Chapter 1: Mental Health and Mental Illness

Multiple Choice
Identify the choice that best completes the statement or answers the question.

____	1.	A nurse is assessing a client who is experiencing occasional feelings of sadness because of the recent death of a beloved pet. The client’s appetite, sleep patterns, and daily routine have not changed. How should the nurse interpret the client’s behaviors?
A.	The client’s behaviors demonstrate mental illness in the form of depression.	
B.	The client’s behaviors are extensive, which indicates the presence of mental illness.	
C.	The client’s behaviors are not congruent with cultural norms.	
D.	The client’s behaviors demonstrate no functional impairment, indicating no mental illness.	

____	2.	At what point should the nurse determine that a client is at risk for developing a mental illness?
A.	When thoughts, feelings, and behaviors are not reflective of the DSM-IV-TR criteria.	
B.	When maladaptive responses to stress are coupled with interference in daily functioning.	
C.	When a client communicates significant distress.	
D.	When a client uses defense mechanisms as ego protection.	

____	3.	A nurse is assessing a set of 15-year-old identical twins who respond very differently to stress. One twin becomes anxious and irritable, while the other withdraws and cries. How should the nurse explain these different responses to stress to the parents?
A.	Reactions to stress are relative rather than absolute; individual responses to stress vary.	
B.	It is abnormal for identical twins to react differently to similar stressors.	
C.	Identical twins should share the same temperament and respond similarly to stress.	
D.	Environmental influences to stress weigh more heavily than genetic influences.	

____	4.	A nurse is completing an interview in which a client’s spouse reports that a client drinks excessively and has lost driving privileges due to conviction of driving while impaired. Refusing treatment, the client states, “I work hard every day to provide for my family. I don’t see why I can’t relax with a little drink.” The nurse should recognize that this response indicates the use of which defense mechanism?
A.	Projection	
B.	Rationalization	
C.	Regression	
D.	Sublimation	

____	5.	Which client should the nurse anticipate to be most receptive to psychiatric treatment?
A.	A Jewish, female social worker	
B.	A Baptist, homeless male	
C.	A Catholic, black male	
D.	A Protestant, Swedish business executive	

____	6.	Which statement about a client’s use of defense mechanisms should a nurse identify as being correct?
A.	Defense mechanisms can be appropriate responses to stress and need not be eliminated.	
B.	Defense mechanisms are a maladaptive attempt of the ego to manage anxiety and should always be eliminated.	
C.	Defense mechanisms, used by individuals with weak ego integrity, should be discouraged and not eliminated.	
D.	Defense mechanisms cause disintegration of the ego and should be fostered and encouraged.	

____	7.	During an intake assessment, a nurse asks both physiological and psychosocial questions. The client angrily responds, “I’m here for my heart, not my head problems.” Which is the nurse’s best response?
A.	“It’s 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 isn’t imperative that we complete this section.”	

____	8.	Which statement reflects a student nurse’s accurate understanding of the concepts of mental health and mental illness?
A.	The concepts are rigid and religiously based.	
B.	The concepts are multidimensional and culturally defined.	
C.	The concepts are universal and unchanging.	
D.	The concepts are unidimensional and fixed.	

____	9.	Looking at a client’s history and physical exam, a nurse notices that a diagnosis of rheumatoid arthritis has not been placed on any axis. Based on knowledge of the DSM-IV-TR, where should the nurse anticipate the coding of this assessment?
A.	Axis I	
B.	Axis II	
C.	Axis III	
D.	Axis IV	
E.	Axis V	

____	10.	A nurse understands that “financial and legal difficulties” are to Axis IV of the DSM-IV-TR as “bipolar disorder” is to which axis?
A.	Axis I	
B.	Axis II	
C.	Axis III	
D.	Axis IV	

____	11.	Which statement should a nurse identify as the most accurate description of the DSM-IV-TR’s definition of a mental disorder?
A.	A mental disorder is said to exist when an individual’s behavior deviates from the group norm.	
B.	A mental disorder results when an individual is unable to cope with the stressors of everyday life.	
C.	A mental disorder exists when subjective distress causes the individual to fail at many tasks.	
D.	A mental disorder is a clinically significant behavioral or psychological pattern that is associated with present distress or disability.	

____	12.	An employee uses the defense mechanism of displacement when the boss openly disagrees with suggestions. What behavior would be expected from this employee?
A.	The employee assertively confronts the boss.	
B.	The employee leaves the staff meeting to work out in the gym.	
C.	The employee criticizes a coworker.	
D.	The employee takes the boss out to lunch.	

____	13.	A teenage boy is attracted to a female teacher. Without objective evidence, a school nurse overhears the boy state, “I know she wants me.” This statement reflects which defense mechanism?
A.	Displacement	
B.	Projection	
C.	Rationalization	
D.	Sublimation	

____	14.	A fourth-grade boy teases and makes jokes about a cute girl in his class. This behavior should be identified by a nurse as indicative of which defense mechanism?
A.	Displacement	
B.	Projection	
C.	Reaction formation	
D.	Sublimation	

____	15.	Which statement about the concept of neuroses should a nurse define as most accurate?
A.	An individual experiencing neurosis is unaware that he or she is experiencing distress.	
B.	An individual experiencing neurosis feels helpless to change his or her situation.	
C.	An individual experiencing neurosis is aware of psychological causes of his or her behavior.	
D.	An individual experiencing neurosis has a loss of contact with reality.	

