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Question 1 1 /
... [Show More] 1 pts
The mother of a 3-year-old child tells the nurse that her child hit
her doll after the mother scolded her for picking the neighbors’
flowers. Which defense mechanism used by the child does the
nurse identify in the mother’s report?
Projection Sublimation
Correct! Displacement
Identification
Rationale: The defense mechanism of displacement
involves the discharge of intense feelings for one person
onto a substitute person or object that is less threatening
to satisfy an impulse. Projection involves attributing an
attitude, behavior, or impulse, such as that which occurs in
blaming or scapegoating, to someone else. Sublimation is
the act of 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
knowledge regarding the subject, defense mechanisms.
Focusing on the data in the question and the child’s
behavior will direct you to the correct option. Review these
defense mechanisms if you had difficulty with this
question.
Cognitive Ability: Understanding
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Mental Health
Question 2 1 / 1 pts
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A client says to the nurse, “I’ve been following my diet and taking
my medication. What else do you want to talk about today?”
Which response would be most helpful during the working phase
of the therapeutic alliance?
“Sounds fine to me. Let’s meet again in 6 months.”
“I don’t believe that you have been following your diet because
you haven’t lost any weight.”
“Well, you’ve talked about diet in your terms, but perhaps I
should test you on specific things.”
“Some people have added exercise to diet and medication
therapy and gotten positive results. Do you think that this would
work for you?”
Correct!
Rationale: Although suggestion or overt giving of advice is
sometimes nontherapeutic, these strategies are
therapeutic when used in the working phase, because in
this situation they will increase the client’s perception of all
available options in the treatment plan. Answering
“Sounds fine to me. Let’s meet again in 6 months” stops
the communication process. Stating to the client that he or
she has not lost any weight implies disbelief and does not
explore the reasons for the client’s failure to lose weight.
“Testing” challenges the client and is nontherapeutic.
Test-Taking Strategy: Use the process of elimination and
therapeutic communication techniques. Noting the words
“working phase” in the question will direct you to the
correct option. Review therapeutic communication
techniques if you had difficulty with this question.
Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Content Area: Mental Health
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Question 3 1 / 1 pts
As the nurse prepares to interview a client being admitted to the
mental health unit, the client says, “I asked my family to bring me
in here to talk to someone, but now I don’t know where to begin.”
Which response by the nurse would be most helpful?
“Why not just start talking and see where it takes you?”
“If I were you, I’d begin with what you were doing this morning.”
“Perhaps you can start by sharing some of your most recent
concerns.”
Correct!
“Don’t worry. Everyone who comes in here for the first time feels
reluctant to talk.”
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Rationale: The intake interview is usually the first contact
with the client. It is intended to establish rapport, to help
the nurse understand the client’s current problem and
level of functioning, and to help the nurse formulate a
nursing care plan. The clinician usually allows the client to
set the pace of the interview and uses open-ended
questions to elicit a comprehensive diagnostic picture of
the client’s problems and level of coping. Sharing
concerns is a good place to start the conversation
because it will allow the client to express feelings. The
response “Why not just start talking and see where it takes
you?” is too general and does not provide the client with a
focus on self. Telling the client not to worry is
nontherapeutic and avoids addressing the client’s
concerns.
Test-Taking Strategy: Use your knowledge of therapeutic
communication techniques. Focusing on the client’s
feelings will direct you to the correct option. Review
therapeutic communication techniques if you had difficulty
with this question.
Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Content Area: Mental Health
Question 4 1 / 1 pts
During a mental health intake interview, a young adult client who
lives with his family rent free says, “I’m tired of not being able to
offer my friends a beer just because my folks don’t believe in
taking a drink socially.” Which nursing response would be
therapeutic?
“Well, I guess you could move out and live on your own if you
wanted to.”
“It seems that your parents expect you to follow their rules when
you live under their roof.”
Correct!
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“You tell me you live rent free, yet you expect the same privileges
as an adult who supports the household?”
“Well, if you directly discussed your concerns with them, I guess
it’s a case of ‘When in Rome, do as the Romans do.’”
