NCLEX-RN TEST BANK Updated 2022-2023
1 The nurse is teaching the family various
factors that are important in understanding the
concepts of mental
... [Show More] health and mental illness.
What factors should be included in the nurse’s
teaching?
Answers: a, b, c, d, e
Rationale:
• Culture. Behavior that can be considered as
being at the mental illness end of the
continuum in one culture can be considered
normal and acceptable in another culture.
• Brain function. Research has shown that
brain chemicals and processes are frequently
Select all that apply.
a. Culture
b. Brain function
c. Personal factors
d. Interpersonal factors
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altered in mental illnesses.
• Personal factors. Movement toward the
mental illness end of the continuum may
begin with a sense of disharmony that is
distressing to the individual.
• Interpersonal factors. Movement toward
the mental illness end of the continuum may
begin with a sense of disharmony that is
distressing to family or friends.
• Social conditions. Movement toward the
mental illness end of the continuum may
begin with a sense of disharmony that is
distressing to the community or society.
Application
Planning
Psychosocial Integrity
Learning Objective 1.1
e. Social conditions
1.2 During the nursing assessment of an adult
client, the nurse finds the client’s beliefs and
actions related to common health practices to
be “bizarre.” Which action would be most
appropriate for the nurse to take at this time?
Answer: c
Rationale: A thorough assessment is needed
before proceeding with other steps of the
nursing process. Cultural beliefs strongly
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influence what is defined as mental illness or
mental health. Behavior that is considered
bizarre in one cultural context may be
considered desirable in another. While findings
will be communicated and used for nursing
diagnosis formulation later in the process,
these steps are built upon a thorough
assessment. Repeating the assessment without
the cultural assessment will most likely result
in the same incomplete data.
Application
Implementation
Psychosocial Integrity
Learning Objective 1.2
a. Repeat the assessment later in the day.
b. Communicate the findings to the health care
team.
c. Inquire as to the culture with which the
client identifies.
d. Write a nursing diagnosis to address the
“bizarre” beliefs and actions.
1.3 The nurse is sharing client assessment data
with the mental health care team. Which
comment by the nurse is most likely irrelevant
and indicates a misunderstanding of mental
illness? “The client reports:
Answer: d
Rationale: Religious ideas and spiritual beliefs
are culturally grounded and are not generally
labeled as symptoms of mental illness, unless
the deviance is causing a sense of disharmony
to the individual, family, friends, community,
or society. Therefore, this choice indicates a
a. A lot of time is spent in fear and anxiety.”
b. A loss of interest in usual pleasurable
interpersonal relationships.”
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misunderstanding of the concept of mental
illness. Reports of fear, anxiety, emotional
distress, and disharmony with interpersonal
relationships are very relevant and are
indications of the client’s movement toward the
mental illness end of the continuum.
Application
Evaluation
Psychosocial Integrity
Learning Objective 1.3
c. Significant emotional distress about the
current situation.”
d. Some very different religious ideas and
spiritual beliefs.”
1.4 The psychiatric-mental health nurse is
collecting data regarding the client’s position
on the mental health mental illness continuum.
Which client behavior will be most relevant to
the assessment of insight? The client is:
Answer: d
Rationale: The ability to self-evaluate or ask
difficult interpersonal questions and give
honest answers indicates the degree of insight.
While finding humor in situations, problemsolving, identifying goals and making plans are
indications of the mental health factor of
resilience; these do not directly measure
insight.
a. Identifying goals and making plans for the
future.
b. Laughing at a few humorous aspects of the
current situation.
c. Demonstrating the ability to accomplish
simple problem-solving.
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Application
Assessment
Psychosocial Integrity
Learning Objective 1.4
d. Self-evaluating personal values, attitudes,
and behaviors.
2.1 The client’s spouse is verbalizing feelings
of guilt and asks the cause of the client’s
mental illness. What is the nurse’s correct
response?
Answer: c
Rationale: Genetic and neurobiological data
indicate that mental illness is basically a brain
disorder. All functions of the mind reflect
functions in the brain. Research has provided
many theories as to the cause of mental illness.
Even though cultural, intrapersonal, and
interpersonal factors impact movement on the
a. “Sometimes people just let their problems
make themselves sick.”
b. “No one really knows the cause of mental
illness.”
c. “Mental illness is the result of a brain
disorder.”
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mental illness-mental health continuum, the
overall causative factors are neurobiological
and not the “fault” of the individual. This “atfault” belief contributes to the stigma
associated with mental illness. Asking the
spouse their perception as to why the mental
illness occurred does not take the opportunity
to teach, puts the spouse in a perceived
defensive position, does not answer the
spouse’s question, and contributes to the
inaccurate perception that mental illness might
be under personal control.
