FOCUS ON MENTAL HEALTH - Questions, Answers and Rationales

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Focus on Mental Health.
1.ID: 2
A nurse overhears a hospitalized client with mania telling another client, “I’m actually a journalist writing an article for a magazine — I’m just posing as... a person with mental illness.” How should the nurse respond? A. Ignoring the delusion B. Taking the client to a quiet room C. Supporting the client’s denial of illness D. Presenting the client with the actual situation Correct
Rationale: When dealing with a delusional client, it is important for the nurse to state clearly that the nurse does not share the client’s perceptions. All three of the other options — ignoring the delusion, taking the client to a quiet room, and supporting the client’s denial of illness — do not focus on reality, and they ignore the issue. Presenting the client with the actual situation helps orient the client to reality.
Test-Taking Strategy: Use the process of elimination and your knowledge that reality orientation is the priority. The correct option illustrates a means of helping orient the client to reality. Review care of the client experiencing delusions if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Psychosocial integrity
Integrated Process: Nursing Process/Implementation
Content Area: Mental Health
Giddens Concepts: Communication, Psychosis
HESI Concepts: Cognition – Psychosis, Stress and Coping – Caregiving
Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. pp. 305, 318-320). St. Louis: Saunders.
Awarded 1.0 points out of 1.0 possible points.
2.ID: 2
A client who is hallucinating fearfully says to the nurse, “Please tell that demon to get out.” How should the nurse respond to the client? A. “If you tell the demon to go away, it will.” B. “I’ll stay here with you until the demon leaves your room.” C. “If you return to bed, you will find that the demon will leave.” D. “I know you must be very upset by this, but I don’t see a demon.” Correct
Rationale: If the client hallucinates, it is best to provide reality-based perceptions and not negate the client’s experience, because this may lead to a regressive struggle with the client. Giving advice or false reassurance is incorrect because such techniques indicate that demons actually are present, which feeds into the client’s hallucination and reinforces the client’s behavior.
Test-Taking Strategy: Use your knowledge of therapeutic communication techniques, noting that the client is hallucinating. Remember that it is most important to maintain reality with the client. This will direct you to the correct option. Review communication techniques for the client who is hallucinating if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Content Area: Mental Health
Giddens Concepts: Communication, Psychosis
HESI Concepts: Cognition – Psychosis, Communication
References: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., pp. 25-29). St. Louis: Mosby.
Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. p. 320). St. Louis: Saunders.
Awarded 1.0 points out of 1.0 possible points.
3.ID: 9
The mother of a 3-year-old says, “My child hit his teddy bear after being scolded for picking the neighbors’ flowers.” Which defense mechanism was the child using? A. Projection B. Sublimation C. Displacement Correct D. Identification
Rationale: The defense mechanism of displacement involves the discharge of intense feelings for one person onto a less threatening substitute person or object to satisfy an impulse. Projection involves attributing an attitude, behavior, or impulse to someone else, such as that which occurs in blaming or scapegoating. Sublimation is rechanneling an impulse into a more socially acceptable object. Identification involves modeling behavior after someone else's.
Test-Taking Strategy: Use the process of elimination and your knowledge regarding defense mechanisms. Focusing on the child’s behavior will direct you to the correct option. Review these defense mechanisms if you had difficulty with this question.
Level of Cognitive Ability: Understanding
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Analysis
Content Area: Mental Health
Giddens Concepts: Development, Coping
HESI Concepts: Developmental, Stress and Coping
Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. pp. 171, 173). St. Louis: Saunders.
Awarded 1.0 points out of 1.0 possible points.
4.ID: 3
A client says to the nurse, “Even though my husband and I keep telling them we don’t want to have children, our parents are pressuring us to ‘start a family.’ What should we say to them?” Which of the following responses by the nurse is therapeutic? A. “This must be very difficult for both of you.” Correct B. “Maybe you should say you can’t have children.” C. “How do you usually cope with that kind of interference?” D. “Tell them to have more children if they want them so badly.”
Rationale: Childless families may elect not to have children or to postpone having them until they have established themselves occupationally or financially. Telling the client to tell the parents that the couple can’t have children is incorrect because the client is being encouraged to lie about life decisions rather than helping the parents understand the couple’s choices. Asking how they usually cope with such interference is incorrect because it indicates that the nurse is judgmental and has decided that the parents are interfering with the client and spouse. Saying, “Tell them to have more children if they want them so badly,” is incorrect because it is sarcastic and ridicules the situation over which the client has expressed concerns.
Test-Taking Strategy: Use your knowledge of therapeutic communication techniques and remember to focus on the client’s feelings. This will direct you to the correct option. Review these techniques if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Content Area: Mental Health
Giddens Concepts: Communication, Family Dynamics
HESI Concepts: Communication, Family Dynamics
Reference: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., p. 27). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
5.ID: 3
A young adult client says, “I just can’t seem to stop snapping at my parents. I know they work hard to support me, but what do I do when th...Continued..... [Show More]

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