Rationale: The therapeutic nursing response uses
reflection, in which the nurse directs the content of the
client’s message back for the client to review from a new
perspective. This technique also includes an element of
focusing on the crux of the issue—in this case, that it is his
parents’ home and they set the rules for living in their
home, just as he someday will in his. Telling the client to
move out is giving advice or suggestions to the client
prematurely. Although this technique can be useful in the
working phase, it is usually nontherapeutic when the nurse
needs to promote client understanding and selfexploration. Stating “You tell me you live rent free, yet you
expect the same privileges as an adult who supports the
household?” is judgmental and poorly timed in that it
humiliates the client unnecessarily. The client has
acknowledged that he pays no rent, so there is no helpful
purpose in reemphasizing this fact. Stating “Well, if you
directly discussed your concerns with them, I guess it’s a
case of ‘When in Rome, do as the Romans do’” is
nontherapeutic in that it offers a cliché and expresses
hopelessness and powerlessness, two emotions that the
client is no doubt already experiencing.
Test-Taking Strategy: Use your knowledge of therapeutic
communication techniques. This will direct you to the
correct option, the nursing response that focuses on the
client’s concerns and feelings. Review therapeutic
communication techniques if you had difficulty with this
question.
Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Content Area: Mental Health
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Question 5 1 / 1 pts
A nurse is participating in a care planning conference regarding
care for a client whose spouse recently died. The registered
nurse formulates a nursing diagnosis of dysfunctional grieving.
Which priority intervention does the nurse expect to see
incorporated into the plan?
Monitoring the client’s sleep pattern Obtaining a physician’s prescription for an antidepressant
Determining the client’s risk for violence toward self and others
Correct!
Assisting the client in resolving the grief through emotional,
cognitive, and behavioral means
Rationale: The priority intervention for a client with
dysfunctional grieving is assessing the client’s risk for
violence toward self and others. Although the nurse will
assist the client in resolving the grief and will monitor the
client’s sleep pattern, these are not priorities in the list of
options given. Obtaining a physician’s prescription for an
antidepressant is not a priority.
Test-Taking Strategy: Use the process of elimination and
the steps of the nursing process. Both monitoring the
client’s sleep pattern and determining the client’s risk for
violence toward self and others involve assessment. From
these options, select the one that addresses the safety of
the client. Review interventions for a client with
dysfunctional grieving if you had difficulty with this
question.
Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Content Area: Mental Health
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Question 6 1 / 1 pts
A client in the mental health unit tells the nurse, “My husband
makes all the decisions about money, but I’m the one who’s
making the money now, not him. He needs to back off, but he’s
always directing every decision we make.” Which nursing
response would be the most therapeutic?
“Have you told your husband to back off”?
“You’re making the most money, so the decisions should be left
to you.”
“How do you feel the money decisions could best be handled in
your household?”
Correct!
“You seem frustrated with your husband’s habit of controlling
financial decisions.”
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Rationale: The therapeutic nursing response is the one
that provides a broad opening or statement and is focused
on the client’s feelings. In this response, the nurse will be
able to assess what the client believes concerning family
financial decision-making. Asking “Have you told your
husband to ‘back off’?” is improperly paraphrasing the
client and assumes that the client’s stance is correct.
Stating that “You’re making the most money, so decisions
should be left to you” is inappropriate restating and
provides an opinion; this response may be seen by the
client as reassurance that her interpretation is being
judged as correct. By stating “You seem to feel
frustrated…,” the nurse is sharing perceptions, which may
appear to be challenging to the client when used in this
context.
Test-Taking Strategy: Use your knowledge of therapeutic
communication techniques. Remember to focus on the
client’s feelings and to provide the client the opportunity to
communicate. This will direct you to the correct option.
Review therapeutic communication techniques if you had
difficulty with this question.
Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Content Area: Mental Health
Question 7 1 / 1 pts
A nurse is attending a care planning conference for a client who
recently received a diagnosis of acquired immunodeficiency
syndrome and is experiencing difficulty adjusting to the illness.
The nurse should question which planned intervention for this
client?
Monitoring the client for signs of self-harm Helping the client verbalize concerns related to fear Assisting the client with problem-solving and decision-making
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Discouraging social networking to prevent the spread of infection
Correct!
