1. A 40-year-old male client diagnosed with schizophrenia and alcohol dependence has not had
any visitors or phone calls since admission. He reports he has no family that cares about him
and was living on the streets prior to this admission. According to Erikson's theory of
psychosocial developm...
a 40 year old male client diagnosed with schizophrenia and alcohol dependence has not had any visitors or phone calls since admission he repo
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NURSING CORE NURS 222
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1. A 40-year-old male client diagnosed with schizophrenia and alcohol dependence has not had
any visitors or phone calls since admission. He reports he has no family that cares about him
and was living on the streets prior to this admission. According to Erikson's theory of
psychosocial development, which stage is the client in at this time?
A. Isolation.
B. Stagnation.
C. Despair.
D. Role confusion.
The client is in Erikson's "Generativity vs. Stagnation" stage (age 24 to 45), and meeting the task
includes maintaining intimate relationships and moving toward developing a family (B). (A)
occurs in young adulthood (age 18 to 25), (C) occurs in maturity (age 45 to death), and (D)
occurs in adolescence (age 12 to 20). These are all stages that occur if individuals are not
successfully coping with their psychosocial developmental stage.
Points Earned: 1/1
Correct Answer: B
Your Response: B
2. An anxious client expressing a fear of people and open places is admitted to the psychiatric
unit. What is the most effective way for the nurse to assist this client?
A. Plan an outing within the first week
admission.
B. Distract her whenever she expresses her discomfort about being with othe
C. Confront her fears and discuss the possible causes of these fears.
D. Accompany her outside for an increasing amount of time each day.
The process of gradual desensitization by controlled exposure to the situation which is feared
(D), is the treatment of choice in phobic reactions. (A and C) are far too aggressive for the initial
treatment period and could even be considered hostile. (B) promotes denial of the problem, and
gives the client the message that discussion of the phobia is not permitted.
Points Earned: 0/1
Correct Answer: D
Your Response: C
3. On admission, a highly anxious client is described as delusional. The nurse understands that
delusions are most likely to occur with which class of disorder?
, A. Neuroti
c.
B. Personality.
C. Anxiety.
D. Psychotic.
Delusions are false beliefs associated with psychotic behavior, and psychotic persons are not in
touch with reality (D). (A, B, and C) are mental health disorders which are not associated with a
break in reality, nor with hallucinations (false sensations such as hearing, or seeing) or delusions
(false beliefs).
Points Earned: 1/1
Correct Answer: D
Your Response: D
4. A child is brought to the emergency room with a broken arm. Because of other injuries, the
nurse suspects the child may be a victim of abuse. When the nurse tries to give the child an
injection, the child's mother becomes very loud and shouts, "I won't leave my son! Don't you
touch him! You'll hurt my child!" What is the best interpretation of the mother's statements?
The mother is
A. regressing to an
earlier behavior
pattern.
B. sublimating her anger.
C. projecting her feelings onto the nurse.
D. suppressing her fear.
Projection is attributing one's own thoughts, impulses, or behaviors onto another--it is the mother
who is probably harming the child and she is attributing her actions to the nurse (C). The mother
may be immature, but (A) is not the best description of her behavior. (B) is substituting a socially
acceptable feeling for an unacceptable one. These are not socially acceptable feelings. The
mother may be suppressing her fear (D) by displaying anger, but such an interpretation cannot be
concluded from the data presented.
Points Earned: 0/1
Correct Answer: C
Your Response: A
5. A male client is admitted to a mental health unit on Friday afternoon and is very upset on
Sunday because he has not had the opportunity to talk with the healthcare provider. Which
, response is best for the nurse to provide this client?
A. Let me call and leave a message
for your healthcare provider.
B. The healthcare provider should be here on Monday morning.
C. How can I help answer your questions?
D. What concerns do you have at this time?
It is best for the nurse to call the healthcare provider (A) because clients have the right to
information about their treatment. Suggesting that the healthcare provider will be available the
following day (B) does not provide immediate reassurance to the client. The nurse can also
implement offer to assist the client (C and D), but the highest priority intervention is contacting
the healthcare provider.
Points Earned: 0/1
Correct Answer: A
Your Response: C
6. A male client is admitted to the mental health unit because he was feeling depressed about the
loss of his wife and job. The client has a history of alcohol dependency and admits that he
was drinking alcohol 12 hours ago. Vital signs are: temperature, 100° F, pulse 100, and BP
142/100. The nurse plans to give the client lorazepam (Ativan) based on which priority
nursing diagnosis?
A. Risk for injury related to
suicidal ideation.
B. Risk for injury related to alcohol detoxification.
C. Knowledge deficit related to ineffective coping.
D. Health seeking behaviors related to personal crisis.
The most important nursing diagnosis is related to alcohol detoxification (B) because the client
has elevated vital signs, a sign of alcohol detoxification. Maintaining client safety related to (A)
should be addressed after giving the client Ativan for elevated vital signs secondary to alcohol
withdrawal. (C and D) can be addressed when immediate needs for safety are met.
Points Earned: 1/1
Correct Answer: B
Your Response: B
7. The nurse suspects child abuse when assessing a 3-year-old boy and noticing several small,
round burns on his legs and trunk that might be the result of cigarette burns. Which parental
, behavior provides the greatest validation for such suspicions?
A. The parents' explanation of ho
occurred is different from the
explanation of how they occu
B. The parents seem to dismiss the severity of the child's burns, saying they
and have not posed any problem.
C. The parents become very anxious when the nurse suggests that the child m
admitted for further evaluation.
D. The parents tell the nurse that the child was burned in a house fire which
with the nurse's observation of the type of burn.
(D) provides the most validation. The parent's explanation (subjective data) is incompatible with
the objective data (small round burns on the legs and trunk). (A) provides only subjective data,
and the child's explanation could be influenced by factors such as age, fear, or imagination. The
parent's apparent lack of concern (B) is inconclusive, but the nurse's opinion of the parents'
reaction is subjective and could be wrong. (C) might provide a clue that child abuse occurred, but
the nurse must remember that most parents are anxious about their child being hospitalized.
Points Earned: 0/1
Correct Answer: D
Your Response: C
8. A male client with schizophrenia tells the nurse that the voices he hears are saying, "You
must kill yourself." To assist the client in coping with these thoughts, which response is best
for the nurse to provide?
A. Tell yourself that the
voices are unreasonable.
B. Exercise when you hear the voices.
C. Talk to someone when you hear the voices.
D. The voices aren't real, so ignore them.
The nurse should teach the client to use self-talk to disprove the voices (A). Although (B) may be
helpful, the client's concrete thinking may make it difficult to understand this suggestion. Clients
with schizophrenia have difficulty initiating interaction with others (C). Auditory hallucinations
are often relentless, so it is difficult to ignore them (D).
Points Earned: 0/1
Correct Answer: A
Your Response: C
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