do
we need to learn about this stuff?” Which is the most appropriateabirb.com/test
nursing reply?
1. “Because your doctor requires you to attend this group to learn how to cooperate.”
2. “Being assertive is the ability to stand up for yourself while respecting the rights of
others.”
abirb.com/test
3. “Assertiveness training teaches you how to ask for what you want, when you want it.”
4. “Assertive people are more vocal and place the needs and rights of others before their
own.”
abirb.com/test
ANS: 2
Chapter: Chapter 13, Assertiveness Training
Objective: Define assertive behavior.
Page: 226
Heading: Assertive Communication
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Easy
1.
2.
3.
4.
abirb.com/test
abirb.com/test
abirb.com/test
Feedback
This is incorrect. This does not define assertiveness nor does it open communication
abirb.com/test
with the client.
This is correct. Assertiveness training assists people with maintaining their own selfrespect and meeting their needs while respecting the rights of others.
This is incorrect. This is not the definition of assertiveness.abirb.com/test
This is incorrect. This is the definition of aggressiveness, not assertiveness.
CON: Communication
abirb.com/test
2. Two clients are roommates on an inpatient psychiatric unit. Atabirb.com/test
breakfast, client A,
who had been missing her gold locket, notices client B wearing it. Which does the nurse
recognize as a nonassertive or passive behavioral response from client A?
1. Client A ignores the situation and decides to buy another necklace.
abirb.com/test
2. Client A discusses the situation with her nurse and develops a plan of action.
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Chapter 13 - ETB
abirb.com/test
3. Client A immediately approaches client B and pulls the necklace off her neck.
4. Client A offers to wash client B’s clothes and “accidentally” spills bleach in the
water.
abirb.com/test
ANS: 1
Chapter: Chapter 13, Assertiveness Training
abirb.com/test
Objective: Differentiate among nonassertive, assertive, aggressive,
and passiveaggressive behaviors.
Page: 226
Heading: Basic Human Rights > Response Patterns > Nonassertive
Behavior; Table 14–
abirb.com/test
2, Comparison of Behavioral Response Patterns
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is correct. By ignoring the situation, client A avoids conflict, denies her
feelings, and does not assertively resolve the problem. An individual displaying
nonassertive (sometimes called passive) behavior seeks to abirb.com/test
please others at the
expense of his or her own basic human rights.
This is incorrect. This is not a nonassertive or passive behavior. When the client
recognizes the need to develop a plan of action, this is an example
of assertiveness.
abirb.com/test
This is incorrect. This is an example of aggressive behavior
This is incorrect. This is an example of passive-aggressive behavior.
CON: Communication
abirb.com/test
abirb.com/test
3. A client on an inpatient unit is angry with a peer. During lunch, when the peer is not
looking, the client spits into his soup. How would the nurse document this interaction?
1. “Client is displaying assertive behaviors.”
abirb.com/test
2. “Client is displaying aggressive behaviors.”
3. “Client is displaying passive behaviors.”
4. “Client is displaying passive-aggressive behaviors.”
abirb.com/test
ANS: 4
Chapter: Chapter 13, Assertiveness Training
Objective: Differentiate among nonassertive, assertive, aggressive, and passiveabirb.com/test
aggressive behaviors.
Page: 227
Heading: Basic Human Rights > Response Patterns > Passive-Aggressive Behavior;
abirb.com/test
Table 14–2, Comparison of Behavioral Response Patterns
Integrated Processes: Nursing Process: Assessment
abirb.com/test
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Chapter 13 - ETB
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Easy
1.
2.
3.
4.
abirb.com/test
Feedback
abirb.com/test
This is incorrect. The client is not directly displaying assertive
behaviors, such as
speaking directly to the peer regarding the issue.
This is incorrect. The client is not displaying aggressive behavior, such as
dominating power or humiliating others.
abirb.com/test
This is incorrect. The client is not avoiding the behavior of the peer.
This is correct. The client is displaying passive-aggressive behavior. The client is
indirectly expressing anger by spitting in the soup when the peer is not looking.
abirb.com/test
CON: Communication
abirb.com/test
4. A client continually waits more than an hour before being seen at the mental health
clinic. The client approaches the nurse and states, “When I have to wait for more than an
abirb.com/test
hour to be seen, I feel like my time is not important.” The nurse recognizes
this as what
type of behavior?
1. Aggressive behavior
2. Assertive behavior
abirb.com/test
3. Passive-aggressive behavior
4. Passive behavior
abirb.com/test
ANS: 2
Chapter: Chapter 13, Assertiveness Training
Objective: Define assertive behavior.
Page: 228
abirb.com/test
Heading: Basic Human Rights > Response Patterns > Assertive Behavior; Table 14–2
Comparison of Behavioral Response Patterns
Integrated Processes: Nursing Process: Assessment
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Easy
abirb.com/test
1.
2.
Feedback
This is incorrect. Individuals displaying aggressive response patterns defend their
abirb.com/test
own basic rights by violating the basic rights of others. They say what is on their
mind, often at the expense of others.
This is correct. The client is openly expressing feelings and attempting to correct a
abirb.com/test
stressful situation. Individuals who demonstrate assertive behavior
stand up for their
own rights while protecting the rights of others. Feelings are expressed openly and
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Chapter 13 - ETB
abirb.com/test
3.
4.
honestly.
This is incorrect. Individuals using passive-aggressive behavior respond to others by
appearing passive and accepting of others’ demands while abirb.com/test
behaving in ways that
suggest anger and resentment are their true feelings.
This is incorrect. Individuals who behave in a nonassertive (passive) manner seek to
please others at the expense of their own basic human rights.
abirb.com/test
CON: Communication
abirb.com/test
5. During an assertiveness training group, a client admits to aggressive behaviors. The
client asks for suggestions for how to become more assertive and less aggressive. Which
abirb.com/test
is the most appropriate nursing reply?
1. “Several techniques, including meditation and progressive muscle relaxation, appear
helpful.”
2. “There’s not much that can be done about aggressive behaviorabirb.com/test
because of biological
responses.”
3. “Certain types of medications have been proven effective in promoting assertive
communication.”
abirb.com/test
4. “There are several techniques, including ‘I’ statements and thought
stopping, that
promote assertive behaviors and decrease aggressive behaviors.”
ANS: 4
abirb.com/test
Chapter: Chapter 13, Assertiveness Training
Objective: Discuss the role of the nurse in assertiveness training.
Page: 227
abirb.com/test
Heading: Basic Human Rights > Response Patterns > Assertive Behavior
Integrated Processes: Teaching/Learning
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
abirb.com/test
Concept: Communication
Difficulty: Moderate
1.
2.
3.
4.
abirb.com/test
Feedback
This is incorrect. These suggestions may facilitate anxiety reduction, not increase
confidence with assertiveness.
This is incorrect. This is a false statement regarding aggressive
behavior and gives
abirb.com/test
the client no guidance toward assertiveness.
This is incorrect. This does not guide the client toward behavioral modification to
increase assertive behaviors and decrease aggressive responses.
abirb.com/test
This is correct. This is the most appropriate nursing reply. These techniques promote
assertive behaviors and would help diminish aggressive responses.
CON: Communication
abirb.com/test
abirb.com/test
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Chapter 13 - ETB
abirb.com/test
6. The nurse encounters a client’s angry family member in the hallway. The nurse states
abirb.com/test
“You seem very angry right now. I don’t want to discuss his matter with you while you
are so upset. I will discuss this matter later today.” What is the technique that the nurse
used to avoid manipulation of the family member?
abirb.com/test
1. The nurse asks the family member to clarify the problem.
2. The nurse accepted negative aspects about oneself.
3. The nurse is defusing the situation with a cooling-off period.
4. The nurse is persistently repeating in a calm voice what is wanted.
abirb.com/test
ANS: 3
Chapter: Chapter 13, Assertiveness Training
Objective: Discuss the role of the nurse in assertiveness training.abirb.com/test
Page: 229
Heading: Techniques That Promote Assertive Behavior
Integrated Processes: Teaching/Learning
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Communication
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
This is incorrect. This is an example of inquiring assertively
for more information.
abirb.com/test
This is incorrect. This is an example of agreeing assertively, where the individual
assertively accepts negative aspects about oneself and admits when an error has been
made.
abirb.com/test
This is correct. The nurse is using a defusing technique to put
off further discussion
with an angry individual until he or she is calmer.
This is incorrect. This is an example of responding as a broken record.
abirb.com/test
CON: Communication
abirb.com/test
7. While trying to control aggressive behavior, a client asks an assertiveness training
nurse to give an example of an “I” statement. Which of the following statements is the
best example of this assertive communication technique?
abirb.com/test
1. “I would like to know why you came home late without calling me.”
2. “I hate it when you think you can just come home late without calling.”
3. “I feel angry when you come home late without calling.”
abirb.com/test
4. “I think you don’t care about me, because if you did, you’d call me.”
ANS: 3
Chapter: Chapter 13, Assertiveness Training
Objective: Discuss the role of the nurse in assertiveness training.abirb.com/test
Page: 229
abirb.com/test
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Chapter 13 - ETB
abirb.com/test
Heading: Techniques That Promote Assertive Behavior> Using “I” Statements
Integrated Processes: Teaching/Learning
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: comprehension [Understanding]
Concept: Communication
Difficulty: Easy
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. This is not a tactful statement, as it can make the receiver become
defensive.
abirb.com/test
This is incorrect. This is a passive-aggressive statement in which the speaker appears
to be sulky.
This is correct. “I” statements clearly state one’s feelings and needs without blaming
or demeaning others. “I” statements allow an individual toabirb.com/test
take ownership for his or
her feelings rather than saying they are caused by another person.
This is incorrect. This is a passive-aggressive statement in which the speaker places
the blame for the issue on the receiver.
abirb.com/test
CON: Communication
abirb.com/test
8. After vying for a nurse management position, nurse A is chosen over nurse B. When
nurse manager A calls for staff meetings, nurse B is chronically late
or absent. Nurse B
abirb.com/test
is exhibiting which type of behavior?
1. Passive
2. Assertive
abirb.com/test
3. Aggressive
4. Passive-aggressive
ANS: 4
abirb.com/test
Chapter: Chapter 13, Assertiveness Training
Objective: Differentiate among nonassertive, assertive, aggressive, and passiveaggressive behaviors.
abirb.com/test
Page: 228
Heading: Basic Human Rights > Response Patterns > Passive-Aggressive Behavior;
Table 14–2, Comparison of Behavioral Response Patterns
Integrated Processes: Nursing Process: Assessment
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Comprehension [Understanding]
Concept: Communication
abirb.com/test
Difficulty: Easy
1.
Feedback
abirb.com/test
This is incorrect. Individuals who behave in a passive manner
seek to please others
at the expense of their own basic human rights.
abirb.com/test
abirb.com/test
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2.
3.
4.
This is incorrect. Individuals who demonstrate assertive behavior stand up for their
own rights while protecting the rights of others and express their feelings openly and
honestly.
abirb.com/test
This is incorrect. Individuals who use aggressive response patterns defend their own
basic rights by violating the basic rights of others and often express their feelings
dishonestly and inappropriately.
abirb.com/test
This is correct. The colleague is expressing anger indirectly
by being late or absent
from the meetings. Individuals using passive-aggressive behavior respond to others
by appearing passive and accepting of other’s demands while behaving in ways that
suggest anger and resentment are their true feelings.
abirb.com/test
CON: Communication
abirb.com/test
9. The nurse is providing tools for clients to become more aware of their behavioral
responses. One client states that they have difficulty not blamingabirb.com/test
others for “making me
mad.” The nurse should assign which nursing diagnosis to this client needing assistance
with assertiveness?
1. Disturbed personal identity
abirb.com/test
2. Disturbed thought processes
3. Defensive coping
4. Impaired verbal communication
abirb.com/test
ANS: 3
Chapter: Chapter 13, Assertiveness Training
Objective: Discuss the role of the nurse in assertiveness training.
abirb.com/test
Page: 231
Heading: Role of the Nurse in Assertiveness Training > Assessment
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. There is no indication that the client is having issues with their
personal identity.
abirb.com/test
This is incorrect. There is no indication that the client is having issues with disturbed
thought processes.
This is correct. Defensive coping reflects a self-protective pattern that defends
abirb.com/test
against underlying perceived threats to positive self-regard. Clients who are utilizing
defensive coping lack assertiveness skills.
This is incorrect. The client does not have issues with verbal communication.
abirb.com/test
CON: Patient-Centered Care
abirb.com/test
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abirb.com/test
abirb.com/test
10. Two clients get into an intense argument regarding TV program selections. The
nurse turns off the TV, asks the clients to go to their rooms to cool off, and tells them
they will discuss and attempt to resolve the problem afterward. Which assertive
abirb.com/test
technique is the nurse using?
1. Defusing
2. Clouding or fogging
3. Responding as a broken record
abirb.com/test
4. Shifting from content to process
ANS: 1
abirb.com/test
Chapter: Chapter 13, Assertiveness Training
Objective: Discuss the role of the nurse in assertiveness training.
Page: 229
Heading: Techniques That Promote Assertive Behavior > Defusing
abirb.com/test
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Communication
Difficulty: Easy
1.
2.
3.
4.
Feedback
abirb.com/test
This is correct. Defusing involves putting off further discussion with an angry
individual until he or she is calmer.
This is incorrect. Clouding or fogging involves concurring with the critic’s argument
abirb.com/test
without becoming defensive and without agreeing to change.
This is incorrect. Responding as a “broken record” involves persistently repeating in
a calm voice what is wanted.
This is incorrect. Shifting from content to process involvesabirb.com/test
changing the focus of the
communication from discussing the topic at hand to analyzing what is going on in
the interaction.
CON: Communication
abirb.com/test
abirb.com/test
11. An emergency department nurse, who has worked 10 straight days, is pulled to the
psychiatric unit. Which of the emergency department nurse’s statements represent a
passive-aggressive response?
abirb.com/test
1. “Get someone else to work 3 to 11! I’ve been working 10 days straight, and I need a
break!”
2. “Okay. I’ll do it,” then purposefully leaves paperwork undone when leaving the unit
abirb.com/test
at 11 p.m.
abirb.com/test
abirb.com/test
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abirb.com/test
3. “I have worked 10 days straight, and I cannot work tonight. I will work for you
tomorrow if you need me.”
4. “Yes, I’ll do it. Anything to keep peace with the hospital administration is a good
abirb.com/test
thing.”
ANS: 2
abirb.com/test
Chapter: Chapter 13, Assertiveness Training
Objective: Differentiate among nonassertive, assertive, aggressive, and passiveaggressive behaviors.
Page: 227
abirb.com/test
Heading: Basic Human Rights > Response Patterns > Passive-Aggressive Behavior;
Table 14–2, Comparison of Behavioral Response Patterns
Integrated Processes: Nursing Process: Assessment
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. This is an example of an aggressive response.
This is correct. This is using a passive-aggressive responseabirb.com/test
to indirectly express
anger. Individuals using passive-aggressive behavior respond to others by appearing
passive and accepting of other’s demands while behaving in ways that suggest anger
and resentment are their true feelings.
abirb.com/test
This is incorrect. This is a nonassertive response, as the nurse is attempting to
bargain with the manager.
This is incorrect. This is a nonassertive response, where the nurse is becoming a
abirb.com/test
victim in response to the request.
CON: Communication
abirb.com/test
12. Which best describes the nurse’s use of assertive behavior?
abirb.com/test
1. The nurse attempts to please others and apologizes for awkwardness in a new role.
2. The nurse becomes defensive and angry when peers offer constructive criticism.
3. The nurse has difficulty making decisions and tends to procrastinate.
4. The nurse is open and direct when asked to complete assignments.
abirb.com/test
ANS: 4
Chapter: Chapter 13, Assertiveness Training
abirb.com/test
Objective: Describe techniques that promote assertive behavior.
Page: 228
Heading: Basic Human Rights > Response Patterns > Assertive Behavior; Table 14–2
abirb.com/test
Comparison of Behavioral Response Patterns
Integrated Processes: Nursing Process: Implementation
abirb.com/test
abirb.com/test
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abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Moderate
1.
2.
3.
4.
abirb.com/test
Feedback
abirb.com/test
This is incorrect. Attempting to please others is a nonassertive
behavior.
This is incorrect. Becoming defensive and angry is an aggressive behavior.
This is incorrect. Procrastination is a passive behavior.
This is correct. An assertive response is characterized by open
and honest expression
abirb.com/test
of feelings.
CON: Communication
abirb.com/test
13. The nurse is providing assertiveness training to a client. One abirb.com/test
of the instructions is for
the client to close their eyes and to shout aloud “STOP” to shift ideas from intrusive to
pleasant and desirable. What is the technique called?
1. Defusing
abirb.com/test
2. Thought stopping
3. Clouding or fogging
4. Agreeing assertively
abirb.com/test
ANS: 2
Chapter: Chapter 13, Assertiveness Training
Objective: Demonstrate thought stopping techniques.
abirb.com/test
Page: 227
Heading: Techniques That Promote Assertive Behavior>Thought-Stopping Behaviors
Identification/Implementation
Integrated Processes: Teaching/Learning
abirb.com/test
Client Need: Health Promotion and Maintenance
Cognitive Level: Application [Applying]
Concept: Communication
abirb.com/test
Difficulty: Easy
1.
2.
3.
4.
Feedback
abirb.com/test
This is incorrect. Defusing is a technique to diffuse a potential
conflict by putting off
further discussion with an angry individual until he or she is calmer.
This is correct. Thought stopping is a technique to shift an unwanted recurring
thought toward a pleasant and desirable thought. This is often
taught to clients with
abirb.com/test
low self-esteem that have repetitive negative thoughts of which the mind refuses to
let go.
This is incorrect. Clouding or fogging is concurring with the critic’s argument
abirb.com/test
without becoming defensive and without agreeing to change.
This is incorrect. Agreeing assertively accepts negative aspects about oneself and
abirb.com/test
abirb.com/test
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abirb.com/test
admitting when an error has been made.
CON: Communication
abirb.com/test
abirb.com/test
14. The nurse is assessing a client who had quietly arrived to their
appointment early
only to be ignored by the receptionist for an hour. The client speaks in a hesitant,
monotone voice and states that it is OK, because “there were so many others waiting to
be seen, too.” What type of behavior is the client displaying at this
time?
abirb.com/test
1. Passive-nonassertive
2. Aggressive
3. Assertive
abirb.com/test
4. Passive-aggressive
ANS: 1
Chapter: Chapter 13, Assertiveness Training
abirb.com/test
Objective: Differentiate among nonassertive, assertive, aggressive, and passiveaggressive behaviors.
Page: 228
abirb.com/test
Heading: Response Patterns> nonassertive behavior Integrated Processes:
Teaching/Learning
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Communication
Difficulty: Easy
1.
2.
3.
4.
abirb.com/test
Feedback
This is correct. The client is displaying nonassertive (passive) behaviors by avoiding
unpleasant situations and confrontations with others. The client seldom lets their true
feelings show and often harbors anger and resentment.
abirb.com/test
This is incorrect. The client is not displaying aggressive behaviors, as the client is
not standing up for self and disregarding others’ needs and feelings.
This is incorrect. This client is not able to stand up for self while protecting the
abirb.com/test
rights of others.
This is incorrect. Although the client is displaying passive tendencies, there is no
aggressive response. If the client had used resistant behaviors such as
“forgetfulness” or dawdling, then this would be passive aggressive.
abirb.com/test
CON: Communication
abirb.com/test
15. One nurse confronts another and says, “You are always so talkative in the meetings.
I don’t know why you can’t stay quiet sometimes.” Which reply abirb.com/test
by the other nurse
reflects the technique of clouding or fogging?
abirb.com/test
abirb.com/test
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abirb.com/test
1. “You’re right. I do speak up a lot.”
2. “Sounds to me like you’re agitated and we need to talk. What are you truly angry
about?”
abirb.com/test
3. “Are you offended that I speak up, or because my thoughts are in opposition to
yours?”
4. “I have the right to express my opinion.”
abirb.com/test
ANS: 1
Chapter: Chapter 13, Assertiveness Training
Objective: Describe techniques that promote assertive behavior. abirb.com/test
Page: 230
Heading: Techniques That Promote Assertive Behavior > Clouding/Fogging
Integrated Processes: Nursing Process: Implementation
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is correct. Clouding or fogging involves concurring with the critic’s argument
abirb.com/test
without becoming defensive and without agreeing to change.
This is incorrect. This is an example of shifting from content to process, to change
the focus of the communication from discussing the topic at hand to analyzing what
is actually going on in the interaction.
abirb.com/test
This is incorrect. This is an example of inquiring assertively, to seek additional
information about critical statements.
This is incorrect. This is an example of standing up for one’s basic human rights.
abirb.com/test
CON: Communication
abirb.com/test
16. A teenager gets a C in algebra. The mother angrily states, “All you ever do is listen
to music and text your friends.” The teenager replies, “What is it that you’re really upset
abirb.com/test
about, mom?” Which response pattern is the teenager expressing?
1. Clouding and fogging
2. Shifting from content to process
3. Delaying assertively
abirb.com/test
4. Assuming responsibility for one’s own statements
ANS: 2
abirb.com/test
Chapter: Chapter 13, Assertiveness Training
Objective: Describe techniques that promote assertive behavior.
Page: 229
abirb.com/test
Heading: Techniques That Promote Assertive Behavior > Shifting
From Content to
Process
abirb.com/test
abirb.com/test
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Chapter 13 - ETB
abirb.com/test
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Moderate
1.
2.
3.
4.
abirb.com/test
abirb.com/test
Feedback
This is incorrect. Clouding or fogging involves concurring with the critic’s argument
without becoming defensive and without agreeing to change
This is correct. The teenager’s response reflects the use of abirb.com/test
shifting from content to
process, which involves changing the focus of the communication from discussing
the topic at hand to analyzing what is going on in the interaction.
This is incorrect. Delaying assertively involves putting off further discussion with
abirb.com/test
another individual until one is calmer.
This is incorrect. Assertive communication involves assuming responsibility for
one’s own choices and allowing others to choose for themselves.
abirb.com/test
CON: Communication
abirb.com/test
17. The dean of nursing criticizes a faculty member about views on academic freedom.
The faculty member states, “Are you upset because I believe in academic freedom or
because you don’t?” Which technique is the faculty member using
to promote assertive
abirb.com/test
behavior?
1. Standing up for one’s basic human rights
2. Delaying assertively
abirb.com/test
3. Inquiring assertively
4. Responding assertively with irony
ANS: 3
abirb.com/test
Chapter: Chapter 13, Assertiveness Training
Objective: Describe techniques that promote assertive behavior.
Page: 229
abirb.com/test
Heading: Techniques That Promote Assertive Behavior > Inquiring Assertively
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Communication
Difficulty: Moderate
abirb.com/test
1.
2.
Feedback
This is incorrect. Standing up for one’s basic human rights is a way to avoid
manipulation by others.
This is incorrect. Delaying assertively involves putting offabirb.com/test
further discussion with
another individual until one is calmer.
abirb.com/test
abirb.com/test
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3.
4.
This is correct. The faculty member is using the technique of inquiring assertively,
which involves seeking additional information about critical statements.
This is incorrect. The faculty member is not using irony. abirb.com/test
CON: Communication
abirb.com/test
18. An aggressive nurse manager tells a staff nurse that she has no business rallying staff
to change the schedule. What would be an example of a technique
that the staff nurse
abirb.com/test
could use to stand up for her basic human rights?
1. “What is the real reason that you don’t want the schedule changed?”
2. “Sounds to me like you’re threatened by this change.”
3. “Are you upset because you don’t want to redo the schedule?”abirb.com/test
4. “I have the right to express my opinion about the schedule.”
ANS: 4
abirb.com/test
Chapter: Chapter 13, Assertiveness Training
Objective: Describe techniques that promote assertive behavior.
Page: 229
abirb.com/test
Heading: Techniques That Promote Assertive Behavior > Standing
Up for One’s Basic
Human Rights
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Easy
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. This statement is an example of inquiring assertively.
This is incorrect. This statement is an example of shifting from
content to process.
abirb.com/test
This is incorrect. This statement is an example of an aggressive statement by
implying that the manager is not willing to change.
This is correct. Standing up for one’s basic human rights is effective in responding to
abirb.com/test
criticism and avoiding manipulation by others.
CON: Communication
abirb.com/test
19. A nursing supervisor is scheduling holiday hours. When the supervisor
tells the staff
abirb.com/test
nurse that she needs to work Christmas day, the staff nurse calmly states, “I worked last
Christmas and will not work this Christmas.” When the supervisor says “But I need you
to work,” the nurse repeats “I worked last Christmas and will not work this Christmas.”
abirb.com/test
This is an example of which assertive behavior technique?
1. Shifting from content to process
abirb.com/test
abirb.com/test
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Chapter 13 - ETB
abirb.com/test
2. Standing up for one’s basic rights
3. Responding as a broken record
4. Clouding or fogging
abirb.com/test
ANS: 3
Chapter: Chapter 13, Assertiveness Training
Objective: Describe techniques that promote assertive behavior. abirb.com/test
Page: 229
Heading: Techniques That Promote Assertive Behavior > Responding as a “Broken
Record”
abirb.com/test
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Communication
Difficulty: Easy
1.
2.
3.
4.
Feedback
abirb.com/test
This is incorrect. Shifting from content to process involves changing the focus of the
communication from discussing the topic at hand to analyzing what is going on in
the interaction.
This is incorrect. Standing up for one’s basic human rightsabirb.com/test
is effective in responding
to criticism and avoiding manipulation by others.
This is correct. This is an example of responding as a broken record, which involves
persistently repeating in a calm voice what is wanted.
abirb.com/test
This is incorrect. Clouding or fogging is concurring with the critic’s argument
without becoming defensive and without agreeing to change.
CON: Communication
abirb.com/test
abirb.com/test
20. A nurse has identified the following nursing diagnosis: “Ineffective communication
related to lack of assertiveness skills as evidenced by inability to state needs.” Which
statement encourages the client to acknowledge the priority of this problem?
abirb.com/test
1. “Are you having thoughts of harming yourself or others?”
2. “With whom are you least assertive?”
3. “On a scale of 1 to 10, rank the importance of being assertive.”
4. “When are you available to attend the assertiveness training class?”
abirb.com/test
ANS: 3
Chapter: Chapter 13, Assertiveness Training
abirb.com/test
Objective: Discuss the role of the nurse in assertiveness training.
Page: 226
Heading: Assertive Communication
abirb.com/test
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
abirb.com/test
abirb.com/test
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abirb.com/test
Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Difficult
1.
2.
3.
4.
abirb.com/test
Feedback
This is incorrect. This would be appropriate for a client who is at risk for self-harm
abirb.com/test
and does not address the communication issue.
This is incorrect. This is not focused on the communication issues, per the diagnosis.
This is correct. This nursing statement encourages the client to evaluate objectively
the priority of being assertive. It is important in patient-centered
care for the client to
abirb.com/test
prioritize his or her goals for treatment.
This is incorrect. Although this may facilitate empowerment for the client, it does
not address the communication issue.
abirb.com/test
CON: Patient-Centered Care
abirb.com/test
21. Which of the following are behavioral components of assertive communication?
1. Active listening
abirb.com/test
2. “You” statements
3. Closed posture
4. Continuous direct eye contact
abirb.com/test
ANS: 1
Chapter: Chapter 13, Assertiveness Training
Objective: Differentiate among nonassertive, assertive, aggressive, and passiveabirb.com/test
aggressive behaviors.
Page: 229
Heading: Behavioral Components of Assertive Behavior > Listening
Integrated Processes: Nursing Process: Implementation
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Comprehension [Understanding]
Concept: Communication
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/testfull attention by
This is correct. Assertive listening means giving the other individual
making eye contact, nodding to indicate acceptance of what is said, and taking time
to understand the message before responding.
This is incorrect. “You” statements are accusatory and put abirb.com/test
the receiver on the
defensive. Listening is a behavioral component of assertive communication.
This is incorrect. A slumped posture conveys passivity or nonassertiveness.
Listening is a behavioral component of assertive communication.
abirb.com/test
This is incorrect. Individuals feel uncomfortable when someone
stares at them
continuously and intently. Intermittent eye contact (i.e., looking directly at the
abirb.com/test
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Chapter 13 - ETB
abirb.com/test
person to whom one is speaking but looking away now and then) is a behavioral
component of assertive communication.
abirb.com/test
CON: Communication
abirb.com/test
22. A client is experiencing high stress. The client states, “My boss treats me like a
doormat and thinks nothing of demanding frequent overtime.” Which nursing
intervention is most appropriate?
abirb.com/test
1. To incorporate the family support system into the client’s plan of care
2. To teach thought-reframing techniques
3. To encourage the client to seek other employment
abirb.com/test
4. To teach the client how to use “I” statements
ANS: 4
Chapter: Chapter 13, Assertiveness Training
abirb.com/test
Objective: Discuss the role of the nurse in assertiveness training.
Page: 230
Heading: Techniques That Promote Assertive Behavior > Using “I” Statements
abirb.com/test
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Communication
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
This is incorrect. This would further exacerbate the client’sabirb.com/test
inability to speak
assertively.
This is incorrect. This would be appropriate for a thought-stopping technique, but it
does not appear that the client is having these issues.
abirb.com/test
This is incorrect. This would not help the client with assertiveness issues, and the
client’s nonassertiveness would not be resolved.
This is correct. The ability to use “I” statements is essential in assertive
abirb.com/test
communication.
CON: Communication
abirb.com/test
MULTIPLE RESPONSE
abirb.com/test
abirb.com/test
23. A nurse is caring for four clients. Which of the following clients
are most likely to
have difficulty being assertive? Select all that apply.
abirb.com/test
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Chapter 13 - ETB
abirb.com/test
1. A 20-year-old woman who completes classmates’ homework.
2. A 69-year-old widow who is socially isolated
3. A 17-year-old boy with conduct disorder
abirb.com/test
4. A 45-year-old successful executive
5. A 50-year-old diagnosed with narcissistic personality disorder
abirb.com/test
ANS: 1, 2, 3
Chapter: Chapter 13, Assertiveness Training
Objective: Discuss the role of the nurse in assertiveness training.
Page: 227
abirb.com/test
Heading: Response Patterns
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Analysis [Analyzing]
Concept: Communication
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
5.
Feedback
This is correct. The woman completing college homework assignments for others
may be having difficulty assertively saying “no.”
abirb.com/test
This is correct. The widow who is socially isolated may lack
the necessary skills to
communicate her needs.
This is correct. The boy with a conduct disorder is likely to demonstrate aggressive
behaviors.
abirb.com/test
This is incorrect. The business executive is one of the least likely to have difficulty
being assertive.
This is incorrect. Although the client may be more aggressive, the client diagnosed
abirb.com/test
with narcissistic personality disorder is one of the least likely
to have difficulty being
assertive.
CON: Communication
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
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Chapter 14 - ETB
abirb.com/test
Chapter 14. Promoting Self-Esteem
abirb.com/test
MULTIPLE CHOICE
abirb.com/test
1. A nurse is working in a nursing home. How can this nurse best foster self-esteem in
the residents of this facility?
abirb.com/test
1. Allowing them to remain in their rooms as much as they desire
2. Administering antianxiety medications as ordered
3. Providing choices when appropriate
abirb.com/test
4. Teaching assertiveness skills and self-esteem principles
ANS: 3
Chapter: Chapter 14, Promoting Self-Esteem
abirb.com/test
Objective: Apply the nursing process with clients who are experiencing disturbances in
self-esteem.
Page: 239
abirb.com/test
Heading: Components of Self-Concept
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Patient-Centered Care
Difficulty: Easy
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. This may provide a sense of power, but this would prohibit social
interaction with others.
abirb.com/test
This is incorrect. This may decrease their overall anxiety but
would not foster selfesteem or personal empowerment.
This is correct. This answer fosters the development of self-esteem. A sense of
having some power and control over one’s life enhances self-esteem.
abirb.com/test
This is incorrect. This would not facilitate a sense of having power over one’s life.
CON: Patient-Centered Care
abirb.com/test
2. A client shows a nurse a piece of artwork that took 3 days to create.
How will this
abirb.com/test
achievement improve the client’s self-esteem?
1. By providing a framework for assertive behavior
2. By providing an expression of feelings and a sense of competence and pride
abirb.com/test
3. By providing a positive perception of body image
4. By providing appropriate boundaries for relationship establishment
abirb.com/test
abirb.com/test
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Chapter 14 - ETB
abirb.com/test
ANS: 2
Chapter: Chapter 14, Promoting Self-Esteem
abirb.com/test
Objective: Discuss influencing factors in the development of self-esteem
and its
progression through the lifespan.
Page: 239
Heading: Components of Self-Concept
abirb.com/test
Integrated Processes: Nursing Process: Evaluation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Self
Difficulty: Easy
1.
2.
3.
4.
Feedback
abirb.com/test
This is incorrect. If this were to provide a framework for assertive behavior, the
client would be able to actively listen to another person’s opinion regarding the
artwork. This is not the focus of this achievement.
abirb.com/test
This is correct. This achievement improves self-esteem by providing an expression
of feelings and a sense of competence and pride.
This is incorrect. This does not pertain to the client’s body image. If it were to
abirb.com/test
pertain to body image, it may be a piece of artwork depicting
how the client
perceives self or their body.
This is incorrect. If the client were to offer this artwork to the nurse, it would
provide an opportunity to discuss boundaries (gift giving) for
relationship
abirb.com/test
establishment.
CON: Self
abirb.com/test
3. A nurse is running a group on self-esteem. A client asks, “Where
does self-esteem
abirb.com/test
come from?” Which is the most appropriate nursing reply?
1. “Factors over the life span influence the development and maintenance of selfesteem.”
abirb.com/test
2. “Self-esteem is determined by factors outside of an individual’s
control.”
3. “Self-esteem is established in childhood and remains relatively fixed throughout life.”
4. “Genetics are the single largest contributor to an individual’s self-esteem.”
abirb.com/test
ANS: 1
Chapter: Chapter 14, Promoting Self-Esteem
Objective: This statement does not improve self-esteem.
Page: 239
Heading: Components of Self-Concept
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
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Chapter 14 - ETB
abirb.com/test
Concept: Self
Difficulty: Easy
1.
2.
3.
4.
abirb.com/test
Feedback
This is correct. Self-esteem refers to the degree of regard or respect that individuals
have for themselves and is a measure of worth that they place on their abilities and
judgments. Many factors influence the development of self-esteem
over a person’s
abirb.com/test
life span.
This is incorrect. Self-esteem is defined as one’s personal perception, not the
perception of the outside world.
abirb.com/test
This is incorrect. The foundation for self-esteem is built during the individual’s
childhood but is adjusted throughout an individual’s life span.
This is incorrect. While genetics may contribute a small amount to the individual’s
abirb.com/test
self-esteem, self-esteem is built during an individual’s childhood
and maintained
through life experiences and personal perceptions.
CON: Self
abirb.com/test
abirb.com/test
4. In what way should a nurse expect a school-age child to gain positive
self-esteem,
according to Erikson’s psychosocial developmental stages?
1. Through basic need fulfillment and environmental predictability
2. Through exploration and experimentation to build self-confidence
in ability
abirb.com/test
3. Through positive reinforcement of creativity and recognition of performance
4. Through receiving recognition when learning, competing, and performing
successfully
abirb.com/test
ANS: 4
Chapter: Chapter 14, Promoting Self-Esteem
Objective: Discuss influencing factors in the development of self-esteem
and its
abirb.com/test
progression through the lifespan.
Page: 239
Heading: Development of Self-Esteem> Developmental Progression of Self-Esteem
abirb.com/test
Through the Life Span
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Self
Difficulty: Easy
1.
2.
abirb.com/test
Feedback
This is incorrect. This would be a component of Erikson’s trust versus mistrust,
which is a task specific to infancy (birth to 18 months).
This is incorrect. This is the stage of autonomy versus shame
and doubt, specific for
abirb.com/test
the age of 18 months to 3 years.
abirb.com/test
abirb.com/test
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Chapter 14 - ETB
abirb.com/test
3.
4.
This is incorrect. This is the stage of initiative versus guilt for the age group of 3 to 6
years.
This is correct. The nurse should expect a school-age child to gain self-esteem
abirb.com/test
through receiving recognition when learning, competing, and
performing
successfully.
CON: Self
abirb.com/test
abirb.com/test
5. The nurse is working with a 15-year-old client suffering from low self-esteem.
According to Erikson’s psychosocial developmental theory, which factor has most likely
influenced this client’s self-esteem?
abirb.com/test
1. Regret over life choices
2. Lack of personal concern for others
3. Inconsistent, overly harsh, or absent parental discipline
4. Parental labeling of the child as “good” regardless of his or her behavior
abirb.com/test
ANS: 3
Chapter: Chapter 14, Promoting Self-Esteem
abirb.com/test
Objective: Discuss influencing factors in the development of self-esteem
and its
progression through the lifespan.
Page: 239
Heading: Development of Self-Esteem
abirb.com/test
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
abirb.com/test
Concept: Self
Difficulty: Easy
1.
2.
3.
4.
Feedback
abirb.com/test
This is incorrect. According to Erikson’s psychosocial developmental theory, regret
over life choices probably has not influenced this client’s self-esteem the most. This
would be indicative of ego integrity versus despair of the older adult.
abirb.com/test theory, lack of
This is incorrect. According to Erikson’s psychosocial developmental
personal concern for others probably has not influenced this client’s self-esteem the
most. This would be indicative of intimacy versus isolation of the young adult.
This is correct. According to Erikson’s psychosocial developmental
abirb.com/testtheory,
inconsistent, overly harsh, or absent parental discipline probably has influenced this
client’s self-esteem the most.
This is incorrect. According to Erikson’s psychosocial developmental theory,
parental labeling of the child as “good” regardless of his orabirb.com/test
her behavior probably
has not influenced this client’s self-esteem the most. This would be indicative of
initiative versus guilt of the young child.
abirb.com/test
CON: Self
abirb.com/test
abirb.com/test
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Chapter 14 - ETB
abirb.com/test
abirb.com/test
6. On the basis of Erikson’s theory, how should a nurse encourage
a 40-year-old client
to improve self-esteem?
1. Encourage the client to review life goals and accomplishments.
2. Encourage the client to volunteer at a school, reading to underprivileged
abirb.com/test children.