Rationale: In planning care for a client experiencing
difficulty in adjusting to an illness, the nurse develops
interventions to promote (not discourage) social
networking that will provide needed information to the
client. The other options are appropriate interventions.
Test-Taking Strategy: Use the process of elimination and
note the strategic word “question.” Recalling that social
support is important will direct you to the correct option.
Also, note the relationship between the word “question” in
the question and “discouraging” in the correct option.
Review interventions for a client experiencing difficulty in
adjusting to an illness if you had difficulty with this
question.
Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Planning
Content Area: Mental Health
Ques 0.75 / 1 pts tion 8
How does a client who has lost a spouse show that she is
successfully completing the tasks of mourning? Select all that
apply.
Relating that its better “he went first”
Correct! Reporting that sleeping alone was hard at first
Correct! Purchasing a smaller car she is comfortable driving
Correct Answer Heard explaining to family that illness “took” her husband
Correct! Heard explaining to family that illness took her husband
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Question 9 1 / 1 pts
A nurse is caring for a 15-year-old girl who has been hospitalized
on the mental health unit for bipolar disorder. The client tells the
nurse that she had her hair styled just like her young math
teacher, whom she admires. The nurse recognizes that the client
is using which defense mechanism?
Projection Regression
Correct! Identification
Intellectualization
Rationale: Identification is the process by which a person
tries to become like someone he or she admires by taking
on the beliefs, mannerisms, or tastes of that person.
Projection is attributing one’s thoughts or impulses to
another person. Regression is retreating to a behavior
characteristic of an earlier level of development.
Intellectualization is excessive reasoning or logic used to
avoid experiencing disturbed feelings.
Test-Taking Strategy: Use the process of elimination,
focusing on the data in the question. Noting that the client
is mimicking a characteristic of another person will direct
you to the correct option. Review these defense
mechanisms if you had difficulty with this question.
Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Content Area: Mental Health
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Question 10 1 / 1 pts
A mental health home care nurse says to the client, “Do you feel
ready to try attending a group session at the clinic?” The client
shakes his head. Which nursing statement would be therapeutic?
“No? Why not?”
“You seem to be saying no. Would you tell me more about your
reluctance?”
Correct!
“OK, but I hope you will let me know when you feel ready to
attend a group session at the clinic.”
“Perhaps a group session would be too overwhelming for you
right now. How about just seeing me?”
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Rationale: The therapeutic nursing statement is seeking
clarification. In this statement, the nurse is asking the
client to put his ideas into words and explain what he
means or feels. This encourages the client to express his
reluctance and to try to work out any reservations about
attending the group session. In responding, “No? Why
not?” the nurse is using a confrontational style, which
could lead to a regressive struggle. The nurse expresses
doubt and uses a laissez-faire style regarding attending a
group session at the clinic when the nurse states “… let
me know when you feel ready to attend.” In stating
“Perhaps a group session would be too overwhelming for
you right now. How about just seeing me?” the nurse
prematurely guesses the reasons for the client’s refusal,
and this is not appropriate.
Test-Taking Strategy: Draw on your knowledge of
therapeutic communication techniques to answer this
question. First eliminate the option containing the word
“why.” To select from the remaining options, focus on the
information in the question. The correct option provides
the client the opportunity to verbalize feelings. Review
therapeutic communication techniques if you had difficulty
with this question.
Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Content Area: Mental Health
Question 11 1 / 1 pts
A single parent whose son was suspended from school for
carrying a gun into the school says to the nurse, “I know he has
no dad, but I’ve brought him up to know better, and anyway,
where did he get the stupid gun? What should I do? He just won’t
listen to me.” Which nursing response would be helpful at this
time?“Boys who are cared for only by their moms are at highest risk for
violent behavior.”
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“There is quite a bit that you can do. Let’s talk about what you’re
already doing first.”
Correct!
“Do you know all of your son’s friends, or is he left alone after
school because you work?”
“Many young people die of gunshots every day in this country, so
your son’s behavior is unacceptable.”
