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At what point should the nurse determine that a client is at risk for developing a mental disorder?
- A. When thoughts, feelings, and behaviors are not reflective of the DSM-5 criteria
- B. When maladaptive responses to stress are coupled with interference in daily functioning
- C. When the client communicates significant distress
- D. When the client uses defense mechanisms as ego protection
Correct Answer: B
Rationale: The correct answer is B. When maladaptive responses to stress are coupled with interference in daily functioning, the nurse should determine that a client is at risk for developing a mental disorder. This is because maladaptive responses to stress, such as excessive worry or avoidance behaviors, can be early signs of mental health issues. When these responses start impacting daily functioning, such as affecting work or relationships, it indicates a higher level of risk for a mental disorder. Choices A, C, and D are incorrect because they do not specifically address the combination of maladaptive responses to stress and interference in daily functioning, which are key indicators of potential mental health issues.
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During the sixth week of a 10-week parenting skills group, a nurse observes as several members get into a heated dispute about spanking. As a group, they 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?
- A. To referee the debate
- B. To adamantly oppose physical discipline measures
- C. To redirect the group to a less controversial topic
- D. To encourage the group to solve the problem collectively
Correct Answer: D
Rationale: The correct answer is D: To encourage the group to solve the problem collectively. The role of the group leader in this situation is to promote group cohesion and problem-solving skills. By encouraging the group to collectively address the issue of differing opinions on spanking, the leader fosters open communication, respect for diverse perspectives, and teamwork. This approach allows group members to explore the topic in a constructive manner, learn from each other, and reach a consensus or understanding.
Choice A is incorrect because the leader's role is not to referee or take sides in the debate. Choice B is incorrect as the leader should not impose personal views but facilitate a balanced discussion. Choice C is incorrect as avoiding controversial topics hinders group growth and learning.
During the first interview with a man from Syria who has just lost his son in a car accident, in sympathy for the mans loss, the female nurse reaches out and hugs him. Which is an accurate evaluation of the nurses action?
- A. The nurses action should be evaluated as unacceptable due to breech of cultural norms.
- B. The nurses action should be evaluated as empathetic, encouraging expression of feelings.
- C. The nurses action should be evaluated as the technique of offering self.
- D. The nurses action should be evaluated as inappropriate due to poor timing.
Correct Answer: A
Rationale: The correct answer is A because the nurse's action of hugging the man from Syria who just lost his son in a car accident breaches cultural norms. In many Middle Eastern cultures, physical touch, especially between unrelated individuals of the opposite sex, is considered inappropriate and can be seen as disrespectful. This can cause discomfort and may even offend the individual. In this scenario, the nurse should respect the man's cultural background and find alternative ways to show empathy and support, such as verbal expressions of sympathy or offering a comforting presence.
Choice B is incorrect because while the nurse may have intended to show empathy, the method of hugging was culturally inappropriate. Choice C is incorrect as offering self typically involves sharing personal experiences to build rapport, not physical touch. Choice D is also incorrect as the issue lies more with cultural norms rather than poor timing.
During an intake assessment, a nurse asks both physiological and psychosocial questions. The client angrily responds, Im here for my heart, not my head problems. Which is the nurses best response?
- A. Its just a routine part of our assessment. All clients are asked these same questions.
- B. Why are you concerned about these types of questions?
- C. Psychological factors, like excessive stress, have been found to affect medical conditions.
- D. We can skip these questions, if you like. It isnt imperative that we complete this section.
Correct Answer: C
Rationale: The correct answer is C because it directly addresses the client's resistance by providing relevant information linking psychological factors to medical conditions. By explaining the impact of stress on health, the nurse demonstrates the importance of addressing psychosocial aspects during the assessment.
Choice A is incorrect as it does not acknowledge the client's concerns and may come off as dismissive. Choice B is also incorrect as it focuses on the client's feelings rather than providing information to address the issue. Choice D is incorrect as it offers to skip the questions, which goes against the best practice of conducting a comprehensive assessment.
When under stress, a client routinely uses an excessive amount of alcohol. Finding her drunk, her husband yells at her about the chronic alcohol abuse. Which reaction should the nurse recognize as the use of the defense mechanism of denial?
- A. Hiding liquor bottles in a closet
- B. Yelling at their son for slouching in his chair
- C. Burning dinner on purpose
- D. Saying to the spouse, I dont drink too much!
Correct Answer: D
Rationale: The correct answer is D because the client is using denial as a defense mechanism to cope with the stress of being confronted about her alcohol abuse. By saying "I don't drink too much," she is refusing to acknowledge the reality of her excessive alcohol consumption. This denial allows her to avoid facing the uncomfortable truth and the need for change.
A: Hiding liquor bottles in a closet is an example of a defense mechanism called displacement, not denial.
B: Yelling at their son for slouching in his chair is an example of a defense mechanism called projection, not denial.
C: Burning dinner on purpose is an example of a defense mechanism called passive-aggression, not denial.
A nurse is caring for a hospitalized client who is quarrelsome and opinionated and has little regard for others. According to Sullivans interpersonal theory, the nurse should associate the clients behaviors with a previous deficit in which stage of development?
- A. Childhood
- B. Early adolescence
- C. Late adolescence
- D. Infancy
Correct Answer: A
Rationale: According to Sullivan's interpersonal theory, childhood is the stage where the foundation of interpersonal relationships is formed. Quarrelsome and opinionated behaviors with little regard for others can be associated with deficits in early childhood development. During this stage, individuals learn emotional regulation, empathy, and social skills. If these skills are not adequately developed in childhood, it can result in maladaptive behaviors in adulthood. Therefore, the correct answer is A.
Choice B, early adolescence, focuses more on identity formation and peer relationships. Choice C, late adolescence, emphasizes the transition to adulthood and independence. Choice D, infancy, is too early in development to have a significant impact on the client's current behavior.