3. Encourage the client to form lasting intimate relationships.
4. Encourage the client to seek recognition for task achievement.
abirb.com/test
ANS: 2
Chapter: Chapter 14, Promoting Self-Esteem
Objective: Discuss influencing factors in the development of self-esteem and its
progression through the lifespan.
abirb.com/test
Page: 244
Heading: The Nursing Process
Integrated Processes: Nursing Process: Implementation
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
Concept: Self
Difficulty: Easy
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. Encouraging the 40-year-old client to review life goals and
abirb.com/test
accomplishments does not lead to increased self-esteem. This would be indicated for
an older adult for ego integrity versus despair.
This is correct. Encouraging the 40-year-old client to volunteer at a school, reading
abirb.com/test
to underprivileged children, can assist in increasing self-esteem.
This would be
indicated for generativity versus stagnation for the middle-age adult.
This is incorrect. Encouraging the 40-year-old client to form lasting intimate
relationships does not help increase self-esteem. This would
be indicated for
abirb.com/test
intimacy versus isolation for the young adult.
This is incorrect. Encouraging the 40-year-old client to seek recognition for task
achievement does not promote an increase in self-esteem. This would be indicated
abirb.com/test
for the young child for initiative versus guilt.
CON: Self
abirb.com/test
7. Which is an appropriate initial nursing intervention for a client with chronic low selfabirb.com/test
esteem?
1. Assessing the content of negative self-talk
2. Administering anxiolytic medications
3. Using reassurance and physical touch
abirb.com/test
4. Using distraction techniques
abirb.com/test
abirb.com/test
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Chapter 14 - ETB
abirb.com/test
ANS: 1
Chapter: Chapter 14, Promoting Self-Esteem
abirb.com/test
Objective: Apply the nursing process with clients who are experiencing
disturbances in
self-esteem.
Page: 244
Heading: The Nursing Process
abirb.com/test
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Self
Difficulty: Easy
1.
2.
3.
4.
Feedback
abirb.com/test
This is correct. Assessing the content of negative self-talk is an appropriate initial
nursing intervention. By acknowledging and guiding the client toward recognition of
negative self-talk, the nurse can then guide the client toward stopping the negative
abirb.com/test
self-talk.
This is incorrect. Administering anxiolytic medications is not an appropriate initial
nursing intervention.
abirb.com/test
This is incorrect. Using reassurance and physical touch is not
an appropriate initial
nursing intervention.
This is incorrect. Using distraction techniques is not an appropriate initial nursing
intervention.
abirb.com/test
CON: Self
abirb.com/test
8. A 30-year-old client diagnosed with depression has been exclusively cared for and
financially subsidized by his parent since age 17 years. According
to Erikson’s theory,
abirb.com/test
the nurse recognizes that the client has been unsuccessful in meeting which
developmental task?
1. Trust
abirb.com/test
2. Initiative
3. Intimacy
4. Ego integrity
abirb.com/test
ANS: 3
Chapter: Chapter 14, Promoting Self-Esteem
Objective: Discuss influencing factors in the development of self-esteem and its
abirb.com/test
progression through the lifespan.
Page: 239
Heading: Development of self-esteem
Integrated Processes: Nursing Process: Analysis
abirb.com/test
Client Need: Psychosocial Integrity
abirb.com/test
abirb.com/test
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Chapter 14 - ETB
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Self
Difficulty: Easy
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. According to Erikson’s theory, the client has been successful in
meeting the trust task. This would have been accomplishedabirb.com/test
during infancy.
This is incorrect. According to Erikson’s theory, the client has been successful in
meeting the initiative task. This is a task for preschool-age children.
This is correct. According to Erikson’s theory, the client has been unsuccessful in
abirb.com/test
meeting the intimacy task. The client’s relationship with his mother has contributed
to failing completion of the developmental task of intimacy in Erikson’s stage of
intimacy versus isolation (20 to 30 years). This has resulted in behaviors such as
withdrawal, social isolation, aloneness, and the inability toabirb.com/test
form lasting
relationships, leading to his diagnosis of depression.
This is incorrect. According to Erikson’s theory, this task would be appropriate for
the client’s parent (older adult), not the client.
abirb.com/test
CON: Self
abirb.com/test
9. A 40-year-old client has never experienced an intimate relationship. A nursing student
tells an instructor that this client remains in Erikson’s developmental
stage of intimacy
abirb.com/test
versus isolation. What is the instructor’s most appropriate reply?
1. “Erikson’s stages of development are assessed by chronological age, not task
achievement. This client is in the generativity versus stagnation stage, which occurs
abirb.com/test
from 30 to 65 years of age.”
2. “Erikson’s stages of development are assessed by task achievement, not chronological
age. This client is in the intimacy versus isolation stage, which occurs from 20 to 30
years of age.”
abirb.com/test
3. “Erikson’s stages of development are assessed by task achievement, not chronological
age. This client is in the generativity versus stagnation stage, which occurs from 30 to 65
years of age.”
abirb.com/test
4. “Erikson’s stages of development are assessed by chronological
age, not task
achievement. This client is in the intimacy versus isolation stage, which occurs from 20
to 30 years of age.”
abirb.com/test
ANS: 1
Chapter: Chapter 14, Promoting Self-Esteem
Objective: Discuss influencing factors in the development of self-esteem and its
abirb.com/test
progression through the lifespan.
Page: 239
Heading: Development of Self-Esteem
Integrated Processes: Teaching and Learning
abirb.com/test
Client Need: Psychosocial Integrity
abirb.com/test
abirb.com/test
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Chapter 14 - ETB
abirb.com/test
Cognitive Level: Analysis [Analyzing]
Concept: Self
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is correct. Erikson’s stages of development are assessed by chronological age,
not task achievement. This client is in Erikson’s stage of generativity
abirb.com/test versus
stagnation because she is 40 years old. The student has failed to recognize that even
though the client did not successfully achieve the intimacy task of the intimacy
versus isolation stage, the client must now be assessed at the age-appropriate
abirb.com/test
developmental stage of generativity versus stagnation.
This is incorrect. Erikson’s stages of development are assessed by chronological age,
not task achievement. The client is not in the intimacy versus isolation stage, which
abirb.com/test
occurs from 20 to 30 years of age.
This is incorrect. The client is not in the generativity versus stagnation stage, which
occurs from 30 to 65 years of age.
This is incorrect. The client is not in the intimacy versus isolation
stage, which
abirb.com/test
occurs from 20 to 30 years of age.
CON: Self
abirb.com/test
10. A home health nurse visits an 18-year-old client who lives with
his parent. The client
abirb.com/test
has been assessed as having low self-esteem. The nurse refers the client for individual
counseling. During the next home visit, which assessed client behavior clearly indicates
treatment success?
abirb.com/test
1. The client wants to buy a dog but has not yet asked his parent’s
permission.
2. The client asks his parent for permission to buy a dog.
3. The client tells his parent he plans to buy a dog.
4. The client buys a dog and hides it in the garage.
abirb.com/test
ANS: 3
Chapter: Chapter 14, Promoting Self-Esteem
abirb.com/test
Objective: Describe the verbal and nonverbal manifestations of low
self-esteem.
Page: 242
Heading: Manifestations of Low Self-Esteem
Integrated Processes: Nursing Process: Evaluation
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Self
abirb.com/test
Difficulty: Easy
1.
Feedback
This is incorrect. This statement does not indicate that treatment
has been successful,
abirb.com/test
as the client seems hesitant to obtain parental approval.
abirb.com/test
abirb.com/test
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Chapter 14 - ETB
abirb.com/test
2.
3.
4.
This is incorrect. This statement does not indicate a change in the client’s status, as
the client is dependent upon parental approval.
This is correct. This statement indicates an increase in self-esteem. When the client
abirb.com/test
tells his mother he plans to buy a dog, he is making decisions
and taking on
responsibilities. This indicates an increase in self-confidence and therefore selfesteem.
This is incorrect. This behavior does not indicate an increase
in self-esteem, as it
abirb.com/test
does not indicate assertive communication of the client’s wishes.
CON: Self
abirb.com/test
abirb.com/test
11. A 40-year-old client lives with her parents. She has a high-school
diploma and works
at a low-paying job. Her parents give her a weekly allowance to supplement her income.
How should the nurse classify their client-parent boundaries?
1. Loose
abirb.com/test
2. Rigid
3. Flexible
4. Enmeshed
abirb.com/test
ANS: 4
Chapter: Chapter 14, Promoting Self-Esteem
Objective: Discuss the concept of boundaries and its relationshipabirb.com/test
to self-esteem
Page: 242
Heading: Manifestations of Low Self-Esteem
Integrated Processes: Nursing Process: Assessment
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Self
Difficulty: Easy
abirb.com/test
1.
2.
3.
Feedback
This is incorrect. The client-parent boundary is not loose. The client and her parents
are overly dependent. The parents control too many aspectsabirb.com/test
of the client’s life. Their
boundaries are blurred so that it is hard for the client to differentiate her wants and
needs from those of her parents. The client-parent boundaries are enmeshed.
This is incorrect. The client-parent boundary is not rigid. The
client and her parents
abirb.com/test
are overly dependent. The parents control too many aspects of the client’s life. Their
boundaries are blurred so that it is hard for the client to differentiate her wants and
needs from those of her parents. The client-parent boundaries are enmeshed.
abirb.com/test
This is incorrect. The client-parent boundary is not flexible.
The client and her
parents are overly dependent. The parents control too many aspects of the client’s
life. Their boundaries are blurred so that it is hard for the client to differentiate her
wants and needs from those of her parents. The client-parent
boundaries are
abirb.com/test
enmeshed.
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 14 - ETB
abirb.com/test
4.
This is correct. The client-parent boundary is enmeshed. The client and her parents
are overly dependent. The parents control too many aspects of the client’s life. Their
boundaries are blurred so that it is hard for the client to differentiate her wants and
abirb.com/test
needs from those of her parents.
CON: Self
abirb.com/test
12. A parent tells his 5-year-old, “Today, instead of picking flowers in the outfield, let’s
abirb.com/test
try to catch a ball.” The child subsequently pays attention and catches a ball. Which
principle of building self-esteem has the parent implemented?
1. A sense of competence
2. Unconditional love
abirb.com/test
3. Realistic goals
4. Reality orientation
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ANS: 3
Chapter: Chapter 14, Promoting Self-Esteem
Objective: Discuss the concept of boundaries and its relationship to self-esteem.
abirb.com/test
Page: 239
Heading: Development of Self-Esteem
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Self
Difficulty: Easy
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. The parent has not implemented a sense of competence. The parent
would have praised the child for catching the ball.
abirb.com/test
This is incorrect. The parent has not implemented unconditional love. An example of
stating unconditional love is, “I love you no matter how you play.”
This is correct. The parent has implemented realistic goals. The parent did not
demand that his child catch a ball; rather, he stated that he abirb.com/test
wanted the child to try to
catch the ball.
This is incorrect. The parent has not implemented reality orientation. There is no
indication that the child is fantasizing while in the outfield.abirb.com/test
CON: Self
abirb.com/test
13. The nurse is providing care to the client who has just retired from a successful law
practice. Which of the following would be the client’s possible lost
component of selfabirb.com/test
concept?
abirb.com/test
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Chapter 14 - ETB
abirb.com/test
1. Body image
2. Moral-ethical self
3. Self-consistency
4. Self-ideal
abirb.com/test
ANS: 3
Chapter: Chapter 14, Promoting Self-Esteem
Objective: Identify and define components of the self-concept.
Page: 239
Heading: Components of Self-Concept
Integrated Processes: Nursing Process: Evaluation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Self
Difficulty: Easy
1.
2.
3.
4.
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abirb.com/test
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Feedback
abirb.com/test
This is incorrect. There is no indication that the client’s body image is at risk for
changes. This would have occurred if the client had undergone a radical procedure
that would have altered their body (e.g., mastectomy, amputation of a limb).
abirb.com/test
This is incorrect. There is no indication that the client is losing
their moral-ethical
self. This would have occurred if the client had broken a law or had gone against
their belief system.
This is correct. The client has to now let go of their old image
of a lawyer to now a
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retiree.
This is incorrect. This would be an appropriate response if the client stated that he or
she was unable to achieve his or her ideals or self-expectations.
abirb.com/test
CON: Self
abirb.com/test
14. A client has continual problematic relationships and rejects others before possibly
being rejected. The client states, “I am afraid of failing in my job responsibilities.”
abirb.com/test
Which correctly written nursing diagnosis should be prioritized for
this client?
1. Poor self-esteem related to (R/T) negative self-image as evidenced by (AEB) fear of
failure
2. Altered thought processes R/T anxiety AEB delusions
abirb.com/test
3. Role confusion R/T rejection and poor job productivity
4. High risk for violence: self-directed R/T rejection of others
abirb.com/test
ANS: 1
Chapter: Chapter 14, Promoting Self-Esteem
Objective: Apply the nursing process with clients who are experiencing disturbances in
self-esteem.
abirb.com/test
Page: 244
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PMHN, 10e
Chapter 14 - ETB
abirb.com/test
Heading: The Nursing Process
Integrated Processes: Nursing Process: Analysis
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Self
Difficulty: Moderate
abirb.com/test
abirb.com/test
1.
2.
3.
4.
Feedback
This is correct. A nursing diagnosis of “poor self-esteem R/T negative self-image
AEB fear of failure” should be prioritized.
abirb.com/test
This is incorrect. “Altered thought processes R/T anxiety AEB delusions” is not the
priority nursing diagnosis. There is no indication that the client has delusions.
This is incorrect. “Role confusion R/T rejection and poor job productivity” is not the
abirb.com/test
priority nursing diagnosis. There is no indication that the client
has role confusion in
this scenario.
This is incorrect. “High risk for violence: self-directed R/T rejection of others” is not
the priority nursing diagnosis. There is no indication that the
client is at high risk for
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violence.
CON: Self
abirb.com/test
MULTIPLE RESPONSE
abirb.com/test
abirb.com/test
15. A nurse is caring for a client who has recently undergone a radical
prostatectomy.
Which of the following should the nurse recognize as objective symptoms of low selfesteem? Select all that apply.
1. Withdrawal from activities
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2. Decrease in self-care behaviors
3. Poor eye contact
4. Reports of pain
abirb.com/test
5. Poor posture
ANS: 1, 2, 3, 5
Chapter: Chapter 14, Promoting Self-Esteem
abirb.com/test
Objective: Describe the verbal and nonverbal manifestations of low self-esteem.
Page: 242
Heading: Manifestations of Low Self-Esteem
abirb.com/test
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
Concept: Self
abirb.com/test
Difficulty: Easy
abirb.com/test
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PMHN, 10e
Chapter 14 - ETB
abirb.com/test
1.
2.
3.
4.
5.
Feedback
This is correct. Withdrawal from activities is an objective symptom of low selfabirb.com/test
esteem.
This is correct. A decrease in self-care behaviors is an objective symptom of low
self-esteem.
abirb.com/test
This is correct. Poor eye contact is an objective symptom of
low self-esteem.
This is incorrect. Reports of pain are not an objective symptom of low self-esteem.
A report of pain should be evaluated as a physical issue before being attributed to
low self-esteem. This is also a subjective assessment finding.
abirb.com/test
This is correct. Poor posture is an objective symptom of low self-esteem.
CON: Self
abirb.com/test
16. A 47-year-old mother of two has recently undergone a radicalabirb.com/test
mastectomy. She
refuses to see anyone and remains isolated and withdrawn. Which of the following may
be relevant nursing diagnoses for this client? Select all that apply.
1. Disturbed body image
abirb.com/test
2. Situational low self-esteem
3. Ineffective coping
4. Altered thought processes
5. Altered sensory perception
abirb.com/test
ANS: 1, 2, 3
Chapter: Chapter 14, Promoting Self-Esteem
abirb.com/test
Objective: Discuss influencing factors in the development of self-esteem
and its
progression through the lifespan.
Page: 244
Heading: The Nursing Process
abirb.com/test
Integrated Processes: Nursing Process: Analysis
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
abirb.com/test
Concept: Self
Difficulty: Esteem
1.
2.
3.
4.
5.
Feedback
abirb.com/test
This is correct. The mastectomy is likely to disturb the client’s body image.
Disturbed body image may be a relevant nursing diagnosis.
This is correct. Situational low self-esteem may be a relevant nursing diagnosis.
abirb.com/test
This is correct. Ineffective coping may be a relevant nursing diagnosis
This is incorrect. Altered thought processes is not a relevant nursing diagnosis.
There is no indication that the client is experiencing an altered thought process.
abirb.com/test
This is incorrect. Altered sensory perception is not a relevant
nursing diagnosis.
There is no indication that the client is experiencing an altered sensory perception.
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PMHN, 10e
Chapter 14 - ETB
abirb.com/test
CON: Self
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 15 - ETB
Chapter 15. Anger and Aggression Management
abirb.com/test
abirb.com/test
MULTIPLE CHOICE
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1. A student nurse has just entered a psychiatric rotation. The student asks a nursing
instructor, “How will we know if someone may get violent?” Which
is the most
abirb.com/test
appropriate reply by the nursing instructor?
1. “You can’t really say for sure. There are limited indicators of potential violence.”
2. “Certain behaviors indicate a potential for violence, such as rigid posture, clenched
abirb.com/test
fists, and raised voice.”
3. “Any client can become violent, so be aware of your surroundings at all times.”
4. “When a client suddenly becomes quiet, is withdrawn, and maintains a flat affect, this
is an indicator of potential violence.”
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ANS: 2
Chapter: Chapter 15, Anger and Aggression Management
abirb.com/test
Objective: Discuss predisposing factors to the maladaptive expression
of anger.
Page: 252
Heading: Predisposing Factors to Anger and Aggression > Environmental Factors
Integrated Processes: Teaching and Learning
abirb.com/test
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Comprehension [Understanding]
Concept: Violence
abirb.com/test
Difficulty: Easy
1.
2.
3.
4.
Feedback
This is incorrect. There are many indicators of potential violence,
many of which are
abirb.com/test
considered “prodromal.”
This is correct. The most appropriate statement by the instructor is “Certain
behaviors indicate a potential for violence. They are labeled as a ‘prodromal
abirb.com/test
syndrome’ and include rigid posture, clenched fists, and raised
voice.” Rigid posture,
clenched fists, and raised voice are predictors of violent behavior.
This is incorrect. Although the prudent nurse and student would be aware of their
surroundings, there are indicators of potential violence thatabirb.com/test
the staff should know to
promote safety.
This is incorrect. This behavior is not typically a sign for the “prodromal syndrome”
of pending violence.
abirb.com/test
CON: Violence
abirb.com/test
abirb.com/test
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Chapter 15 - ETB
abirb.com/test
2. The nurse is discussing the concept of anger versus aggression with clients during a
counseling session. Which of the following statements best differentiates between anger
and aggression?
abirb.com/test where anger
1. “Aggression is a physiological arousal state due to a painful experience,
is a learned behavior.”
2. “Anger is a normal, healthy emotional response to a negative stimulus, where
aggression is an expression of anger.”
abirb.com/test
3. “Aggression is a normal emotional response to a negative stimulus, where anger is an
emotional expression of aggression.”
4. “There is no difference between anger and aggression; they are essentially the same
abirb.com/test
phenomenon.”
ANS: 2
Chapter: Chapter 15, Anger and Aggression Management
abirb.com/test
Objective: Define and differentiate between anger and aggression.
Page: 252
Heading: Anger and Aggression, Defined
abirb.com/test
Integrated Processes: Teaching and Learning
Client Need: Psychosocial Integrity
Cognitive Level: Comprehension [Understanding]
Concept: Violence
abirb.com/test
Difficulty: Easy
1.
2.
3.
4.
Feedback
abirb.com/test
This is incorrect. Aggression is a learned behavior in response
to anger, which is a
physiological state of arousal.
This is correct. Anger is a normal emotion that is typically experienced as an almostautomatic inner response to negative stimuli such as emotional
pain, frustration, or
abirb.com/test
fear. Aggression is a behavioral response of anger intended to inflict pain to or injury
to others.
This is incorrect. Aggression is not a normal emotional response to a negative
abirb.com/test
stimulus, as it is typically a violent act toward a person or object in response to
anger.
This is incorrect. Anger and aggression are significantly different.
abirb.com/test
CON: Violence
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3. Which client statement demonstrates improvement in anger and aggression
management?
abirb.com/test
1. “I realize I have a problem expressing my anger appropriately.”
2. “I know I can’t use physical force anymore, but I can verbally intimidate others.”
3. “It’s bad to feel as angry as I feel. I’m working on eliminating this poisonous emotion
entirely.”
abirb.com/test
abirb.com/test
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Chapter 15 - ETB
abirb.com/test
4. “Because my wife seems to be the one to set me off, I’ve decided to remain separated
from her.”
abirb.com/test
ANS: 1
Chapter: Chapter 15, Anger/Aggression Management
Objective: Apply the nursing process to clients expressing anger or aggression, (d)
Evaluate achievement of the projected outcomes in the intervention
with clients
abirb.com/test
demonstrating maladaptive expression of anger.
Page: 257
Heading: The Nursing Process > Evaluation; Table 16–2, Care Plan for the Individual
abirb.com/test
Who Expresses Anger Inappropriately
Integrated Processes: Nursing Process: Evaluation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Violence
Difficulty: Moderate
1.
2.
3.
4.
abirb.com/test
Feedback
This is correct. This statement indicates that the client is taking responsibility for his
or her anger.
This is incorrect. The client does not recognize that aggression
can be verbal as well
abirb.com/test
as physical.
This is incorrect. The client does not recognize the difference between anger and
aggression. Anger is a powerful and normal emotion, whereas aggression is a
abirb.com/test
negative form of expressing anger.
This is incorrect. The client does not recognize that the expression of anger can
come under personal control. By eliminating the stimulus (interactions with the
wife), the client does not learn how to control their aggressive
tendencies.
abirb.com/test
CON: Violence
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4. A client is served divorce papers while on the inpatient psychiatric unit. When the
abirb.com/test
nurse tells the client that the unit telephone cannot be used after-hours,
the client raises
his fists, swears, and spits at the nurse. What would be the priority nursing diagnosis at
this time?
1. Ineffective coping related to dysfunctional family system as evidenced
by (AEB)
abirb.com/test
aggressive behavior
2. Risk for violence related to dysfunctional family system AEB aggressive behavior
3. Risk for anger related to dysfunctional family system AEB aggressive behavior
abirb.com/test
4. Ineffective grieving related to dysfunctional family system AEB
pending divorce
ANS: 2
Chapter: Chapter 15, Anger and Aggression Management
abirb.com/test
Objective: Apply the nursing process to clients expressing anger or aggression, (a)
abirb.com/test
abirb.com/test
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Chapter 15 - ETB
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Assessment: Describe physical and psychological responses to anger.
Page: 257
Heading: Table 16–2, Care Plan for the Individual Who Expresses Anger
abirb.com/test
Inappropriately
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Violence
Difficulty: Moderate
1.
2.
3.
4.
abirb.com/test
Feedback
This is incorrect. This would not be a priority nursing diagnosis compared with the
other answer options.
This is correct. This would be a priority nursing diagnosis abirb.com/test
as the client has displayed
aggressive and violent behavior toward the nurse.
This is incorrect. This is not a NANDA International-approved nursing diagnosis.
This is incorrect. This is not a priority nursing diagnosis.
abirb.com/test
CON: Violence
abirb.com/test
5. A nurse is caring for four clients. Which client does the nurse identify is least prone to
developing problems with anger and aggression?
abirb.com/test
1. A child raised by a physically abusive parent
2. An adult with a history of epilepsy
3. A young adult living in the ghetto of an inner city
abirb.com/test
4. An adolescent raised by Scandinavian immigrant parents
ANS: 4
Chapter: Chapter 15, Anger and Aggression Management
abirb.com/test
Objective: Discuss predisposing factors to the maladaptive expression of anger.
Page: 252
Heading: Predisposing Factors to Anger and Aggression > Environmental Factors
abirb.com/test
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
Concept: Violence
abirb.com/test
Difficulty: Difficult
1.
2.
3.
Feedback
abirb.com/test
This is incorrect. A history of abuse is a predisposing factor
to anger and aggression.
This is incorrect. A history of epilepsy is a predisposing factor to anger and
aggression.
This is incorrect. A history of overcrowding and poverty are
predisposing factors to
abirb.com/test
anger and aggression.
abirb.com/test
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Chapter 15 - ETB
abirb.com/test
4.
This is correct. An adolescent raised by Scandinavian immigrant parents would be
least prone to developing problems with anger and aggression as compared with the
other clients presented.
abirb.com/test
CON: Violence
abirb.com/test
6. After less-restrictive means have been attempted, an order for client restraints has
been obtained for a hostile, aggressive 30-year-old client. If client aggression continues,
abirb.com/test
how long will the nurse expect the client to remain in restraints without
a physician
order renewal?
1. 1 hour
2. 2 hours
abirb.com/test
3. 3 hours
4. 4 hours
abirb.com/test
ANS: 4
Chapter: Chapter 15, Anger and Aggression Management
Objective: Apply the nursing process to clients expressing anger or aggression, (d)
Evaluation: Evaluate achievement of the projected outcomes in the
intervention with
abirb.com/test
clients demonstrating maladaptive expression of anger.
Page: 257
Heading: The Nursing Process > Evaluation; Table 16–2, Care Plan for the Individual
abirb.com/test
Who Expresses Anger Inappropriately
Integrated Processes: Nursing Process: Implementation
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Safety
Difficulty: Moderate
1.
2.
3.
4.
abirb.com/test
Feedback
This is incorrect. The Joint Commission requires that a physician or licensed
independent provider (LIP) must reissue a new order for restraints every 1 hour for
clients younger than 9 years.
abirb.com/test
This is incorrect. The Joint Commission requires that a physician or LIP must
reissue a new order for restraints every 2 hours for clients age 9 to 17 years.
This is incorrect. Joint Commission requirements do not stipulate
that a physician or
abirb.com/test
LIP must reissue a new order for restraints every 3 hours for adults.
This is correct. The Joint Commission requires that a physician or LIP must reissue a
new order for restraints every 4 hours for adults.
abirb.com/test
CON: Safety
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 15 - ETB
abirb.com/test
7. An adult client assaults another client and is placed in restraints. Which client
statement alerts the nurse that further assessment is necessary?
1. “I hate all of you!”
abirb.com/test
2. “My fingers are tingly.”
3. “You wait until I tell my lawyer.”
4. “I have a sinus headache.”
abirb.com/test
ANS: 2
Chapter: Chapter 15, Anger and Aggression Management
Objective: Apply the nursing process to clients expressing anger or aggression, (a)
abirb.com/test
Assessment: Describe physical and psychological responses to anger.
Page: 257
Heading: The Nursing Process > Assessment; Table 16–2, Care Plan for the Individual
Who Expresses Anger Inappropriately
abirb.com/test
Integrated Processes: Nursing Process: Assessment
Client Need: Physiological Integrity
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Patient-Centered Care
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/test
This is incorrect. This is an aggressive statement and would not necessitate further
assessment.
This is correct. The client’s statement “My fingers are tingly” indicates that the
abirb.com/test
restraints are too tight and impeding circulation.
This is incorrect. This is an aggressive statement, which may be part of the reason
why the client is in restraints.
This is incorrect. The client may be using this statement toabirb.com/test
distract the rationale for
the restraints and does not need further assessment.
CON: Patient-Centered Care
abirb.com/test
8. After the client’s restraints are removed, the staff discusses theabirb.com/test
incident and
establishes guidelines for the client’s return to the therapeutic milieu. Which unit
procedure is the staff implementing?
1. Milieu reenactment
abirb.com/test
2. Treatment planning
3. Crisis intervention
4. Debriefing
abirb.com/test
ANS: 4
Chapter: Chapter 15, Anger and Aggression Management
Objective: Apply the nursing process to clients expressing anger abirb.com/test
or aggression, (d)
Evaluation: Evaluate achievement of the projected outcomes in the intervention with
abirb.com/test
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Chapter 15 - ETB
abirb.com/test
clients demonstrating maladaptive expression of anger.
Page: 258
Heading: Table 16–2, Care Plan for the Individual Who Expresses Anger
abirb.com/test
Inappropriately > Nursing Diagnosis: Risk for Self-Directed or Other-Directed
Violence
Integrated Processes: Nursing Process: Evaluation
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Stress
Difficulty: Moderate
1.
2.
3.
4.
abirb.com/test
Feedback
This is incorrect. This would not diminish the emotional impact of the intervention.
This is incorrect. Treatment planning would be an intervention as a result of
debriefing.
abirb.com/test
This is incorrect. This occurred during the crisis, not afterward.
This is correct. Debriefing following the incident allows the staff the opportunity to
express feelings, review, and learn from the experience.
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CON: Stress
abirb.com/test
9. Once the nurse initiates restraints for an out-of-control 45-year-old patient, per Joint
Commission standards, what must occur within 1 hour?
abirb.com/test
1. The patient must be let out of restraints.
2. A physician or other LIP must conduct an in-person evaluation.
3. The patient must be bathed and fed.
abirb.com/test
4. The patient must be included in debriefing.
ANS: 2
Chapter: Chapter 15, Anger and Aggression Management
abirb.com/test
Objective: Apply the nursing process to clients expressing anger or aggression, (d)
Evaluation: Evaluate achievement of the projected outcomes in the intervention with
clients demonstrating maladaptive expression of anger.
abirb.com/test
Page: 256
Heading: Table 16–2, Care Plan for the Individual Who Expresses Anger
Inappropriately > Nursing Diagnosis: Risk for Self-Directed or Other-Directed Violence
Integrated Processes: Nursing Process: Implementation
abirb.com/test
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Comprehension [Understanding]
Concept: Patient-Centered Care
abirb.com/test
Difficulty: Moderate
1.
Feedback
This is incorrect. The client may still pose a danger to self abirb.com/test
and others at this time,
and removing the restraints may potentiate the risk for violence.
abirb.com/test
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PMHN, 10e
Chapter 15 - ETB
abirb.com/test
2.
3.
4.
This is correct. Joint Commission standards require that a physician or other LIP
conduct an in-person evaluation of the client within 1 hour of the initiation of
restraint.
abirb.com/test
This is incorrect. There is no indication that the client would
need to be bathed or fed
at this time. The client may still be out of control of their emotions and aggressive.
This is incorrect. When a client loses control, it is important for debriefing to occur.
This debriefing provides an opportunity to follow up with abirb.com/test
a discussion about the
situation. The client is able to provide input once they are able to regain control.
CON: Patient-Centered Care
abirb.com/test
10. Physical restraints are sometimes a necessary intervention forabirb.com/test
clients. This is based
on which premise?
1. Clients with poor boundaries do not respond to verbal redirection, and they need firm
and consistent limit-setting.
abirb.com/test
2. Clients with limited internal control over their behavior need external
controls to
prevent harm to themself and others.
3. Clients with antisocial tendencies need to submit to the staff’s authority.
4. Clients with behavioral dysfunction need strict limits and behavioral
interventions.
abirb.com/test
ANS: 2
Chapter: Chapter 15, Anger and Aggression Management
Objective: Apply the nursing process to clients expressing anger abirb.com/test
or aggression, (a)
Assessment: Describe physical and psychological responses to anger.
Page: 256
Heading: Table 16–2, Care Plan for the Individual Who Expresses
Anger
abirb.com/test
Inappropriately > Nursing Diagnosis: Risk for Self-Directed or Other-Directed Violence
Integrated Processes: Nursing Process: Evaluation
Client Need: Safe and Effective Care Environment: Management of Care
abirb.com/test
Cognitive Level: Comprehension [Understanding]
Concept: Safety
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. The least-restrictive interventions, such as removal of privileges,
are used first.
abirb.com/test
This is correct. Restraints are sometimes necessary when clients have limited
internal control over their behavior and need external controls (restraints) to prevent
harm to themself and others. Restraints are removed as soon as the client has
abirb.com/test
regained control. The least-restrictive interventions are used
unless the client is a
danger to self or others.
This is incorrect. Antisocial behaviors do not necessitate severe limitations such as
restraints.
abirb.com/test
This is incorrect. The least-restrictive interventions should be used to modify
abirb.com/test
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PMHN, 10e
Chapter 15 - ETB
abirb.com/test
nonviolent behavior.
CON: Safety
abirb.com/test
11. A client diagnosed with paranoid schizophrenia has a historyabirb.com/test
of aggravated assault.
The nurse assigns “Risk for other-directed violence” as the client’s priority nursing
diagnosis. Which is an appropriate, correctly written outcome for the client?
1. The client will not verbalize anger or hit anyone.
abirb.com/test
2. The client will verbalize anger rather than hit others.
3. The client will not inflict harm on others during this shift.
4. The client will be restrained if any abuse is observed during this shift.
abirb.com/test
ANS: 3
Chapter: Chapter 15, Anger and Aggression Management
Objective: Apply the nursing process to clients expressing anger or aggression, (b)
Diagnosis/Outcome Identification: Formulate nursing diagnoses abirb.com/test
and outcome criteria for
clients expressing anger and aggression.
Page: 256
Heading: The Nursing Process > Diagnosis/Outcome Identification;
Table 16–2, Care
abirb.com/test
Plan for the Individual Who Expresses Anger Inappropriately > Nursing Diagnosis: Risk
for Self-Directed or Other-Directed Violence
Integrated Processes: Nursing Process: Planning
Client Need: Safe and Effective Care Environment: Managementabirb.com/test
of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. Outcomes must be client-centered, specific, realistic, and
abirb.com/test
measurable and contain a time frame. This nursing diagnosis is incorrect because
there is no time frame.
This is incorrect. There is no time frame in this outcome. Outcomes must be clientabirb.com/test
centered, specific, realistic, and measurable and have a time
frame.
This is correct. Preventing injury to others is the appropriate outcome. Outcomes
must be client-centered, specific, realistic, and measurable and contain a time frame.
This is incorrect. This would be considered an intervention,abirb.com/test
not an outcome.
CON: Patient-Centered Care
abirb.com/test
12. When least-restrictive methods fail for an angry, aggressive client, a physician
orders restraints at 3 a.m. Per Joint Commission standards, at what
time and by whom
abirb.com/test
does the nurse expect an in-person client evaluation?
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 15 - ETB
abirb.com/test
1. No later than 4 a.m., by a physician or an LIP
2. No later than 5 a.m., by a physician or an LIP
3. No later than 4 a.m., by a psychiatrist or the clinical nurse specialist
abirb.com/test
4. No later than 5 a.m., by the psychiatrist or a clinical nurse specialist
ANS: 1
Chapter: Chapter 15, Anger and Aggression Management
abirb.com/test
Objective: Apply the nursing process to clients expressing anger or aggression, (c)
Planning/Intervention: Describe nursing interventions for clients demonstrating
maladaptive expressions of anger.
abirb.com/test
Page: 256
Heading: Table 16–2, Care Plan for the Individual Who Expresses Anger
Inappropriately > Nursing Diagnosis: Risk for Self-Directed or Other-Directed Violence
Integrated Processes: Nursing Process: Implementation
abirb.com/test
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Safety
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
This is correct. A physician or LIP must perform an in-person
evaluation of the
abirb.com/test
client no later than 4 a.m. Per Joint Commission standards, an in-person evaluation
by a physician or LIP must be conducted within 1 hour of the initiation of restraints.
This is incorrect. Per Joint Commission standards, an in-person evaluation must be
completed within 1 hour of the initiation of the restraints. abirb.com/test
This is incorrect. Per Joint Commission standards, an in-person evaluation by a
physician or LIP, not a clinical nurse specialist, must be conducted within 1 hour of
the initiation of restraints.
abirb.com/test
This is incorrect. A physician or LIP must perform an in-person evaluation of the
client no later than one hour after initiation of restraints. Per Joint Commission
standards, an in-person evaluation by a physician or LIP must be conducted within 1
abirb.com/test
hour of the initiation of restraints.
CON: Safety
abirb.com/test
13. Which risk factor should a nurse recognize as the most reliable
indicator of potential
abirb.com/test
client violence?
1. Diagnosis of schizotypal personality disorder
2. History of assaultive behavior
abirb.com/test
3. Family history of violence
4. Recent eviction from a homeless shelter
ANS: 2
Chapter: Chapter 15, Anger and Aggression Management
abirb.com/test
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 15 - ETB
abirb.com/test
Objective: Discuss predisposing factors to the maladaptive expression of anger.
Page: 254
Heading: Predisposing Factors to Anger and Aggression > Environmental Factors
abirb.com/test
Integrated Processes: Nursing Process: Assessment
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Comprehension [Understanding]
Concept: Violence
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/test
This is incorrect. Although a mental health disorder is considered
a risk factor, it is
not the strongest indicator listed.
This is correct. The most widely recognized risk factor for client violence is a prior
history of assault.
abirb.com/test
This is incorrect. Although a family history of violence is considered a risk factor for
violence, it is not the strongest indicator listed.
This is incorrect. There is no reason for the eviction from the homeless shelter to be
abirb.com/test
considered a risk factor for violence.
CON: Violence
abirb.com/test
14. During the debriefing after a violent episode, the client states that they acted out on
abirb.com/test
their perceived threat from which of the staff behaviors?
1. The staff member administered the client’s prn medications when the client showed
signs of “prodromal syndrome.”
abirb.com/test
2. The staff member attempted to soothe the client by stroking their
arm and shoulder
and talking in a firm tone.
3. The staff member called for assistance and asked the ward secretary to contact the
client’s physician.
abirb.com/test
4. The nurse separated the client from the others with signs of “prodromal syndrome.”
ANS: 2
abirb.com/test
Chapter: Chapter 15, Anger and Aggression Management
Objective: Apply the nursing process to clients expressing anger or aggression, (c)
Planning/Intervention: Describe nursing interventions for clients demonstrating
maladaptive expressions of anger.
abirb.com/test
Page: 256
Heading: Table 16–2, Care Plan for the Individual Who Expresses Anger
Inappropriately > Nursing Diagnosis > Ineffective Coping
abirb.com/test
Integrated Processes: Nursing Process: Implementation
Client Need: Teaching and Learning
Cognitive Level: Comprehension [Understanding]
Concept: Violence
abirb.com/test
Difficulty: Moderate
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 15 - ETB
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. Administering the prn medication to alleviate the symptoms of
potential violence may not increase the violent behavior. abirb.com/test
This is correct. Touching the client may be perceived as a threat and provoke further
violence.