Rationale: It is important to help parents to identify
children at risk for violent behavior. Unfortunately, this
young person has already engaged in threatening and
potentially violent behavior, but there are parenting
measures and therapies that this single parent can use to
help her son express his feelings of anger verbally rather
than by acting out. The nurse responds nontherapeutically
in telling the mother that boys who are cared for only by
their mothers are at high risk for violence; this response
could generate guilt in the mother. Asking “Do you know
all of your son’s friends, or is he left alone after school
because you work?” is both inappropriate and premature.
Telling the woman that her son’s behavior is unacceptable
is lecturing an upset parent, which is inappropriate.
Test-Taking Strategy: Use your knowledge of therapeutic
communication techniques, and focus on the information
in the question. Note that the client of the question (the
mother) is asking the nurse for assistance. The correct
option is the only option that addresses the mother’s
concern and encourages verbalization. Review therapeutic
communication techniques if you had difficulty with this
question.
Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Content Area: Mental Health
Question 12 1 / 1 pts
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A client says to the nurse, “My health care provider says he
thinks I’m ready to taper off my pain medication, but the new
painkiller he prescribed doesn’t relieve my pain the way the other
pill did. I get pain when I try to do things.” Which nursing
response would be most supportive to the client?
“Your physician feels that your body is physically ready to make
the change in medication.”
“I think you need to listen to your physician when it comes to
taking such strong medication.”
“Well, your health care provider is concerned that you will
become physically dependent on the first painkiller.”
“Perhaps if I medicate you about a half-hour before you plan to
start your daily activities, the medicine will be more effective.”
Correct!
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Rationale: The most supportive response is the one that
addresses the client’s concern and provides a plan that
will help minimize the client’s pain. If this nursing measure
does not afford pain relief, then the nurse can report the
client’s continued pain to the physician. In stating “Your
physician feels that your body is physically ready to make
the change in medication,” the nurse is shifting attention
from the client’s feelings to the physician’s view. In telling
the client that he or she needs to listen to the physician,
the nurse is nontherapeutically giving advice and
patronizing the client. Stating “Well, your health care
provider is concerned that you will become physically
dependent on the first painkiller” is a defensive response,
and the nurse’s assertion about dependence may not be
based on fact.
Test-Taking Strategy: Use your knowledge of therapeutic
communication techniques and focus on the subject, the
client’s concern about pain relief. Eliminate the
comparable or alike options that focus on the physician,
not the client. From the remaining options, select the one
that addresses the client’s concern. Review therapeutic
communication techniques if you had difficulty with this
question.
Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Content Area: Mental Health
Question 13 1 / 1 pts
A client who was employed as a corporate manager before being
laid off says to the nurse, “My wife thinks that I should work in a
menial job to maintain our lifestyles until I find another job as a
corporate manager, but I don’t feel I should have to humiliate
myself like that.” Which nursing response would be therapeutic?
Correct! “Have you shared your feelings with your wife?”
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“You seem to feel that a less prestigious job would be humiliating
for you.”
“Oh, I agree with you. Let her get another job if she needs that
much money.”
“How soon will you be able to find work? If this is permanent, you
may need to swallow your pride.”
Rationale: The therapeutic response is the one that helps
determine whether the client is sharing his feelings with
his wife and providing her with the opportunity to join in the
decision-making process. Stating “You seem to feel that a
less prestigious job would be humiliating for you” is
reflection to some degree; however, its focus is
nontherapeutic because the nurse is making a premature
judgment of the client’s concerns. In stating “Oh, I agree
with you. Let her get another job if she needs that much
money,” the nurse is using a nontherapeutic response of
giving approval. “How soon will you be able to find work? If
this is permanent, you may need to swallow your pride” is
a probing question that the client is probably unable to
answer and gives an unsolicited opinion, which is a
nontherapeutic communication.
Test-Taking Strategy: Use your knowledge of therapeutic
communication techniques. Note the words “shared your
feelings” in the correct option. Remember to focus on the
client’s feelings. Review therapeutic communication
techniques if you had difficulty with this question.
Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Content Area: Mental Health
Question 14 1 / 1 pts
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A young woman who has been divorced twice says to the nurse,
“I’ve decided not to date men ever again! It never works out for
me. Now I’m left with two children to bring up.” Which nursing
response would be therapeutic?
“Oh, me too. I always pick the worst kind of men, so I know just
how you feel.”
“Divorce is more difficult for children. Maybe you should focus on
them for now.”
