Nokea
The nurse is assessing a nervous 18-year-old patient who has vital signs of P 120, R 30, and BP 160/90. The patient states that he feels something bad is about to happen. Based on this data alone, how should the nurse identify the patient's level of anxiety?
- A. Mild
- B. Moderate
- C. Severe
- D. Panic
Correct Answer: C
Rationale: Severe anxiety may be manifested by elevated blood pressure, pulse, and respiratory rate, a feeling of impending danger, and feelings of fatigue.
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In the movie Gone With the Wind, Scarlett O'Hara says, 'I'll think about that tomorrow. Tomorrow is another day.' The nurse recognizes the defense mechanism of
Correct Answer: repression
Rationale: Repression is an unconscious barring of anxiety-producing thoughts.
What definition should the nurse use to clarify the concept of 'mental health'?
- A. A wellness of attitude
- B. A person's response to disease and dysfunction
- C. The ability to cope and adjust to everyday stresses
- D. How the person performs activities of daily living
Correct Answer: C
Rationale: Mental health can be defined as a person's ability to cope and adjust to everyday stresses.
What coping mechanism demonstrated by a patient should indicate to the nurse that the patient is seeking ways to deal with and resolve stress?
- A. Projection
- B. Adaptation
- C. Reaction formation
- D. Compensation
Correct Answer: B
Rationale: An individual who develops ways to deal with stress and resolve it has adapted.
The nurse is assessing a young woman who is a teacher, happily married, raising two children, taking care of her disabled mother, and going to school to get a master's degree. How should the behavior of the young woman be classified?
- A. Ego-centered
- B. Role integrated
- C. High-level wellness
- D. Unbounded energy
Correct Answer: B
Rationale: Role integration is performing several ascribed roles at the same time.
When the patient who overeats insists that weight gain is related to retained fluids, the nurse recognizes the patient is using which defense mechanism?
- A. Compensation
- B. Rationalization
- C. Sublimation
- D. Regression
Correct Answer: B
Rationale: Defense mechanisms are unconscious reactions that offer protection to the self from stressful situations. Rationalization offers a reasonable explanation for an event rather than facing reality.