This is incorrect. Asking for assistance to prevent violenceabirb.com/test
would not have increased
the likelihood of an outburst or increased behavioral issues.
This is incorrect. This would be an appropriate response to “prodromal syndrome”
by removing others from potential harm.
abirb.com/test
CON: Violence
abirb.com/test
15. A client begins to smash furniture, cannot be “talked down,” and refuses
medications. Which is the priority nursing intervention?
abirb.com/test
1. Call a violence code.
2. Ask the ward clerk to put in a call to the physician.
3. Place the client in seclusion.
4. Place the client in four-point restraints.
abirb.com/test
ANS: 1
Chapter: Chapter 15, Anger and Aggression Management
abirb.com/test
Objective: Apply the nursing process to clients expressing anger or aggression, (c)
Planning/Intervention: Describe nursing interventions for clients demonstrating
maladaptive expressions of anger.
abirb.com/test
Page: 256
Heading: Table 16–2, Care Plan for the Individual Who Expresses Anger
Inappropriately > Nursing Diagnosis: Risk for Self-Directed or Other-Directed Violence
Integrated Processes: Nursing Process: Implementation
abirb.com/test
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Safety
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
This is correct. Patient and staff safety are the priorities. Have
several trained staff
abirb.com/test
respond to a violence code to prevent injury to the client and staff.
This is incorrect. Patient and staff safety are the priorities. The ward clerk can place
a call to the physician as soon as the violence code has been called.
This is incorrect. Patient and staff safety are the priorities. abirb.com/test
The client can be placed
in the seclusion room after the violence code has been called.
This is incorrect. Patient and staff safety are the priorities. If needed, the client can
be placed in four-point restraints after the violence code has
been called.
abirb.com/test
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 15 - ETB
abirb.com/test
CON: Safety
abirb.com/test
16. On an inpatient psychiatric unit, a restrained 16-year-old client continues to lash out
verbally and threatens to abuse staff and kill himself or herself when released. Per Joint
Commission standards, when does the nurse expect the physicianabirb.com/test
or LIP to renew the
client’s restraint order?
1. Within 1 hour of the original restraint order
2. Within 2 hours of the original restraint order
abirb.com/test
3. Within 3 hours of the original restraint order
4. Within 4 hours of the original restraint order
ANS: 2
abirb.com/test
Chapter: Chapter 15, Anger and Aggression Management
Objective: Apply the nursing process to clients expressing anger or aggression, (c)
Planning/Intervention: Describe nursing interventions for clients demonstrating
abirb.com/test
maladaptive expressions of anger.
Page: 256
Heading: Table 16–2, Care Plan for the Individual Who Expresses Anger
Inappropriately > Nursing Diagnosis: Risk for Self-Directed or Other-Directed
Violence
abirb.com/test
Integrated Processes: Nursing Process: Implementation
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Knowledge [Remembering]
abirb.com/test
Concept: Patient-Centered Care
Difficulty: Easy
1.
2.
3.
4.
Feedback
abirb.com/test
This is incorrect. The Joint Commission requires a physician or an LIP to reissue a
new order for restraints every 1 hour for children.
This is correct. The Joint Commission requires a physician or an LIP to reissue a
abirb.com/test
new order for restraints every 2 hours for adolescents.
This is incorrect. Although the Joint Commission requires new orders at different
time frames for each level of client age (children, adolescents, and adults), there are
no 3-hour time frames.
abirb.com/test
This is incorrect. The Joint Commission requires that a physician or an LIP to
reissue a new order for restraints every 4 hours for adults.
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
17. A client diagnosed with brief psychotic disorder is pacing the milieu and
occasionally punches the wall. Which is the initial nursing action?
1. Assertively instruct the client to stop punching the wall.
abirb.com/test
2. Encourage the client to write down feelings in a journal.
abirb.com/test
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PMHN, 10e
Chapter 15 - ETB
abirb.com/test
3. With the help of staff, initiate seclusion protocol.
4. Ensure adequate physical space between the nurse and the client.
abirb.com/test
ANS: 4
Chapter: Chapter 15, Anger and Aggression Management
Objective: Apply the nursing process to clients expressing anger or aggression, (c)
Planning/Intervention: Describe nursing interventions for clientsabirb.com/test
demonstrating
maladaptive expressions of anger.
Page: 256
Heading: Table 16–2, Care Plan for the Individual Who Expresses Anger
abirb.com/test
Inappropriately > Nursing Diagnosis: Risk for Self-Directed or Other-Directed
Violence
Integrated Processes: Nursing Process: Implementation
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Safety
Difficulty: Moderate
1.
2.
3.
4.
abirb.com/test
Feedback
This is incorrect. This action could increase the likelihood of an escalation in violent
behavior. Safety is the initial nursing action.
This is incorrect. The initial step would be to ensure safetyabirb.com/test
for the nurse, other
clients, and the client. This would not be an initial step for safety.
This is incorrect. Seclusion protocol would be used when the safety of the client and
others is being compromised. At this time, the initial action would be to decrease the
abirb.com/test
risk for violence.
This is correct. Maintaining client and nurse safety is always the priority. The initial
nursing action is to ensure that there is adequate physical space between the nurse
and the client. Decreased defensible space and increased contact
are related to an
abirb.com/test
increased risk of violence.
CON: Safety
abirb.com/test
abirb.com/test
18. The nurse observes a client’s escalating anger. The client begins
to pace the hall and
shouts, “You all better watch out. I’m going to hurt anyone who gets in my way.” Which
is the priority nursing intervention?
1. Calmly tell the client, “Staff will help you to control your impulse
to hurt others.”
abirb.com/test
2. Remove other clients from the area and maintain milieu safety.
3. Gather a show of force by contacting security for assistance.
4. Calmly tell the client, “You will need to be medicated and secluded.”
abirb.com/test
ANS: 2
Chapter: Chapter 15, Anger and Aggression Management
Objective: Apply the nursing process to clients expressing anger abirb.com/test
or aggression, (c)
Planning/Intervention: Describe nursing interventions for clients demonstrating
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 15 - ETB
abirb.com/test
maladaptive expressions of anger.
Page: 256
Heading: Table 16–2, Care Plan for the Individual Who Expresses Anger
abirb.com/test
Inappropriately > Nursing Diagnosis: Risk for Self-Directed or Other-Directed
Violence
Integrated Processes: Nursing Process: Implementation
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Safety
Difficulty: Moderate
1.
2.
3.
4.
abirb.com/test
Feedback
This is incorrect. This may provoke an escalation in an aggressive client. If the nurse
were to provide alternative ways of releasing tension, this may help the client in the
future, but at this moment the priority is safety.
abirb.com/test
This is correct. Maintaining client and nurse safety is always the priority. The
nurse’s priority action is to remove all clients from the area of conflict, as the
situation is emergent.
abirb.com/test
This is incorrect. By gathering a show of force, this may provoke
an escalation of
aggressive behavior.
This is incorrect. Although this can be considered a limit on the behavior, it is not a
priority intervention.
abirb.com/test
CON: Safety
abirb.com/test
19. The client states, “I get into trouble because I respond violently without thinking.
abirb.com/test
That usually gets me into a mess.” Which nursing reply is most therapeutic?
1. “Everybody loses their temper. It’s good that you know that about yourself.”
2. “I’ll bet you have some interesting stories to share about overreacting.”
3. “Let’s explore methods to help you stop and think before taking action.”
abirb.com/test
4. “It’s good that you are showing readiness for behavioral change.”
ANS: 3
abirb.com/test
Chapter: Chapter 15, Anger and Aggression Management
Objective: Apply the nursing process to clients expressing anger or aggression, (c)
Planning/Intervention: Describe nursing interventions for clients demonstrating
maladaptive expressions of anger.
abirb.com/test
Page: 255
Heading: The Nursing Process > Assessment > Assessing Risk Factors
Integrated Processes: Nursing Process: Implementation
Client Need: Safe and Effective Care Environment: Managementabirb.com/test
of Care
Cognitive Level: Application [Applying]
Concept: Violence
Difficulty: Moderate
abirb.com/test
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 15 - ETB
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. This does not provide the client an opportunity to find an
alternative to violence.
This is incorrect. If the client is encouraged to tell “stories”abirb.com/test
about previous actions,
there may be an increased likelihood of more violence.
This is correct. Helping the client identify appropriate problem-solving behaviors
and alternative ways to release tension is a therapeutic nursing
intervention.
abirb.com/test
Prevention is the key issue in managing aggressive or violent behavior.
This is incorrect. Although this acknowledges the client’s acceptance of
responsibility, it does nothing to stop any further violent behavior.
abirb.com/test
CON: Violence
abirb.com/test
20. Which initial nursing approach assists clients who are aggressively acting out to
accept limit-setting better?
abirb.com/test
1. Confronting clients with their needs for secondary gains
2. Teaching relaxation techniques
3. Empathizing with the client about the client’s distress
4. Presenting appropriate values that need to be modified
abirb.com/test
ANS: 3
Chapter: Chapter 15, Anger and Aggression Management
abirb.com/test
Objective: Apply the nursing process to clients expressing anger or aggression, (c)
Planning/Intervention: Describe nursing interventions for clients demonstrating
maladaptive expressions of anger.
abirb.com/test
Page: 256
Heading: Table 16–2, Care Plan for the Individual Who Expresses Anger
Inappropriately > Nursing Diagnosis: Risk for Self-Directed or Other-Directed Violence
Integrated Processes: Nursing Process: Implementation
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Violence
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
This is incorrect. Confronting a client leads to anger and defensive
behavior.
abirb.com/test
This is incorrect. The nurse must first establish trust in order to teach relaxation
techniques.
This is correct. Empathizing with a client promotes a trusting relationship and may
prevent the client’s anxiety from escalating when limits areabirb.com/test
set.
This is incorrect. The client may be receptive to discussing values that need to be
modified after trust is established.
abirb.com/test
CON: Violence
abirb.com/test
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PMHN, 10e
Chapter 15 - ETB
abirb.com/test
21. Which nursing approach is likely to be most therapeutic whenabirb.com/test
dealing with a newly
admitted, hostile, suspicious client?
1. Place a hand on the client’s shoulder and state, “I will help you to your room.”
2. Slowly and matter-of-factly state, “I am your nurse and I will show
you to your
abirb.com/test
room.”
3. Firmly set limits by stating, “If your behavior does not improve, you will be
secluded.”
4. Smile and state, “I am your nurse. When do you want to go to abirb.com/test
your room?”
ANS: 2
Chapter: Chapter 15, Anger and Aggression Management
abirb.com/test
Objective: Apply the nursing process to clients expressing anger or aggression, (c)
Planning/Intervention: Describe nursing interventions for clients demonstrating
maladaptive expressions of anger.
abirb.com/test
Page: 256
Heading: Table 16–2, Care Plan for the Individual Who Expresses Anger
Inappropriately > Nursing Diagnosis: Ineffective Coping
Integrated Processes: Nursing Process: Implementation
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Violence
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
This is incorrect. Touching the client may be perceived as abirb.com/test
a threat and provoke
further hostility.
This is correct. Remain calm when dealing with an angry client. Anger expressed by
the nurse will most likely incite increased anger in the client.
abirb.com/test
This is incorrect. The client may perceive this statement as a threat and react with
additional hostility.
This is incorrect. Asking the client a question may provoke further hostility.
abirb.com/test
CON: Violence
abirb.com/test
22. A client arrives at the primary care physician with complaints of increased
symptoms of colitis. During the intake interview, the patient mentions having two
abirb.com/test
migraines in the past 3 weeks and asks for a new medication, stating,
“It doesn’t seem
like the current medication is working as well as I expected.” In reviewing the client’s
medical record, it is noted that the client was prescribed medication for depression and a
referral to a marriage counselor at her last visit 2 months ago. Which
of the following
abirb.com/test
might the nurse suspect?
abirb.com/test
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PMHN, 10e
Chapter 15 - ETB
1. Maladaptive expression of anger
2. Hypersensitivity to migraine medication
3. Exhibiting signs of domestic abuse
4. Operant conditioning
abirb.com/test
abirb.com/test
ANS: 1
Chapter: Chapter 15, Anger and Aggression Management
abirb.com/test
Objective: Identify when the expression of anger becomes a problem.
Page: 252
Heading: Anger and Aggression, Defined
abirb.com/test
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
Concept: Self
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/test
This is correct. The patient presents with a diagnosis of colitis
and depression and
has recently received medications for depression and migraines. These symptoms are
manifestations of ineffective expression of anger. The symptoms will not go away if
the cause (ineffective anger expression) is not resolved. abirb.com/test
This is incorrect. Medication that does not appear to be effective does not necessarily
indicate a hypersensitivity.
This is incorrect. There is no mention of physical evidence of domestic abuse.
abirb.com/test
This is incorrect. Operant conditioning refers to a specific behavior that is
reinforced. It may be true that patient has learned to suppress her feelings of anger,
but that is not indicated in the scenario.
abirb.com/test
CON: Self
abirb.com/test
23. Yelling, name-calling, hitting others, and temper tantrums as expressions of anger
are all evidence supporting which nursing diagnosis?
abirb.com/test factors
1. Risk for self-directed or other-directed violence related to socioeconomic
2. Anger related to dysfunctional relationships and ineffective coping skills
3. Ineffective coping related to negative role modeling and dysfunctional family systems
4. Complicated grieving related to a loss of support system
abirb.com/test
ANS: 3
Chapter: Chapter 15, Anger and Aggression Management
Objective: Apply the nursing process to clients expressing anger abirb.com/test
or aggression >
Diagnosis/Outcome Identification: Form nursing diagnosis and outcome criteria for
clients expressing anger and aggression.
Page: 252
abirb.com/test
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Chapter 15 - ETB
abirb.com/test
Heading: The Nursing Process > Assessment > Aggression> Assessing Risk Factors >
Diagnosis/Outcome Identification
Integrated Processes: Nursing Process
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Stress
Difficulty: Difficult
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. This nursing diagnosis requires evidence of having been nurtured
abirb.com/test
in an atmosphere of violence.
This is incorrect. NANDA International does not include a separate nursing
diagnosis for anger.
This is correct. Clients demonstrating inappropriate expression
of anger exhibit
abirb.com/test
ineffective coping related to negative role modeling and dysfunctional family
system, evidenced by yelling, name-calling, hitting others, and temper tantrums as
expressions of anger.
abirb.com/test
This is incorrect. Anger expressed inappropriately when the
etiology is related to a
loss would indicate evidence of complicated grieving.
CON: Stress
abirb.com/test
abirb.com/test
24. What is likely to happen if anger is communicated passive-aggressively or
aggressively?
1. The individual uses the power to intimidate others.
abirb.com/test
2. It is discharged against an object or person unrelated to the true
target of the anger.
3. Impulsive behavior can result, disregarding possible negative consequences.
4. Conflict escalates, and the problem that created the conflict goes unresolved.
abirb.com/test
ANS: 4
Chapter: Chapter 15, Anger and Aggression Management
Objective: Identify when the expression of anger becomes a problem.
abirb.com/test
Page: 253
Heading: Table 16–1, The Functions of Anger
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Comprehension [Understanding]
Concept: Mood
Difficulty: Easy
abirb.com/test
1.
Feedback
This is incorrect. This response describes the negative functions or destructive uses
of anger that occur when the feeling of control is exaggerated.
abirb.com/test
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Chapter 15 - ETB
abirb.com/test
2.
3.
4.
This is incorrect. This response describes the negative functions or destructive uses
of anger that occur when the coping response is displacement.
This is incorrect. This response describes the negative functions or destructive uses
abirb.com/test
of anger that occur without cognitive input.
This is correct. Passive-aggressive and aggressive responses are likely to escalate
conflict.
abirb.com/test
CON: Mood
abirb.com/test
25. Which of the following client statements would appear in a nursing assessment of a
person exhibiting the appropriate expression of anger?
1. “I’m sick and tired of my family asking me how I am doing. How
do they think I’m
abirb.com/test
doing?”
2. “I wonder how he would feel if I got drunk then drove head-on into his wife’s car?”
3. “I smashed a hole in the wall and broke a table. It’s not like I hit my wife or
abirb.com/test
anything.”
4. “I don’t really hit my kids. I just tell them I’m going to beat their backside if they
don’t clean their room.”
abirb.com/test
ANS: 1
Chapter: Chapter 15, Anger and Aggression Management
Objective: Apply the nursing process to clients expressing anger or aggression, (a)
abirb.com/test
Assessment: Describe physical and psychological responses to anger.
Page: 255
Heading: The Nursing Process > Assessment > Anger
Integrated Processes: Nursing Process
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
Concept: Stress
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/test
This is correct. A patient who is appropriately expressing anger
through
hypersensitivity, being easily offended, or having a defensive response to criticism
could make this statement.
This is incorrect. This statement is considered aggressive, as
a threat of homicide,
abirb.com/test
physical harm, or possible destruction of property is implied.
This is incorrect. Destruction of property is an aggressive behavior.
This is incorrect. Making a verbal or physical threat to another person is considered
abirb.com/test
an act of aggression.
CON: Stress
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 15 - ETB
abirb.com/test
MULTIPLE RESPONSE
abirb.com/test
26. A nurse notices a client clenching fists periodically and pacing the hallway. Which
nursing interventions should the nurse implement? Select all thatabirb.com/test
apply.
1. Acknowledge the client’s behavior.
2. Initiate forced-medication protocol.
3. Assist the client to a quiet area.
abirb.com/test
4. Initiate confinement measures.
5. Speak with a soft and calming voice.
ANS: 1, 3, 5
abirb.com/test
Chapter: Chapter 15, Anger and Aggression Management
Objective: Apply the nursing process to clients expressing anger or aggression, (c)
Planning/Intervention: Describe nursing interventions for clients demonstrating
abirb.com/test
maladaptive expressions of anger.
Page: 256
Heading: Table 16–2, Care Plan for the Individual Who Expresses Anger
Inappropriately > Nursing Diagnosis: Ineffective Coping
abirb.com/test
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
abirb.com/test
Concept: Violence
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
abirb.com/test
This is correct. Acknowledging the client’s behavior communicates empathy and
validates the client’s feelings.
This is incorrect. Forcing medication may cause the client to feel more out of control
abirb.com/test
and escalate the client’s anger.
This is correct. Reducing stimulation in the environment de-escalates anger.
Acknowledging the client’s behavior communicates empathy and validates the
client’s feelings.
abirb.com/test
This is incorrect. The client may feel threatened by confinement and react with
escalated anger.
This is correct. Remaining calm reduces agitation. Anger expressed
by the nurse will
abirb.com/test
most likely incite increased anger in the client.
CON: Violence
abirb.com/test
27. Which of the following statements about anger are true? Select
all that apply.
abirb.com/test
1. Anger is not a primary emotion.
abirb.com/test
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Chapter 15 - ETB
abirb.com/test
2. Anger is a physiological arousal.
3. Anger reflects a desire for dominance and control.
4. Anger, in general, may range from a self-protective response to a violent act.
abirb.com/test
5. Anger, when not expressed appropriately, can result in depression
and low selfesteem.
ANS: 1, 2, 5
abirb.com/test
Chapter: Chapter 15, Anger and Aggression Management
Objective: Define and differentiate between anger and aggression.
Page: 252
abirb.com/test
Heading: Anger and Aggression, Defined
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Comprehension [Understanding]
abirb.com/test
Concept: Stress
Difficulty: Easy
1.
2.
3.
4.
5.
abirb.com/test
Feedback
This is correct. Anger is not a primary emotion, but it is typically experienced as an
almost-automatic inner response to hurt, frustration, or fear.
This is correct. Anger is a physiological arousal. It instills abirb.com/test
feelings of power and
generates preparedness.
This is incorrect. Aggression, not anger, reflects a desire for dominance and control.
This is incorrect. Aggression, not anger, in general may range from a self-protective
abirb.com/test
response to a destructive, violent act.
This is correct. When turned inward on oneself, anger can result in depression and
low self-esteem.
abirb.com/test
CON: Stress
abirb.com/test
FILL IN THE BLANK
abirb.com/test
28. The nurse determines that the goal has been met when the client with anger issues is
able to___________________.
abirb.com/test
1. Take medications on a routine basis.
2. Transfer tension into artwork.
3. Decide what to have for dinner.
abirb.com/test
4. Speak in front of a large crowd.
ANS: 2
Chapter: Chapter 15, Anger and Aggression Management
abirb.com/test
abirb.com/test
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Chapter 15 - ETB
abirb.com/test
Objective: Apply the nursing process to clients expressing anger or aggression, (a)
Assessment: Describe physical and psychological responses to anger.
Page: 255
abirb.com/test
Heading: The Nursing Process > Evaluation > Aggression
Integrated Processes: The Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
abirb.com/test
Concept: Stress
Difficulty: Moderate
1.
2.
3.
4.
abirb.com/test
Feedback
This is incorrect. This would not determine successful management of anger.
This is correct. The client is able to transfer tension generated by the anger into
constructive activities instead of violent behavior. This is aabirb.com/test
positive outcome.
This is incorrect. This is not an appropriate determination of anger management.
This is incorrect. Although low self-esteem may be a manifestation of anger issues,
this would not be a positive outcome of an intervention for anger management.
abirb.com/test
CON: Stress
abirb.com/test
29. ___________ ____________ is a personal signal of threat or injustice against the
self. The signal elicits coping responses to deal with the distress.
abirb.com/test
1. Passive-aggressiveness
2. Anger arousal
3. Impulsive behavior
abirb.com/test
4. Exaggerated control
ANS: 2
abirb.com/test
Chapter: Chapter 15, Anger and Aggression Management
Objective: Identify when the expression of anger becomes a problem.
Page: 255
abirb.com/test
Heading: Table 16–1, The Functions of Anger
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Comprehension [Understanding]
abirb.com/test
Concept: Stress
Difficulty: Moderate
1.
2.
abirb.com/test
Feedback
This is incorrect. Passive-aggressive behavior is an indication of conflict and
unresolved anger.
This is correct. Anger arousal is a personal signal of threatabirb.com/test
or injustice against the
self. The signal elicits coping responses to deal with the distress.
abirb.com/test
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Chapter 15 - ETB
abirb.com/test
3.
4.
This is incorrect. Impulsive behavior may be an indicator of destructive anger.
This is incorrect. It is a sign of aggression when an individual uses power to control
or intimidate others.
abirb.com/test
CON: Stress
abirb.com/test
30. A person who demonstrates the ability to exert _________ __________ over
feelings of anger would demonstrate a successful nursing outcome in the care of the
abirb.com/test
client needing assistance with anger management.
1. Internal control
2. Problem-solving
3. Aggression diffusion
abirb.com/test
4. Constructive tension
ANS: 1
abirb.com/test
Chapter: Chapter 15, Anger and Aggression Management
Objective: Apply the nursing process to clients experiencing anger or aggression, (b)
Diagnosis/Outcome Identification: Form nursing diagnoses and outcome criteria for
clients expressing anger and aggression.
abirb.com/test
Page: 257
Heading: The Nursing Process > Diagnosis/Outcome Identification > Outcome Criteria
Integrated Processes: Nursing Process
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
Concept: Behavior Modification
Difficulty: Difficult
abirb.com/test
1.
2.
3.
4.
Feedback
This is correct. Demonstrating the ability to exert internal control over feelings of
abirb.com/test
anger, taking responsibility for one’s own feelings of anger, recognizing anger,
seeking support to talk about feelings, and using the tension generated by the anger
in a constructive manner are all examples of successful outcomes.
abirb.com/test
This is incorrect. Although using problem-solving as opposed
to becoming violent
demonstrates a successful outcome, it does not fit the question.
This is incorrect. The question is asking for outcomes over feelings of anger, not
aggression.
abirb.com/test
This is incorrect. Using tension in a constructive manner is a positive outcome;
however, it does not fit the question.
CON: Behavior Modification
abirb.com/test
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 16 - ETB
Chapter 16. Suicide Prevention
abirb.com/test
abirb.com/test
MULTIPLE CHOICE
abirb.com/test
1. A nurse discovers a client’s suicide note that details the time, place, and means to
commit suicide. What is the priority nursing intervention and accompanying
rationale
abirb.com/test
for this action?
1. Administering lorazepam (Ativan) prn, because the client is angry about the discovery
of the note
2. Establishing room restrictions, because the client’s threat is anabirb.com/test
attempt to manipulate
the staff
3. Placing this client on one-to-one suicide precautions, because the more specific the
plan, the more likely the client will attempt suicide
abirb.com/test
4. Calling an emergency treatment team meeting, because the client’s threat must be
addressed
abirb.com/test
ANS: 3
Chapter: Chapter 16, Suicide Prevention
Objective: Apply the nursing process to individuals exhibiting suicidal behavior.
Page: 276
abirb.com/test
Heading: Suicidal Ideas or Acts > Table 16–3, Care Plan for the Suicidal Client: Nursing
Diagnosis: Risk for Suicide
Integrated Processes: Nursing Process: Implementation
Client Need: Safe and Effective Care Environment: Managementabirb.com/test
of Care
Cognitive Level: Analysis [Analyzing]
Concept: Safety
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. Administering Ativan does not address the client’s situation, and
abirb.com/test
there is no indication the client is upset about the note being
discovered.
This is incorrect. Room restrictions are not appropriate for the suicidal client and
there is no indication of manipulation.
This is correct. The priority nursing action is to place the client
on one-to-one
abirb.com/test
suicide precautions. A client with a specific plan is at very high risk of attempting
suicide. The appropriate nursing diagnosis for this client is “risk for suicide.”
This is incorrect. An emergency team meeting is unnecessary; the client’s safety
abirb.com/test
needs can be addressed with one-to-one precautions.
CON: Safety
abirb.com/test
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Chapter 16 - ETB
abirb.com/test
2. During the planning of care for a suicidal client, which correctly written outcome
should be the nurse’s priority?
abirb.com/test
1. The client will not physically harm self.
2. The client will express hope for the future by day 3.
3. The client will establish a trusting relationship.
4. The client will remain safe during the hospital stay.
abirb.com/test
ANS: 4
Chapter: Chapter 16, Suicide Prevention
abirb.com/test
Objective: Apply the nursing process to individuals exhibiting suicidal
behavior.
Page: 276
Heading: Table 16–3, Care Plan for the Suicidal Client: Nursing Diagnosis: Risk for
Suicide
abirb.com/test
Integrated Processes: Nursing Process: Planning
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: [Applying]
abirb.com/test
Concept: Safety
Difficulty: Easy
1.
2.
3.
4.
Feedback
abirb.com/test
This is incorrect. This outcome is incorrectly addressed by not providing a
measurable time frame.
This is incorrect. Client safety is always the nurse’s priority. An expression of hope
abirb.com/test
does not address the priority of safety.
This is incorrect. Client safety is always the nurse’s priority. Establishing a trusting
relationship does not demonstrate the priority of safety, and there is no time frame
provided.
abirb.com/test
This is correct. Client safety is always the nurse’s priority. The outcome to remain
safe during the hospital stay addresses the priority and provides a measurable time
frame.
abirb.com/test
CON: Safety
abirb.com/test
3. A client diagnosed with major depressive disorder with psychotic features hears
voices commanding self-harm. The client refuses to commit to developing
a plan for
abirb.com/test
safety. Which is the nurse’s priority intervention at this time?
1. Obtaining an order for locked seclusion until the client is no longer suicidal
2. Conducting 15-minute checks to ensure safety
3. Placing the client on one-to-one observation while monitoringabirb.com/test
suicidal ideations
4. Encouraging client to express feelings related to suicide
ANS: 3
Chapter: Chapter 16, Suicide Prevention
abirb.com/test
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Chapter 16 - ETB
abirb.com/test
Objective: Apply the nursing process to individuals exhibiting suicidal behavior.
Page: 276
Heading: Suicidal Ideas or Acts > Table 16–3, Care Plan for the Suicidal Client: Nursing
abirb.com/test
Diagnosis: Risk for Suicide
Integrated Processes: Nursing Process: Implementation
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
abirb.com/test
Concept: Safety
Difficulty: Moderate
1.
2.
3.
4.
abirb.com/test
Feedback
This is incorrect. Client safety is always the nurse’s priority. Locked seclusion is not
appropriate for this situation; the client must be continuously monitored.
This is incorrect. Conducting checks every 15-minutes does
not provide continuous
abirb.com/test
monitoring of the client. Client safety must remain the nurse’s priority.
This is correct. Client safety is always the nurse’s priority. The nurse must place the
client on one-to-one observation and continue to monitor suicidal ideations.
abirb.com/test
This is incorrect. Encouraging communication with the client
is appropriate;
however, this does not provide continuous monitoring to maintain client safety,
which is the priority.
abirb.com/test
CON: Safety
abirb.com/test
4. A client with a history of three suicide attempts has been taking fluoxetine (Prozac)
for 1 month. The client suddenly presents with a bright affect, is much more
communicative, and rates mood at 9/10. Which action should be abirb.com/test
the nurse’s priority at
this time?
1. Give the client off-unit privileges as positive reinforcement.
2. Encourage the client to share mood improvement in group.
abirb.com/test
3. Increase frequency of client observation.
4. Request a medication reevaluation.
abirb.com/test
ANS: 3
Chapter: Chapter 16, Suicide Prevention
Objective: Apply the nursing process to individuals exhibiting suicidal behavior.
Page: 276
abirb.com/test
Heading: Suicidal Ideas or Acts > Table 16–3, Care Plan for the Suicidal Client: Nursing
Diagnosis: Risk for Suicide
Integrated Processes: Nursing Process: Implementation
Client Need: Safe and Effective Care Environment: Managementabirb.com/test
of Care
Cognitive Level: Analysis [Analyzing]
Concept: Safety
Difficulty: Moderate
abirb.com/test
abirb.com/test
abirb.com/test
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Chapter 16 - ETB
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. A sudden increase in mood rating and change in affect may
indicate the client is at serious risk for suicide. Off-unit privileges do not provide the
abirb.com/test
close monitoring needed for the client’s safety.
This is incorrect. A sudden increase in mood rating and change in affect may
indicate the client is at serious risk for suicide. Encouraging sharing improvement in
mood does not provide the close monitoring needed for theabirb.com/test
client’s safety.
This is correct. The nurse should monitor the client more frequently or implement
one-to-one observation. A sudden increase in mood rating and change in affect may
indicate the client is at serious risk for suicide. Serious suicide risk may occur early
abirb.com/test
during treatment with antidepressants.
This is incorrect. Serious suicide risk may occur early during treatment with
antidepressants. A medication reevaluation is not indicated at this time.
abirb.com/test
CON: Safety
abirb.com/test
5. A nurse recently admitted a client to an inpatient unit after a suicide attempt. The
health-care provider orders amitriptyline (Elavil) for the client. Which intervention
related to this medication should be initiated to maintain this client’s
safety upon
abirb.com/test
discharge?
1. Provide a 6-month supply of Elavil to ensure long-term compliance.
2. Provide a 3-day supply of Elavil with refills given at follow-up appointments.
abirb.com/test
3. Provide a pill dispenser and a smart-phone application as a reminder system.
4. Provide education regarding the avoidance of foods containing tyramine.
abirb.com/test
ANS: 2
Chapter: Chapter 16, Suicide Prevention
Objective: Apply the nursing process to individuals exhibiting suicidal behavior.
Page: 281
abirb.com/test
Heading: Intervention With the Suicidal Client Following Discharge or in an Outpatient
Setting
Integrated Processes: Nursing Process: Implementation
Client Need: Safe and Effective Care Environment: Managementabirb.com/test
of Care
Cognitive Level: [Applying]
Concept: Safety
Difficulty: Easy
abirb.com/test
1.
2.
Feedback
This is incorrect. Amitriptyline (Elavil) is a tricyclic antidepressant. Tricyclic
abirb.com/test
antidepressants can be used to commit suicide by overdosing.
A 6-month supply is
more than enough to allow the client to overdose and would not be safe for the client
to possess.
This is correct. Amitriptyline (Elavil) is a tricyclic antidepressant.
Tricyclic
abirb.com/test
antidepressants have a narrow therapeutic range and can be used to commit suicide
abirb.com/test
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PMHN, 10e
Chapter 16 - ETB
abirb.com/test
3.
4.
by overdosing. The physician or nurse practitioner should prescribe no more than a
3-day supply of the medication with no refills.
This is incorrect. While a pill dispenser and a smart-phone application may assist to
abirb.com/test
maintain medication compliance, neither addresses client safety,
which is a priority
in this situation.
This is incorrect. Tyramine is restricted in monoamine oxidase inhibitors rather than
tricyclics; therefore, this is not appropriate to the situation abirb.com/test
and would not address the
safety concerns for this client.
CON: Safety
abirb.com/test
6. During a one-to-one session, the client states, “Nothing will ever
get better” and
abirb.com/test
“Nobody can help me.” Which nursing diagnosis is most appropriate for the nurse to
assign at this time?
1. Powerlessness related to (R/T) altered mood as evidenced by (AEB) client statements
abirb.com/test
2. Risk for injury R/T altered mood AEB client statements
3. Risk for suicide R/T altered mood AEB client statements
4. Hopelessness R/T altered mood AEB client statements
abirb.com/test
ANS: 4
Chapter: Chapter 16, Suicide Prevention
Objective: Apply the nursing process to individuals exhibiting suicidal behavior.
abirb.com/test
Page: 276
Heading: Diagnosis and Outcome Identification > Table 17–3, Care Plan for the Suicidal
Client: Nursing Diagnosis: Hopelessness
Integrated Processes: Nursing Process: Analysis
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: [Applying]
Concept: Safety
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/test
This is incorrect. The client’s statements indicate the problem
of hopelessness.
Powerlessness is not supported by the client’s statements.
This is incorrect. The client’s statements indicate the problem of hopelessness.
Further evaluation of the client’s suicidal ideations and intent
would be necessary
abirb.com/test
prior to assigning risk for injury.
This is incorrect. The client’s statements indicate the problem of hopelessness.
Further evaluation of the client’s suicidal ideations and intent would be necessary
abirb.com/test
prior to assigning risk for suicide.
This is correct. The client’s statements indicate the problem of hopelessness.
CON: Safety
abirb.com/test
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Chapter 16 - ETB
abirb.com/test
7. The treatment team is planning to discharge a previously suicidal client from the
abirb.com/test
hospital. Which assessment information should the nurse recognize
as contributing to
the team’s decision to discharge the client safely?
1. No previous admissions for major depressive disorder
2. Vital signs stable; no psychosis noted and positive mood
abirb.com/test
3. Able to comply with medication regimen; able to problem-solve life issues
4. Able to participate in a plan for safety; family agrees to constant observation
abirb.com/test
ANS: 4
Chapter: Chapter 16, Suicide Prevention
Objective: Apply the nursing process to individuals exhibiting suicidal behavior.
Page: 276
abirb.com/test
Heading: Intervention With the Suicidal Client Following Discharge or in an Outpatient
Setting
Integrated Processes: Nursing Process: Assessment
Client Need: Safe and Effective Care Environment: Managementabirb.com/test
of Care
Cognitive Level: [Applying]
Concept: Safety
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. Previous history is not the primary consideration when determining
abirb.com/test
whether a client is safe for discharge.
This is incorrect. Stable vital signs, absence of psychosis, and positive mood are not
the primary considerations when determining whether a client is safe for discharge.
This is incorrect. Though the client’s ability to comply with
medication regimen and
abirb.com/test
to problem-solve life issues are important considerations, safety is always the first
consideration.
This is correct. The client’s ability to participate in a safety plan and constant family
abirb.com/test
observation will also decrease the risk for self-harm. These aspects support the
client’s safety.
CON: Safety
abirb.com/test
abirb.com/test
8. The family of a suicidal client is supportive and requests more facts related to caring
for their family member after discharge. Which information should the nurse provide?
1. Address only serious suicide threats to avoid the possibility of secondary gain.
abirb.com/test
2. Promote trust by not sharing suicide attempt information outside
the family.
3. Offer a private environment to provide needed time alone at least once a day.
4. Be available to actively listen, support, and accept the client’s feelings.
ANS: 4
abirb.com/test
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Chapter 16 - ETB
abirb.com/test
Chapter: Chapter 17, Suicide Prevention
Objective: Apply the nursing process to individuals exhibiting suicidal behavior.
Page: 280
abirb.com/test
Heading: Information for Family and Friends of the Suicidal Client
Integrated Processes: Teaching and Learning
Client Need: Psychosocial Integrity
Cognitive Level: [Applying]
abirb.com/test
Concept: Safety
Difficulty: Easy
1.
2.
3.
4.
abirb.com/test
Feedback
This is incorrect. Any expression of suicidal thoughts should be taken seriously.
This is incorrect. Family members should not promise they will not tell anyone when
the client expresses suicidal thoughts.
abirb.com/test
This is incorrect. Family members should not leave the client alone. They should go
where the client is, if needed.
This is correct. Active listening, providing support, and accepting feelings increase
the potential that a client would confide suicidal ideations abirb.com/test
to family members.
CON: Safety
abirb.com/test
9. A stockbroker commits suicide after being convicted of insider trading. While
abirb.com/test
speaking with the family, which statement by the nurse demonstrates accurate and
appropriate sharing of information?
1. “Your grieving will subside within 1 year; until then, I recommend antidepressants.”
abirb.com/test
2. “Support groups are available specifically for survivors of suicide,
and I would be
glad to help you locate one in this area.”
3. “The only way to deal effectively with this kind of grief is to write a letter to the
brokerage firm to express your anger with them.”
abirb.com/test
4. “Since stigmatization often occurs in these situations, it would be best if you avoid
discussing the suicide with anyone.”
abirb.com/test
ANS: 2
Chapter: Chapter 16, Suicide Prevention
Objective: Apply the nursing process to individuals exhibiting suicidal behavior.
Page: 281
abirb.com/test
Heading: Intervention With Families and Friends of Suicide Victims
Integrated Processes: Teaching and Learning
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: [Applying]
Concept: Grief and Loss
Difficulty: Moderate
abirb.com/test
Feedback
abirb.com/test
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Chapter 16 - ETB
abirb.com/test
1.
2.
3.
4.
This is incorrect. Bereavement following suicide is complicated, and one cannot
predict how long the grieving process will last. Antidepressants may or may not be
appropriate for the family.
abirb.com/test
This is correct. Bereavement following suicide is complicated
by the complex
psychological impact of the act on those close to the victim. Support groups for
survivors can provide a meaningful resource for grief work.