“You’ve been unfortunate, but you seem to be focusing on
yourself and what you have to do.”
“You talk about how the divorces affected you. Tell me how your
children are dealing with the loss.”
Correct!
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Rationale: When clients experience loss, they can become
self-absorbed. In responding, “You talk about how the
divorces affected you. Tell me how your children are
dealing with the loss,” the nurse is trying to refocus the
client’s attention on her children and their needs during
this time. By stating “Oh, me too. I always pick the worst
kind of men, so I know just how you feel,” the nurse
personalizes and exaggerates the client’s problems, using
a nontherapeutic response. In stating “Divorce is more
difficult for children. Maybe you should focus on them for
now,” the nurse is being judgmental when he or she
should be refocusing the client’s energies. In stating
“You’ve been unfortunate, but you seem to be focusing on
yourself and what you have to do,” the nurse is responding
with empathy, but the choice of wording suggests that the
nurse is judging and blaming the client for not focusing on
her children.
Test-Taking Strategy: Use your knowledge of therapeutic
communication techniques. Eliminate the option that is a
nontherapeutic response and does not focus on the
client’s concern. To select from the remaining options,
note that the correct option is the only option that
encourages the client to discuss the loss and its effect on
her children. Review therapeutic communication
techniques if you had difficulty with this question.
Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Content Area: Mental Health
Question 15 1 / 1 pts
A client says to the nurse, “What does my psychiatrist mean
when she says that my illness is biologically based?” Which
nursing statement would be the most informative?
“Mental illness always has its roots in the family.” “Mental illness is a result of environmental factors.”
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“Today we know that all mental illness is genetically inherited.”
“There are many possible physical causes of mental illness, and
they include problems in the brain.”
Correct!
Rationale: Biologically based mental illnesses are caused
by neurotransmitter dysfunction, abnormal brain structure,
inherited genetic factors, or other biological causes.
Biologically influenced illnesses include schizophrenia,
bipolar disorder, major depression, obsessive-compulsive
disorder, panic disorder, posttraumatic stress disorder,
autism, anorexia nervosa, and attentiondeficit/hyperactivity disorder. Stating that all mental illness
is a result of genetic factors or that it is caused by
environmental factors or family dynamics is incorrect and
not associated with a biologically based disorder.
Test-Taking Strategy: Use the process of elimination.
Eliminate the options that include the closed-ended words
“always” and “all.” To select from the remaining options,
focus on the words “biologically based” in the question,
which will direct you to the correct answer. Review the
causes of mental illness if you had difficulty with this
question.
Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Mental Health
Question 16 1 / 1 pts
A nurse is caring for a 39-year-old client who has experienced a
mild brain attack (stroke). The client is recently widowed, is very
active physically, and has two young sons. The client says to the
nurse, “I don’t know what my sons will do if anything permanent
happens to me. We have no other relatives, even on my late
wife’s side.” Which nursing response would be therapeutic?
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Correct! “You seem to be feeling very troubled.”
“You are working to get better, but you’re worrying about things
that aren’t going to happen.”
“You seem to be feeling very powerless right now, yet you’re
getting better, so why worry about what won’t happen?”
“I am troubled that you are worried over the worst possible things
that could happen rather than worrying about the efforts needed
to strengthen your family situation.”
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Rationale: The client has suffered two major losses and is
expressing worry and concern about his health and his
children. The correct response conveys the nurse’s
expression of empathy and willingness to understand and
help the client explore ways of coping with difficulties. In
stating “You are working to get better and are doing so.
But you are worrying about things that aren’t going to
happen,” the nurse is making a pat and clichéd response
that may or may not be true. In stating “You seem to be
feeling very powerless right now, yet you’re getting better,
so why worry about what won’t happen?” the nurse is
displaying empathy but also minimizing the client’s
feelings with a false reassurance. In stating “I am troubled
that you are worried over the worst possible things that
could happen rather than worrying about the efforts
needed to strengthen your family situation,” the nurse is
not focusing on the client’s concern, and the statement
could be interpreted as minimizing or belittling by the
client.