Application
Implementation
Psychosocial Integrity
Learning Objective 2.1
d. “Why do you think the mental illness
occurred?”
2.2 The psychiatric-mental health nurse is
employed in a community mental health center
that uses a neurobiological theoretical
perspective to guide treatment. The nurse
understands that the neurobiological principle
that supports the use of counseling and therapy
is that these treatment modalities:
Answer: c
Rationale: Neurobiological theory offers the
belief that all functions of the mind reflect
functions of the brain and includes the
principle that counseling and therapy can
create long-term changes through learning
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which in turn creates changes in neuronal
functioning. Self-discovery of unconscious
personality components, completion of
developmental tasks, and reinforcement of
desirable thoughts, feelings, and behaviors
describe earlier prebiological models of mental
disorders rather than principles associated with
neurobiological theory.
Analysis
Planning
Psychosocial Integrity
Learning Objective 2.2
a. Encourage completion of developmental
tasks that were not successfully completed
earlier in life.
b. Increase the client’s capacity for selfdiscovery of unconscious personality
components.
c. Create changes through learning that in turn
create changes in neuronal functioning.
d. Allow for reinforcement of desirable
thoughts, feelings, and behaviors.
2.3 The psychiatric-mental health nurse is
admitting a new client to the psychiatric unit.
Given the contemporary neurobiological
perspective of mental disorders, the nurse’s
priority assessment is:
Answer: a
Rationale: Neurobiological research theorizes a
genetic susceptibility and a familial genetic
anticipation; therefore, a family history of
mental illness becomes priority information in
a nursing assessment. While self-esteem,
interpersonal relationships, and perhaps dreams
a. A family history of mental illness.
b. A description of self-esteem.
c. The degree of satisfaction with interpersonal
relationships.
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will be assessed at some point, these concepts
are derived from earlier prebiological theories
and are not the priority in this situation.
Application
Assessment
Psychosocial Integrity
Learning Objective 2.3
d. The content and frequency of recent
dreams.
2.4 The psychiatric-mental health nurse is
planning interventions for a client using the
diathesis-stress model as a theoretical guide.
Given this framework, which of the following
nursing interventions should be included in the
plan of care?
Answer: a
Rationale: The diathesis-stress model proposes
that disease develops in biologically vulnerable
persons when exposed to stressors; therefore,
anxiety management skills to decrease the
impact of the stressors are appropriate and
should be included as interventions. Defense
mechanisms and gratification issues (Freud)
and self-actualization (Maslow) are associated
with older intrapersonal and socialinterpersonal theories.
Application
Planning
Psychosocial Integrity
Learning Objective 2.4
a. Teach anxiety management skills for use in
various situations.
b. Teach common defense mechanisms.
c. Assist to identify strategies to delay
gratification.
d. Assist to identify ways to achieve selfactualization.
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2.5 The psychiatric-mental health nurse attends
a presentation on various theories of mental
disorders. Which comment by the psychiatric
nurse indicates an understanding of
intrapersonal theories of personality
development?
Answer: b
Rationale: Intrapersonal theorists believe that
personality is shaped by events occurring in the
earliest years of life. This theory states that
symptoms of mental disorders are rooted in
events in the first five years of life. The theory
that personality is genetically driven and
individually developed is consistent with
neurobiological theory. The theory that
personality is manifested only in a person’s
interactions with others is more congruent with
social-interpersonal theory, particularly Harry
Stack Sullivan. The theory that people become
who they are through a learning process using
reinforcements and punishments reflects
behavioral theory, particularly B.F. Skinner.
Analysis
Evaluation
Psychosocial Integrity
Learning Objective 2.5
a. “Every human’s personality is genetically
driven and individually developed.”
b. “Personality is more strongly shaped by
events occurring in the earliest years of life
than by those occurring later.”
c. “Personality is manifested only in a person’s
interactions with another person or group.”
d. “People become who they are through a
learning process using reinforcements and
punishments.”
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2.6 The psychiatric-mental health nurse is
planning care for the client. The nurse first
plans to establish a therapeutic nurse-client
relationship. Which theorist espouses a
therapeutic nurse-client relationship?
Answer: b
Rationale: Hildegard Peplau, the mother of
psychiatric nursing, defined nursing as an
interpersonal process using the nurse-client
relationship to facilitate change in the client.
B.F. Skinner, a behavioral theorist, promoted
learning through the use of reinforcements and
punishment as an avenue for behavioral
change. Erik Erickson [Show Less]