This is incorrect. There are numerous ways to cope with grief,
as no two people
abirb.com/test
grieve in the same way.
This is incorrect. The nurse should encourage the clients to talk about the suicide,
respond to others’ viewpoints, reconstruct events, and share memories.
abirb.com/test
CON: Grief and Loss
abirb.com/test
10. After years of dialysis, an 84-year-old states, “I’m exhausted, depressed, and done
with these attempts to keep me alive.” Which question should the nurse ask the spouse
abirb.com/test
when preparing a discharge plan of care?
1. “Have there been any changes in your spouse’s appetite or sleep?”
2. “How often is your spouse left alone?”
3. “Has your spouse been following a diet and exercise program abirb.com/test
consistently?”
4. “How does your spouse cope with illness?”
ANS: 2
abirb.com/test
Chapter: Chapter 16, Suicide Prevention
Objective: Apply the nursing process to individuals exhibiting suicidal behavior.
Page: 281
Heading: Intervention With the Suicidal Client Following Discharge
or in an Outpatient
abirb.com/test
Setting
Integrated Processes: Nursing Process: Assessment
Client Need: Safe and Effective Care Environment: Management of Care
abirb.com/test
Cognitive Level: [Applying]
Concept: Safety
Difficulty: Moderate
abirb.com/test
1.
2.
3.
Feedback
This is incorrect. Determining if a change in appetite or sleep has occurred may
provide insight to the client’s mental state but does not address
client safety when
abirb.com/test
the client is suicidal.
This is correct. The term following hospital discharge is a high-risk period, and the
client has numerous risk factors for suicide: exhaustion, depression, and a chronic
medical illness. A detailed safety plan should be developedabirb.com/test
that includes preventing
the client from being left alone.
This is incorrect. While following the diet and exercise program gives insight to the
client’s well-being, it does not address the safety needs of abirb.com/test
the client who
demonstrates risk factors for suicide.
abirb.com/test
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Chapter 16 - ETB
abirb.com/test
4.
This is incorrect. Knowing how the client copes with illness may provide insight to
the client’s strengths, weaknesses, and needs, it does not address the safety concerns
for the client at risk for suicide.
abirb.com/test
CON: Safety
abirb.com/test
11. A nursing instructor is teaching about suicide in the elderly population. Which
information is appropriate to include?
abirb.com/test
1. Elderly men use less-lethal means to commit suicide.
2. The second-highest rates of suicide are among those 85 years or older.
3. Suicide is the second-leading cause of death among the elderly.
4. The elderly who are single are less likely to attempt and succeed
at suicide.
abirb.com/test
ANS: 2
Chapter: Chapter 16, Suicide Prevention
abirb.com/test
Objective: Discuss epidemiological statistics and risk factors related
to suicide.
Page: 264
Heading: Epidemiologic Factors > Risk Factors > Age
Integrated Processes: Teaching and Learning
abirb.com/test
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Comprehension [Understanding]
Concept: Violence
abirb.com/test
Difficulty: Difficult
1.
2.
3.
4.
Feedback
This is incorrect. Men consistently use more lethal means to
commit suicide.
abirb.com/test
This is correct. The second-highest rates of suicide are among those 85 years or
older.
This is incorrect. Suicide is not the second-leading cause of death among the elderly.
abirb.com/test
This is incorrect. People who are single or have experienced divorce are more likely
to commit suicide than those who are married.
CON: Violence
abirb.com/test
abirb.com/test
12. A nurse is caring for a client threatening to commit suicide by hanging. The client
states, “I’m going to use a knotted shower curtain when no one is around.” Which factor
will guide the nurse’s plan of care for the client?
abirb.com/test
1. The more specific the plan is, the more likely the client will attempt
suicide.
2. Clients who talk about suicide never actually commit it.
3. Clients who threaten suicide should be observed every 15 minutes.
4. After a brief assessment, the nurse should avoid the topic of suicide.
abirb.com/test
abirb.com/test
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Chapter 16 - ETB
abirb.com/test
ANS: 1
Chapter: Chapter 16, Suicide Prevention
Objective: Differentiate between facts and myths regarding suicide.
abirb.com/test
Page: 266
Heading: Assessment > Suicidal Ideas or Acts; Table 16–1, Facts and Myths About
Suicide; Table 16–2, Guiding Principles for Suicide Risk Assessment
Integrated Processes: Nursing Process: Assessment
abirb.com/test
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: [Applying]
Concept: Violence
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
This is correct. The risk of suicide is greatly increased if the
client has developed a
abirb.com/test
plan with lethal means, particularly if means are accessible for the client to execute
the plan.
This is incorrect. Eight out of ten people who kill themself have given definite clues
abirb.com/test
and warnings about their suicidal intentions. Very subtle clues
may be ignored or
disregarded by others.
This is incorrect. Depending on the level of suicide precaution, the nurse should
provide one-to-one contact, constant visual observation, orabirb.com/test
15-minute checks.
This is incorrect. The nurse should ask client directly, “Have you thought about
harming yourself in any way? If so, what do you plan to do? Do you have the means
to carry out this plan?” and “How strong are your intentions to die?”
abirb.com/test
CON: Violence
abirb.com/test
13. A suicidal client says to a nurse, “There’s nothing to live for anymore.” Which is the
best nursing reply?
abirb.com/test
1. “Have you considered doing volunteer work?”
2. “Let’s discuss the negative aspects of your life.”
3. “Things will look better to you in the morning.”
abirb.com/test
4. “It sounds like you are feeling pretty hopeless.”
ANS: 4
Chapter: Chapter 16, Suicide Prevention
abirb.com/test
Objective: Apply the nursing process to individuals exhibiting suicidal behavior.
Page: 275
Heading: Table 16–2, Guiding Principles for Suicide Risk Assessment
abirb.com/test
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: [Applying]
Concept: Communication
abirb.com/test
Difficulty: Moderate
abirb.com/test
abirb.com/test
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Chapter 16 - ETB
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. The statement “Have you considered doing volunteer work?” is an
example of the nontherapeutic communication technique ofabirb.com/test
advice giving and does
not acknowledge the client’s feelings.
This is incorrect. The statement “Let’s discuss the negative aspects of your life”
reinforces the client’s hopelessness.
abirb.com/test
This is incorrect. The statement “Things will look better to you in the morning”
disregards the client’s feelings.
This is correct. The statement “It sounds like you are feeling pretty hopeless” helps
abirb.com/test
establish trust and a therapeutic relationship. The nurse is verbalizing
the client’s
implied feelings and allowing the client to validate and explore them.
CON: Communication
abirb.com/test
abirb.com/test
14. A new nursing graduate asks the psychiatric-mental health nurse manager how to
best classify suicide. Which is the nurse manager’s best reply?
1. “Suicide is a medical diagnosis.”
2. “Suicide is a mental disorder.”
abirb.com/test
3. “Suicide is a behavior.”
4. “Suicide is an antisocial affliction.”
abirb.com/test
ANS: 3
Chapter: Chapter 16, Suicide Prevention
Objective: Differentiate between facts and myths regarding suicide.
abirb.com/test
Page: 270
Heading: Homework Assignment
Integrated Processes: Teaching and Learning
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: [Applying]
Concept: Violence
Difficulty: Easy
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. Suicide is not a diagnosis.
This is incorrect. Suicide is not a mental disorder.
This is correct. Suicide is a behavior.
This is incorrect. Suicide is not an affliction.
CON: Violence
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
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Chapter 16 - ETB
abirb.com/test
15. A nursing student is developing a plan of care for a suicidal client. Which
intervention should the student implement first?
1. Communicate therapeutically.
abirb.com/test
2. Observe the client.
3. Provide a hazard-free environment.
4. Assess suicide risk.
abirb.com/test
ANS: 4
Chapter: Chapter 16, Suicide Prevention
Objective: Apply the nursing process to individuals exhibiting suicidal behavior.
abirb.com/test
Page: 277
Heading: Planning and Implementation; Table 16–3, Care Plan for the Suicidal Client
Nursing Diagnosis: Risk for Suicide
Integrated Processes: Nursing Process: Implementation
abirb.com/test
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Violence
abirb.com/test
Difficulty: Easy
1.
2.
3.
4.
Feedback
This is incorrect. While therapeutic communication is important,
the first step of the
abirb.com/test
nursing process is to assess the client. Assessing the suicide risk assists to keep the
client safe.
This is incorrect. Observing the client is part of nursing care; assessment is the first
step of the nursing process. Assessing suicide risk assists toabirb.com/test
keep the client safe.
This is incorrect. Providing a hazard-free environment is an intervention and should
not occur prior to complete assessment. Without assessment, the nurse cannot
determine the appropriate most appropriate way to keep anabirb.com/test
environment hazard-free.
This is correct. Assessment is the first step of the nursing process. Interventions are
based on data gathered from the nursing assessment.
CON: Violence
abirb.com/test
abirb.com/test
16. Which is a correctly written, appropriate outcome for a client with a history of
suicide attempts who is currently exhibiting symptoms of low self-esteem by isolating
self?
abirb.com/test
1. The client will not physically harm self.
2. The client will express three positive self-attributes by day 4.
3. The client will reveal a suicide plan.
4. The client will establish a trusting relationship with the nurse. abirb.com/test
ANS: 2
Chapter: Chapter 16, Suicide Prevention
abirb.com/test
Objective: Apply the nursing process to individuals exhibiting suicidal behavior.
abirb.com/test
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Chapter 16 - ETB
abirb.com/test
Page: 277
Heading: Diagnosis and Outcome Identification > Outcome Criteria
Integrated Processes: Nursing Process: Planning
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. The current problem is isolative behaviors based on low selfabirb.com/test
esteem, and the prevention of physical harm does not address
this situation. In
addition, this outcome is not measurable.
This is correct. This outcome is measurable, specific, and addresses self-esteem.
This is incorrect. Although the client has a history of suicide
attempts, the current
abirb.com/test
problem is isolative behaviors based on low self-esteem. Revealing a suicide plan
could suggest worsening condition and does not address self-esteem. This outcome
is not measurable.
abirb.com/test
This is incorrect. This outcome is not specific, does not contain
a time frame, and
does not relate to self-esteem.
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
17. A nursing instructor is teaching about suicide. Which student statement indicates that
learning has occurred?
1. “Suicidal threats and gestures should be considered manipulative and/or attention
abirb.com/test
seeking.”
2. “Suicide is the act of a psychotic person.”
3. “All suicidal individuals are mentally ill.”
4. “Fifty to eighty percent of all people who kill themself have a history of a previous
abirb.com/test
attempt.”
ANS: 4
abirb.com/test
Chapter: Chapter 16, Suicide Prevention
Objective: Differentiate between facts and myths regarding suicide.
Page: 266
Heading: Table 16–1, Facts and Myths About Suicide
abirb.com/test
Integrated Processes: Teaching and Learning
Client Need: Psychosocial Integrity
Cognitive Level: Comprehension [Understanding]
abirb.com/test
Concept: Violence
Difficulty: Easy
1.
Feedback
abirb.com/test
This is incorrect. The statement “Suicidal threats and gestures should be considered
abirb.com/test
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Chapter 16 - ETB
abirb.com/test
2.
3.
4.
manipulative and/or attention seeking” is a myth about suicide.
This is incorrect. The statement “Suicide is the act of a psychotic person” is a myth
about suicide.
abirb.com/test
This is incorrect. The statement “All suicidal individuals are
mentally ill” is a myth
about suicide.
This is correct. This statement is a fact.
abirb.com/test
CON: Violence
abirb.com/test
18. A nurse is caring for four clients diagnosed with major depressive disorder. What
impact could religion have on the risk for suicide in these clients?
1. Religious affiliation has no impact on suicide risk.
abirb.com/test
2. One’s type of religion can eliminate suicide risk.
3. Religious affiliation can be protective against suicide attempts.
4. One’s type of religion is more important than social support.
abirb.com/test
ANS: 3
Chapter: Chapter 16, Suicide Prevention
Objective: Discuss epidemiological statistics and risk factors related
to suicide.
abirb.com/test
Page: 267
Heading: Risk Factors > Religion
Integrated Processes: Nursing Process: Analysis
abirb.com/test
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Comprehension [Understanding]
Concept: Violence
Difficulty: Easy
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. Religious affiliation may have some impact on suicide risk.
abirb.com/test
This is incorrect. One’s type of religion does not eliminate suicide risk.
This is correct. Religious affiliation can be protective against suicide attempts.
This is incorrect. Religious affiliation is not necessarily more important than social
abirb.com/test
support systems in suicide risk.
CON: Violence
abirb.com/test
19. Which strategy should the nurse implement first with a suicidal patient?
1. Ask a direct question such as, “Do you ever think about killingabirb.com/test
yourself?”
2. Ask the patient to rate his or her mood on a scale from 1 to 10.
3. Establish a trusting nurse–patient relationship.
4. Apply the nursing process to the planning of patient care.
abirb.com/test
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Chapter 16 - ETB
abirb.com/test
ANS: 1
Chapter: Chapter 16, Suicide Prevention
Objective: Apply the nursing process to individuals exhibiting suicidal behavior.
abirb.com/test
Page: 277
Heading: Assessment > Table 16–3, Care Plan for the Suicidal Client
Nursing Diagnosis: Risk for Suicide
Integrated Processes: Nursing Process: Assessment
abirb.com/test
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: [Applying]
Concept: Violence
abirb.com/test
Difficulty: Easy
1.
2.
3.
4.
Feedback
This is correct. Client safety is always the nurse’s priority.abirb.com/test
The nurse must determine
whether the client has suicidal ideations, has developed a plan, and, if so, the means
exist to execute the plan.
This is incorrect. Rating the client’s mood does not assist the nurse to determine the
abirb.com/test
client’s suicidal ideations.
This is incorrect. Establishing a trusting nurse–client relationship is important but is
not the priority when determining the client’s risk for harm due to suicidal ideation.
This is incorrect. The first priority for the nurse caring for abirb.com/test
the suicidal client is to
determine suicide risk. Although applying the nursing process is important, it is not
the priority at this time.
CON: Violence
abirb.com/test
abirb.com/test
20. A client is newly committed to an inpatient psychiatric unit. Which nursing
intervention best lowers this client’s risk for suicide?
1. Encouraging participation in the milieu to promote hope
abirb.com/test
2. Developing a strong personal relationship with the client
3. Observing the client at intervals determined by assessed data
4. Encouraging and redirecting the client to concentrate on happier times
abirb.com/test
ANS: 3
Chapter: Chapter 16, Suicide Prevention
Objective: Apply the nursing process to individuals exhibiting suicidal
behavior.
abirb.com/test
Page: 277
Heading: Assessment > Table 16–3, Care Plan for the Suicidal Client
Nursing Diagnosis: Risk for Suicide
abirb.com/test
Integrated Processes: Nursing Process: Implementation
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: [Applying]
Concept: Violence
abirb.com/test
Difficulty: Moderate
abirb.com/test
abirb.com/test
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Chapter 16 - ETB
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. Encouraging participation in the milieu to promote hope does not
abirb.com/test
reduce the risk for self-harm due to suicidal behavior.
This is incorrect. A strong personal relationship with a client is unprofessional and
does not support the client’s well-being. .
This is correct. The nurse should continuously observe theabirb.com/test
actively suicidal client for
the first hour after admission then as frequently as needed based on assessment
findings. Observation of the client allows the nurse to interrupt any observed suicidal
behaviors.
abirb.com/test
This is incorrect. Encouraging the client to focus on happier
times does not support
the client’s needs.
CON: Violence
abirb.com/test
abirb.com/test
21. Which datum indicates a suicidal client is participating in a safety plan?
1. Compliance with antidepressant therapy
2. A mood rating of 9/10
3. Disclosing a plan for suicide to staff
abirb.com/test
4. Expressing feelings of hopelessness to the nurse
ANS: 3
abirb.com/test
Chapter: Chapter 16, Suicide Prevention
Objective: Apply the nursing process to individuals exhibiting suicidal behavior.
Page: 277
abirb.com/test
Heading: Diagnosis and Outcome Identification > Outcome Criteria;
Table 16–3, Care
Plan for the Suicidal Client
Nursing Diagnosis: Risk for Suicide
Integrated Processes: Nursing Process: Evaluation
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: [Applying]
Concept: Safety
abirb.com/test
Difficulty: Easy
1.
2.
3.
4.
Feedback
This is incorrect. While compliance with antidepressant therapy
is important, it does
abirb.com/test
not demonstrate participation in the safety plan to prevent self-harm.
This is incorrect. An improved mood may be an indication that therapy is effective
but does not address the safety plan to keep the client safe from harm.
abirb.com/test
This is correct. A degree of the responsibility for the suicidal
client’s safety is given
to the client. When a client shares with staff a plan for suicide, the client is
participating in a plan for safety by communicating thoughts of self-harm that would
initiate interventions to prevent suicide.
abirb.com/test
This is incorrect. Expressing feelings of hopelessness to the nurse is part of the
abirb.com/test
abirb.com/test
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Chapter 16 - ETB
abirb.com/test
therapeutic relationship; however, it does not address the safety plan to keep the
client safe from harm.
CON: Safety
abirb.com/test
abirb.com/test
22. Which statement indicates that the nurse is acting as an advocate for a client who
was hospitalized after a suicide attempt and is now nearing discharge?
1. “I must observe you continually for 1 hour to keep you safe.”
abirb.com/test
2. “Let’s review the resources that you may need after discharge.”
3. “You must have been very upset to do what you did today.”
4. “Are you currently thinking about harming yourself?”
abirb.com/test
ANS: 2
Chapter: Chapter 16, Suicide Prevention
Objective: Apply the nursing process to individuals exhibiting suicidal behavior.
abirb.com/test
Page: 265
Heading: Presenting Symptoms
Integrated Processes: Nursing Process: Implementation
Client Need: Safe and Effective Care Environment: Managementabirb.com/test
of Care
Cognitive Level: [Applying]
Concept: Collaboration
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. Observing the client for 1 hour is done on admission and does not
demonstrate collaboration with the client and treatment team
to meet the client’s
abirb.com/test
needs.
This is correct. The nurse functions in the advocacy role by collaborating with the
client and treatment team to provide client-centered interventions based on the
abirb.com/test
client’s problems and needs. Reviewing the resources the client may need after
discharge demonstrates collaboration.
This is incorrect. Stating that the client must be upset by what was done does not
demonstrate the collaboration appropriate to the advocacy abirb.com/test
role.
This is incorrect. Asking if the client is thinking of harming himself or herself does
not demonstrate the advocacy role and collaboration with the client. This statement
assesses the client.
abirb.com/test
CON: Collaboration
abirb.com/test
23. A client is newly admitted to an inpatient psychiatric unit. Which of the following is
the most critical assessment when determining risk for suicide? abirb.com/test
1. Family history of depression
abirb.com/test
abirb.com/test
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Chapter 16 - ETB
2. The client’s orientation to reality
3. The client’s history of suicide attempts
4. Family support systems
abirb.com/test
abirb.com/test
ANS: 3
Chapter: Chapter 16, Suicide Prevention
Objective: Discuss epidemiological statistics and risk factors related
to suicide.
abirb.com/test
Page: 267
Heading: Epidemiological Factors > Other Risk Factors
Integrated Processes: Nursing Process: Assessment
Client Need: Safe and Effective Care Environment: Managementabirb.com/test
of Care
Cognitive Level: Comprehension [Understanding]
Concept: Violence
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. A family history of depression is not predictive of suicide risk.
abirb.com/test
Suicide risk is higher for individuals who have made previous
suicide attempts.
This is incorrect. The client’s orientation to reality does not reflect the client’s risk
for suicide. Suicide risk is higher for individuals who have made previous suicide
attempts.
abirb.com/test
This is correct. Suicide risk is higher for individuals who have made previous
suicide attempts. About half of individuals who kill themself have previously
attempted suicide.
abirb.com/test
This is incorrect. Family support systems are not predictive of suicide risk. Suicide
risk is higher for individuals who have made previous suicide attempts.
CON: Violence
abirb.com/test
abirb.com/test
24. Which epidemiological factor related to suicide makes it difficult to determine the
number of attempts that happen each year?
1. The number of suicide attempts reflects only those who enter treatment.
2. More people attempt suicide than die by suicide each year. abirb.com/test
3. Unintentional injuries kill more people than suicide attempts each year.
4. Suicide rates consistently increased from 2000 to 2017.
abirb.com/test
ANS: 1
Chapter: Chapter 16, Suicide Prevention
Objective: Discuss epidemiological statistics and risk factors related to suicide
abirb.com/test
Page: 264
Heading: Epidemiological Factors
Integrated Processes: Nursing Process: Assessment
Client Need: Safe and Effective Care Environment: Managementabirb.com/test
of Care
Cognitive Level: Analysis [Analyzing]
abirb.com/test
abirb.com/test
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Chapter 16 - ETB
Concept: Patient-Centered Care
Difficulty: Moderate
1.
2.
3.
4.
abirb.com/test
abirb.com/test
Feedback
This is correct. When people who attempt suicide do not enter treatment settings,
they are not counted in the number of suicide attempts, making it difficult to fully
understand the number of attempts each year.
abirb.com/test
This is incorrect. The number of people who die by suicide each year does not make
it difficult to determine the number of attempts each year.
This is incorrect. Unintentional injuries do not relate to the number of attempts that
abirb.com/test
happen each year.
This is incorrect. Increased suicide rates do not determine the number of attempts
each year.
abirb.com/test
CON: Patient-Centered Care
abirb.com/test
25. The predisposing factor, anger turned inward, is a psychological theory of Freud’s
proposing which of the following?
1. The strength of a person’s intention to die is as significant as his
or her feelings of
abirb.com/test
hopelessness.
2. Suicide occurs because of an earlier repressed desire to kill someone else.
3. Suicide is a way to prevent public humiliation following a social defeat.
abirb.com/test
4. Suicide occurs when a person feels separate from the mainstream of society.
ANS: 2
abirb.com/test
Chapter: Chapter 16, Suicide Prevention
Objective: Describe predisposing factors implicated in the etiology of suicide.
Page: 268
Heading: Psychological Theories > Anger Turned Inward
abirb.com/test
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
abirb.com/test
Concept: Crisis Intervention
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/test
This is incorrect. In addition to hopelessness, the strength of the person’s intention to
die is significant and may be more predictive of the move from ideation to attempts.
This is correct. Freud believed that suicide was a response to intense self-hatred. The
abirb.com/test
anger originated toward a love object but was ultimately turned
inward against the
self.
This is incorrect. Individuals too embarrassed to seek treatment or other support
systems sometimes resort to suicide due to the shame and humiliation
abirb.com/test they feel.
This is incorrect. This describes an egoistic suicide theory proposed by Durkheim.
abirb.com/test
abirb.com/test
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Chapter 16 - ETB
abirb.com/test
CON: Crisis Intervention
abirb.com/test
26. Thomas Joiner’s interpersonal theory of suicide proposes which of the following?
1. An interruption in the customary norms of behavior instills fears
of being without
abirb.com/test
support.
2. Impulsivity is elevated in people who have made suicide attempts.
3. Allegiance is so strong to a group that the individual will sacrifice their life for the
abirb.com/test
group.
4. The concept of suicide ideation and suicide attempts are distinct processes.
ANS: 4
abirb.com/test
Chapter: Chapter 16, Suicide Prevention
Objective: Describe predisposing factors implicated in the etiology of suicide.
Page: 269
abirb.com/test
Heading: Sociological Theories > Interpersonal Theory of Suicide
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
abirb.com/test
Concept: Crisis Intervention
Difficulty: Difficult
1.
2.
3.
4.
abirb.com/test
Feedback
This is incorrect. Anomic suicide occurs in response to changes in an individual’s
life, such as divorce or job loss. The situation causes a disruption of relatedness to a
group.
abirb.com/test
This is incorrect. As described in the Three-Step Theory, research findings indicate
that impulsivity is elevated in people who have made suicide attempts and who have
thoughts of suicide but have never made an attempt.
abirb.com/test
This is incorrect. Altruistic suicide is included in Durkheim’s theories, which
describe an allegiance being so strong that the individual will sacrifice his or her life
for the group. The group is often governed by cultural, religious, or political ties.
This is correct. Joiner’s theory introduces the concept that abirb.com/test
suicide ideation and
suicide attempts need to be understood as distinct processes.
CON: Crisis Intervention
abirb.com/test
27. Which of the following is considered a fact about suicide? abirb.com/test
1. Drug overdose is the leading cause of death among suicide victims.
2. Once a person is considered suicidal, he or she should be viewed as suicidal
indefinitely.
abirb.com/test
3. Most suicidal people have ambivalent feelings regarding living or dying.
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 16 - ETB
4. Suicide runs in families.
abirb.com/test
ANS: 3
abirb.com/test
Chapter: Chapter 16, Suicide Prevention
Objective: Differentiate between facts and myths regarding suicide.
Page: 266
Heading: Table 16–1, Facts and Myths About Suicide
abirb.com/test
Integrated Processes: Teaching and Learning
Client Need: Health Promotion and Maintenance
Cognitive Level: Comprehension [Understanding]
abirb.com/test
Concept: Addiction and Behaviors
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/test
This is incorrect. Gunshot wounds are the leading cause of death among suicide
victims.
This is incorrect. Suicide ideation and risk fluctuate over time and may be time
abirb.com/test
limited. If provided adequate support and resources, a suicidal
person can go on to
lead a normal life.
This is correct. It is a myth that you cannot stop a suicidal person. Most suicidal
people are ambivalent about their feelings regarding livingabirb.com/test
or dying. Most are
“gambling with death” and see it as a cry for someone to save them.
This is incorrect. Suicide is not inherited. However, suicide by a close family
member increases an individual’s risk factor for suicide.
abirb.com/test
CON: Addiction and Behaviors
abirb.com/test
28. Which of the following occupational groups are at highest risk of suicide?
1. Mechanics
abirb.com/test
2. Priests
3. Teachers
4. Librarians
abirb.com/test
ANS: 1
Chapter: Chapter 16, Suicide Prevention
Objective: Describe predisposing factors implicated in the etiology
of suicide.
abirb.com/test
Page: 270
Heading: Application of the Nursing Process With the Suicidal Client > Assessment >
Demographics > Occupation
abirb.com/test
Integrated Processes: Nursing Process
Client Need: Health Promotion and Maintenance
Cognitive Level: Knowledge [Remembering]
Concept: Risk
abirb.com/test
Difficulty: Difficult
abirb.com/test
abirb.com/test
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Chapter 16 - ETB
abirb.com/test
1.
2.
3.
4.
Feedback
This is correct. While the occupational demographic alone does not directly translate
into an individual’s risk, it will provide information as partabirb.com/test
of a comprehensive
assessment of potentiating risk factors.
This is incorrect. People with close religious affiliations may be at lower risk for
attempting suicide. This especially applies to priests, who believe
that suicide is
abirb.com/test
strictly forbidden within the religion as an unforgivable sin.
This is incorrect. Teachers are among the occupations at lowest risk for suicide.
This is incorrect. Librarians are among the occupations at lowest risk for suicide.
abirb.com/test
CON: Risk
abirb.com/test
29. According to the Three-Step Theory, when strong, active suicide ideation is present:
1. An attempt occurs usually within 3 to 6 months of the initial ideation.
abirb.com/test
2. Pain management usually prevents escalation to an attempt.
3. It leads to an attempt only if the individual has the capacity to make an attempt.
4. Connectedness to family typically resolves any attempt.
abirb.com/test
ANS: 3
Chapter: Chapter 16, Suicide Prevention
Objective: Describe predisposing factors implicated in the etiology of suicide.
abirb.com/test
Page: 269
Heading: Sociological Theories > The Three-Step Theory
Integrated Processes: Nursing Process
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Understanding [Comprehension]
Concept: Crisis Intervention
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. The Three-Step Theory makes no mention of any timeline
abirb.com/test
associated with ideation and attempt.
This is incorrect. Pain is found in the first step of the Three-Step Theory. Pain when
combined with hopelessness significantly increases suicide ideation. The question
states that a strong, active suicide ideation is already present.
abirb.com/test
This is correct. The Three-Step Theory mentions that when a strong, active ideation
is present, it leads to an attempt if the capacity to make the attempt is present.
This is incorrect. This is the second step of the Three-Step Theory. Connectedness
abirb.com/test
prevents suicide ideation from escalating in those at risk, but
when pain and
hopelessness exceed one’s sense of connectedness to others, suicide ideation
becomes active.
abirb.com/test
CON: Crisis Intervention
abirb.com/test
abirb.com/test
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Chapter 16 - ETB
abirb.com/test
abirb.com/test
30. Based on epidemiological factors, who is at the greatest risk for
suicide?
1. An 11-year old African American male
2. A 31-year old American Indian female
3. A 68-year old Hispanic female
abirb.com/test
4. An 82-year old Caucasian male
ANS: 4
abirb.com/test
Chapter: Chapter 16, Suicide Prevention
Objective: Discuss epidemiological statistics and risk factors related to suicide.
Page: 265
Heading: Epidemiological Factors > Risk Factors > Age
abirb.com/test
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Knowledge [Remembering]
abirb.com/test
Concept: Crisis Intervention
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/test
This is incorrect. Although adolescents may statistically have a lower rate of suicide
than other age groups, it is important to note that suicide is the second-leading cause
of death among adolescents.
abirb.com/test
This is incorrect. More women than men attempt suicide, but
men succeed (70%)
more often than women do (30%). American Indians are the second-highest ethnic
group, along with Alaska Natives, at 10.9%
This is incorrect. After the age of 65, the overall suicide rate
for females declines.
abirb.com/test
Hispanic Americans account for 6.3% of all suicides.
This is correct. Caucasian Americans account for 14.7% of all suicides, representing
the highest risk statistically for suicide.
abirb.com/test
CON: Crisis Intervention
abirb.com/test
31. A client was diagnosed with depression resulting from the loss of her twin sister in a
skiing accident. Her parents reported that all the client has done since
the accident was
abirb.com/test
lay in her bed and cry, asking why she survived the accident. The physician prescribed
Prozac to treat the depression and suggested that the parents “keep a close eye on her.”
After a week, the client began to show some signs of improvement, even coming out of
abirb.com/test
her room to eat with the family. After 2 months, the client committed
suicide despite
seeming to come out of the depression. What is the likeliest reason?
1. The Prozac prescription was not effective.
2. Suicide risk can increase early in treatment with antidepressants.
abirb.com/test
3. The client was not kept under direct supervision.
abirb.com/test
abirb.com/test
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Chapter 16 - ETB
abirb.com/test
4. A preexisting mental illness was compounded by the death of her sister.
ANS: 2
abirb.com/test
Chapter: 16, Suicide Prevention
Objective: Discuss epidemiological statistics and risk factors related to suicide.
Page: 267
Heading: Epidemiological Factors > Other Risk Factors
abirb.com/test
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
abirb.com/test
Concept: Crisis Intervention
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/test
This is incorrect. In fact, the Prozac prescription was effective in elevating the
client’s mood.
This is correct. Suicide risk may increase early in treatment with antidepressants.
abirb.com/test
One possible reason is that as an individual’s energy returns,
he or she may have an
increased ability to act out self-destructive wishes.
This is incorrect. Direct supervision may have prevented the suicide; however, the
most likely reason for the increased risk was related to treatment
with an
abirb.com/test
antidepressant.
This is incorrect. Nothing in the scenario indicates that the client had a preexisting
mental illness.
abirb.com/test
CON: Crisis Intervention
abirb.com/test
MULTIPLE RESPONSE
abirb.com/test
32. After a teenager reveals that he is gay, his parent responds by beating him. The next
morning, the teenager is found to have committed suicide. Whichabirb.com/test
parental grief
responses should a nurse anticipate? Select all that apply.
1. “I can’t believe this is happening.”
2. “If only I had been more understanding.”
abirb.com/test
3. “How dare he do this to me!”
4. “I’m just going to have to accept that he was gay.”
5. “Well, that was a selfish thing to do.”
abirb.com/test
ANS: 1, 2, 3, 5
Chapter: Chapter 16, Suicide Prevention
Objective: Apply the nursing process to individuals exhibiting suicidal
behavior.
abirb.com/test
Page: 272
abirb.com/test
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Chapter 16 - ETB
abirb.com/test
Heading: Intervention With Families and Friends of Suicide Victims
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Analysis [Analyzing]
Concept: Grief and Loss
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
5.
Feedback
This is correct. Suicide of a family member can induce several feelings in the
survivors. A survivor of suicide may feel a sense of confusion.
abirb.com/test
This is correct. Suicide of a family member can induce several
feelings in the
survivors. A survivor of suicide may undergo a period of recurring self-searching.
This is correct. Suicide of a family member can induce several feelings in the
survivors. A survivor of suicide may experience anger, resentment,
and rage.
abirb.com/test
This is incorrect. A survivor of suicide is more likely to experience a sense of inner
injury; the family feels wounded and does not know how they will ever get over it
and get on with life. This statement reflects acceptance and understanding.
abirb.com/test
This is correct. Suicide of a family member can induce several feelings in the
survivors. A survivor of suicide may experience resentment.
CON: Grief and Loss
abirb.com/test
abirb.com/test
33. A nursing student is developing a study guide related to historical facts about
suicide. Which of the following facts should the student include? Select all that apply.
1. In the Middle Ages, suicide was viewed as a selfish and criminal act.
abirb.com/test
2. During the Roman Empire, suicide was followed by incineration
of the body.
3. Suicide was an offense in ancient Greece, and a common-site burial was denied.
4. During the Renaissance, suicide was discussed and viewed more philosophically.
5. Old Norse traditions set a person who committed suicide adrift in the North Sea.
abirb.com/test
ANS: 1, 3, 4
Chapter: Chapter 16, Suicide Prevention
abirb.com/test
Objective: Differentiate between facts and myths regarding suicide.
Page: 264
Heading: Historical Perspectives
Integrated Processes: Teaching and Learning
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Knowledge [Remembering]
Concept: Violence
abirb.com/test
Difficulty: Moderate
1.
Feedback
This is correct. In the Middle Ages, suicide was viewed as abirb.com/test
a selfish or criminal act
(Minois, 2001).
abirb.com/test
abirb.com/test
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Chapter 16 - ETB
abirb.com/test
2.
3.
4.
5.
This is incorrect. In the culture of the imperial Roman army, individuals sometimes
resorted to suicide to escape humiliation or abuse.
This is correct. In ancient Greece, suicide was considered an offense against the
state, and individuals who committed suicide were denied abirb.com/test
burial in community sites
(Minois, 2001).
This is correct. The issue of suicide changed during the Renaissance period.
Although condemnation was still expected, the view became
philosophical, allowing
abirb.com/test
intellectuals to discuss the issue more freely.
This is incorrect. Per Norse mythology, the practice of suicide ensured an individual
a place in Valhalla (Stillion and McDowell, 1996).
abirb.com/test
CON: Violence
abirb.com/test
34. Nursing students were provided serum blood levels of 30 different clients and were
asked to identify those most at risk for a future suicide attempt based on the laboratory
abirb.com/test
levels alone. Which two of the following factors should the students
focus on for
statistically significant biological factors? Select two choices.
1. Serotonin
2. Fish oil nutrients
abirb.com/test
3. Cytokines
4. 5-hydroxyindole acetic acid (5-HIAA)
abirb.com/test
ANS: 2, 3
Chapter: Chapter 16, Suicide Prevention
Objective: Describe predisposing factors implicated in the etiology of suicide.
Page: 270
abirb.com/test
Heading: Predisposing Factors: Theories of Suicide > Biological Theories >
Neurochemical Factors
Integrated Processes: Nursing Process
abirb.com/test
Client Need: Physiological Integrity
Cognitive Level: Comprehension [Understanding]
Concept: Evidence-Based Practice
abirb.com/test
Difficulty: Difficult
1.
2.
3.
4.
Feedback
This is incorrect. Studies that support deficient levels of serotonin
are measuring
abirb.com/test
cerebrospinal fluid (CSF), not serum blood levels.
This is correct. Fish oil nutrients, including omega-3, was one of two biological
factors that have statistical significance for a future suicide attempt.
abirb.com/test
This is correct. Cytokines were one of two biological factors
that have statistical
significance for a future suicide attempt.
This is incorrect. 5-HIAA is evaluated as the measurement of serotonin in the CSF.
abirb.com/test
CON: Evidence-Based Practice
abirb.com/test
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PMHN, 10e
Chapter 17 - ETB
abirb.com/test
Chapter 17. Behavior Therapy
abirb.com/test
MULTIPLE CHOICE
abirb.com/test
1. A kindergarten rule states that if unacceptable behavior occurs,abirb.com/test
a child’s personalized
fish will be moved to the sea grass. Children who behave keep their fish out of the sea
grass. The school nurse identifies this intervention is based on which principle of
behavior therapy?
abirb.com/test
1. Classical conditioning
2. Conditioned response
3. Positive reinforcement
4. Negative reinforcement
abirb.com/test
ANS: 4
Chapter: Chapter 17, Behavior Therapy
abirb.com/test
Objective: Discuss the principles of classical and operant conditioning
as foundations
for behavior therapy.
Page: 292
Heading: Operant Conditioning > Negative Reinforcement
abirb.com/test
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Health Promotion
Difficulty: Easy
1.
2.
3.
4.
Feedback
abirb.com/test
This is incorrect. Classical conditioning is a process of learning demonstrated by
conditioned responses to environmental stimuli.
This is incorrect. Conditioned responses are part of the classical conditioning
abirb.com/test
learning process.
This is incorrect. Positive reinforcement refers to a stimulus that increases the
probability a behavior will recur.
This is correct. Negative reinforcement increases the probability
that a behavior
abirb.com/test
(appropriate classroom behavior) will recur by the removal of an undesirable
reinforcing stimulus (personalized fish in sea grass).
CON: Health Promotion
abirb.com/test
abirb.com/test
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Chapter 17 - ETB
abirb.com/test
2. An adolescent comes from a family where physical and verbal abuse prevails. The
adolescent bullies and fights with classmates at school. Which of the following is the
abirb.com/test
probable source of this behavior?
1. Shaping
2. Modeling
3. Premack principle
abirb.com/test
4. Reciprocal inhibition
ANS: 2
abirb.com/test
Chapter: Chapter 17, Behavior Therapy
Objective: Identify various techniques used in the modification of client behavior.