Test-Taking Strategy: Use your knowledge of therapeutic
communication techniques. Select the option that focuses
on the client’s feelings and encourages the client to
express his feelings. Review therapeutic communication
techniques if you had difficulty with this question.
Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Mental Health
Question 17 1 / 1 pts
A client who has been admitted to a surgical unit with a diagnosis
of cancer is scheduled for surgery in the morning. When the
nurse enters the room and begins the surgical preparation, the
client states, “I’m not having surgery—you must have the wrong
person! My test results were negative. I’ll be going home
tomorrow.” The nurse recognizes that the client is engaging in the
use of which defense mechanism?
Correct! Denial
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Psychosis Delusions Displacement
Rationale: Defense mechanisms protect us against
anxiety. Denial is the defense mechanism used to block
out painful or anxiety-inducing events or feelings. In this
case, the client cannot deal with the upcoming cancer
surgery and therefore denies that he or she is ill.
Psychosis and delusions are not defense mechanisms.
Displacement is acting out in anger or frustration with
people who did not arouse the feelings.
Test-Taking Strategy: Use the process of elimination and
focus on the subject, defense mechanisms. First, eliminate
the options that are not defense mechanisms. From the
remaining options, focus on the data in the question to find
the correct option. Review defense mechanisms if you had
difficulty with this question
Cognitive Ability: Understanding
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Mental Health
Question 18 1 / 1 pts
A young adult client who is dying says to the nurse, “I keep
asking my wife what I can do for her and our daughter before I
die, but she refuses to tell me.” On the basis of the client’s
statement, what is the appropriate nursing intervention?
Teaching the client’s wife to write down her thoughts and feelings
and to read them to her husband
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Saying to the client, “It sounds to me like your wife is truly
comfortable and doesn’t want you to worry needlessly.”
Talking with both the client and his wife about the importance of
expressing their feelings and how to do it in healthy ways
Correct!
Talking with all family members, including the daughter, about the
importance of expressing their concerns and feelings to the dying
client
Rationale: The appropriate nursing intervention is to help
the client and spouse describe feelings that, left unspoken,
might cause disruption and delay resolution. Teaching the
client’s wife to write down her thoughts and feelings and
read them to her husband is inappropriate without a prior
determination of the wife’s feelings. In saying to the client,
“It sounds to me as if your wife is truly comfortable and
doesn’t want you to worry needlessly,” the nurse
verbalizes a statement without a basis in fact, a
nontherapeutic technique. Talking with all family members
is inappropriate and could violate client confidentiality.
Test-Taking Strategy: Use your knowledge of therapeutic
communication techniques. Eliminate the option that does
not address the client’s feelings and places the client’s
feelings on hold. Next, eliminate the comparable or alike
options because they both address an intervention with a
family member before determining their feelings. Review
therapeutic communication techniques if you had difficulty
with this question.
Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Mental Health
Question 19 1 / 1 pts
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A 45-year-old client says to the nurse, “Since I left my wife and
children, I can hardly make ends meet between child support and
trying to support myself. I don’t know why I bother going to work
when my wife and kids take just about everything I make.” Which
nursing statement would be therapeutic?
“I wonder why you left your wife and children.”
“What would you expect your wife and children to do? They didn’t
leave you.”
“You seem to be very angry about carrying out your responsibility
to your children.”
“Do you feel that child support is designed to help children, not
punish spouses who leave?”
Correct!
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Rationale: The nurse employs the therapeutic
communication technique of seeking clarification to
support the client in processing his feelings more
specifically. In maintaining a neutral, unbiased, and
nonjudgmental stance, the nurse can establish a trusting
relationship with the client. In stating “I wonder why you
left your wife and children,” the nurse changes the focus of
the client’s concern and uses a “why” question that implies
criticism and could cause the client to become defensive.
“What would you expect your wife and children to do?
They didn’t leave you” is sarcasm, which is nontherapeutic
and alienates the client. In stating “You seem very angry
about carrying out your responsibility to your children,” the
nurse is making an interpretation and labeling the client’s
feelings prematurely.
Test-Taking Strategy: Use your knowledge of therapeutic
communication techniques. Eliminate the option
containing the word “why.” Next, eliminate the option that
is sarcastic and the option that labels the client’s feelings.
