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During a mental health assessment on an adult client, which client action would demonstrate the highest achievement in terms of mental health according to Maslow's hierarchy of needs?
- A. Maintaining a long-term, faithful, intimate relationship
- B. Achieving a sense of self-confidence
- C. Possessing a feeling of self-fulfillment and realizing full potential
- D. Developing a sense of purpose and the ability to direct activities
Correct Answer: C
Rationale: In Maslow's hierarchy of needs, self-actualization is the highest level. Possessing a feeling of self-fulfillment and realizing full potential reflects self-actualization. This level represents achieving personal growth, self-improvement, and reaching one's full potential, indicating optimal mental health. Choices A, B, and D represent lower levels of needs according to Maslow's hierarchy. Maintaining a long-term relationship indicates belongingness and love needs, achieving self-confidence pertains to esteem needs, and developing a sense of purpose relates to self-esteem and self-actualization needs, but they are not at the pinnacle of self-actualization as in choice C.
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Which symptom should a healthcare provider identify as typical of the fight-or-flight response?
- A. Pupil dilation
- B. Increased heart rate
- C. Decreased salivation
- D. Decreased peristalsis
Correct Answer: B
Rationale: The correct answer is B: Increased heart rate. During the fight-or-flight response, the sympathetic nervous system is activated, causing the release of epinephrine. This hormone triggers an increase in heart rate to supply more blood to the muscles for a rapid response. Pupil dilation occurs to enhance vision in preparation for quick reactions. On the other hand, salivation and peristalsis decrease as the body prioritizes functions necessary for immediate action rather than digestion-related activities. Therefore, choices A, C, and D are incorrect as they do not align with the typical physiological changes associated with the fight-or-flight response.
A bright student confides in the school nurse about conflicts related to attending college or working to add needed financial support to the family. Which coping strategy is most appropriate for the nurse to recommend to the student at this time?
- A. Meditation
- B. Problem-solving training
- C. Relaxation
- D. Journaling
Correct Answer: B
Rationale: In this scenario, the student is dealing with conflicting priorities of attending college or working to support the family financially. Problem-solving training is the most appropriate coping strategy to recommend. It can help the student objectively assess the situation, identify potential solutions, and make informed decisions. Problem-solving training provides structure and guidance, empowering the student to navigate the conflicting priorities effectively and choose the best course of action. Meditation, relaxation, and journaling may be beneficial for stress relief but may not directly address the decision-making process required in this situation.
A healthcare professional is assessing a client diagnosed with anorexia nervosa. Which of the following findings should the healthcare professional expect? Select one that doesn't apply.
- A. Amenorrhea
- B. Lanugo
- C. Hypotension
- D. Hyperkalemia
Correct Answer: D
Rationale: Findings in a client diagnosed with anorexia nervosa include amenorrhea, lanugo, hypotension, and bradycardia. Hyperkalemia is not typically associated with anorexia nervosa. In anorexia nervosa, electrolyte imbalances often lead to hypokalemia, which is low potassium levels, due to malnutrition and potential purging behaviors. Hyperkalemia, high potassium levels, is not a common finding in individuals with anorexia nervosa.
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 nurse should determine that the client is at risk for mental disorder when responses to stress are maladaptive and interfere with daily functioning. The DSM-5 indicates that in order to be diagnosed with a mental disorder, there must be significant disturbance in cognition, emotion, regulation, or behavior that reflects a dysfunction in the psychological, biological or developmental processes underlying mental functioning. These disorders are usually associated with significant distress or disability in social, occupational, or other important activities. The client's ability to communicate distress would be considered a positive attribute.
Which should the healthcare provider recognize as a DSM-5 disorder?
- A. Obesity
- B. Generalized anxiety disorder
- C. Hypertension
- D. Grief
Correct Answer: B
Rationale: The DSM-5 categorizes mental health disorders for diagnostic purposes. Generalized anxiety disorder is one of the disorders listed in the DSM-5, characterized by persistent and excessive worry about various events or activities. This disorder falls under the category of anxiety disorders, which also include panic disorder, phobias, and others. Choices A, C, and D are not DSM-5 disorders. Obesity and hypertension are medical conditions, while grief, though a significant emotional response, is not classified as a mental health disorder in the DSM-5.