Page: 292
Heading: Techniques for Modifying Client Behavior > Modelingabirb.com/test
Integrated Processes: Nursing Process: Analysis
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Family Dynamics
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/test
This is incorrect. Shaping is a technique in which reinforcements are given for
increasingly closer approximations to the desired response.
This is correct. Modeling is the learning of new behaviors by imitating the behaviors
abirb.com/test
seen in others. The adolescent is imitating physical and verbal
abuse behavior
patterns witnessed at home.
This is incorrect. The Premack principle is a technique that states that a frequently
occurring response can serve as a positive reinforcement for
a response that occurs
abirb.com/test
less frequently.
This is incorrect. Reciprocal inhibition is a technique that decreases or eliminates a
behavior by introducing a more-adaptive behavior that is incompatible with the
abirb.com/test
unacceptable behavior.
CON: Family Dynamics
abirb.com/test
3. A third-grader feigns illness to avoid doing homework. The teacher recommends an
abirb.com/test
educational program that uses token economy. Which of the following statements by the
school nurse best explains token economy?
1. “Your child will receive green tokens for completing homework that can be cashed in
abirb.com/test
for desired rewards.”
2. “Your child will receive red tokens when homework is incomplete, and this will result
in school suspension.”
3. “Without any tokens, your child will receive a time-out for each
homework
abirb.com/test
assignment not completed.
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Chapter 17 - ETB
abirb.com/test
4. “You will use tokens or stars to help your child envision receiving rewards when
homework is completed.”
abirb.com/test
ANS: 1
Chapter: Chapter 17, Behavior Therapy
Objective: Identify various techniques used in the modification of
client behavior.
abirb.com/test
Page: 293
Heading: Techniques for Modifying Client Behavior > Token Economy
Integrated Processes: Nursing Process: Implementation
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Health Promotion
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is correct. Token economy is a type of contingency contracting in which tokens
abirb.com/testand are later
immediately reinforce appropriate behavior (completed homework)
exchanged for a desired reward.
This is incorrect. The tokens would be considered a reward system, not a
punishment.
abirb.com/test
This is incorrect. The time-out is an aversive stimulus or punishment, not a reward
stimulus.
This is incorrect. This is covert sensitization and would not be a component of the
abirb.com/test
token system of rewards.
CON: Health Promotion
abirb.com/test
4. A client is diagnosed with an anxiety disorder. The nurse counselor recommends the
abirb.com/test
behavioral technique of reciprocal inhibition. The client asks, “What’s that?” Which is
the best nursing reply?
1. “At the beginning of this intervention, a contract will be drawn up explicitly stating
abirb.com/test
the behavior change agreed upon.”
2. “By introducing an adaptive behavior that is mutually exclusive to your maladaptive
behavior, we will expect subsequent behavior to improve.”
3. “Through a series of increasingly anxiety-provoking steps, we will gradually increase
abirb.com/test
your tolerance to anxiety.”
4. “In one intense session, you will be exposed to a maximum level of anxiety that you
will learn to tolerate.”
abirb.com/test
ANS: 2
Chapter: Chapter 17, Behavior Therapy
Objective: Identify various techniques used in the modification of
client behavior.
abirb.com/test
Page: 293
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Chapter 17 - ETB
abirb.com/test
Heading: Techniques for Modifying Client Behavior > Reciprocal Inhibition
Integrated Processes: Nursing Process: Implementation
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Health Promotion
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. This is contingency contracting, which has specifics on how
abirb.com/test
reinforces and punishment will be presented.
This is correct. Reciprocal inhibition decreases or eliminates an undesired behavior
by introducing a more adaptive behavior that is incompatible with the undesired
behavior.
abirb.com/test
This is incorrect. This is systematic desensitization where the client is exposed to a
hierarchy of anxiety-producing events through which the individual progresses
during therapy.
abirb.com/test
This is incorrect. This is “flooding” where the client is exposed
to a continuous
presentation (through mental imagery) of the phobic stimulus until it no longer
elicits anxiety.
abirb.com/test
CON: Health Promotion
abirb.com/test
5. A client reports, “My friend panicked at the sight of spiders. Her therapist used
gradual exposure to spiders that initially made her increasingly more anxious.” Which
technique was the friend’s therapist using?
abirb.com/test
1. Extinction
2. Covert sensitization
3. Systematic desensitization
abirb.com/test
4. Reciprocal inhibition
ANS: 3
abirb.com/test
Chapter: Chapter 17, Behavior Therapy
Objective: Identify various techniques used in the modification of client behavior.
Page: 294
Heading: Techniques for Modifying Client Behavior > Systematic Desensitization
abirb.com/test
Integrated Processes: Nursing Process: Evaluation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Health Promotion
Difficulty: Moderate
1.
Feedback
abirb.com/test
This is incorrect. Extinction is the gradual decrease in frequency or disappearance of
abirb.com/test
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Chapter 17 - ETB
2.
3.
4.
abirb.com/test
a response when the positive reinforcement is withheld.
This is incorrect. Covert sensitization relies on an individual’s imagination to
abirb.com/test
produce unpleasant consequences for undesirable behaviors.
This is correct. Systematic desensitization is a treatment for phobias in which a
phobic individual is gradually exposed to increasing amounts of the phobic stimulus
while practicing relaxation techniques. Eventually, the phobic
stimulus causes little
abirb.com/test
or no anxiety.
This is incorrect. Reciprocal inhibition is a technique that decreases or eliminates a
behavior by introducing a more adaptive behavior that is incompatible with the
abirb.com/test
unacceptable behavior.
CON: Health Promotion
abirb.com/test
6. A 2-year-old engages in frequent temper tantrums that usually result in the parents
giving in to the child’s demands. During family therapy, which isabirb.com/test
the best nursing
statement when counseling the parents?
1. “You are shaping your child’s behavior.”
2. “Your child has modeled your behavior.”
abirb.com/test
3. “You are positively reinforcing your child’s behavior.”
4. “You are negatively reinforcing your child’s behavior.”
abirb.com/test
ANS: 3
Chapter: Chapter 17, Behavior Therapy
Objective: Identify various techniques used in the modification of client behavior.
Page: 294
abirb.com/test
Heading: Techniques for Modifying Client Behavior > Positive Reinforcement
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Family Dynamics
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. Shaping is a technique in which reinforcements are given for
increasingly closer approximations to the desired response.abirb.com/test
This is incorrect. Modeling is the learning of new behaviors by imitating the
behaviors in others.
This is correct. Positive reinforcement refers to a stimulus (giving in) that increases
the probability a behavior (child’s demands) will recur. abirb.com/test
This is incorrect. Negative reinforcement increases the probability that behavior will
recur by removal of an undesirable reinforcing stimulus.
abirb.com/test
CON: Family Dynamics
abirb.com/test
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Chapter 17 - ETB
abirb.com/test
abirb.com/test
7. When seeking special privileges, a child always chooses to ask the mother rather than
the father. The father is more apt to disagree with the child’s requests, whereas the
mother usually consents. Which component of operant conditioning
explains the child’s
abirb.com/test
choice?
1. Conditioned stimuli
2. Unconditioned stimuli
abirb.com/test
3. Aversive stimuli
4. Discriminative stimuli
ANS: 4
abirb.com/test
Chapter: Chapter 17, Behavior Therapy
Objective: Discuss the principles of classical and operant conditioning as foundations
for behavior therapy.
abirb.com/test
Page: 294
Heading: Operant Conditioning > Negative Reinforcement
Integrated Processes: Nursing Process: Evaluation
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Analysis [Analyzing]
Concept: Family Dynamics
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. A conditioned response is an unexpected, nonreflexive response to
an environmental stimulus.
abirb.com/test
This is incorrect. An unconditioned response is a reflexive, expected response to an
environmental stimulus.
This is incorrect. An aversive stimulus follows a behavioral response and decreases
abirb.com/test
the probability that the behavior will recur.
This is correct. Discriminative stimuli are under an individual’s control. The child
can discriminate between stimuli and can predict with assurance that asking the
mother (not the father) will result in a desired response. abirb.com/test
CON: Family Dynamics
abirb.com/test
8. Parents decide to try the nurse practitioner’s suggestion of time-out when their child
abirb.com/test
misbehaves. Which is the nurse practitioner’s best statement when
teaching the parents?
1. “Correct your child’s behavior by spanking for a specified time period.”
2. “Ignore the child’s negative behavior.”
3. “Add positive reinforcement for acceptable behavior.”
abirb.com/test
4. “Temporarily move your child to an area where behavior is not being reinforced.”
abirb.com/test
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Chapter 17 - ETB
abirb.com/test
ANS: 4
abirb.com/test
Chapter: Chapter 17, Behavior Therapy
Objective: Implement the principles of behavior therapy using the steps of the nursing
process.
Page: 293
abirb.com/test
Heading: Techniques for Modifying Client Behavior > Time-Out
Integrated Processes: Teaching and Learning
Client Need: Health Promotion and Maintenance
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Health Promotion
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. This is an attempt to explain operant conditioning, where
additional attention is given to the consequence of the behavioral response. There is
abirb.com/test
no indication that spanking is appropriate discipline.
This is incorrect. This is an example of extinction, where positive reinforcement is
withheld (parental attention).
This is incorrect. This is an example of operant conditioning
with positive
abirb.com/test
reinforcement, not a time-out.
This is correct. Removing the child from the environment where the unacceptable
behavior is occurring (a time-out) is an aversive stimulus or punishment. There is no
abirb.com/test
reinforcing attention during the time the child is isolated, which
discourages a
reoccurrence of the undesired behavior.
CON: Health Promotion
abirb.com/test
abirb.com/test
9. The spouse of an alcoholic comes to the clinic and asks for some medication to help
the client stop drinking. The spouse states that there is a drug given to help stop drinking
by making them sick after ingesting alcohol. Which of the following is the most
abirb.com/test
appropriate response to this request?
1. “This may work, as it has been a form of eliminating behavior with a more-adaptive
behavior.”
2. “This would be a discussion with the individual who wishes to stop drinking by
abirb.com/test
replacing the euphoric feeling with a severe punishment.”
3. “I am sure that the therapist can prescribe this and you can add it to your spouse’s
food.”
abirb.com/test
4. “Have you tried to use a written contract with your spouse first?
The side effects of
the medication are dangerous.”
ANS: 2
Chapter: Chapter 17, Behavior Therapy
abirb.com/test
abirb.com/test
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Chapter 17 - ETB
abirb.com/test
Objective: Identify various techniques used in the modification of client behavior.
Page: 293
abirb.com/test
Heading: Techniques For Modifying Client Behavior> Overt Sensitization
Integrated Processes: Nursing Process: Evaluation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Health Promotion
Difficulty: Easy
1.
2.
3.
4.
abirb.com/test
Feedback
This is incorrect. This describes reciprocal inhibition, where the client with a more
adaptive behavior for the unacceptable behavior
This is correct This is a form of overt sensitization, or aversion
therapy, that
abirb.com/test
produces unpleasant consequences. This disulfiram (Antabuse) is given to
individuals who wish to stop drinking. Further discussion is necessary, as the client
must agree to this treatment.
abirb.com/test
This is incorrect. This would be ethically incorrect, as the client
must be willing to
use the medication and wish to stop drinking.
This is incorrect. This is an example of contingency contracting. A contract is drawn
up among all parties involved. The desired behavior change
and specified reinforcers
abirb.com/test
for performing this behavior are stated explicitly in writing.
CON: Health Promotion
abirb.com/test
10. A client is in therapy with a nurse practitioner for the treatment
of arachnophobia.
abirb.com/test
The nurse practitioner decides to use the technique of flooding. Which intervention best
exemplifies flooding?
1. Giving rewards for demonstrating a decrease in fear of spiders
abirb.com/test
2. Encouraging the client to sit through the movie Spider-Man
3. Accompanying the client to a 1-hour visit to the local zoo’s spider room
4. Offering a computer program that progressively presents anxiety-producing spider
abirb.com/test
scenarios
ANS: 3
Chapter: Chapter 17, Behavior Therapy
abirb.com/test
Objective: Identify various techniques used in the modification of client behavior.
Page: 294
Heading: Techniques for Modifying Client Behavior > Flooding
abirb.com/test
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Stress
abirb.com/test
Difficulty: Moderate
abirb.com/test
abirb.com/test
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Chapter 17 - ETB
1.
2.
3.
4.
abirb.com/test
Feedback
abirb.com/test
This is incorrect. This is token economy, a system of reinforcing
desired behaviors.
This is incorrect. This would be an attempt at systematic desensitization.
This is correct. Flooding is used to desensitize individuals to phobic stimuli. The
individual is flooded with a continuous presentation (visiting
the spider room) of the
abirb.com/test
phobic stimulus until it no longer elicits anxiety.
This is incorrect. This would be a systematic desensitization technique.
CON: Stress
abirb.com/test
abirb.com/test
11. During a smoking cessation group, the community health nurse explains that in their
effort to quit smoking, a reciprocal inhibition approach will be used. The nurse should
give the group which example of this technique?
1. “Before you can smoke, you must first take a half-hour walk.”abirb.com/test
2. “When you have the urge to smoke, imagine being short of breath.”
3. “You’ll receive $1 for each cigarette not smoked and forfeit $2 for each cigarette
smoked.”
abirb.com/test
4. “When you have the urge to smoke, hold your breath and then rhythmically breathe.”
ANS: 4
abirb.com/test
Chapter: Chapter 17, Behavior Therapy
Objective: Implement the principles of behavior therapy using the steps of the nursing
process.
Page: 293
abirb.com/test
Heading: Techniques for Modifying Client Behavior > Reciprocal Inhibition
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Health Promotion
Difficulty: Difficult
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. This is an example of reciprocal inhibition by
“counterconditioning” the individual’s behavior to a more-adaptive
behavior.
abirb.com/test
This is incorrect. This is a covert sensitization, where the individual imagines
unpleasant symptoms or negative consequences.
This is incorrect. This is an example of token economy.
abirb.com/test
This is correct. Breathing exercises are an example of reciprocal
inhibition.
Reciprocal inhibition is a technique that decreases or eliminates an unacceptable
behavior (smoking) by introducing a more-adaptive behavior (smoking cessation)
that is incompatible with the unacceptable behavior.
abirb.com/test
abirb.com/test
abirb.com/test
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Chapter 17 - ETB
abirb.com/test
CON: Health Promotion
abirb.com/test
12. A mother states, “You are old enough to clean your own bedroom.” Upon later
inspection, the mother finds the floor is clear and everything is stacked
in a chair. The
abirb.com/test
mother praises the child for clearing the floor. This is consistent with which technique of
behavior modification?
1. Shaping
abirb.com/test
2. Extinction
3. Stimulus generalization
4. Reciprocal inhibition
abirb.com/test
ANS: 1
Chapter: Chapter 17, Behavior Therapy
Objective: Identify various techniques used in the modification of client behavior.
abirb.com/test
Page: 292
Heading: Techniques for Modifying Client Behavior > Shaping
Integrated Processes: Nursing Process: Evaluation
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Health Promotion
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is correct. The mother is using shaping, which involves molding behavior in a
desired direction by reinforcing (praise for clearing the floor)
each small step toward
abirb.com/test
the desired behavior (child cleaning own bedroom).
This is incorrect. Extinction is the gradual decrease in frequency or disappearance of
a response when the positive reinforcement is withheld.
abirb.com/test
This is incorrect. Stimulus generalization is the process by which the fear response is
elicited from similar stimuli.
This is incorrect. Reciprocal inhibition decreases or eliminates an undesired behavior
by introducing a more-adaptive behavior that is incompatible
with the undesired
abirb.com/test
behavior.
CON: Health Promotion
abirb.com/test
abirb.com/test
13. During hospitalization, an attention-seeking client has repeatedly
cut herself. After
threatening to cut herself again, the nurse states, “Here are some Band-Aids so you
won’t bleed on the sheets.” Which is the underlying reason for this nurse’s response?
1. The nurse is using an aversive stimulus in response to the client’s
manipulative
abirb.com/test
cutting behavior.
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Chapter 17 - ETB
abirb.com/test
2. The nurse is using negative reinforcement in response to the client’s behavior.
3. The nurse is working to extinguish the client’s manipulative behavior.
abirb.com/test
4. The nurse lacks empathy for the client’s recurring self-injurious
behavior.
ANS: 3
Chapter: Chapter 17, Behavior Therapy
abirb.com/test
Objective: Implement the principles of behavior therapy using the steps of the nursing
process.
Page: 293
Heading: Techniques for Modifying Client Behavior > Extinctionabirb.com/test
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Health Promotion
Difficulty: Difficult
1.
2.
3.
4.
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Feedback
This is incorrect. An aversive stimulus follows a behavioral response and decreases
the probability that the behavior will recur.
This is incorrect. Negative reinforcement increases the probability
that behavior will
abirb.com/test
recur by removal of an undesirable reinforcing stimulus.
This is correct. The nurse’s goal is extinction of the client’s manipulative, attentionseeking behavior. Extinction is the gradual decrease in frequency or disappearance
of a response when a positive reinforcement is withheld. abirb.com/test
This is incorrect. The nurse is not displaying a lack of empathy; rather, the nurse is
using behavioral modification.
abirb.com/test
CON: Health Promotion
abirb.com/test
14. A nursing instructor is teaching about the behavior technique of modeling. When
asked to give an example of this behavioral intervention, which student statement
abirb.com/test
indicates learning has occurred?
1. “A child is first rewarded for using a spoon to eat and then rewarded for using a fork,
and finally rewarded for cutting food with a knife.”
2. “An adolescent imitates their parents by using and caring for household appliances
abirb.com/test
appropriately.”
3. “A client and therapist agree to conditions of therapy, stating explicitly in writing the
behavior change that is desired.”
abirb.com/test
4. “A mother tells her child that television can be watched only after
homework is
completed.”
ANS: 2
Chapter: Chapter 17, Behavior Therapy
abirb.com/test
abirb.com/test
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Chapter 17 - ETB
abirb.com/test
Objective: Implement the principles of behavior therapy using the steps of the nursing
process.
abirb.com/test
Page: 292
Heading: Techniques for Modifying Client Behavior > Modeling
Integrated Processes: Teaching and Learning
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Health Promotion
Difficulty: Easy
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. This is an example of token economy or positive reinforcement.
This is correct. Modeling is the learning of new behaviors abirb.com/test
by imitating the behaviors
in others.
This is incorrect. This is an example of contingency contracting.
This is incorrect. This is an example of token economy, where the television is a
abirb.com/test
form of rewarding positive behavior.
CON: Health Promotion
abirb.com/test
15. A mother tells her teenager that for college tuition to be paid, the teenager must quit
abirb.com/test
smoking. They develop a written agreement stipulating time frames and consequences.
This is an example of which technique of behavior modification?
1. Shaping
2. Modeling
abirb.com/test
3. Contracting
4. Premack principle
abirb.com/test
ANS: 3
Chapter: Chapter 17, Behavior Therapy
Objective: Identify various techniques used in the modification of client behavior.
abirb.com/test
Page: 293
Heading: Techniques for Modifying Client Behavior > Contingency Contracting
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Health Promotion
Difficulty: Easy
abirb.com/test
1.
2.
Feedback
This is incorrect. Shaping is a technique in which reinforcements are given for
increasingly closer approximations to the desired response.abirb.com/test
This is incorrect Modeling is the learning of new behaviors by imitating the
abirb.com/test
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Chapter 17 - ETB
3.
4.
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behaviors in others.
This is correct. The mother is using contingency contracting, which is the process of
abirb.com/test
creating a contract specifying a specific behavior change (smoking
cessation) and
the reinforcers to be given (paid college tuition) for performing the desired
behaviors.
This is incorrect. The Premack principle is a technique thatabirb.com/test
states a frequently
occurring response can serve as a positive reinforcement for a response that occurs
less frequently.
CON: Health Promotion
abirb.com/test
abirb.com/test
16. The parents of a 10-year-old child come to the office to discuss the issues raised
during the most recent parent-teacher conference. One parent states that the child is able
to act age appropriately unless given a task to complete, such as making their bed. In this
abirb.com/test
case, the child crawls on the floor and begins to speak “baby talk”
until the other parent
relents and does the task for the child. What is the most appropriate reason for this
maladaptive behavior?
1. This is an example of extinction technique.
abirb.com/test
2. This is an example of overt sensitization.
3. This is an example of systematic desensitization.
4. This is an example of classical conditioning.
abirb.com/test
ANS: 4
Chapter: Chapter 17, Behavior Therapy
Objective: Discuss the principles of classical and operant conditioning
as foundations
abirb.com/test
for behavior therapy.
Page: 291
Heading: Core Concepts
abirb.com/test
Integrated Processes: Teaching and Learning
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Health Promotion
abirb.com/test
Difficulty: Easy
1.
2.
3.
4.
Feedback
abirb.com/test
This is incorrect. Extinction behavioral modification is the gradual decrease in
frequency or disappearance of a response when the positive reinforcement is
withheld.
abirb.com/test
This is incorrect. Overt sensitization is a type of aversion therapy
that produces
unpleasant consequences for undesirable behavior.
This is incorrect. Systematic desensitization is a technique used for assisting
individuals to overcome their fear of a phobic stimulus. abirb.com/test
This is correct. The father has been conditioned by the child to perform the tasks for
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Chapter 17 - ETB
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the child’s maladaptive behavior.
CON: Health Promotion
abirb.com/test
abirb.com/test
17. Which assumption is most reflective of a behavioral theory model?
1. Mental illness is characterized by biochemical alterations.
2. Cognitive reasoning influences behaviors.
3. Personality development is dependent upon social context. abirb.com/test
4. There is a fundamental relationship between stimulus and response.
ANS: 4
abirb.com/test
Chapter: Chapter 17, Behavior Therapy
Objective: Discuss the principles of classical and operant conditioning as foundations
for behavior therapy.
abirb.com/test
Page: 291
Heading: Classical Conditioning
Integrated Processes: Teaching and Learning
Client Need: Psychosocial Integrity
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Cognitive Level: Comprehension [Understanding]
Concept: Evidence-Based Practice
Difficulty: Easy
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. This is a definition of mental illness and does
not provide how
abirb.com/test
behavioral theory would work.
This is incorrect. Although this is partially true, it does not discuss how behavioral
theory would relate to cognition.
abirb.com/test
This is incorrect. Although this may be a true statement, it does not discuss
behavioral theory.
This is correct. Pavlov’s behavioral theory introduced the assumption that there is a
basic relationship between a stimulus and a response. The abirb.com/test
connection between a
stimulus and a response is strengthened or weakened by the consequences of the
response.
CON: Evidence-Based Practice
abirb.com/test
abirb.com/test
18. A nurse recognizes which intervention within a behavioral therapy program is best?
1. A child is given a Popsicle for staying dry and clean.
2. A child is put in time-out after soiling his or her undergarments.
abirb.com/test
3. A child is allowed to remain in soiled undergarments.
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Chapter 17 - ETB
abirb.com/test
4. A child is taught the advantages of staying dry and clean.
abirb.com/test
ANS: 1
Chapter: Chapter 17, Behavior Therapy
Objective: Implement the principles of behavior therapy using the steps of the nursing
process.
abirb.com/test
Page: 291
Heading: Operant Conditioning
Integrated Processes: Nursing Process: Implementation
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Evidence-Based Practice
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is correct. This is an example of positive reinforcement. A stimulus that follows
abirb.com/testThe Popsicle is
a behavior or response is called a reinforcing stimulus or reinforcer.
a reinforcer, or stimulus, for the child to stay dry and clean. This is an example of
operant conditioning, a form of behavioral therapy.
This is incorrect. A time-out is an example of an aversive reinforcer.
abirb.com/test
This is incorrect. Allowing a child to remain in soiled undergarments is an example
of an aversive reinforcer.
This is incorrect. Teaching the child is not an element of behavioral therapy, such as
abirb.com/test
operant conditioning.
CON: Evidence-Based Practice
abirb.com/test
19. An adolescent client was recently admitted to the psychiatric unit because of
abirb.com/test
impulsivity and acting-out behavior at school. Which nursing action should the nurse
implement first?
1. Redirect the client to activities to decrease stress.
2. Explain the unit rules and consequences of breaking the rules. abirb.com/test
3. Place the client on close observation to ensure a trusting relationship.
4. Administer an antianxiety medication.
abirb.com/test
ANS: 2
Chapter: Chapter 17, Behavior Therapy
Objective: Implement the principles of behavior therapy using the steps of the nursing
abirb.com/test
process.
Page: 292
Heading: Operant Conditioning
Integrated Processes: Nursing Process: Implementation
abirb.com/test
Client Need: Psychosocial Integrity
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Chapter 17 - ETB
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
1.
2.
3.
4.
abirb.com/test
Feedback
This is incorrect. This is not the first nursing action; this would
occur after the client
abirb.com/test
were to define boundaries.
This is correct. The first nursing action is to explain the unit rules and the
consequences of breaking the rules to influence the adolescent’s behavior. Operant
abirb.com/test
conditioning theory asserts that stimuli (environmental events)
interact with and
influence an individual’s behavior.
This is incorrect. Close observation would be necessary if the client were a danger to
self or others.
abirb.com/test
This is incorrect. There is no indication that the client has anxiety.
CON: Patient-Centered Care
abirb.com/test
20. Per behavioral theory, the treatment of phobic symptoms involves
which action?
abirb.com/test
1. Decrease the environmental stimuli in the room.
2. Progressive exposure of the phobia to the actual experience.
3. Request the family participate in the care planning.
abirb.com/test
4. Discovery of previous noxious experiences via hypnosis.
ANS: 2
Chapter: Chapter 17, Behavior Therapy
abirb.com/test
Objective: Identify various techniques used in the modification of client behavior.
Page: 294
Heading: Techniques for Modifying Client Behavior > Systematic Desensitization
abirb.com/test
Integrated Process: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Health Promotion
Difficulty: Easy
1.
2.
3.
4.
Feedback
abirb.com/test
This is incorrect. Manipulating the environment, such as dimming the lights and
sounds, may decrease the client’s overall anxiety but does not address the phobias.
This is correct. This is an example of systematic desensitization, which is used to
assist an individual overcome fear of a phobic stimulus. It abirb.com/test
is systematic in that there
is a hierarchy of anxiety-producing events through which the individual progresses
during therapy.
This is incorrect. Family inclusion is not a component of behavior
theory.
abirb.com/test
This is incorrect. Hypnosis or revisiting incidents that produced the phobia is not a
abirb.com/test
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Chapter 17 - ETB
abirb.com/test
component of behavior theory.
CON: Health Promotion
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
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Chapter 18 - ETB
Chapter 18. Cognitive Behavior Therapy
abirb.com/test
abirb.com/test
MULTIPLE CHOICE
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1. Which of the following best defines the basis of cognitive behavior therapy?
1. Cognitive behavior therapy is based on the concept that distorted
thoughts are the
abirb.com/test
foundation of many emotional, mental, and behavioral disorders.
2. Cognitive behavior therapy is based on the concept that higher education can prevent
emotional, mental, and behavioral disorders.
abirb.com/test
3. Cognitive behavior therapy is based on the concept that a contingency
contract can
help a client develop adaptive behaviors.
4. Cognitive behavior therapy is based on a reward system of positive reinforcement of
positive self-statements.
abirb.com/test
ANS: 1
Chapter: Chapter 18, Cognitive Behavior Therapy
abirb.com/test
Objective: Describe goals, principles, and basic concepts of cognitive
behavior therapy.
Page: 299
Heading: Introduction
Integrated Processes: Cognition
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
abirb.com/test
Difficulty: Easy
1.
2.
3.
4.
Feedback
This is correct. Cognitive behavior therapy is based on theabirb.com/test
theory that distorted
perceptions, or cognition, are the foundation of many emotional, mental, and
behavioral disorders.
This is incorrect. There is no correlation with education level and mental health.
abirb.com/test
This is incorrect. A contract for improved behavior is a component
of behavioral
therapy, not cognitive behavior therapy.
This is incorrect. This type of positive reward as a form of positive reinforcement is
a component of behavioral therapy, not cognitive behaviorabirb.com/test
therapy.
CON: Patient-Centered Care
abirb.com/test
2. A psychiatric-mental health nurse is counseling a client who has thought patterns
abirb.com/test
consisting of rapid responses to a situation without rational analysis.
Which assessment
data will the nurse document?
abirb.com/test
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Chapter 18 - ETB
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1. “Thought patterns are triggered by specific stressful stimuli.”
2. “Thought patterns contain the client’s fundamental beliefs and assumptions.”
3. “Thought patterns are flexible and based on personal experience.”
abirb.com/test
4. “Thought patterns include a predominance of automatic thoughts.”
ANS: 4
Chapter: Chapter 18, Cognitive Behavior Therapy
abirb.com/test
Objective: Apply techniques of cognitive behavior therapy within the context of the
nursing process.
Page: 301
Heading: Goals and Principles of Cognitive Behavior Therapy >abirb.com/test
Basic Concepts >
Automatic Thoughts
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Difficult
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. This is not a specific documentation but rather a definition of the
term automatic thoughts.
abirb.com/test
This is incorrect. This is not a specific documentation of the client’s issues and is an
example of the client’s schema. Schema can be adaptive or maladaptive.
This is incorrect. This is not an example of negative automatic thoughts but rather a
abirb.com/test
statement of the client’s schema, or core beliefs, which seem
to be adaptive.
This is correct. Automatic thoughts consist of rapid responses to a situation without
rational analysis. These thoughts are often negative and based on erroneous logic.
abirb.com/test
CON: Patient-Centered Care
abirb.com/test
3. A successful business executive continually thinks her job accomplishments are not
adequate. The nurse recognizes the client’s thinking reflects which cognitive error?
abirb.com/test
1. Minimization
2. Dichotomous thinking
3. Arbitrary inference
4. Personalization
abirb.com/test
ANS: 1
Chapter: Chapter 18, Cognitive Behavior Therapy
abirb.com/test
Objective: Describe goals, principles, and basic concepts of cognitive
behavior therapy.
Page: 301
Heading: Goals and Principles of Cognitive Behavior Therapy > Basic Concepts >
Minimization
abirb.com/test
Integrated Processes: Nursing Process: Assessment
abirb.com/test
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Chapter 18 - ETB
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Easy
1.
2.
3.
4.
abirb.com/test
abirb.com/test
Feedback
This is correct. Minimization is the cognitive error that undervalues
abirb.com/testpositive events
and experiences. The client cannot give credit for personal strengths.
This is incorrect. Dichotomous thinking is viewing situations in terms of all or
nothing, black or white, or good or bad.
abirb.com/test
This is incorrect. Arbitrary inference occurs when the individual
automatically
comes to a conclusion without facts to support it and despite contradictory evidence.
This is incorrect. Personalization occurs when a person takes complete responsibility
for situations without considering other circumstances thatabirb.com/test
may have contributed to
the outcome.
CON: Patient-Centered Care
abirb.com/test
4. A nursing student states, “The instructor gave me a failing grade
on my research
abirb.com/test
paper. I know it’s because the instructor doesn’t like me.” Which cognitive error does
the nurse recognize in this student’s statement?
1. Dichotomous thinking
abirb.com/test
2. Catastrophic thinking
3. Magnification
4. Overgeneralization
abirb.com/test
ANS: 3
Chapter: Chapter 18, Cognitive Behavior Therapy
Objective: Describe goals, principles, and basic concepts of cognitive behavior therapy.
abirb.com/test
Page: 301
Heading: Goals and Principles of Cognitive Behavior Therapy > Basic Concepts >
Magnification
abirb.com/test
Integrated Processes: Teaching and Learning
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
abirb.com/test
Difficulty: Moderate
1.
2.
3.
Feedback
abirb.com/test
This is incorrect. Dichotomous thinking is viewing situations
in terms of all or
nothing, black or white, or good or bad.
This is incorrect. Catastrophic thinking is always thinking the worst will occur
without considering the possibility of positive outcomes. abirb.com/test
This is correct. Magnification is exaggerating the negative significance of an event.
abirb.com/test
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Chapter 18 - ETB
abirb.com/test
4.
This is incorrect. Overgeneralization is a type of absolutistic thinking in which an
individual makes a sweeping conclusion made based on one incident.
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
5. An advanced practice nurse recommends that a client participate in cognitive behavior
therapy. The client asks, “What’s cognitive behavior therapy, and how can it help me?”
Which is the nurse’s best reply?
abirb.com/test
1. “It is a system of techniques in which you use positive thinking
to improve your
mood.”
2. “It is a long-term interpersonal approach that emphasizes the role of early childhood
experiences.”
abirb.com/test
3. “It is an interpersonal treatment approach that specifically targets magical thinking.”
4. “It is a focused treatment for the modification of distorted thinking and maladaptive
behaviors.”
abirb.com/test
ANS: 4
Chapter: Chapter 18, Cognitive Behavior Therapy
Objective: Describe goals, principles, and basic concepts of cognitive
behavior therapy.
abirb.com/test
Page: 300
Heading: Indications for Cognitive Behavior Therapy
Integrated Processes: Nursing Process: Implementation
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. This does not answer the client’s question on cognitive behavior
abirb.com/test
therapy. Cognitive behavior therapy utilizes interventions to modify the client’s
perceptions and responses to stressors.
This is incorrect. Although principle 1 states that the therapist identifies current
abirb.com/test
thinking patterns that may have developed early in life, cognitive
behavior therapy is
often a time-limited approach.
This is incorrect. The goal of cognitive behavior therapy is to substitute morerealistic interpretations for the client’s biased cognitions, not
recommend “magical
abirb.com/test
thinking.”
This is correct. Cognitive behavior therapy is a time-limited intervention in which
the therapist works in collaboration with the client to modify thinking to eliminate
abirb.com/test
cognitive errors that reinforce emotional disturbances.
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
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Chapter 18 - ETB
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6. A welder has been selected as employee of the year. The welder wants to ask for a
promotion but is hampered by poor self-esteem. Which is the best technique for the
abirb.com/test
employee health nurse to use to help the employee request the promotion?
1. Socratic questioning
2. Activity scheduling
3. Distraction
abirb.com/test
4. Cognitive rehearsal
ANS: 4
abirb.com/test
Chapter: Chapter 18, Cognitive Behavior Therapy
Objective: Apply techniques of cognitive behavior therapy within the context of the
nursing process.
Page: 303
abirb.com/test
Heading: Techniques of Cognitive Behavior Therapy > Cognitive Rehearsal
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. Socratic dialogue involves using “who, what, when, where, why,
and how” questions to assist the client to describe feelings related to specific
abirb.com/test
scenarios.
This is incorrect. Activity scheduling is when clients are asked to keep a daily log of
their activities on an hourly basis and rate each activity.
This is incorrect. Distraction redirects and diverts intrusiveabirb.com/test
thoughts or depressive
ruminations that contribute to maladaptive responses.
This is correct. The employee health nurse can utilize cognitive rehearsal before the
employee requests the promotion. Cognitive rehearsal helps an individual identify
abirb.com/test
and modify any dysfunctional thoughts.
CON: Patient-Centered Care
abirb.com/test
7. An advanced practice nurse is counseling a client diagnosed with
generalized anxiety
abirb.com/test
disorder. The nurse plans to use activity scheduling to address this client’s concerns.
What is the purpose of this nursing intervention?
1. To identify important areas needing concentration during therapy
2. To increase self-esteem and decrease feelings of helplessness abirb.com/test
3. To modify maladaptive behaviors using role-play
4. To divert away from intrusive thoughts and depressive ruminations
ANS: 1
abirb.com/test
abirb.com/test
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Chapter 18 - ETB
abirb.com/test
Chapter: Chapter 18, Cognitive Behavior Therapy
Objective: Apply techniques of cognitive behavior therapy within the context of the
nursing process.
abirb.com/test
Page: 303
Heading: Techniques of Cognitive Behavior Therapy > Behavioral Interventions >
Activity Scheduling
Integrated Processes: Nursing Process: Implementation
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
This is correct. In activity scheduling, the client is asked toabirb.com/test
keep a daily log of
activities and rate them for mastery and pleasure to identify recurring daily patterns
that can be addressed in therapy.
This is incorrect This is an example of graded task assignment goal.
abirb.com/test
This is incorrect. This is an example of behavioral rehearsal;
role-play assumes the
role of an individual in a situation that produces a maladaptive response in the client.
This is incorrect. This is an example of distraction technique.
abirb.com/test
CON: Patient-Centered Care
abirb.com/test
8. The student comes in to the instructor’s office and reports that they wish to drop out
of nursing school due to the overwhelming work. The instructor advises the student to
abirb.com/test
write assignments and due dates on a calendar to help break down
what needs to be done
and when. What technique is the instructor using?
1. Activity scheduling
2. Distraction
abirb.com/test
3. Graded task assignments
4. Behavioral rehearsal
abirb.com/test
ANS: 3
Chapter: Chapter 18, Cognitive Behavior Therapy
Objective: Apply techniques of cognitive behavior therapy within the context of the
nursing process.
abirb.com/test
Page: 306
Heading: Table 19–4, Care Plan for “Sam” (An Example of Intervention With Cognitive
Behavior Therapy): Nursing Diagnosis: Chronic Low Self-esteem
abirb.com/test
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
abirb.com/test
Difficulty: Difficult
abirb.com/test
abirb.com/test
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Chapter 18 - ETB
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. Activity scheduling identifies important areas needing
abirb.com/test
concentration during therapy, where the client is asked to keep
a daily log of their
activities on an hourly basis.
This is incorrect. Distraction redirects the client’s thinking and diverts from intrusive
thoughts or depressive ruminations that are contributing toabirb.com/test
maladaptive responses.
This is correct. Graded task assignments are used to break down the task into
subtasks that the client can complete one step at a time. Using a calendar with the
assignments and due dates may help the student/client increase self-esteem and
abirb.com/test
decrease feeling of helplessness.
This is incorrect. Behavioral rehearsal would include miscellaneous techniques such
as role-modeling, social skills training, and other behavioral interventions.
abirb.com/test
CON: Patient-Centered Care
abirb.com/test
9. A nursing student evaluates her group project partner as irresponsible because of
minimal participation in planning. When told of this situation, the nursing instructor
plans to use the cognitive technique of examining the evidence. Which
response by the
abirb.com/test
nursing instructor exemplifies this technique?
1. “Let’s look at the potential reasons why your partner has not participated.”
2. “How do you define irresponsibility?”
abirb.com/test
3. “Has it occurred to you that your partner may be working on the project at home?”