Also note that the correct option is the only option that
focuses on the client’s concern and encourages the client
to further verbalize feelings. Review therapeutic
communication techniques if you had difficulty with this
question.
Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Content Area: Mental Health
Question 20 1 / 1 pts
A survivor of a nightclub fire that killed more than 100 people
says to the nurse, “It should have been me. How come I got out
and they didn’t?” Which response by the nurse is appropriate? “I don’t know what to say. It was a terrible fire. I’m so sorry this
happened.”
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“It seems that you’re blaming yourself for something that was
beyond your control.”
Correct!
“It seems to me that you’re making this all about you when many
people died in that fire.”
“You should be thankful that you’re a survivor. The victims and
their families lost, not you.”
Rationale: The correct option involves the use of the
communication technique of reflection and encourages the
client to further verbalize his thoughts and feelings. In
stating “I don’t know what to say. It was a terrible fire. I’m
so sorry this happened,” the nurse is using a social
response and the nontherapeutic communication
technique of agreeing. In stating “It seems to me that
you’re making this all about you when many people died in
that fire,” the nurse is using the nontherapeutic
communication techniques of disapproval and judging. In
stating “You should be thankful that you’re a survivor. The
victims and their families lost, not you,” the nurse is
nontherapeutically lecturing the client.
Test-Taking Strategy: Use your knowledge of therapeutic
communication techniques. The correct option is the only
option that is therapeutic, involves the use of reflection,
and encourages verbalization of the client’s feelings.
Review therapeutic communication techniques if you had
difficulty with this question.
Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Content Area: Mental Health
Question 21 1 / 1 pts
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When assisting with the plan of care of a client dying of cancer,
the nurse seeks to have the client verbalize acceptance of his
impending death. Which statement indicates to the nurse that this
goal has been met?
Correct! “I’d like to have my family here when I die.”
“I’ll be ready to die once my daughter gets married.” “I want to go to my family reunion; then I’ll be ready to die.”
“I just want to live to see my grandchildren graduate from
college.”
Rationale: Acceptance is often characterized by plans for
death. Often the client wants loved ones near. Therefore
the statement “I’d like to have my family here when I die”
indicates acceptance of impending death. The incorrect
options reflect the bargaining stage of coping, in which the
client tries to negotiate with his or her God or with fate.
Test-Taking Strategy: Use the process of elimination.
Eliminate the comparable or alike options that
demonstrate negotiation for something else to happen
before death occurs. The correct option is the option that
reflects acceptance. Review the stages of death and dying
if you had difficulty with this question.
Cognitive Ability: Evaluating
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Mental Health
Ques 1 / 1 pts tion 22
A client says to the nurse at the mental health clinic, “My husband
and sister-in-law both have terminal illnesses, and my family
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thinks that because I’m a nurse I should be able to handle
everything.” Which nursing response would be therapeutic?
“Are you saying you are overly involved and will need to
emotionally distance yourself to be therapeutic for your family?”
“Shame on them for expecting so much from you. Perhaps we
need to schedule a family meeting so I can help you set them
straight.”
“I’m sorry to hear that your loved ones are so ill. As a nurse, you
should be able to assist them by using your professional
expertise. Perhaps that’s what your family expects from you.”
“You’ve seen your loved ones dealing with some troubling events
recently. Sounds as if you feel that your family expects more from
you than from others in the family because you’re a nurse.”
Correct!
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Rationale: The therapeutic response is the one in which
the nurse makes observations and then clarifies his or her
perception of what the client has said. Stating “Are you
saying you are overly involved and will need to emotionally
distance yourself to be therapeutic for your family?” is
paraphrasing, a therapeutic technique, but this response is
premature and reflects unfounded assumptions. In stating
“Shame on them for expecting so much from you. Perhaps
we need to schedule a family meeting so I can help you
set them straight,” the nurse expresses disapproval, a
nontherapeutic communication technique, and then offers
to “beat up” the family verbally in a family intervention. The
statement “I’m sorry to hear that your loved ones are so ill.
As a nurse, you should be able to assist them, using your
professional expertise. Perhaps that’s what your family
expects from you,” expresses sympathy but also lectures
the client.