4. “Are you telling me that you feel totally responsible for this project?”
abirb.com/test
ANS: 1
Chapter: Chapter 18, Cognitive Behavior Therapy
Objective: Discuss a variety of cognitive behavior therapy techniques.
Page: 301
abirb.com/test
Heading: Goals and Principles of Cognitive Behavior Therapy > Principle 9. Cognitive
behavior therapy teaches clients to identify, evaluate, and respond to their dysfunctional
thoughts and beliefs.
abirb.com/test
Integrated Processes: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
abirb.com/test
Difficulty: Moderate
1.
2.
3.
Feedback
This is correct. The nursing instructor uses the technique ofabirb.com/test
examining evidence to
help review data that supports or contradicts the accuracy of the student beliefs.
This is incorrect. This deflects the student’s feelings regarding this situation.
This is incorrect. This does not help the student find a solution
to the perception of
abirb.com/test
the problem.
abirb.com/test
abirb.com/test
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Chapter 18 - ETB
abirb.com/test
4.
This is incorrect. Although this may help the instructor understand the student’s
perceptions by rewording the student’s statement, it does not examine the evidence.
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
10. Beck’s original concept for cognitive behavior therapy has been expanded by many
theorists, but the foundation remains. Which of the following best describes the
historical foundation of cognitive behavior therapy?
1. Rejection of passive listening used in psychoanalysis in favor abirb.com/test
of active, direct
dialogues with clients.
2. Utilization of the psychoanalytic view of seeing depression as “anger turned inward.”
3. Recognition that cognitive behavior therapy works for depression
but not for other
abirb.com/test
emotional disorders.
4. Cognitive behavior therapy has been the forefront of the Freudian framework of
psychoanalysis.
abirb.com/test
ANS: 1
Chapter: Chapter 18, Cognitive Behavior Therapy
Objective: Discuss historical perspectives associated with cognitive
behavior therapy.
abirb.com/test
Page: 300
Heading: Historical Background
Integrated Processes: Nursing Process: Assessment
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Knowledge [Remembering]
Concept: Patient-Centered Care
Difficulty: Easy
abirb.com/test
1.
2.
3.
4.
Feedback
This is correct. Beck was trained in the Freudian psychoanalytic view of depression
abirb.com/test
but began to observe a common theme of negative cognitive processing in thoughts
and dreams of his depressed clients.
This is incorrect. This is the Freudian psychoanalytic view of depression and
abirb.com/test
encourages passive listening of therapists.
This is incorrect. Indications for cognitive behavioral therapy have been recognized
as effective for several clinical conditions, such as post-traumatic stress disorder,
panic disorder, and substance abuse.
abirb.com/test
This is incorrect. Beck, the originator of cognitive behavior therapy, was trained in
Freudian psychoanalysis.
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
abirb.com/test
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Chapter 18 - ETB
abirb.com/test
11. A high-school basketball player sustains a serious knee injury and states to the
school nurse, “I will never get into college if I don’t receive a basketball scholarship.”
Which nursing reply would assist the student to see a broader range of possibilities?
abirb.com/test
1. “Let’s look at the alternatives for funding your college education.”
2. “I know you are feeling helpless now, but you are looking at this from only one
perspective.”
3. “Can your family afford knee surgery?”
abirb.com/test
4. “You now need to prioritize your academics and not focus on basketball.”
ANS: 1
abirb.com/test
Chapter: Chapter 18, Cognitive Behavior Therapy
Objective: Discuss a variety of cognitive behavior therapy techniques.
Page: 303
Heading: Techniques of Cognitive Behavior Therapy > Examining
Options and
abirb.com/test
Alternatives
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is correct. The cognitive technique of generating alternatives will help the
student see a broader range of possibilities.
abirb.com/test
This is incorrect. Although this recognizes the student’s dilemma,
it does not offer
any alternatives.
This is incorrect. This does not address the issue of the possibility of not acquiring a
college education based on only one path.
abirb.com/test
This is incorrect. This does not address the issue of the cognition of a knee injury
causing the student to not being able acquire their dreams of a scholarship.
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
12. A labor and delivery nurse listens to a new mother relate thoughts regarding her
healthy, 8-lb baby. Which statement by the mother indicates to the nurse the use of the
cognitive error of selective abstraction?
abirb.com/test
1. “My baby is refusing to nurse, and I know it’s because she already hates me.”
2. “My baby needs to be under the ‘bilirubin lights,’ but I resent her time away from
me.”
abirb.com/test
3. “My baby is wonderful, but I’m depressed because I had my heart
set on having
twins.”
4. “My baby has an elevated bilirubin; I know it will get worse, and she will die.”
ANS: 3
abirb.com/test
abirb.com/test
abirb.com/test
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Chapter 18 - ETB
abirb.com/test
Chapter: Chapter 18, Cognitive Behavior Therapy
Objective: Describe goals, principles, and basic concepts of cognitive behavior therapy.
Page: 301
Heading: Goals and Principles of Cognitive Behavior Therapy >abirb.com/test
Automatic Thoughts >
Selective Abstraction
Integrated Processes: Assessment
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. This is an example of arbitrary inference, where the client has
come to a conclusion about an incident without the facts toabirb.com/test
support it.
This is incorrect. This may be an example of minimization by undervaluing the
positive significance of an event.
This is correct. In selective abstraction, the individual focuses attention on evidence
abirb.com/test
that is viewed as a failure (not having twins) rather than any
successes (a healthy
baby) that have occurred.
This is incorrect This is an example of catastrophic thinking, where the client thinks
the worst will occur without considering the possibility of abirb.com/test
a positive outcome.
CON: Patient-Centered Care
abirb.com/test
13. A client admitted to a Veterans Administration hospital with a diagnosis of major
abirb.com/test
depressive disorder tells the nurse, “I failed my battalion by giving
the wrong order.
Fortunately, no one was injured.” Which nursing diagnosis will the nurse assign this
client?
1. Chronic low self-esteem
abirb.com/test
2. Risk for self-directed violence
3. Powerlessness
4. Situational low self-esteem
abirb.com/test
ANS: 4
Chapter: Chapter 18, Cognitive Behavior Therapy
Objective: Apply techniques of cognitive behavior therapy withinabirb.com/test
the context of the
nursing process.
Page: 306
Heading: Table 19–4, Care Plan for “Sam” (An Example of Intervention With Cognitive
abirb.com/test
Behavior Therapy): Nursing Diagnosis: Chronic Low Self-Esteem
Integrated Processes: Nursing Process: Analysis
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
abirb.com/test
Concept: Self
abirb.com/test
abirb.com/test
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Chapter 18 - ETB
Difficulty: Moderate
1.
2.
3.
4.
abirb.com/test
Feedback
abirb.com/test
This is incorrect. There is no indication that the client has chronic
low self-esteem.
This is incorrect. There is no indication that the client is at risk for self-harm.
This is incorrect. There is no indication that the client is feeling powerless.
This is correct. The nursing diagnosis of situational low self-esteem
abirb.com/testis used with
individuals who have a negative perception of self-worth in response to a current
situation. This client’s low self-esteem is related to the emotional response, which
led to the client’s cognitive appraisal of the situation. The psychiatric diagnosis of
abirb.com/test
major depressive disorder is based on the client’s depressive
symptoms (emotional
response).
CON: Self
abirb.com/test
abirb.com/test
14. The director of nursing (DON) sets up a meeting with the newly appointed nurse
manager who has been doing an excellent job. The DON anticipates that the nurse
manager plans to resign. Which is the best description of the DON’s cognitive error?
1. Thinking from an all-or-nothing perspective
abirb.com/test
2. Always thinking the worst will occur without considering positive outcomes
3. Viewing only selected negative evidence while editing out positive aspects
4. Undervaluing the positive significance of an event
abirb.com/test
ANS: 2
Chapter: Chapter 18, Cognitive Behavior Therapy
abirb.com/test
Objective: Describe goals, principles, and basic concepts of cognitive
behavior therapy.
Page: 301
Heading: Goals and Principles of Cognitive Behavior Therapy > Basic Concepts >
Catastrophic Thinking
abirb.com/test
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Patient-Centered Care
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/test
This is incorrect. Thinking from an all-or-nothing perspective would be dichotomous
thinking.
This is correct. Catastrophic thinking involves always thinking that the worst will
abirb.com/test
occur without considering the possibility of positive outcomes.
The DON quickly
jumped to the conclusion that the new nurse manager plans to resign.
This is incorrect. This is an example of selective abstraction, where the selected
portion is usually the negative evidence viewed rather thanabirb.com/test
any positive information.
This is incorrect. This is an example of minimization, where the positive
abirb.com/test
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Chapter 18 - ETB
abirb.com/test
significance is undervalued.
CON: Patient-Centered Care
abirb.com/test
15. A nursing instructor is teaching about dichotomous thinking.abirb.com/test
Which student
statement indicates learning has occurred?
1. “Dichotomous thinking is when an individual views a situation as being good or bad
or black or white.”
abirb.com/test
2. “Dichotomous thinking is when an individual takes complete responsibility
for
situations without considering other circumstances.”
3. “Dichotomous thinking is when an individual exaggerates the negative significance of
an event.”
abirb.com/test
4. “Dichotomous thinking is when an individual undervalues the positive significance of
an event.”
abirb.com/test
ANS: 1
Chapter: Chapter 18, Cognitive Behavior Therapy
Objective: Describe goals, principles, and basic concepts of cognitive behavior therapy.
Page: 301
abirb.com/test
Heading: Goals and Principles of Cognitive Behavior Therapy > Basic Concepts >
Dichotomous Thinking
Integrated Processes: Teaching and Learning
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Easy
abirb.com/test
1.
2.
3.
4.
Feedback
This is correct. An individual who is using dichotomous thinking views situations in
abirb.com/test
terms of all or nothing, good or bad, or black or white.
This is incorrect. This is an example of personalization.
This is incorrect. This is an example of magnification.
abirb.com/test
This is incorrect. This is an example of minimization.
CON: Patient-Centered Care
abirb.com/test
16. A client states, “I keep having horrible nightmares about the car accident that killed
my child. I shouldn’t have taken her with me to the store.” Usingabirb.com/test
a cognitive approach,
which nursing reply is most therapeutic?
1. “Are other issues from your past affecting your ability to move on?”
2. “Describe your current feelings about your loss.”
abirb.com/test
3. “Let’s talk about something that will help you move on.”
abirb.com/test
abirb.com/test
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Chapter 18 - ETB
4. “Can anyone predict when a car accident will happen?”
abirb.com/test
ANS: 4
abirb.com/test
Chapter: Chapter 18, Cognitive Behavior Therapy
Objective: Discuss a variety of cognitive behavior therapy techniques.
Page: 305
Heading: Roles of the Nurse in Cognitive Behavior Therapy
abirb.com/test
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Patient-Centered Care
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/test
This is incorrect. This would be a guided discovery, where the therapist questions
the evidence that may prohibit the client from moving forward.
This is incorrect. This is reattribution, where the aim is to reverse self-blame to a
abirb.com/test
more-balanced attribution of responsibility.
This is incorrect. This is a combination of cognitive and behavioral interventions to
help the client with their loss.
This is correct. Reframing thoughts is the most therapeuticabirb.com/test
cognitive approach.
Cognitive behavior therapy facilitates problem-solving skills to guide clients’
thinking.
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
17. Which statement does the nurse recognize as exemplifying the level of cognitive
function of a client experiencing mild anxiety?
1. “Right now I feel as sharp as a tack.”
abirb.com/test
2. “I’m having a tough time focusing.”
3. “Sometimes I feel like I’m having an out-of-body experience.”
4. “All I seem to focus on is my anger.”
abirb.com/test
ANS: 1
Chapter: Chapter 18, Cognitive Behavior Therapy
Objective: Identify various indications for cognitive behavior therapy.
abirb.com/test
Page: 300
Heading: Indications for Cognitive Behavior Therapy
Integrated Processes: Nursing Process: Assessment
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Stress
Difficulty: Moderate
abirb.com/test
abirb.com/test
abirb.com/test
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Chapter 18 - ETB
abirb.com/test
1.
2.
3.
4.
Feedback
This is correct. A client experiencing mild anxiety has enhanced cognitive ability.
Mild anxiety prepares the individual for heightened responses to environmental
abirb.com/test
stimuli.
This is incorrect. This would be an example of cognition for moderate to high levels
of anxiety.
This is incorrect. This would be an example of cognition for
high anxiety levels.
abirb.com/test
This is incorrect. Obsessing about an emotion is an example of moderate to high
anxiety.
CON: Stress
abirb.com/test
abirb.com/test
18. Which statement demonstrates that the nurse is using a cognitive approach when
teaching a client about panic disorder?
1. “You might want to stay in the house when you notice the symptoms beginning.”
abirb.com/test
2. “Medications such as lorazepam (Ativan) should be taken when symptoms start.”
3. “Remind yourself that symptoms of a panic attack are time limited and will end.”
4. “Keep a journal to note feelings surrounding the panic attacks.”
abirb.com/test
ANS: 3
Chapter: Chapter 18, Cognitive Behavior Therapy
Objective: Discuss a variety of cognitive behavior therapy techniques.
abirb.com/test
Page: 300
Heading: Indications for Cognitive Behavior Therapy
Integrated Processes: Nursing Process: Implementation
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Stress
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. It would not be therapeutic for the client to avoid the source of
abirb.com/test
their anxiety rather than modify their behavior/perception of
the stressor.
This is incorrect. This would not be a component of cognitive behavior therapy.
This is correct. By teaching the client that symptoms of a panic attack are time
limited and will end, the nurse is using the cognitive approach
of presenting rational
abirb.com/test
thinking.
This is incorrect. This would be a component of the assessment portion of the
nursing process.
abirb.com/test
CON: Stress
abirb.com/test
abirb.com/test
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Chapter 18 - ETB
abirb.com/test
19. Using a cognitive approach, which intervention would the nurse choose to assist
clients in managing anger without the use of violence?
1. Assist the client in identifying thoughts that trigger anger and substitute reality-based
abirb.com/test
thinking.
2. Provide consequences, such as removal from group therapy, in response to angry
outbursts.
3. Administer antipsychotic medications and use limit setting, such
as a room restriction.
abirb.com/test
4. Administer antianxiety medication, and encourage participation in a group on
medication actions.
abirb.com/test
ANS: 1
Chapter: Chapter 18, Cognitive Behavior Therapy
Objective: Describe goals, principles, and basic concepts of cognitive behavior therapy.
Page: 301
abirb.com/test
Heading: Goals and Principles of Cognitive Behavior Therapy > Principle 9. Cognitive
behavior therapy teaches clients to identify, evaluate, and respond to their dysfunctional
thoughts and beliefs.
abirb.com/test
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/test
This is correct. The nurse can help the client to alter dysfunctional
beliefs that
predispose the client to distort experiences by assisting the client in identifying
thoughts that trigger anger and encourage the substitution of reality-based thinking.
This is incorrect. This would be a component of behavioralabirb.com/test
management not
cognitive behavior therapy in which the client changes their perception of the
experience.
This is incorrect. This is not a component of cognitive behavior therapy.
abirb.com/test
This is incorrect. This is not a component of cognitive behavior therapy in which the
client’s perceptions are changed.
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
20. A client recovering from alcohol toxicity is using minimization. Which statement
reflects this cognitive distortion?
1. “I can’t give up alcohol right now because I just gave up smoking.”
abirb.com/test
2. “I just read that red wine has health benefits.”
3. “I may have a minor problem, but I can handle it.”
4. “I don’t drink as much as my spouse, and nobody thinks she has a problem.”
ANS: 3
abirb.com/test
abirb.com/test
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Chapter 18 - ETB
abirb.com/test
Chapter: Chapter 18, Cognitive Behavior Therapy
Objective: Describe goals, principles, and basic concepts of cognitive behavior therapy.
Page: 302
Heading: Goals and Principles of Cognitive Behavior Therapy >abirb.com/test
Basic Concepts >
Minimization
Integrated Processes: Nursing Process: Evaluation
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Addiction and Behaviors
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. This is an example of selective abstraction; the client uses the
mental filter that he cannot quit two bad habits at once. abirb.com/test
This is incorrect. This is selective abstraction; the client is making a conclusion
based on only a portion of the evidence.
This is correct. This statement is an example of the cognitive distortion of
minimization, where an individual undervalues the positiveabirb.com/test
significance of an event.
This is incorrect. This is an example of overgeneralization, where the client
compares himself to his spouse, who may or may not be an alcoholic.
abirb.com/test
CON: Addiction and Behaviors
abirb.com/test
21. A client is experiencing auditory hallucinations. Using a cognitive strategy, the nurse
would encourage the client to do which of the following?
abirb.com/test
1. “Try singing ‘Happy Birthday’ until the voices are gone.”
2. “Document what the voices are saying to note cause and effect.”
3. “Try listening to music using headphones for distraction.”
4. “Remind yourself that the voices are symptoms of your disease.”
abirb.com/test
ANS: 4
Chapter: Chapter 18, Cognitive Behavior Therapy
abirb.com/test
Objective: Discuss a variety of cognitive behavior therapy techniques.
Page: 301
Heading: Goals and Principles of Cognitive Behavior Therapy > Principle 10. Cognitive
behavior therapy uses a variety of techniques to change thinking,abirb.com/test
mood, and behavior.
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Cognition
Difficulty: Moderate
1.
Feedback
abirb.com/test
This is incorrect. This would be an example of distraction therapy.
abirb.com/test
abirb.com/test
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Chapter 18 - ETB
abirb.com/test
2.
3.
4.
This is incorrect. This is an example of Socratic dialogue.
This is incorrect. This is an example of distraction therapy.
This is correct. The focus of cognitive behavior therapy is on the modification of
abirb.com/test
distorted cognitions and maladaptive behaviors.
CON: Cognition
abirb.com/test
22. A client diagnosed with borderline personality disorder states, “Get out of here. No
abirb.com/test
one cares about me or my situation!” Which nursing reply is an example
of a cognitive
intervention?
1. “You have an antianxiety medication ordered. It may make you feel better.”
2. “It sounds like you are feeling really frustrated.”
abirb.com/test
3. “Can you explain further your thinking about your situation?”
4. “No one cares about you?”
abirb.com/test
ANS: 3
Chapter: Chapter 18, Cognitive Behavior Therapy
Objective: Discuss a variety of cognitive behavior therapy techniques.
Page: 303
abirb.com/test
Heading: Techniques of Cognitive Behavior Therapy > Cognitive Strategies >
Behavioral Interventions
Integrated Processes: Nursing Process: Implementation
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
abirb.com/test
.
Feedback
1. This is incorrect. This is not an intervention to facilitate a change in perception of
abirb.com/test
the stress or open communication between the nurse and the client.
2. This is incorrect. This is an empathetic statement, not cognitive behavior therapy.
3. This is correct. The nurse is using a cognitive approach to assessment by asking for
abirb.com/test
an explanation about the client’s thinking. The focus of cognitive
interventions is on
the modification of distorted cognitions and maladaptive behaviors.
4. This is incorrect. This is nontherapeutic. If the nurse was attempting to find the root
cause of the client’s feelings and to help change their perception,
perhaps it would
abirb.com/test
have been better to ask, “How do you feel that no one cares about you?”
CON: Patient-Centered Care
abirb.com/test
MULTIPLE RESPONSE
abirb.com/test
abirb.com/test
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Chapter 18 - ETB
abirb.com/test
23. A nursing instructor is lecturing about cognitive behavior therapy. Which of the
abirb.com/test
following are objectives of implementation of this therapy? Select
all that apply.
1. To modify automatic thoughts to promote minimization of negative cognitions
2. To apply a variety of methods to create change in an individual’s thinking
3. To apply cognitive principles to change an individual’s basic schema
abirb.com/test
4. To modify belief systems to bring about emotional change
5. To modify belief systems to bring about behavioral change
abirb.com/test
ANS: 2, 4, 5
Chapter: Chapter 18, Cognitive Behavior Therapy
Objective: Describe goals, principles, and basic concepts of cognitive behavior therapy.
Page: 299
abirb.com/test
Heading: Historical Background
Integrated Processes: Teaching and Learning
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
5.
Feedback
This is incorrect. Modification of automatic thoughts is one technique used in
cognitive behavior therapy.
This is correct. The objective of cognitive behavior therapyabirb.com/test
involves using a variety
of methods to create change in a client’s thinking.
This is incorrect. Schemas are deeper cognitive structures that serve to screen
information from the environment. They are often more difficult
to modify than
abirb.com/test
automatic thoughts.
This is correct. The objective of cognitive behavior therapy is to create change in a
client’s belief system to bring about lasting emotional changes.
abirb.com/test
This is correct. The objective of cognitive behavior therapy is to create change in a
client’s belief system to bring about lasting behavioral changes.
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
24. A nurse practitioner uses cognitive behavior therapy with depressed clients. The
nurse asks clients to keep a daily record of dysfunctional thoughts (DRDT). Which of
the following are appropriate nursing replies to a client asking about the purpose of this
abirb.com/test
exercise? Select all that apply.
1. “The purpose of this exercise is to identify automatic thoughts.”
2. “The purpose of this exercise is to identify rational alternatives.”
3. “The purpose of this exercise is to modify cognitive errors.” abirb.com/test
4. “The purpose of this exercise is to eliminate irrational beliefs.”
abirb.com/test
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Chapter 18 - ETB
abirb.com/test
5. “The purpose of this exercise is to monitor thoughts related to self-esteem.”
ANS: 1, 2, 3
abirb.com/test
Chapter: Chapter 18, Cognitive Behavior Therapy
Objective: Discuss a variety of cognitive behavior therapy techniques.
Page: 303
Heading: Techniques of Cognitive Behavior Therapy > Cognitive
Strategies > Daily
abirb.com/test
Record of Dysfunctional Thoughts; Table 19–3
Integrated Processes: Nursing Process: Implementation
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Easy
abirb.com/test
1.
2.
3.
4.
5.
Feedback
This is correct. The DRDT is a tool commonly used in cognitive behavior therapy to
help clients identify automatic thoughts.
abirb.com/test
This is correct. The DRDT is a tool commonly used in cognitive
behavior therapy to
help clients generate rational alternatives.
This is correct. The DRDT is a tool commonly used in cognitive behavior therapy to
help clients modify thinking.
abirb.com/test
This is incorrect. The DRDT does not help eliminate irrational beliefs.
This is incorrect. The DRDT does not monitor a client’s thoughts related to selfesteem.
abirb.com/test
CON: Patient-Centered Care….
abirb.com/test
25. Which of the following statements regarding role-playing is correct? Select all that
apply.
1. Role-playing is a type of distractor from negative thinking.
abirb.com/test
2. The client assumes the role of the antagonist that produces the maladaptive response.
3. The situation is played out to help the client recognize their automatic thinking.
4. Role-play is limited to strong relationships between client and therapist.
abirb.com/test
5. Role-play teaching increases awareness of controlled breathing.
ANS: 3, 4
Chapter: Chapter 18, Cognitive Behavior Therapy
abirb.com/test
Objective: Apply techniques of cognitive behavior therapy within the context of the
nursing process.
Page: 303
abirb.com/testand
Heading: Techniques of Cognitive Behavior Therapy > Guided relaxation
behavioral rehearsal.
Integrated Processes: Nursing Process: Application
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Application [Applying]
abirb.com/test
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Chapter 18 - ETB
Concept: Patient-Centered Care
Difficulty: Moderate
1.
2.
3.
4.
5.
abirb.com/test
abirb.com/test
Feedback
This is incorrect. Role-play is a technique to allow the client to practice a new way
of responding to distressing situations.
This is incorrect. The therapist assumes the role of the antagonist
that produces the
abirb.com/test
maladaptive response in the client.
This is correct. The situation is played out to elicit recognition of automatic thinking
on the part of the client.
abirb.com/test
This is correct. Role-play is a technique that should be used
only when the
relationship between client and therapist is strong and there is little likelihood of
maladaptive transference.
This is incorrect. Guided relaxation is aimed at reducing autonomic
abirb.com/testresponses to
anxiety, which also increases awareness of conscious control over breathing, anxiety
symptoms, and thoughts.
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 19 - ETB
abirb.com/test
Chapter 19. Electroconvulsive Therapy
abirb.com/test
MULTIPLE CHOICE
abirb.com/test
1. A nurse administers pure oxygen to a client during and after electroconvulsive therapy
abirb.com/test
(ECT). Which statement describes the rationale for this procedure?
1. To prevent increased intracranial pressure resulting from anoxia
2. To prevent hypotension, bradycardia, and bradypnea due to electrical stimulation
3. To prevent anoxia due to medication-induced paralysis of respiratory muscles
abirb.com/test
4. To prevent blocked airway resulting from seizure activity
ANS: 3
abirb.com/test
Chapter: Chapter 19, Electroconvulsive Therapy
Objective: Identify risks associated with electroconvulsive therapy.
Page: 314
Heading: The Role of the Nurse in Electroconvulsive Therapy > abirb.com/test
Planning/Implementation
Integrated Processes: Nursing Process
Nursing Process: Implementation
Client Need: Physiological Integrity: Physiological Adaptation abirb.com/test
Cognitive Level: Application [Applying]
Concept: Oxygenation
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. Administering pure oxygen will not decrease increased intracranial
abirb.com/test
pressure.
This is incorrect. Administering pure oxygen will not prevent hypotension,
bradycardia, and bradypnea.
This is correct. The nurse administers 100% oxygen duringabirb.com/test
and after ECT to prevent
anoxia due to medication-induced paralysis of respiratory muscles.
This is incorrect. Administering pure oxygen will not prevent an airway from being
blocked.
abirb.com/test
CON: Oxygenation
abirb.com/test
2. In which position would the nurse place the client immediately after electroconvulsive
therapy (ECT)?
abirb.com/test
1. On his or her side to prevent aspiration
abirb.com/test
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Chapter 19 - ETB
abirb.com/test
2. In semi-Fowler’s position to promote oxygenation
3. In Trendelenburg’s position to promote blood flow to vital organs
4. In prone position to prevent airway blockage
abirb.com/test
ANS: 1
Chapter: Chapter 19, Electroconvulsive Therapy
Objective: Describe the role of the nurse in the administration ofabirb.com/test
electroconvulsive
therapy.
Page: 314
Heading: The Role of the Nurse in Electroconvulsive Therapy > abirb.com/test
Planning/Implementation
Integrated Processes: Nursing Process
Nursing Process: Implementation
Client Need: Physiological Integrity: Physiological Adaptation abirb.com/test
Cognitive Level: Application [Applying]
Concept: Safety
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is correct. After the ECT procedure, the client should be positioned on his or
abirb.com/test
her side to prevent aspiration.
This is incorrect. Following ECT, a client is at high risk for aspiration. The priority
is preventing aspiration and then promoting oxygenation.
This is incorrect. The client is at risk for aspiration following
ECT and should be
abirb.com/test
placed on their side. Trendelenburg’s position would place the client at risk for
aspiration.
This is incorrect. The nurse should prioritize reducing the risk for aspiration by
abirb.com/test
placing the client on their side. If the client aspirates, this will
cause a blocked
airway.
CON: Safety
abirb.com/test
abirb.com/test
3. Which student statement indicates that learning has occurred regarding
electroconvulsive therapy (ECT)?
1. “During ECT, a state of euphoria is induced.”
2. “ECT induces a grand mal seizure.”
abirb.com/test
3. “During ECT, a state of catatonia is induced.”
4. “ECT induces a petit mal seizure.”
ANS: 2
Chapter: Chapter 19, Electroconvulsive Therapy
Objective: Define electroconvulsive therapy.
Page: 311
Heading: Electroconvulsive Therapy, Defined
abirb.com/test
abirb.com/test
abirb.com/test
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Chapter 19 - ETB
abirb.com/test
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Physiological Adaptation
Nursing Process: Evaluation
Cognitive Level: Evaluation [Evaluating]
Concept: Patient-Centered Care
Difficulty: Easy
abirb.com/test
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. ECT does not induce a state of euphoria; rather, it induces a grand
mal seizure.
abirb.com/test
This is correct. ECT is the induction of a grand mal seizure through the application
of electrical current to the brain to decrease depression.
This is incorrect. A state of catatonia is not induced during ECT.
This is incorrect. ECT does not induce a petit mal seizure. abirb.com/test
CON: Patient-Centered Care
abirb.com/test
4. For which client would the nurse question the use of electroconvulsive therapy
abirb.com/test
(ECT)?
1. A client with schizophrenia and hypertension
2. A client with mania and seasonal allergies
3. A client with obsessive-compulsive disorder (OCD) and a history
of cancer
abirb.com/test
4. A client with major depressive disorder (MDD) who feels sad
ANS: 1
abirb.com/test
Chapter: Chapter 19, Electroconvulsive Therapy
Objective: Discuss indications, contraindications, mechanism of action, and side effects
of electroconvulsive therapy.
Page: 313
abirb.com/test
Heading: Contraindications
Integrated Processes: Nursing Process
Nursing Process: Assessment
abirb.com/test
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Moderate
abirb.com/test
1.
2.
3.
Feedback
This is correct. ECT is contraindicated in clients with untreated hypertension or heart
abirb.com/test
disease.
This is incorrect. ECT is used for clients with mania; seasonal allergies are not a
contraindication.
This is incorrect. ECT is not commonly used for OCD but abirb.com/test
can be useful to treat
OCD; it is not contraindicated for clients with a history of cancer.
abirb.com/test
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Chapter 19 - ETB
abirb.com/test
4.
This is incorrect. ECT is used for MDD; sadness is a symptom of MDD.
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
5. After undergoing two of nine electroconvulsive (ECT) procedures,
a client states, “I
can’t even remember eating breakfast, so I want to stop the ECT.” Which reply by the
nurse is appropriate?
1. “After you begin the course of treatments, you must complete abirb.com/test
all of them.”
2. “You’ll need to talk with your doctor about what you’re thinking.”
3. “It is within your right to discontinue the treatments, but let’s talk about your
concerns.”
abirb.com/test
4. “Memory loss is a rare side effect of the treatment. I don’t think
it should be a
concern.”
ANS: 3
abirb.com/test
Chapter: Chapter 19, Electroconvulsive Therapy
Objective: Describe the role of the nurse in the administration of electroconvulsive
therapy.
abirb.com/test
Page: 314
Heading: The Role of the Nurse in Electroconvulsive Therapy > Assessment
Integrated Processes: Nursing Process: Implementation
Client Need: Safe and Effective Care Environment: Managementabirb.com/test
of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. The nurse cannot force the client to complete all ECT treatments.
The client has the right to stop treatment at any time.
abirb.com/test
This is incorrect. Although the client will need to speak to the physician, the nurse
would still need to actively listen to the client’s concerns and validate that they do
not need to continue treatment if they do not choose to do so.
abirb.com/test
This is correct. ECT is voluntary, and client consent may be withdrawn at any time.
This reply acknowledges this right and focuses on the client’s concerns so the nurse
can address them.
This is incorrect. This statement dismisses the client’s concern
of memory loss. The
abirb.com/test
nurse should actively listen to what the client is feeling regarding ECT.
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
abirb.com/test
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Chapter 19 - ETB
abirb.com/test
6. Immediately after an initial electroconvulsive (ECT) procedure, a client states, “I’m
not hungry and just want to stay in bed and sleep.” Based on this information, which
nursing intervention is appropriate?
abirb.com/test
1. Allow the client to remain in bed.
2. Encourage the client to join the milieu to promote socialization.
3. Obtain a physician’s order for parenteral nutrition.
4. Involve the client in physical activities to stimulate circulation.abirb.com/test
ANS: 1
Chapter: Chapter 19, Electroconvulsive Therapy
abirb.com/test
Objective: Describe the role of the nurse in the administration of electroconvulsive
therapy.
Page: 314
Heading: The Role of the Nurse in Electroconvulsive Therapy > abirb.com/test
Planning/Implementation
Integrated Processes: Nursing Process
Nursing Process: Implementation
abirb.com/test
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Safety
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
This is correct. Immediately after ECT, the nurse should monitor
pulse, respirations,
abirb.com/test
and blood pressure every 15 minutes for the first hour, during which time the client
should remain in bed.
This is incorrect. Socialization should not be encouraged immediately after ECT; the
abirb.com/test
client should remain in bed, and some may feel like sleeping
for 1 to 2 hours.
This is incorrect. The client may not feel like eating but will likely not require
parenteral nutrition.
This is incorrect. Immediately after ECT, the client shouldabirb.com/test
remain in bed and should
not be physically active.
CON: Safety
abirb.com/test
7. A nurse administers ordered preoperative glycopyrrolate 30 minutes
prior to a client’s
abirb.com/test
electroconvulsive (ECT) procedure. Which statement describes the rationale for
administering this medication?
1. Glycopyrrolate decreases anxiety during the ECT procedure.
abirb.com/test
2. Glycopyrrolate induces an unconscious state to prevent pain during the ECT
procedure.
3. Glycopyrrolate prevents severe muscle contractions during the ECT procedure.
abirb.com/test
4. Glycopyrrolate decreases secretions to prevent aspiration during
the ECT procedure.
abirb.com/test
abirb.com/test
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Chapter 19 - ETB
abirb.com/test
ANS: 4
Chapter: Chapter 19, Electroconvulsive Therapy
Objective: Describe the role of the nurse in the administration of electroconvulsive
abirb.com/test
therapy.
Page: 314
Heading: The Role of the Nurse in Electroconvulsive Therapy >
abirb.com/test
Planning/Implementation
Integrated Process: Nursing Process
Nursing Process: Implementation
Client Need: Physiological Integrity: Pharmacological and Parenteral
Therapies
abirb.com/test
Cognitive Level: Knowledge [Remembering]
Concept: Safety
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. Glycopyrrolate is not given to decrease anxiety.
This is incorrect. Glycopyrrolate is not given to induce an unconscious
state.
abirb.com/test
This is incorrect. Glycopyrrolate is not given to prevent muscle contractions.
This is correct. Glycopyrrolate is given to decrease secretions and counteract the
effects of vagal stimulation (bradycardia) induced by ECT.
abirb.com/test
CON: Safety
abirb.com/test
8. Which statement by the student indicates a need for further teaching regarding client
preparation for electroconvulsive therapy (ECT)?
abirb.com/test
1. “I will ensure my client has voided before the procedure.”
2. “My client’s spouse is holding his wedding band while he is having ECT.”
3. “I told my client it is okay for him to wear his contact lenses during the procedure so
he does not lose them.”
abirb.com/test
4. “My client has removed her dentures and placed them in a denture cup with her name
on it.”
abirb.com/test
ANS: 3
Chapter: Chapter 19, Electroconvulsive Therapy
Objective: Describe the role of the nurse in the administration of electroconvulsive
therapy.
abirb.com/test
Page: 316
Heading: The Role of the Nurse in Electroconvulsive Therapy >
Planning/Implementation
abirb.com/test
Integrated Process: Teaching and Learning
Nursing Process: Evaluation
Client Need: Physiological Integrity: Physiological Adaptation
abirb.com/test
Cognitive Level: Evaluation [Evaluating]
Concept: Safety
abirb.com/test
abirb.com/test
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Chapter 19 - ETB
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/test
This is incorrect. Teaching has been effective since the student has instructed the
client to void.
This is incorrect. Teaching has been effective since the client’s spouse is holding his
abirb.com/test
jewelry during the procedure.
This is correct. Teaching was ineffective because the student told the client they
could wear their contact lenses during the procedure. The client must remove
eyeglasses and contact lenses for ECT.
abirb.com/test
This is incorrect. Teaching has been effective if the student has instructed the client
to remove their dentures for ECT.
CON: Safety
abirb.com/test
abirb.com/test
9. A client scheduled for ECT at 9:00 a.m. is discovered eating breakfast at 8:00 a.m.
Based on this observation, which action would the nurse take?
1. Notify the client’s physician of the situation and cancel the ECT.
abirb.com/test
2. Remove the breakfast tray and assist the client to the ECT procedure
room.
3. Allow the client to finish breakfast and reschedule ECT for 10:00 a.m.
4. Increase the client’s fluid intake to facilitate the digestive process.
abirb.com/test
ANS: 1
Chapter: Chapter 19, Electroconvulsive Therapy
Objective: Describe the role of the nurse in the administration of electroconvulsive
abirb.com/test
therapy.
Page: 316
Heading: The Role of the Nurse in Electroconvulsive Therapy >
Planning/Implementation
abirb.com/test
Integrated Processes: Nursing Process
Nursing Process: Implementation
Client Need: Physiological Integrity: Reduction of Risk Potential
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Safety
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is correct. A client who is scheduled for an ECT treatment is given nothing by
mouth for a minimum of 6 to 8 hours before treatment.
abirb.com/test
This is incorrect. The client has eaten and therefore cannot undergo ECT as
scheduled.
This is incorrect. The nurse would not allow the client to finish the breakfast. The
abirb.com/test
ECT would be rescheduled.
This is incorrect. The client would not be allowed oral intake prior to ECT. The
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PMHN, 10e
Chapter 19 - ETB
abirb.com/test
procedure would be canceled and rescheduled.
CON: Safety
abirb.com/test
abirb.com/test
10. A client who is learning about electroconvulsive therapy (ECT)
asks a nurse, “Isn’t
this treatment dangerous?” Which reply by the nurse is appropriate?
1. “ECT is not dangerous because there are no side effects.
2. “There can be temporary paralysis, but full functioning returnsabirb.com/test
within 3 hours of
treatment.”
3. “You will have a thorough examination beforehand to ensure you can safely undergo
ECT.”
abirb.com/test
4. “Transient ischemic attacks can occur but are rare.”
ANS: 3
Chapter: Chapter 19, Electroconvulsive Therapy
abirb.com/test
Objective: Describe the role of the nurse in the administration of electroconvulsive
therapy.
Page: 316
abirb.com/test
Heading: Risks The Role of the Nurse in Electroconvulsive Therapy
> Assessment
Nursing Process: Implementation
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Reduction of Risk Potentialabirb.com/test
Cognitive Level: Application [Applying]
Concept: Safety
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. The nurse would not inform the client ECT is not dangerous
because there are side effects associated with ECT.
abirb.com/test
This is incorrect. Succinylcholine chloride is given intravenously to prevent severe
muscle contractions during the seizure, thereby reducing the possibility of fractured
or dislocated bones.
abirb.com/test
This is correct. A complete physical examination must be conducted by the
appropriate medical professional prior to the initiation of ECT. Studies indicate that
the mortality rate from ECT is about 0.002% per treatment and 0.01% for each client
(Sadock et al., 2015).
abirb.com/test
This is incorrect. Although the occurrence is rare, the major cause of death with ECT
is from cardiovascular complications (e.g., acute myocardial infarction,
cerebrovascular accident), usually in individuals with previously compromised
abirb.com/test
cardiac status.
CON: Safety
abirb.com/test
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Chapter 19 - ETB
abirb.com/test
11. A client experienced bradycardia during electroconvulsive therapy (ECT). A nurse
assigns a nursing diagnosis of decreased cardiac output related to (R/T) vagal
abirb.com/test
stimulation occurring during ECT. Which outcome would the nurse expect the client to
achieve?
1. The client will verbalize an understanding of the need for moving slowly after
abirb.com/test
treatment.
2. The client will maintain an oxygen saturation level of 88% 1 hour after treatment.
3. The client will continue adequate tissue perfusion 1 hour after treatment.
4. The client will verbalize an understanding of common side effects
of ECT.
abirb.com/test
ANS: 3
Chapter: Chapter 19, Electroconvulsive Therapy
Objective: Describe the role of the nurse in the administration ofabirb.com/test
electroconvulsive
therapy.
Page: 315
Heading: Table 19–1: Potential Nursing Diagnoses and Outcomeabirb.com/test
Criteria for Client
Receiving ECT
Integrated Processes: Nursing Process
Nursing Process: Planning
Client Need: Physiological Integrity: Physiological Adaptation abirb.com/test
Cognitive Level: Analysis [Analyzing]
Concept: Perfusion
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. Verbalization of the need to move slowly reduces risk of injury
abirb.com/test
related to orthostatic hypotension.
This is incorrect. An oxygen saturation of 88% indicates poor perfusion and is not an
expected or desired outcome.
This is correct. Adequate tissue perfusion is a priority outcome.
Reestablishment of a
abirb.com/test
normal heart rate within 1 hour reflects adequate circulation and tissue perfusion.
This is incorrect. The client is expected to verbalize an understanding of the side
effects before the procedure.
abirb.com/test
CON: Perfusion
abirb.com/test
12. Which response by the instructor is accurate regarding blood pressure cuff
placement on the client’s lower leg during an electroconvulsive therapy (ECT)
abirb.com/test
procedure?
1. “The cuff has to be placed on the leg because both arms are used for IV fluids.”
2. “The cuff functions to prevent succinylcholine from reaching the foot.”
abirb.com/test
3. “The cuff position gives a more-accurate blood pressure reading
during the
treatment.”
abirb.com/test
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Chapter 19 - ETB
abirb.com/test
4. “The cuff is placed on the leg so that arms can easily be restrained during seizure.”
ANS: 2
abirb.com/test
Chapter: Chapter 19, Electroconvulsive Therapy
Objective: Describe the role of the nurse in the administration of electroconvulsive
therapy.
abirb.com/test
Page: 316
Heading: The Role of the Nurse in Electroconvulsive Therapy >
Planning/Implementation
Integrated Processes: Teaching and Learning
abirb.com/test
Nursing Process: Evaluation
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Evaluation [Evaluating]
abirb.com/test
Concept: Patient-Centered Care
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/test
This is incorrect. Both arms are not used for IV therapy.
This is correct. A blood pressure cuff is placed on the lower leg and inflated above
systolic pressure before injection of succinylcholine. This is to ensure that seizure
abirb.com/test by the paralytic
activity can be observed and timed in the one limb that is unaffected
agent.
This is incorrect. The leg does not give a more-accurate blood pressure reading.
This is incorrect. A cuff is not placed on the leg in order toabirb.com/test
restrain the arms.
CON: Patient-Centered Care
abirb.com/test
13. A client states, “My doctor has told me I am a candidate for electroconvulsive
therapy (ECT). Where will the treatment take place, and how much
time would this
abirb.com/test
entail?” Which nursing reply is best?
1. “Clients typically receive ECT in their hospital room daily for 1 month.”
2. “Clients typically undergo 6 to 12 ECT procedures three times a week in an outpatient
abirb.com/test
setting.”
3. “Clients typically receive an unlimited number of treatment, in the hospital procedure
room.”
4. “Clients typically receive two to three treatment, in either an outpatient
abirb.com/testor inpatient
setting.”
ANS: 2
Chapter: Chapter 19, Electroconvulsive Therapy
Objective: Define electroconvulsive therapy.
Page: 313
Heading: Electroconvulsive Therapy, Defined
Nursing Process: Implementation
abirb.com/test
abirb.com/test
abirb.com/test
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Chapter 19 - ETB
abirb.com/test
Integrated Process: Teaching and Learning
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Patient-Centered Care
Difficulty: Moderate
1.
2.
3.
4.
abirb.com/test
Feedback
This is incorrect. ECT treatments are not administered daily.
This is correct. Most clients require an average of 6 to 12 ECT treatments, but some
may require up to 20. Treatments are usually administeredabirb.com/test
every other day, three
times per week. Treatments are performed on either an inpatient or outpatient basis,
depending on the need for client monitoring.
This is incorrect. Clients do not receive an unlimited number of treatments for safety
abirb.com/test
reasons.
This is incorrect. Clients receive more than three treatments, usually 6 to 12,
sometimes up to 20.
abirb.com/test
CON: Patient-Centered Care
abirb.com/test
14. Which information will the nurse include when teaching a client about the potential
side effects of electroconvulsive (ECT)?
1. “You may experience transient tangential thinking.”
abirb.com/test
2. “You may experience some memory deficit surrounding the ECT.”
3. “You may experience avolition for the remainder of the day.”
4. “You may experience a higher risk for subsequent seizures.”
abirb.com/test
ANS: 2
Chapter: Chapter 19, Electroconvulsive Therapy
Objective: Describe the role of the nurse in the administration ofabirb.com/test
electroconvulsive
therapy.
Page: 313
Heading: Side Effects
abirb.com/test
Integrated Processes: Teaching and Learning
Nursing Process: Implementation
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Patient-Centered Care
Difficulty: Moderate
abirb.com/test
1.
2.
Feedback
This is incorrect. Transient tangential thinking is not a typical side effect following
ECT.
abirb.com/test
This is correct. The most common side effect of ECT is temporary
amnesia
following the ECT procedure.
abirb.com/test
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Chapter 19 - ETB
abirb.com/test
3.
4.
This is incorrect. Avolition is not a typical side effect of ECT.
This is incorrect. Subsequent seizures are not a common side effect following ECT.
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
15. When scheduling electroconvulsive (ECT), which client would the nurse prioritize?
1. A client in bed in a fetal position who is experiencing active suicidal ideations
2. A client with an irritable mood who is exhibiting angry outbursts
abirb.com/test
3. A client experiencing command hallucinations and delusions of reference
4. A client experiencing manic episodes of bipolar disorder
abirb.com/test
ANS: 1
Chapter: Chapter 19, Electroconvulsive Therapy
Objective: Describe the role of the nurse in the administration of electroconvulsive
therapy.
abirb.com/test
Page: 312
Heading: Indications > Major Depression
Integrated Processes: Nursing Process
abirb.com/test
Nursing Process: Implementation
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Safety
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/test
This is correct. The nurse should prioritize the client experiencing
suicidal ideation.
Severely suicidal clients require urgent treatment to prevent self-harm.
This is incorrect. Although the client who is irritable will need to be seen, the
priority is the client experiencing suicidal ideation. Severely
suicidal clients require
abirb.com/test
urgent treatment to prevent self-harm.
This is incorrect. Although the client experiencing hallucinations will need to be
seen, the client experiencing suicidal ideation is the priority. Severely suicidal clients
abirb.com/test
require urgent treatment to prevent self-harm.
This is incorrect. Although the manic client will need to be seen, the client
experiencing suicidal ideation would be seen first. Severely suicidal clients require
abirb.com/test
urgent treatment to prevent self-harm.
CON: Safety
abirb.com/test
16. A client with cognitive deficits is extremely suicidal. The client has not responded to
abirb.com/test
antidepressants, and the treatment team is considering electroconvulsive
therapy (ECT).
What client information would impact the feasibility of this treatment option?
abirb.com/test
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PMHN, 10e
Chapter 19 - ETB
abirb.com/test
1. Because the client is extremely suicidal, ECT is an appropriate option.
2. Because antidepressant medications have been ineffective, ECT is a good alternative.
3. Because informed consent is required for ECT, cognitive deficits could preclude this
abirb.com/test
option.
4. Because of the client’s cognitive deficits, a signed consent form is waived.
abirb.com/test
ANS: 3
Chapter: Chapter 19, Electroconvulsive Therapy
Objective: Discuss indications, contraindications, mechanism of action, and side effects
of electroconvulsive therapy.
abirb.com/test
Page: 315
Heading: The Role of the Nurse in Electroconvulsive Therapy > Assessment
Integrated Processes: Nursing Process
abirb.com/test
Nursing Process: Evaluation
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Legal
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/test
This is incorrect. Since ECT would be a good option but the
client is not able to
provide consent, a judge would have to determine competency.
This is incorrect. Although ECT would be a good option, informed consent is still
required; since the client cannot provide it, a judge would have
to appoint a guardian
abirb.com/test
if the client was not deemed competent.
This is correct. A client experiencing cognitive deficits cannot give informed
consent, which is required prior to ECT. A court proceeding would determine the
client’s level of competency, and a judge would appoint a abirb.com/test
guardian if necessary.
This is incorrect. A signed consent form cannot be waived.
CON: Legal
abirb.com/test
MULTIPLE RESPONSE
abirb.com/test
abirb.com/test
17. The nurse recognizes that electroconvulsive therapy (ECT) would potentially
improve the symptoms of clients with which of the following diagnoses? Select all that
apply.
abirb.com/test
1. Major depressive disorder
2. Bipolar I disorder: acute mania
3. Schizoaffective disorder
abirb.com/test
4. Obsessive-compulsive disorder (OCD)
5. Body dysmorphic disorder
abirb.com/test
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Chapter 19 - ETB
abirb.com/test
ANS: 1, 2, 3
Chapter: Chapter 19, Electroconvulsive Therapy
abirb.com/test
Objective: Describe the role of the nurse in the administration of electroconvulsive
therapy.
Page: 312
abirb.com/test
Heading: Indications
Integrated Processes: Nursing Process
Nursing Process: Assessment
Client Need: Safe and Effective Care Environment: Managementabirb.com/test
of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
5.
Feedback
This is correct. ECT has been shown to be effective in the treatment of severe
depression.
abirb.com/test
This is correct. ECT has been shown to be effective in the treatment of acute mania,
particularly if it is accompanied by catatonic or affective (depression or mania)
symptomatology.
This is correct. ECT has been shown to be effective in the abirb.com/test
treatment of severe
depression, acute mania, and acute schizophrenia, particularly if it is accompanied
by catatonic or affective (depression or mania) symptomatology.
This is incorrect. ECT has also been tried with OCD, but little
evidence exists to
abirb.com/test
support its efficacy in the treatment of this condition.
This is incorrect. ECT has also been tried with anxiety disorders, but little evidence
exists to support its efficacy in the treatment of this condition.
abirb.com/test
CON: Patient-Centered Care
abirb.com/test
18. Which assessment results would the nurse evaluate and report to prepare a client for
electroconvulsive therapy (ECT)? Select all that apply.
abirb.com/test
1. Electrocardiographic records
2. Pulmonary function study results
3. Electroencephalogram analysis
4. Complete blood count values
abirb.com/test
5. Urinalysis results
ANS: 1, 2, 4, 5
abirb.com/test
Chapter: Chapter 19, Electroconvulsive Therapy
Objective: Describe the role of the nurse in the administration of electroconvulsive
therapy.
abirb.com/test
Page: 315
Heading: The Role of the Nurse in Electroconvulsive Therapy >
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 19 - ETB
abirb.com/test
Planning/Implementation
Integrated Processes: Nursing Process
Nursing Process: Assessment
abirb.com/test
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
This is correct. Electrocardiographs should be obtained prior
to ECT.
abirb.com/test
This is correct. Pulmonary function study results should be available prior to
scheduling a client for ECT.
This is incorrect. An electroencephalogram is not required for medical clearance
abirb.com/test
prior to ECT.
This is correct. A complete blood count should be performed prior to scheduling a
client for ECT.
This is correct. Results of a urinalysis should be reviewed abirb.com/test
prior to scheduling the
client for ECT.
CON: Patient-Centered Care
abirb.com/test
19. During a course of 12 electroconvulsive therapy (ECT) procedures,
an anxious client
abirb.com/test
diagnosed with major depressive disorder (MDD) refuses to bathe or attend group
therapy. The client reports some memory problems and says he has trouble figuring out
what time of day it is. Which of the following nursing diagnoses should be assigned to
abirb.com/test
this client? Select all that apply.
1. Anxiety R/T post-ECT confusion and memory loss
2. Risk for injury R/T post-ECT confusion and memory loss
3. Risk for activity intolerance R/T post-ECT confusion and memory
loss
abirb.com/test
4. Altered sensory perception R/T post-ECT confusion and memory loss
5. Social isolation R/T post-ECT confusion and memory loss
abirb.com/test
ANS: 1, 2, 3, 5
Chapter: Chapter 19, Electroconvulsive Therapy
Objective: Describe the role of the nurse in the administration of electroconvulsive
therapy.
abirb.com/test
Page: 315
Heading: Side Effects; Table 19–1, Potential Nursing Diagnoses and Outcome Criteria
for Client Receiving ECT
abirb.com/test
Integrated Processes: Nursing Process
Nursing Process: Assessment
Client Need: Safe and Effective Care Environment: Management of Care
abirb.com/test
Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
abirb.com/test
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Chapter 19 - ETB
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
abirb.com/test
This is correct. The most common side effects of ECT leading to client anxiety are
temporary memory loss and confusion.
This is correct. The client is at risk for injury due to anxiety related to post-ECT side
abirb.com/test
effects of confusion and memory loss.
This is correct. The client is at risk for activity intolerance due to post-ECT side
effects of confusion and memory loss.
This is incorrect. Altered sensory perception is related to psychosis
and
abirb.com/test
hallucinations associated with schizophrenia rather than MDD.
This is correct. Social isolation characterized by not attending group therapy is
related to post-ECT side effects of confusion and memory loss.
abirb.com/test
CON: Patient-Centered Care
abirb.com/test
20. Which conditions place a client at risk for injury during electroconvulsive therapy
(ECT)? Select all that apply.
abirb.com/test
1. Severe osteoporosis
2. Acute and chronic pulmonary disorders
3. Hypothyroidism
4. Recent cardiovascular accident
abirb.com/test
5. Prostatic hypertrophy
ANS: 1, 2, 4
abirb.com/test
Chapter: Chapter 19, Electroconvulsive Therapy
Objective: Identify risks associated with electroconvulsive therapy.
Page: 313
Heading: Contraindications
abirb.com/test
Integrated Process: Nursing Process
Nursing Process: Assessment
Client Need: Safe and Effective Care Environment: Management of Care
abirb.com/test
Cognitive Level: Analysis [Analyzing]
Concept: Safety
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is correct. Severe osteoporosis places a client at risk for injury during ECT.
This is correct. Acute and chronic pulmonary disorders place
a client at risk for
abirb.com/test
injury during ECT.
This is incorrect. Hypothyroidism is not noted to render clients at high risk for injury
during ECT.
abirb.com/test
This is correct. Cardiovascular conditions that place a client
at high risk for injury
during ECT include myocardial infarction or cerebrovascular accident within the
abirb.com/test
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Chapter 19 - ETB
abirb.com/test
5.
preceding 3 to 6 months, aortic or cerebral aneurysm, severe underlying
hypertension, and congestive heart failure. Clients with cardiovascular problems are
at risk because of the body’s response to the seizure itself.
abirb.com/test
This is incorrect. Prostatic hypertrophy is not noted to render clients at high risk for
injury during ECT.
CON: Safety
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 20 - ETB
abirb.com/test
Chapter 20. The Recovery Model
abirb.com/test
MULTIPLE CHOICE
abirb.com/test
1. Which student statement indicates that further teaching is needed regarding recovery
as it applies to mental illness?
abirb.com/test
1. “The goal of recovery is improved health and wellness.”
2. “The goal of recovery is expedient, comprehensive behavioral change.”
3. “The goal of recovery is the ability to live a self-directed life.”
4. “The goal of recovery is the ability to reach full potential.” abirb.com/test
ANS: 2
Chapter: Chapter 20, The Recovery Model
abirb.com/test
Objective: Discuss the 10 guiding principles of recovery as delineated by the Substance
Abuse and Mental Health Services Administration.
Page: 321
abirb.com/test
Heading: What Is Recovery?
Integrated Processes: Nursing Process
Nursing Process: Evaluation
Integrated Process: Nursing Process
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Evaluation [Evaluating]
Concept: Patient-Centered Care
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/test
This is incorrect. The goal of recovery is improved health and
wellness.
This is correct. The goal of recovery is not expedient, comprehensive behavioral
change.
This is incorrect. The goal of recovery is the ability to liveabirb.com/test
a self-directed life.
This is incorrect. The goal of recovery is the ability to reach full potential.
CON: Patient-Centered Care
abirb.com/test
2. Which situation describes an example of the basic concept of aabirb.com/test
recovery model?
1. The client’s family is encouraged to make decisions to facilitate discharge.
2. A social worker, discovering the client’s income, changes the client’s discharge
placement.
abirb.com/test
3. A psychiatrist prescribes an antipsychotic drug based on observed
symptoms.
abirb.com/test
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Chapter 20 - ETB
abirb.com/test
4. A client diagnosed with schizophrenia schedules follow-up appointments and group
therapy.
abirb.com/test
ANS: 4
Chapter: Chapter 20, The Recovery Model
Objective: Describe three models of recovery: the Tidal Model, the WRAP Model, and
the Psychological Recovery Model.
abirb.com/test
Page: 323
Heading: Models of Recovery
Integrated Processes: Nursing Process
abirb.com/test
Nursing Process: Assessment
Client Need: Psychosocial Integrity
Cognitive Level: Comprehension [Understanding]
Concept: Patient-Centered Care
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/test
This is incorrect. This is not a basic example of the recovery remodel.
This is incorrect. This option does not give the consumer empowerment.
This is incorrect. This is incorrect, as it does not place the client in control.
abirb.com/test
This is correct. The basic concept of a recovery model is empowerment
of the
consumer. The recovery model is designed to allow consumers primary control over
decisions about their own care.
abirb.com/test
CON: Patient-Centered Care
abirb.com/test
3. A client diagnosed with alcohol abuse disorder is referred to a residential care facility
after discharge. According to the Substance Abuse and Mental Health
Services
abirb.com/test
Administration (SAMHSA), which dimension of recovery is supporting this client?
1. Health
2. Home
abirb.com/test
3. Purpose
4. Community
ANS: 2
abirb.com/test
Chapter: Chapter 20, The Recovery Model
Objective: Identify nursing interventions to assist individuals with mental illness in the
process of recovery.
abirb.com/test
Page: 322
Heading: What Is Recovery?
Integrated Processes: Nursing Process
Nursing Process: Assessment
abirb.com/test
Client Need: Psychosocial Integrity
abirb.com/test
abirb.com/test
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Chapter 20 - ETB
abirb.com/test
Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Easy
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. SAMHSA does not describe the dimension of health as a stable
and safe place to live.
abirb.com/test
This is correct. SAMHSA describes the dimension of home as a stable and safe place
to live.
This is incorrect. SAMHSA does not describe the dimension of purpose as a stable
abirb.com/test
and safe place to live.
This is incorrect. SAMHSA does not describe the dimension of community as a
stable and safe place to live.
abirb.com/test
CON: Patient-Centered Care
abirb.com/test
4. A client diagnosed with obsessive-compulsive disorder states, “I really think my
future will improve because of my successful treatment choices. I’m going to make my
life better.” Which guiding principle of recovery has assisted thisabirb.com/test
client?
1. Recovery emerges from hope.
2. Recovery is person-driven.
3. Recovery occurs via many pathways.
abirb.com/test
4. Recovery is holistic.
ANS: 1
abirb.com/test
Chapter: Chapter 20, The Recovery Model
Objective: Discuss the 10 guiding principles of recovery as delineated by the Substance
Abuse and Mental Health Services Administration.
Page: 321
abirb.com/test
Heading: Guiding Principles of Recovery
Integrated Processes: Nursing Process
Nursing Process: Assessment
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is correct. This client has internalized hope. This hope is the catalyst of the
abirb.com/test
recovery process.
This is incorrect. This guiding principle is important, but hope is the catalyst of
recovery.
This is incorrect. The guiding principle of hope is assistingabirb.com/test
this client.
This is incorrect. The holistic guiding principle has not assisted the client in this
abirb.com/test
abirb.com/test
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Chapter 20 - ETB
abirb.com/test
realization.
CON: Patient-Centered Care
abirb.com/test
5. A nurse maintains a client’s confidentiality, addresses the client
appropriately, and
abirb.com/test
does not discriminate based on sex, age, race, or religion. Which guiding principle of
recovery has this nurse employed?
1. Recovery is culturally based and influenced.
abirb.com/test
2. Recovery is based on respect.
3. Recovery involves individual, family, and community strengths and responsibility.
4. Recovery is person-driven.
abirb.com/test
ANS: 2
Chapter: Chapter 20, The Recovery Model
Objective: Describe three models of recovery: the Tidal Model, the WRAP Model, and
abirb.com/test
the Psychological Recovery Model.
Page: 323
Heading: Models of Recovery
abirb.com/test
Integrated Processes: Caring
Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Patient-Centered Care
Difficulty: Moderate
1.
2.
3.
4.
abirb.com/test
Feedback
This is incorrect. The nurse has not employed the use of culturally based and
influenced recovery.
This is correct. This nurse accepts and appreciates clients who
are affected by mental
abirb.com/test
health and substance use problems. This nurse protects the rights of clients and does
not discriminate against them.
This is incorrect. The nurse has not employed the use of individual, family, and
abirb.com/test
community strengths and responsibility recovery.
This is incorrect. The nurse has not employed the use of person-driven recovery.
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
6. A nurse on an inpatient unit helps a client understand the significance
of treatments
and provides the client with copies of all documents related to the plan of care. This
nurse is employing which commitment in the Tidal Model of Recovery?
1. Know that change is constant.
abirb.com/test
2. Reveal personal wisdom.
abirb.com/test
abirb.com/test
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Chapter 20 - ETB
abirb.com/test
3. Be transparent.
4. Give the gift of time.
abirb.com/test
ANS: 3
Chapter: Chapter 20, The Recovery Model
Objective: Describe three models of recovery: the Tidal Model, the WRAP Model, and
the Psychological Recovery Model.
abirb.com/test
Page: 323
Heading: Models of Recovery
Integrated Processes: Nursing Process
abirb.com/test
Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/test
This is incorrect. The nurse is not employing the recovery commitment of knowing
that change is constant in this scenario.
This is incorrect. The nurse is not employing the recovery commitment of revealing
abirb.com/test
personal wisdom in this scenario.
This is correct. Barker & Buchanan-Barker developed a set of essential values
termed The 10 Tidal Commitments on which the Tidal Model of Recovery is based.
They include value the voice, respect the language, develop
genuine curiosity,
abirb.com/test
become the apprentice, use the available toolkit, craft the step beyond, give the gift
of time, reveal personal wisdom, know that change is constant, and be transparent.
This nurse is employing the recovery commitment of being transparent.
This is incorrect. The nurse is not employing the recovery abirb.com/test
commitment of giving the
gift of time in this situation.
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
7. Which statement is true regarding the priority focus of recovery
models?
1. Empowerment of the health-care team to bring its expertise to decision-making
2. Empowerment of the client to make decisions related to individual health care
3. Empowerment of the family system to provide supportive careabirb.com/test
4. Empowerment of the physician to provide appropriate treatments
ANS: 2
abirb.com/test
Chapter: Chapter 20, The Recovery Model
Objective: Describe three models of recovery: the Tidal Model, the WRAP Model, and
the Psychological Recovery Model.
Page: 323
abirb.com/test
Heading: Models of Recovery
abirb.com/test
abirb.com/test
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Chapter 20 - ETB
abirb.com/test
Integrated Processes: Nursing Process
Nursing Process: Assessment
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Moderate
abirb.com/test
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. Empowering the health-care team to bring its expertise to decisionmaking is not the priority focus of recovery models.
abirb.com/test
This is correct. The basic concept of a recovery model is empowerment of the client.
The recovery model is designed to allow clients primary control over decisions
about their own care.
abirb.com/test
This is incorrect. Empowering the family system to provide
supportive care is not
the basis of the recovery model.
This is incorrect. Empowering the physician to provide appropriate treatments is not
the priority of the recovery mode.
abirb.com/test
CON: Patient-Centered Care
abirb.com/test
8. A client experiences an exacerbation of psychiatric symptoms to the point of
threatening self-harm. Which action step of the Wellness Recovery
Action Plan
abirb.com/test
(WRAP) Model should be employed, and which action reflects this step?
1. Step 3: Triggers that cause distress or discomfort are listed.
2. Step 4: Signs indicating a relapse are identified and plans for responding are
abirb.com/test
developed.
3. Step 5: A specific plan to help with symptoms is formulated.
4. Step 6: Following a client-designed plan, caregivers now become decision-makers.
abirb.com/test
ANS: 4
Chapter: Chapter 20, The Recovery Model
Objective: Describe three models of recovery: the Tidal Model, the WRAP Model, and
abirb.com/test
the Psychological Recovery Model.
Page: 323
Heading: Models of Recovery
Integrated Processes: Nursing Process
abirb.com/test
Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
abirb.com/test
Concept: Patient-Centered Care
Difficulty: Moderate
1.
Feedback
abirb.com/test
This is incorrect. Step 3 is not appropriate because it requires the client to be
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 20 - ETB
abirb.com/test
2.
3.
4.
responsible for self.
This is incorrect. Step 4 is not appropriate because it requires the client to be
responsible for self.
abirb.com/test
This is incorrect. Step 5 is not appropriate because it requires the client to be
responsible for self.
This is correct. In step 6 (crisis planning), clients can no longer care for themselves,
abirb.com/test
make independent decisions, or keep themselves safe. Caregivers
take an active role
in this step on behalf of the client and implement the plan that the client has
previously developed.
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
9. Which student statement indicates that further teaching is needed regarding the
recovery process according to Andresen and associates?
1. “A client has a better chance of recovery if he or she truly believes
that recovery can
abirb.com/test
occur.”
2. “If a client is willing to give the responsibility of treatment to the health-care team, he
or she is likely to recover.”
abirb.com/test
3. “A client who has a positive sense of self and a positive identity
is likely to recover.”
4. “A client has a better chance of recovery if he or she has purpose and meaning in
life.”
abirb.com/test
ANS: 2
Chapter: Chapter 20, The Recovery Model
Objective: Describe three models of recovery: the Tidal Model, the WRAP Model, and
abirb.com/test
the Psychological Recovery Model.
Page: 323
Heading: Models of Recovery
Integrated Processes: Nursing Process
abirb.com/test
Nursing Process: Evaluation
Client Need: Psychosocial Integrity
Cognitive Level: Evaluation [Evaluating]
abirb.com/test
Concept: Patient-Centered Care
Difficulty: Moderate
1.
2.
3.
Feedback
abirb.com/test
This is incorrect. This statement is accurate; if a client believes recovery can occur,
then they are likely to recover. Teaching has been effective.
This is correct. In examining a number of studies, Andresen and associates identified
abirb.com/test
four components that were consistently evident in the recovery
process. Under
responsibility, this model tasks the client, not the health-care team, with taking
responsibility for his or her life and well-being. Further teaching is required.
This is incorrect. This statement is accurate; A client who has
a positive sense of self
abirb.com/test
and a positive identity is likely to recover. No further teaching is required.
abirb.com/test
abirb.com/test
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Chapter 20 - ETB
abirb.com/test
4.
This is incorrect. If a client feels they have a purpose in life, then they have a better
chance of recovery. This statement is accurate, and no further teaching is required.
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
10. A client states, “My illness is so devastating; I feel like my life is on hold.” The
nurse recognizes that this client is in which stage of the Psychological Recovery Model
as described by Andresen and associates?
abirb.com/test
1. Moratorium
2. Awareness
3. Preparation
4. Rebuilding
abirb.com/test
ANS: 1
Chapter: Chapter 20, The Recovery Model
abirb.com/test
Objective: Describe three models of recovery: the Tidal Model, the WRAP Model, and
the Psychological Recovery Model.
Page: 323
abirb.com/test
Heading: Models of Recovery
Integrated Processes: Nursing Process
Nursing Process: Evaluation
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Comprehension [Understanding]
Concept: Patient-Centered Care
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is correct. Andresen and associates have conceptualized a five-stage model of
recovery called the Psychological Recovery Model. The moratorium
stage is
abirb.com/test
identified by dark despair and confusion. It is called moratorium because it seems
that “life is on hold.”
This is incorrect. In the awareness stage, the client realizes a possibility for recovery
abirb.com/test
does exist.
This is incorrect. In the preparation stage, the individual resolves to begin the work
of recovery.
This is incorrect. In the rebuilding stage, the client begins the
hard work towards his
abirb.com/test
or her goals of building a meaningful life.
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
abirb.com/test
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Chapter 20 - ETB
abirb.com/test
11. A client states, “I have come to the conclusion that this disease has not paralyzed
me.” The nurse recognizes that this client is in which stage of the Psychological
Recovery Model as described by Andresen and associates?
abirb.com/test
1. Moratorium
2. Awareness
3. Preparation
4. Rebuilding
abirb.com/test
ANS: 2
Chapter: Chapter 20, The Recovery Model
abirb.com/test
Objective: Describe three models of recovery: the Tidal Model, the
WRAP Model, and
the Psychological Recovery Model.
Page: 323
Heading: Models of Recovery
abirb.com/test
Integrated Processes: Nursing Process
Nursing Process: Evaluation
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. The moratorium stage is identified by dark despair and confusion.
It is called moratorium because it seems that “life is on hold.”
abirb.com/test
This is correct. Andresen and associates have conceptualized a five-stage model of
recovery called the Psychological Recovery Model. In the awareness stage, the
individual comes to a realization that a possibility for recovery exists. Andresen and
associates state, “It involves an awareness of a possible selfabirb.com/test
other than that of ‘sick
person’: a self that is capable of recovery.”
This is incorrect. In the preparation stage, the individual resolves to begin the work
of recovery.
abirb.com/test
This is incorrect. In the rebuilding stage, the client begins the hard work toward his
or her goals of building a meaningful life.
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
12. A psychiatrist who embraces the Psychological Recovery Model tells the nurse that a
client is in the growth stage. Which characteristics would the nurse expect to find when
assessing this client?
abirb.com/test
1. A client feeling confident about achieving goals in life
2. A client who is aware of the need to set goals in life
3. A client who has mobilized personal and external resources
4. A client who begins to actively take control of his or her life abirb.com/test
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 20 - ETB
abirb.com/test
ANS: 1
Chapter: Chapter 20, The Recovery Model
Objective: Describe three models of recovery: the Tidal Model, the WRAP Model, and
abirb.com/test
the Psychological Recovery Model.
Page: 323
Heading: Models of Recovery
Integrated Processes: Nursing Process
abirb.com/test
Nursing Process: Assessment
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
abirb.com/test
Concept: Patient-Centered Care
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/test
This is correct. Andresen and associates have conceptualized a five-stage model of
recovery called the Psychological Recovery Model. In the growth stage, the
individual feels a sense of optimism and hope of a rewarding future. Skills that have
abirb.com/test
been nurtured in the previous stages are applied with confidence, and the individual
strives for higher levels of well-being.
This is incorrect. This describes the awareness stage.
abirb.com/test
This is incorrect. This describes the preparation stage.
This is incorrect. This describes the rebuilding stage.
CON: Patient-Centered Care
MULTIPLE RESPONSE
abirb.com/test
abirb.com/test
abirb.com/test
13 Which concepts has SAMHSA described as major dimensions of support for a life in
recovery? Select all that apply.
1. Health
abirb.com/test
2. Community
3. Home
4. Religious affiliation
5. Purpose
abirb.com/test
ANS: 1, 2, 3, 5
Chapter: Chapter 20, The Recovery Model
abirb.com/test
Objective: Discuss the 10 guiding principles of recovery as delineated
by the Substance
Abuse and Mental Health Services Administration.
Page: 321
Heading: Guiding Principles of Recovery
abirb.com/test
Integrated Processes: Nursing Process
abirb.com/test
abirb.com/test
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Chapter 20 - ETB
abirb.com/test
Nursing Process: Assessment
Client Need: Psychosocial Integrity
Cognitive Level: Comprehension [Understanding]
Concept: Patient-Centered Care
Difficulty: Easy
1.
2.
3.
4.
5.
abirb.com/test
Feedback
abirb.com/test
This is correct. SAMHSA suggests that a life in recovery is supported by health.
This is correct. SAMHSA suggests that a life in recovery is supported by
community.
abirb.com/test
This is correct. SAMHSA suggests that a life in recovery is supported by home.
This is incorrect. Religious affiliation is not included in the listed dimensions.
This is correct. SAMHSA suggests that a life in recovery is supported by purpose.
abirb.com/test
CON: Patient-Centered Care
abirb.com/test
14. A nurse uses the commitments of the Tidal Model of Recovery in psychiatric-mental
health nursing practice. Which nursing actions reflect the use of the Develop Genuine
abirb.com/test
Curiosity commitment? Select all that apply.
1. Expresses interest in the client’s story
2. Asks for clarification of certain points
3. Encourages the client to speak his or her own words in his or her
own unique way
abirb.com/test
4. Assists the client to unfold the story at his or her own rate
5. Provides the clients with copies of all documents relevant to care.
abirb.com/test
ANS: 1, 2, 4
Chapter: Chapter 20, The Recovery Model
Objective: Discuss the 10 guiding principles of recovery as delineated by the Substance
Abuse and Mental Health Services Administration.
abirb.com/test
Page: 321
Heading: Guiding Principles of Recovery
Integrated Processes: Nursing Process
abirb.com/test
Nursing Process: Implementation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
abirb.com/test
Difficulty: Moderate
1.
2.
3.
Feedback
abirb.com/test
This is correct. This nurse is employing the Develop Genuine
Curiosity commitment
by expressing interest in the client’s story.
This is correct. This nurse is employing the Develop Genuine Curiosity commitment
by asking for clarification
abirb.com/test
This is incorrect. Asking the client to speak his or her own words in his or her own
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 20 - ETB
abirb.com/test
4.
5.
unique was does not reflect the use of the Develop Genuine Curiosity commitment.
This is correct. This nurse is employing the Develop Genuine Curiosity commitment
by assisting the client to unfold the story at his or her own rate.
abirb.com/test
This is incorrect. Providing the client with copies of documents relevant to care does
not reflect the use of the Develop Genuine Curiosity commitment.
CON: Patient-Centered Care
abirb.com/test
15. A client tells the nurse they are working on step 3 of the WRAP model and would
like some assistance. With which activities would the nurse anticipate assisting the
abirb.com/test
client?
1. Encouraging the client to write a list of strategies to alleviate disturbing symptoms
2. Creating a to-do list and checking off tasks on those lists, such as doing laundry
3. Helping the client list triggers that cause stress or discomfort abirb.com/test
4. Encouraging the client to use items from the toolbox when confronted with triggers
5. Identifying warning signs and visiting with a counselor when experiencing warning
signs
abirb.com/test
ANS: 3, 4
Chapter: Chapter 20, The Recovery Model
abirb.com/test
Objective: Describe three models of recovery: Tidal model, WRAP
model, and
Psychological Recovery model.
Page: 325
Heading: The Wellness Recovery Action Plan (WRAP) > Step 6:abirb.com/test
Crisis Planning
Integrated Processes: Nursing Process
Nursing Process: Implementation
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
5.
Feedback
This is incorrect. This describes step 1 (developing a wellness toolbox so the client
can use these tools when they are needed later).
This is incorrect. This describes step 2 (daily maintenance abirb.com/test
list).
This is correct. Step 3 of the WRAP model involves the client creating a list of
triggers that have caused stress or discomfort in the past.
This is correct. Step 3 of the WRAP model involves the client
creating a list of
abirb.com/test
triggers that have caused stress or discomfort in the past and using items from their
toolbox created in step 1 when confronted with those triggers.
This is incorrect. This describes step 4 (early warning signs). During this stage, the
abirb.com/test
individual recognizes symptoms are worsening and that the individual should seek
help.
CON: Patient-Centered Care
abirb.com/test
abirb.com/test
abirb.com/test
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Chapter 20 - ETB
abirb.com/test
ORDERED RESPONSE
abirb.com/test
16. Order the six steps of the WRAP Model as described by Copeland
and associates.
abirb.com/test
1. _______ Daily maintenance list
2. _______ Things are breaking down or getting worse
3. _______ Crisis planning
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4. _______ Develop a wellness toolbox
5. _______ Early warning signs
6. _______ Triggers
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ANS: The correct order is 2, 5, 6, 1, 4, 3.
Chapter: Chapter 20, The Recovery Model
Objective: Describe three models of recovery: the Tidal Model, the WRAP Model, and
abirb.com/test
the Psychological Recovery Model.
Page: 323
Heading: Models of Recovery
Integrated Processes: Nursing Process
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Nursing Process: Assessment
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
abirb.com/test
Concept: Patient-Centered Care
Difficulty: Moderate
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Feedback: The WRAP Model is a stepwise process through which
an individual can
monitor and manage distressing symptoms that occur in daily life. The six steps include,
in order, (1) develop a wellness toolbox, (2) daily maintenance list, (3) triggers, (4)
early warning signs, (5) things are breaking down or getting worse, and (6) crisis
abirb.com/test
planning.
CON: Patient-Centered Care
COMPLETION
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17. ____________________ from mental health disorders and substance use disorders is
a process of change through which individuals improve their health and wellness, live a
self-directed life, and strive to reach their full potential.
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PMHN, 10e
Chapter 20 - ETB
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ANS: Recovery
Chapter: Chapter 20, The Recovery Model
Objective: Define recovery.
Page: 321
Heading: What Is Recovery?