Test-Taking Strategy: Use your knowledge of therapeutic
communication techniques. The correct option is the only
option that specifically addresses the client’s feelings and
encourages verbalization about the client’s concern.
Review therapeutic communication techniques if you had
difficulty with this question.
Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Content Area: Mental Health
Question 23 1 / 1 pts
A 79-year-old client, recently widowed, says to the nurse, “My
wife kept up our condominium single-handedly, and now my kids
expect me to cook and clean for myself. I’m not lazy, but I don’t
know how to cook and I’ve burnt myself twice just frying up what
was supposed to be bacon and eggs. I’m so frustrated and I’ve
already lost 10 pounds this month.” Which initial nursing
statement should the nurse make to the client?
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“I’m calling the health care provider immediately to obtain a
homemaker for you!”
“It seems as if you feel lost without your wife and maybe a bit
ignored by your children.”
Correct!
“First things first. What are you doing eating bacon and eggs?
That’s not a good meal for you.”
“Meals-on-Wheels can help you minimize the frustration you are
having cooking. Are you a member of the local senior center?”
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Rationale: The client is exhibiting grief over the recent loss
of his wife; feelings of insecurity, inexperience, and
helplessness; weight loss (a vegetative sign of
depression); evidence of poor nutritional habits; isolation;
and a lack of safety in activities of daily living. The initial
nursing statement should seek clarification of the client’s
feelings so that the nurse can estimate the extent of mood
alteration. In stating “I’m calling the health care provider
immediately to obtain a homemaker for you!” the nurse is
responding too abruptly. Although the stated intervention
may be a part of mutual planning, the client may not need
or qualify for such support at this time; more data should
be gathered. In stating “First things first. What are you
doing eating bacon and eggs? That’s not a good meal for
you,” the nurse begins by ordering data from the client but
veers off into expressing disapproval of the one meal that
the client has cited, which may not be representative of his
dietary habits. The nurse jumps to conclusions on the
basis of inadequate information, and being judgmental is
nontherapeutic. Saying, “Meals-on-Wheels can help you
minimize your frustration. Are you a member of the local
senior center?” jumps prematurely to referral to community
resources that may be helpful. However, it is too early to
address resources; a complete assessment of the client’s
stated complaints should be obtained first.
Test-Taking Strategy: Use your knowledge of therapeutic
communication techniques. This will direct you to the
correct option, which is the only option that addresses the
client’s feelings. Review therapeutic communication
techniques if you had difficulty with this question.
Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Content Area: Mental Health
Question 24 1 / 1 pts
A physician tells a client that she has cancer, that her illness is
terminal, and that she has a 6-month prognosis. After the
physician leaves the client’s room, which therapeutic statement
should the nurse make to the client?
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“I am so sorry about this. You are my favorite client, and I will
take good care of you.”
“What did your health care provider tell you about your condition?
Can you tell me what you’re thinking about?”
Correct!
“Do you have any questions about what is happening with you? I
can assure you that I will do everything I can to help minimize
your pain.”
“Do you want me to get the phone so you can talk to your loved
ones, or do you have questions for me about what’s happening
with you?”
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Rationale: When communicating with the dying client and
those who grieve, the nurse should use statements that
indicate a willingness to follow the client’s lead. Openended statements such as “Can you tell me what you are
thinking about?” are appropriate and encourage
verbalization of feelings. In stating “I am so sorry about
this. You are my favorite client, and I will take good care of
you,” the nurse expresses sympathy but provides only a
social response. By stating “Do you have any questions
about what is happening with you? I can assure you that I
will do everything I can to help minimize your pain,” the
nurse begins with a therapeutic response but then gives a
false reassurance. By stating “Do you want me to get the
phone so you can talk to your loved ones, or do you have
questions for me about what’s happening with you?” the
nurse demonstrates discomfort and is seemingly reluctant
to offer help. In this statement the nurse tells the client that
the nurse would prefer that the client discuss feelings and
concerns with loved ones.
Test-Taking Strategy: Use your knowledge of therapeutic
communication techniques and remember to focus on the
client’s feelings. The correct option focuses on the client’s
feelings and encourages client verbalization. Review
therapeutic communication techniques if you had difficulty
with this question.
Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Content Area: Mental Health [Show Less]