Integrated Processes: Nursing Process
Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
Cognitive Level: Knowledge [Remembering]
Concept: Patient-Centered Care
Difficulty: Easy
abirb.com/test
abirb.com/test
abirb.com/test
Feedback: Recovery from mental health disorders and substance use disorders is a
process of change through which individuals improve their healthabirb.com/test
and wellness, live a
self-directed life, and strive to reach their full potential. Recovery is the restoration to a
former or better state or condition.
abirb.com/test
CON: Patient-Centered Care
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abirb.com/test
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abirb.com/test
abirb.com/test
abirb.com/test
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PMHN, 10e
Chapter 21 – ETB
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Chapter 21. The Psychiatric-Mental Health Client in Nonpsychiatric Settings
abirb.com/test
MULTIPLE CHOICE
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1. The nurse in the emergency department (ED) is assessing a client with a long history of
abirb.com/test
depression. The nurse finds that the client has gained weight,
has dry skin, and has cold sensitivity.
The nurse determines the client’s depression is exacerbating; further examination and testing
reveal the client has hypothyroidism. Which phenomenon occurred?
1. Depression screening
abirb.com/test
2. Social distancing
3. Trauma-informed caring
4. Diagnostic overshadowing
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ANS: 4
Chapter: Chapter 21, Caring for Clients with Mental Illness and Substance Use Disorders in
General Practice Settings
abirb.com/test
Objective: Recognize the impact of inadequate assessment, treatment, and referral for the client
with mental health and substance use disorders.
Page: 334
Heading: The Need for Education of Health-Care Providersabirb.com/test
Integrated Processes: Nursing Process
Client Need: Reduction of Risk Potential
Cognitive Level: Comprehension [Understanding]
abirb.com/test
Concept: Mood
Difficulty: Easy
1.
2.
3.
4.
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Feedback
This is incorrect. The nurse did not screen for depression; rather, the nurse assessed
inadequately and incorrectly.
This is incorrect. The nurse did not use social distancing,
a type of stigmatization in
abirb.com/test
which health-care workers and others avoid clients with mental illness or addiction.
The nurse made a premature, inaccurate decision.
This is incorrect. The nurse did not use trauma-informed caring, care that assesses
abirb.com/test
for and demonstrates sensitivity to the impact of trauma
history (violence, abuse,
trauma) on current behavior and relationships. The nurse inadequately assessed the
client.
This is correct. The nurse used diagnostic overshadowing,
a phenomenon in which
abirb.com/test
clients’ physical symptoms are attributed to their mental illness. The nurse attributed
the weight gain, dry skin, and cold sensitivity to the depression rather than to
hypothyroidism.
abirb.com/test
Copyright © 2020 F. A. Davis Company
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Chapter 21 – ETB
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CON: Mood
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2. The client arrives to the ED complaining of severe abdominal pains. The attending health-care
provider determines that the client is in labor. Upon further investigation, the nurse discovers that
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the client uses illegal substances and did not seek prenatal care.
Which of the following would best
explain this lack of prenatal care?
1. Many states consider substance use during pregnancy as child abuse.
2. The client was never educated about the need for prenatal
care.
abirb.com/test
3. The client had children at home and considered prenatal care unnecessary.
4. The client did not have the financial resources to obtain prenatal care.
abirb.com/test
ANS: 1
Chapter: Chapter 21, Caring for Clients with Mental Illness and Substance Use Disorders in
General Practice Settings
Objective: Analyze barriers that influence the screening, intervention,
and referral process for
abirb.com/test
clients with mental health and substance use concerns.
Page: 338
Heading: Substance Use Disorders
abirb.com/test
Integrated Processes: Nursing Process
Client Need: Management of Care
Cognitive Level: Application [Applying]
Concept: Collaboration
abirb.com/test
Difficulty: Easy
1.
2.
3.
4.
Feedback
abirb.com/test
This is correct. Many states consider substance use during
pregnancy to be child
abuse with legal consequences, and health-care professionals are required to report
suspected prenatal drug use.
This is incorrect. Despite no education for the need for
prenatal care, this is not the
abirb.com/test
best explanation for lack of care.
This is incorrect. Each pregnancy is unique, and prenatal care is paramount for the
well-being of both mother and infant.
abirb.com/test
This is incorrect. Although prenatal care can be costly,
there are resources to help the
mother obtain adequate prenatal care.
CON: Addictions and Behaviors
abirb.com/test
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3. The client with a myocardial infarction tells the intensive care nurse, “You won’t have to care
for me pretty soon. I will not be a burden to you or others.” Which initial action should the nurse
take?
abirb.com/test
1. Screen the client for suicide.
2. Transfer the client to the medical unit.
Copyright © 2020 F. A. Davis Company
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Chapter 21 – ETB
abirb.com/test
3. Allow the client some private, quiet time.
4. Reinforce independence with self-care.
abirb.com/test
ANS: 1
Chapter: Chapter 21, Caring for Clients with Mental Illness and Substance Use Disorders in
General Practice Settings
abirb.com/test
Objective: Describe essential elements in appropriate screening
and referral of mental health and
substance abuse clients.
Page: 336
Heading: Priority Issues for Screening in Any Health Care abirb.com/test
Setting > Risk for Suicide
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
abirb.com/test
Concept: Violence
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/test
This is correct. The nurse should screen the client for suicide as the initial action.
Even though the client has a myocardial infarction and not a mental health disorder,
the client’s statement indicates possible depression and suicide. The nurse must
remember that clients in all medical settings may notabirb.com/test
be forthcoming with thoughts
of suicide unless specifically asked.
This is incorrect. The nurse should not transfer the client to the medical unit as the
initial action. The client’s statement does not indicateabirb.com/test
improvement in the client’s
condition. The nurse needs to follow-up on the client’s statement first.
This is incorrect. The nurse should not allow private, quiet time as the initial action.
The client’s statement indicates the client needs support and follow-up.
abirb.com/test
This is incorrect. The nurse should not teach the client
that he or she will be able to
care for himself or herself as the initial action. The initial action involves follow-up
for the client’s statement and needs to address the priority issue. However, the nurse
may inform the client later of the ability to perform self-care.
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CON: Violence
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4. The nurse is providing care for clients in a free community clinic. Which technique should the
nurse use to conduct a trauma screening?
abirb.com/test
1. Perform a general environmental survey.
2. Implement a thorough head-to-toe assessment.
3. Interview in a secluded area.
abirb.com/test
4. Use empathy with the family members.
ANS: 3
Chapter: Chapter 21, Caring for Clients with Mental Illnessabirb.com/test
and Substance Use Disorders in
General Practice Settings
Copyright © 2020 F. A. Davis Company
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Chapter 21 – ETB
abirb.com/test
Objective: Describe essential elements in appropriate screening and referral of mental health and
substance abuse clients.
Page: 336
abirb.com/test
Heading: Priority Issues for Screening in Any Health Care Setting > Trauma
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Violence
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. Quickly assessing the overall situation is not the technique or
purpose of a trauma screening.
abirb.com/test
This is incorrect. Implementing a thorough head-to-toe
assessment is not the
technique a nurse should use for a trauma screening.
This is correct. Interviewing in a secluded area is the technique the nurse should use
during a trauma screening. It is critical that nurses conduct
trauma screenings in
abirb.com/test
private and communicate with a compassionate, nonjudgmental attitude.
This is incorrect. While using empathy is appropriate in a trauma screening, the
client is the focus for the empathy. When clients have been abused, experienced
abirb.com/test
violence, or lived through trauma, compassion and sensitivity
are needed.
CON: Violence
abirb.com/test
5. The family practice clinic nurse is triaging clients. The nurse should require which client with
nonsuicidal self-injuring behavior to be seen immediately? abirb.com/test
1. The patient who is self-cutting in response to command hallucinations
2. The patient who has a history of borderline personality disorder
3. The patient who has recently retired from the military abirb.com/test
4. The patient who has thoughts of being detached from the body
ANS: 1
abirb.com/test
Chapter: Chapter 21, Caring for Clients with Mental Illness and Substance Use Disorders in
General Practice Settings
Objective: Describe essential elements in appropriate screening and referral of mental health and
substance abuse clients.
abirb.com/test
Page: 336
Heading: Priority Issues for Screening in Any Health Care Setting > Risk for Suicide
Integrated Processes: Nursing Process
abirb.com/test
Client Need: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
abirb.com/test
Difficulty: Moderate
Copyright © 2020 F. A. Davis Company
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Chapter 21 – ETB
abirb.com/test
1.
2.
3.
4.
Feedback
This is correct. A client who exhibits nonsuicidal self-injuring behavior (self-cutting)
in response to command hallucinations should be considered
in need of immediate
abirb.com/test
medical attention.
This is incorrect. While clients with nonsuicidal self-injuring behavior and
borderline personality disorder should be referred to specialized mental health care
services. This does not require immediate attention. abirb.com/test
This is incorrect. A client who has retired from the military and has nonsuicidal selfinjuring behavior should be seen but does not require immediate medical attention.
This is incorrect. While clients with nonsuicidal self-injuring
behavior and
abirb.com/test
depersonalization (having thoughts of being detached from the body) should be
referred to specialized mental health care services, this does not require immediate
medical attention.
abirb.com/test
CON: Patient-Centered Care
abirb.com/test
6. The nurse is working in an ED. With which client should the nurse use the screening, brief
intervention, and referral to treatment approach (SBIRT)?
abirb.com/test
1. The patient who has suicidal thoughts
2. The patient who has nonsuicidal self-injuring behavior
3. The patient who has an opioid addiction
4. The patient who has been sexually assaulted
abirb.com/test
ANS: 3
Chapter: Chapter 21, Caring for Clients with Mental Illness and Substance Use Disorders in
abirb.com/test
General Practice Settings
Objective: Describe essential elements in appropriate screening and referral of mental health and
substance abuse clients.
Page: 336
abirb.com/test
Heading: Priority Issues for Screening in Any Health Care Settings > Substance Use Disorders
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Analysis [Analyzing]
Concept: Addiction and Behaviors
Difficulty: Moderate
abirb.com/test
1.
2.
3.
Feedback
This is incorrect. The client with suicidal thoughts should be screened for depression
and suicide, but not with SBIRT.
abirb.com/test
This is incorrect. The client with nonsuicidal self-injuring behavior should be
screened using the Self-Harm Inventory but not with SBIRT.
This is correct. The client with an opioid addiction should be screened and cared for
abirb.com/test
using the SBIRT. The SBIRT is an evidence-based approach
that can be used in
various settings for substance abuse and addiction.
Copyright © 2020 F. A. Davis Company
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Chapter 21 – ETB
abirb.com/test
4.
This is incorrect. The client who has been sexually assaulted should be approached
using trauma-informed care as well as a screening for trauma. The SBIRT is not
used for this type of client.
abirb.com/test
CON: Addiction and Behaviors
abirb.com/test
7. What is the first step the nurse should take to reduce the stigmatization of mental health clients?
1. Increase social contact with mental health clients.
abirb.com/test
2. Attend on-the-job training about mental health clients.
3. Have a willingness to interact with mental health clients.
4. Understand the person as a mental health client.
abirb.com/test
ANS: 3
Chapter: Chapter 21, Caring for Clients with Mental Illness and Substance Use Disorders in
General Practice Settings
abirb.com/test
Objective: Analyze barriers that influence the screening, intervention, and referral process for
clients with mental health and substance use concerns.
Page: 340
abirb.com/test
Heading: Stigma
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
Cognitive Level: Comprehension [Understanding]
abirb.com/test
Concept: Professionalism
Difficulty: Easy
1.
2.
3.
4.
abirb.com/test
Feedback
This is incorrect. While efforts to increase social contact with mental health clients
are important to reduce stigmatization, they are not the first step.
This is incorrect. Attending on-the-job training is notabirb.com/test
the first step the nurse should
take to reduce the stigmatization of mental health clients.
This is correct. The first step is to have a willingness to interact with mental health
clients. The nurse should be willing to engage in meaningful relationships with
abirb.com/test
people who have mental illnesses and addictions.
This is incorrect. The nurse should understand the person as a mental health client,
but this is not the first step the nurse should take to reduce the stigmatization of
mental health clients.
abirb.com/test
CON: Professionalism
abirb.com/test
8. The nurse is providing care to a depressed, introverted client who is recovering from surgery for
abirb.com/test
a fractured hip. Which action should the nurse take to provide
client-centered care?
1. Refer the client for involuntary hospitalization.
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Chapter 21 – ETB
abirb.com/test
2. Allow the client plenty of solitude during the day.
3. Involve the client in choosing a blue or green gown to wear.
4. Develop a partnership with the spouse who is not withdrawn.
abirb.com/test
ANS: 3
Chapter: Chapter 21, Caring for Clients with Mental Illness and Substance Use Disorders in
abirb.com/test
General Practice Settings
Objective: Describe essential aspects of the nurse’s role in providing care for clients with
psychiatric-mental health and substance use disorders in general practice.
Page: 339
abirb.com/test
Heading: Referral
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. The nurse only refers clients for involuntary hospitalization when
they are a danger to themself or others or do not have the current capacity to make
abirb.com/test
decisions in the interest of their personal safety and livelihood.
This is incorrect. Allowing the client plenty of solitude is a type of social distancing
that is not indicative of client-centered care. It is stigmatizing the depressed,
introverted client.
abirb.com/test
This is correct. Allowing the client to make decisions about their care (choosing a
blue or green gown) is an indication of client-centered care. Just because a client has
a mental illness does not necessarily mean that they are incapable of making
abirb.com/test
decisions.
This is incorrect. To provide client-centered care, the nurse should establish a
collaborative partnership with the depressed, introverted client, not the client’s
spouse.
abirb.com/test
CON: Patient-Centered Care
abirb.com/test
9. In which setting should the nurse be aware that the client with a substance use disorder would
most likely seek initial treatment?
abirb.com/test
1. Psychiatric hospital
2. Addiction treatment center
3. Urgent care clinic
abirb.com/test
4. Inpatient psychiatric unit
ANS: 3
Chapter: Chapter 21, Caring for Clients with Mental Illnessabirb.com/test
and Substance Use Disorders in
General Practice Settings
Copyright © 2020 F. A. Davis Company
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Chapter 21 – ETB
abirb.com/test
Objective: Discuss the evidence identifying the need for further mental health and substance use
disorder education among health-care providers in primary care and other nonpsychiatric settings.
Page: 334
abirb.com/test
Heading: The Need for Education of Health-Care Providers
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Knowledge [Remembering]
Concept: Addiction and Behaviors
Difficulty: Easy
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. Clients with substance use disorders do not obtain initial treatment
in a psychiatric hospital.
This is incorrect. An addiction treatment center is notabirb.com/test
the setting for initial treatment
of clients with substance use disorders.
This is correct. Clients with substance use disorders commonly seek care first in
general medical and community practice settings, likeabirb.com/test
an urgent care clinic, before
being treated in psychiatric or substance abuse treatment settings.
This is incorrect. An inpatient psychiatric unit is not the first place a client with
substance use disorder will go for initial treatment.
abirb.com/test
CON: Addiction and Behaviors
abirb.com/test
10. The nurse manager has set a new policy on the unit to facilitate effective collaboration and
locate referrals for clients who require mental health services. Which of the following is an
abirb.com/test
appropriate resource to locate resources?
1. Online treatment map provided by the Substance Abuse and Mental Health Services
Administration
2. Nonsuicidal self-injuring behavioral screening tool
abirb.com/test
3. Screen for adverse childhood events
4. SBIRT
abirb.com/test
ANS: 1
Chapter: Chapter 21, Caring for Clients with Mental Illness and Substance Use Disorders in
General Practice Settings
Objective: Describe essential elements in appropriate screening
and referral of mental health and
abirb.com/test
substance abuse clients.
Page: 336
Heading: Priority Issues for Screening in Any Health Care Setting > Core Concept > Patient
abirb.com/test
Centered Care
Integrated Processes: Nursing Process
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Copyright © 2020 F. A. Davis Company
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Chapter 21 – ETB
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/test
This is correct. This map provides an online locator to identify mental health and
substance abuse treatment services in localities throughout the United States.
This is incorrect. This is a screening tool, not a tool for collaboration or referrals.
abirb.com/test
This is incorrect. This is a screening tool regarding the
client’s background, not a
tool for collaboration or referrals.
This is incorrect. This is a tool to treat clients with substance abuse disorders.
abirb.com/test
CON: Patient Centered Care
abirb.com/test
11. A home care nurse notices the client who startles easily is exhibiting signs of posttraumatic
stress disorder. The nurse asks, “Have you ever made a suicide attempt?” to which the client
responds, “Yes, I have.” Which response should the nurse make
next?
abirb.com/test
1. Immediately notify the primary care provider.
2. Gently touch the client’s arm.
3. Ask “Why would you do that?”
abirb.com/test
4. Ask “Are you having thoughts of suicide now?”
ANS: 4
Chapter: Chapter 21, Caring for Clients with Mental Illnessabirb.com/test
and Substance Use Disorders in
General Practice Settings
Objective: Describe essential elements in appropriate screening and referral of mental health and
substance abuse clients.
abirb.com/test
Page: 334
Heading: Screening
Integrated Processes: Communication and Documentation
Client Need: Psychosocial Integrity
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Violence
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. Notifying the primary care provider is premature. The nurse needs
abirb.com/test
to take another action before notifying the primary care
provider.
This is incorrect. While gently touching the client’s arm may be acceptable, the
nurse should take another action before this. However, touching should be used
judiciously for clients with posttraumatic stress disorder
who startle easily.
abirb.com/test
This is incorrect. Asking “Why would you do that?” belittles the client’s feelings
and causes the client to become defensive.
This is correct. A “yes” response to either question (“In the past month, have you
abirb.com/test
had thoughts about suicide?” and “Have you ever made
a suicide attempt?”) should
Copyright © 2020 F. A. Davis Company
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PMHN, 10e
Chapter 21 – ETB
abirb.com/test
prompt the nurse to ask a third question, “Are you having thoughts of suicide right
now?”
abirb.com/test
CON: Violence
abirb.com/test
MULTIPLE RESPONSE
abirb.com/test
12. The nurse is preparing a staff development presentation to improve the screening, intervention,
and referral process for clients in the geriatric community center. Which information should the
abirb.com/test
nurse identify as barriers to this initiative? Select all that apply.
1. Client privacy concerns
2. Competing workload demands
3. Novice nurses
abirb.com/test
4. Staff attitude
5. Changing screening requirements
abirb.com/test
ANS: 1, 2, 3, 4
Chapter: Chapter 21, Caring for Clients with Mental Illness and Substance Use Disorders in
General Practice Settings
Objective: Analyze barriers that influence the screening, intervention,
abirb.com/test and referral process for
clients with mental health and substance use concerns.
Page: 336
Heading: Priority Issues for Screening in Any Health Care Setting > Substance Use Disorders and
abirb.com/test
Stigma
Integrated Processes: Teaching and Learning
Client Need: Management of Care
Cognitive Level: Analysis [Analyzing]
abirb.com/test
Concept: Evidence-Based Practice
Difficulty: Difficult
1.
2.
3.
4.
abirb.com/test
Feedback
This is correct. Client fears about lack of privacy could be a barrier to this initiative.
Clients may deny using substances, especially illegal substances, because of legal
consequences.
abirb.com/test
This is correct. A barrier to this initiative would be competing workload demands.
This is correct. Less-experienced nurses or new nurses would be barriers to this
initiative. Less-experienced nurses were more fearful and more likely to think mental
abirb.com/test
health clients should be segregated.
This is correct. The staff’s attitudes can be barriers to this initiative. Attitudes toward
the client manifesting symptoms of mental illness or substance addiction are primary
abirb.com/test
influences.
Copyright © 2020 F. A. Davis Company
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Chapter 21 – ETB
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5.
This is incorrect. Changing screening requirements are not a barrier to this initiative.
In fact, nurse leaders should encourage and direct changes in screening requirements
if they address critical public health care needs.
abirb.com/test
CON: Evidence-Based Practice
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13. The nurse is a manager of a unit in an acute care setting. Which actions should the nurse
manager take to equip staff to address neuropsychiatric symptoms
in the clients? Select all that
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apply.
1. Encourage the use of screening tools.
2. Provide education of staff members.
abirb.com/test
3. Keep referrals to a minimum.
4. Increase social contact with individuals with mental illness.
5. Promote defensive medicine.
abirb.com/test
ANS: 1, 2, 4
Chapter: Chapter 21, Caring for Clients with Mental Illness and Substance Use Disorders in
General Practice Settings
Objective: Describe essential aspects of the nurse’s role in abirb.com/test
providing care for clients with
psychiatric-mental health and substance use disorders in general practice.
Page: 334
Heading: Introduction and Screening
abirb.com/test
Integrated Processes: Teaching and Learning
Client Need: Management of Care
Cognitive Level: Application [Applying]
abirb.com/test
Concept: Leadership and Management
Difficulty: Moderate
1.
2.
3.
4.
5.
Feedback
abirb.com/test
This is correct. The nurse manager should encourage the use of screening tools to
address neuropsychiatric symptoms in clients.
This is correct. The nurse manager should provide education to help staff address
abirb.com/test
neuropsychiatric symptoms in clients in a confident manner.
This is incorrect. The nurse manager should not keep referrals to a minimum. In fact,
the manager should encourage the nurses to collaborate effectively with other healthcare providers to ensure appropriate referral when specialized
mental health and
abirb.com/test
addiction treatment are needed.
This is correct. The nurse manager should attempt to prevent stigmatization of
individuals with mental illness. Research suggests that increasing positive social
abirb.com/test
contact reduces stigma.
This is incorrect. The nurse manager should not promote defensive medicine, the
practice of implementing the minimum amount of interventions to “meet the letter of
abirb.com/test
the law.” This limits the staff’s ability to address neuropsychiatric
symptoms in
clients.
Copyright © 2020 F. A. Davis Company
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Chapter 21 – ETB
abirb.com/test
CON: Leadership and Management
abirb.com/test
14. The clinic nurse is caring for a client with ulcerative colitis who has signs of depression. Which
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additional conditions should the nurse assess for in this client?
Select all that apply.
1. Mania
2. Cardiovascular disease
3. Metabolic syndrome
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4. Diabetes
5. Emphysema
abirb.com/test
ANS: 1, 2, 3, 4
Chapter: Chapter 21, Caring for Clients with Mental Illness and Substance Use Disorders in
General Practice Settings
Objective: Discuss the evidence identifying the need for further
mental health and substance use
abirb.com/test
disorder education among health-care providers in primary care and other nonpsychiatric settings.
Page: 334
Heading: The Need for Education of Health-Care Providers
abirb.com/test
Integrated Processes: Nursing Process > Assessment
Client Need: Reduction of Risk Potential
Cognitive Level: Application [Applying]
Concept: Mood
abirb.com/test
Difficulty: Difficult
1.
2.
3.
4.
5.
Feedback
abirb.com/test
This is correct. The nurse should assess for mania because
bipolar disorder, which is
characterized by bouts of depression and mania, accounts for up to 50% of all cases
of depression.
This is correct. The nurse should assess for cardiovascular
disease, as evidence has
abirb.com/test
demonstrated that depression is a risk factor for cardiovascular disease.
This is correct. The nurse should assess for metabolic syndrome, since depression is
a risk factor for metabolic syndrome.
This is correct. The nurse should assess for diabetes. abirb.com/test
Depression is a risk factor for
diabetes.
This is incorrect. The nurse should not assess for emphysema. While depression is a
risk factor for asthma, it is not a risk factor for emphysema.
abirb.com/test
CON: Mood
abirb.com/test
abirb.com/test
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Chapter 21 – ETB
abirb.com/test
COMPLETION
abirb.com/test
15. ____________________ who choose to work in nonpsychiatric settings are the frontline
responders in recognizing, intervening, and referring clientsabirb.com/test
with neuropsychiatric illnesses for
further treatment.
ANS: Nurses
abirb.com/test
Chapter: Chapter 21, Caring for Clients with Mental Illness and Substance Use Disorders in
General Practice Settings
Objective: Describe essential aspects of the nurse’s role in providing care for clients with
abirb.com/test
psychiatric-mental health and substance use disorders in general
practice.
Page: 334
Heading: Introduction
Integrated Processes: Caring
abirb.com/test
Client Need: Management of Care
Cognitive Level: Knowledge [Remembering]
Concept: Professionalism
abirb.com/test
Difficulty: Easy
Feedback: Nurses are the frontline responders for clients with neuropsychiatric illnesses.
Recognizing, intervening, and referring clients with neuropsychiatric
illnesses for further treatment
abirb.com/test
helps reduce poor outcomes, improves individuals’ quality of life, and minimizes early death.
CON: Professionalism
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
abirb.com/test
Copyright © 2020 F. A. Davis Company
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Chapter 22 - ETB
abirb.com/test
Chapter 22. Neurocognitive Disorders
abirb.com/test
MULTIPLE CHOICE
abirb.com/test
1. Which student statement indicates that learning has occurred regarding risk factors for
abirb.com/test
the development of delirium in older adults?
1. “Taking multiple medications may lead to adverse interactions or toxicity.”
2. “Age-related cognitive changes may lead to alterations in mental status.”
3. “Lack of rigorous exercise may lead to decreased cerebral blood flow.”
abirb.com/test
4. “Decreased social interaction may lead to profound isolation and psychosis.”
ANS: 1
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Chapter: Chapter 22, Neurocognitive Disorders
Objective: Define and differentiate among various NCDs.
Page: 349
Heading: Delirium > Medication-Inducted Delirium
abirb.com/test
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Reduction of Risk Potential
Cognitive Level: Evaluation [Evaluating]
abirb.com/test
Concept: Cognition
Difficulty: Moderate
1.
2.
3.
4.
Feedback
abirb.com/test
This is correct. Taking multiple medications may lead to adverse reactions or
toxicity and put an older adult at risk for the development of delirium. Symptoms of
delirium include difficulty sustaining and shifting attention, impaired memory, and
abirb.com/test
confusion (disorientation to time and place).
This is incorrect. Age-related cognitive changes do not lead to delirium.
This is incorrect. Lack of rigorous exercise does not lead to a decrease in cerebral
blood flow.
abirb.com/test
This is incorrect. Decreased social isolation does not lead to profound isolation and
psychosis; an increase in isolation does this.
CON: Cognition
abirb.com/test
abirb.com/test
2. A client diagnosed with vascular dementia is discharged to home under the care of his
spouse. Which information causes the nurse to question the client’s safety?
1. His spouse works from home in telecommunication.
abirb.com/test
2. The client has worked the night shift his entire career.
abirb.com/test
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Chapter 22 - ETB
abirb.com/test
3. His spouse has minimal family support.
4. The client smokes one pack of cigarettes per day.
abirb.com/test
ANS: 4
Chapter: Chapter 22, Neurocognitive Disorders
Objective: Describe clinical symptoms and use the information to assess clients with
abirb.com/test
NCDs.
Page: 350
Heading: Neurocognitive Disorder > Vascular Neurocognitive Disorder
Integrated Processes: Nursing Process: Assessment
abirb.com/test
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Analysis [Analyzing]
Concept: Safety
abirb.com/test
Difficulty: Difficult
1.
2.
3.
4.
Feedback
This is incorrect. The spouse working at home would not lead
the nurse to question
abirb.com/test
the client’s safety.
This is incorrect. A history of working nights does not place the client at risk for
vascular dementia.
This is incorrect. A lack of family support for the spouse isabirb.com/test
not a cause of concern
for the nurse. There are community resources to which the nurse can refer the
family.
This is correct. Forgetfulness is an early symptom of vascular
neurocognitive
abirb.com/test
disorder (VNCD), and the client is at risk for burns related to forgotten smoking
materials. VNCD is directly related to an interruption of blood flow to the brain.
Symptoms result from death of nerve cells in regions nourished by diseased vessels.
abirb.com/test
Hypertension is one of the most significant factors in the etiology.
CON: Safety
abirb.com/test
3. A client diagnosed with a neurocognitive disorder (NCD) due to Alzheimer’s disease
abirb.com/test
can no longer ambulate, does not recognize family members, and communicates with
agitated behaviors and incoherent verbalizations. The nurse recognizes that these
symptoms indicate which stage of the illness?
1. Moderate cognitive decline
abirb.com/test
2. Very mild change
3. Moderately severe cognitive decline
4. Very severe cognitive decline
abirb.com/test
ANS: 4
Chapter: Chapter 22, Neurocognitive Disorders
Objective: Describe clinical symptoms and use the information toabirb.com/test
assess clients with
NCDs.
abirb.com/test
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Chapter 22 - ETB
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Page: 350
Heading: Neurocognitive Disorder > Clinical Findings, Epidemiology, and Course >
Stage 7. Very Severe Cognitive Decline
abirb.com/test
Integrated Processes: Nursing Process
Nursing Process: Assessment
Client Need: Physiological Integrity: Physiological Adaptation
abirb.com/test
Cognitive Level: Analysis [Analyzing]
Concept: Cognition
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. At the moderate cognitive decline stage, the individual may forget
major events in personal history, experience a declining ability to perform tasks
abirb.com/test
(e.g., managing finances), or be unable to understand current
news events.
This is incorrect. During the very mild change stage, the individual begins to lose
things or forget names of people. Losses in short-term memory are common.
This is incorrect. During the moderately severe cognitive decline
stage, individuals
abirb.com/test
lose the ability to independently perform some activities of daily living (ADLs) and
require some assistance to manage them. They may forget addresses, phone
numbers, and names of close relatives and become disoriented about place and time;
abirb.com/test
however, they maintain knowledge about themself.
This is correct. The very severe cognitive decline stage is characterized by a severe
cognitive decline. Speech and language are severely impaired, with greatly
decreased verbal communication. The person may no longer
recognize any family
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members. Muscles are rigid, contractures may develop, and primitive reflexes may
be present.
CON: Cognition
abirb.com/test
abirb.com/test
4. Which nursing intervention would take priority for a client in the late stage of
Alzheimer’s disease?
1. Improve cognitive status by encouraging involvement in social activities.
abirb.com/test
2. Decrease social isolation by providing group therapies.
3. Promote dignity by providing comfort, safety, and self-care measures.
4. Facilitate communication by providing assistive devices.
abirb.com/test
ANS: 3
Chapter: Chapter 22, Neurocognitive Disorders
Objective: Discuss criteria for evaluating nursing care of clients with NCDs.
abirb.com/test
Page: 350
Heading: Neurocognitive Disorder > Clinical Findings, Epidemiology, and Course >
Stage 7. Severe Cognitive Decline
abirb.com/test
Integrated Processes: Nursing Process
Nursing Process: Implementation
abirb.com/test
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Chapter 22 - ETB
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Client Need: Physiological Integrity: Basic Care and Comfort
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
1.
2.
3.
4.
abirb.com/test
Feedback
abirb.com/test
This is incorrect. Encouraging social activities is appropriate
during the early stage.
The nursing priority is to promote dignity.
This is incorrect. Decreasing isolation is appropriate during the early stage.
This is correct. The nursing priority is to promote dignity. abirb.com/test
During the late stage, the
person becomes bedbound and may have very active hands and repetitive
movements, grunting, or other vocalizations. Speech and language are severely
impaired, and the person may no longer recognize any family members. Caregivers
abirb.com/test
need to complete most ADLs.
This is incorrect. Using assistive communication devices is appropriate during the
middle stage, when communication becomes more difficult due to increasing loss of
language skills.
abirb.com/test
CON: Cognition
abirb.com/test
5. A client is experiencing progressive changes in memory that have interfered with
personal, social, and occupational functioning. The client exhibits
poor judgment and
abirb.com/test
has a short attention span. The nurse recognizes these as classic signs of which
condition?
1. Mania
abirb.com/test
2. Delirium
3. NCD
4. Parkinsonism
abirb.com/test
ANS: 3
Chapter: Chapter 22, Neurocognitive Disorders
Objective: Describe clinical symptoms and use the information to assess clients with
abirb.com/test
NCDs.
Page: 350
Heading: Neurocognitive Disorder > Dementia (Major Neurocognitive Disorder);
Box 22–1, A Comparison of Diagnostic Criteria for Neurocognitive
Disorder
abirb.com/test
Integrated Processes: Nursing Process
Nursing Process: Assessment
Client Need: Physiological Integrity
abirb.com/test
Cognitive Level: Application [Applying]
Concept: Cognition
Difficulty: Moderate
abirb.com/test
Feedback
abirb.com/test
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Chapter 22 - ETB
abirb.com/test
1.
2.
3.
4.
This is incorrect. The client is not exhibiting symptoms of mania.
This is incorrect. These are not symptoms consistent with delirium.
This is correct. The client is exhibiting signs of an NCD, which
is characterized by
abirb.com/test
impairment in abstract thinking, judgment, and impulse control. Behavior may be
uninhibited and inappropriate.
This is incorrect. These are not symptoms consistent with Parkinson’s disease.
abirb.com/test
CON: Cognition
abirb.com/test
6. A nursing instructor is teaching about donepezil. A student asks, “How does this
work? Will this cure Alzheimer’s disease?” Which reply by the instructor is appropriate?
1. “Donepezil delays the destruction of acetylcholine, a chemicalabirb.com/test
in the brain necessary
for memory processes. Although most effective in the early stages, it serves to delay, but
not stop, the progression of the disease.”
2. “Donepezil encourages production of acetylcholine, a chemical
in the brain necessary
abirb.com/test
for memory processes. It delays the progression of the disease.”
3. “Donepezil delays the destruction of dopamine, a chemical in the brain necessary for
memory processes. Although most effective in the early stages, it serves to delay, but
abirb.com/test
not stop, the progression of the disease.”
4. “Donepezil encourages production of dopamine, a chemical in the brain necessary for
memory processes. It delays the progression of the disease.”
abirb.com/test
ANS: 1
Chapter: Chapter 22, Neurocognitive Disorders
Objective: Describe various treatment modalities relevant to care of clients with NCDs.
abirb.com/test
Page: 370
Heading: Medical Treatment Modalities > Neurocognitive Disorder > Cognitive
Impairment; Table 22–4, Selected Medications Used in the Treatment
of Clients With
abirb.com/test
NCD
Integrated Processes: Teaching and Learning
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
abirb.com/test
Cognitive Level: Comprehension [Understanding]
Concept: Cognition
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is correct. Donepezil slows the progression of Alzheimer’s disease by inhibiting
acetylcholinesterase, which delays the destruction of the neurotransmitter
abirb.com/test
acetylcholine, which is necessary for memory processes.
This is incorrect. Donepezil does not encourage production of acetylcholinesterase;
rather, it inhibits the production.
This is incorrect. Donepezil does not delay the destruction abirb.com/test
of dopamine.
This is incorrect. Donepezil does not encourage the production of dopamine, but
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Chapter 22 - ETB
abirb.com/test
inhibits acetylcholinesterase.
CON: Cognition
abirb.com/test
abirb.com/test
7. Which nursing student statement requires further teaching regarding
care for the client
with NCD experiencing hallucinations?
1. “I will assess for side effects of medications that could cause hallucinations.”
2. “My client wears a hearing aid. I need to ensure it is working properly.”
abirb.com/test
3. “If I am not experiencing the hallucination, then it is likely the client is not either.”
4. “I took the mirror off the wall because the client was seeing a false image.”
abirb.com/test
ANS: 3
Chapter: Chapter 22, Neurocognitive Disorders
Objective: Describe clinical symptoms and use the information to assess clients with
NCDs.
abirb.com/test
Page: 367
Heading: For the Patient with Delusions and Hallucinations
Integrated Processes: Nursing Process
abirb.com/test
Nursing Process: Assessment
Client Need: Psychosocial Integrity
Cognitive Level: Evaluation [Evaluating]
Concept: Cognition
abirb.com/test
Difficulty: Moderate
1.
2.
3.
4.
Feedback
This is incorrect. Assessing for side effects of medicationsabirb.com/test
that could cause
hallucinations is an appropriate action, and no further teaching is required.
This is incorrect. If a hearing aid is working incorrectly and transmitting faulty
sounds, it can cause delusions/hallucinations. This action isabirb.com/test
correct and does not
require further teaching.
This is correct. This statement requires further teaching. Just because the student
cannot see or hear what the client sees or hears does not mean it is not real to the
abirb.com/test
client.
This is incorrect. This action is correct and does not require further teaching. Clients
will often see false images in photographs and mirrors. If they are causing distress to
the client, they should be removed.
abirb.com/test
CON: Cognition
abirb.com/test
8. At which time during a 24-hour period should a nurse expect clients with Alzheimer’s
abirb.com/test
disease to exhibit more pronounced symptoms?
1. When they first awaken
abirb.com/test
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Chapter 22 - ETB
abirb.com/test
2. In the middle of the night
3. At twilight
4. After taking medications
abirb.com/test
ANS: 3
Chapter: Chapter 22, Neurocognitive Disorders
Objective: Describe clinical symptoms and use the information toabirb.com/test
assess clients with
NCDs.
Page: 358
Heading: Neurocognitive Disorder > Clinical Findings, Epidemiology,
and Course >
abirb.com/test
Stage 6. Severe Cognitive Decline
Integrated Processes: Nursing Process
Nursing Process: Assessment
abirb.com/test
Client Need: Psychosocial Integrity
Cognitive Level: Comprehension [Understanding]
Concept: Cognition
Difficulty: Moderate
abirb.com/test
1.
2.
3.
4.
Feedback
This is incorrect. Symptoms of Alzheimer’s disease are not more pronounced upon
abirb.com/test
awakening.
This is incorrect. Symptoms of Alzheimer’s disease are not more pronounced in the
middle of the night.
This is correct. Clients with Alzheimer’s disease exhibit more-pronounced
abirb.com/test
symptoms at twilight (late afternoon and evening), a phenomenon termed
sundowning.
This is incorrect. Although some medications may contribute to confusion,
abirb.com/test
symptoms directly related to Alzheimer’s disease are not worse
right after taking
medications.
CON: Cognition
abirb.com/test
abirb.com/test
9. A client diagnosed with NCD has progressive memory loss, diminished cognitive
functioning, verbal aggression, and is experiencing frustration. Which nursing
intervention is most appropriate?
1. Schedule structured daily routines.
abirb.com/test
2. Minimize environmental lighting.
3. Organize a group activity to present reality.
4. Explain the consequences for aggressive behaviors.
abirb.com/test
ANS: 1
Chapter: Chapter 22, Neurocognitive Disorders
abirb.com/test
Objective: Identify nursing diagnoses common to clients with NCDs
and select
appropriate nursing interventions for each.
abirb.com/test
abirb.com/test
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