____	16.	Which statement should a nurse identify as most accurate regarding the concept of psychosis?
A.	Individuals experiencing psychoses are aware that their behaviors are maladaptive.	
B.	Individuals experiencing psychoses experience little distress.	
C.	Individuals experiencing psychoses are aware of experiencing psychological problems.	
D.	Individuals experiencing psychoses are based in reality.	

____	17.	While taking a client’s health history, a nurse learns that, when under stress, a client routinely uses an excessive amount of alcohol. The client states that a spouse constantly yells at the client about the chronic alcohol abuse. Which reported action should the nurse associate with 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 don’t drink too much!”	

____	18.	Devastated by a divorce from an abusive husband, a wife completes grief counseling. Which statement by the wife should indicate to a nurse that the client is in the acceptance stage of grief?
A.	“If only we could have tried again, things might have worked out.”	
B.	“I am so mad that the children and I had to put up with him as long as we did.”	
C.	“Yes, it was a difficult relationship, but I think I have learned from the experience.”	
D.	“I still don’t have any appetite and continue to lose weight.”	

____	19.	A nurse is performing a mental health assessment on an adult client. According to Maslow’s hierarchy of needs, which client action would demonstrate the highest achievement in terms of mental health?
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.	

____	20.	According to Maslow’s hierarchy of needs, which situation on an in-patient psychiatric unit would require priority intervention by a nurse?
A.	A client rudely complaining about limited visiting hours.	
B.	A client exhibiting aggressive behavior toward another client.	
C.	A client stating that no one cares.	
D.	A client verbalizing feelings of failure.	

Multiple Response
Identify one or more choices that best complete the statement or answer the question.

____	1.	A nurse is assessing a client who appears to by experiencing some anxiety during questioning. Which symptoms might the client demonstrate that would indicate anxiety? (Select all that apply.)
A.	Fidgeting	
B.	Laughing inappropriately	
C.	Palpitations	
D.	Nail biting	
E.	Limited attention span	

____	2.	Which information should a nurse code on a DSM-IV-TR axis? (Select all that apply.)
A.	Physical disorders	
B.	Psychosocial stressors	
C.	Treatment recommendations	
D.	Global assessment of functioning	
E.	Past suicide attempts	

____	3.	How is the DSM-IV-TR useful in the practice of psychiatric nursing? (Select all that apply.)
A.	It considers level of functioning as well as problems.	
B.	It represents progress toward a more holistic view of mind–body.	
C.	It provides a framework for interdisciplinary communication.	
D.	It provides a template for nursing care plans.	
E.	It provides a framework for communication with the client.	

Chapter 1: Mental Health and Mental Illness
Answer Section

MULTIPLE CHOICE

	1.	ANS:	D
The nurse should assess that the client’s daily functioning is not impaired. The client who experiences feelings of sadness after the loss of a pet is responding within normal expectations. Without significant impairment, the client’s distress does not indicate a mental illness.

PTS:	1	REF:	Page: 6	
KEY:	Cognitive Level: Analysis | Integrated Process: Assessment	

	2.	ANS:	B
The nurse should determine that the client is at risk for mental illness when responses to stress are maladaptive and interfere with daily functioning. The DSM-IV-TR indicates that in order to be diagnosed with a mental illness, daily functioning must be significantly impaired. The client’s ability to communicate distress would be considered a positive attribute.

PTS:	1	REF:	Page: 6	
KEY:	Cognitive Level: Application | Integrated Process: Assessment	

	3.	ANS:	A
The nurse should explain to the parents that, although the twins have identical DNA, there are several other factors that affect reactions to stress. Mental health is a state of being that is relative to the individual client. Environmental influences and temperament can affect stress reactions.

PTS:	1	REF:	Page: 5	
KEY:	Cognitive Level: Application | Integrated Process: Implementation

	4.	ANS:	B
The nurse should recognize that the client is using rationalization, a common defense mechanism. The client is attempting to make excuses and create logical reasons to justify unacceptable feelings or behaviors.

PTS:	1	REF:	Page: 9	
KEY:	Cognitive Level: Comprehension | Integrated Process: Assessment

	5.	ANS:	A
The nurse should anticipate that the client of Jewish culture would place a high importance on preventative health care and would consider mental health as equally important as physical health. Women are also more likely to seek treatment for mental health problems than men.

PTS:	1	REF:	Page: 4	
KEY:	Cognitive Level: Application | Integrated Process: Planning	

	6.	ANS:	A
The nurse should determine that defense mechanisms can be appropriate during times of stress. The client with no defense mechanisms may have a lower tolerance for stress, thus leading to anxiety disorders. Defense mechanisms should be confronted when they impede the client from developing healthy coping skills.

PTS:	1	REF:	Page: 8	
KEY:	Cognitive Level: Application | Integrated Process: Implementation

	7.	ANS:	C
The nurse should attempt to educate the client on the negative effects of excessive stress on medical conditions. It is not appropriate to skip physiological and psychosocial questions, as this would lead to an inaccurate assessment.

PTS:	1	REF:	Page: 8	
KEY:	Cognitive Level: Analysis | Integrated Process: Communication/Documentation

	8.	ANS:	B
The student nurse should understand that mental health and mental illness are multidimensional and culturally defined. It is important for nurses to be aware of cultural norms when evaluating the client’s mental state.

PTS:	1	REF:	Page: 4	
KEY:	Cognitive Level: Application | Integrated Process: Evaluation	

	9.	ANS:	C
The nurse should anticipate that a diagnosis of rheumatoid arthritis should be coded on Axis III of the DSM-IV-TR diagnosis. The DSM-IV-TR uses a multiaxial system in which each axis refers to a different domain of information. Axis I should include clinical disorders and other conditions that may be a focus of clinical attention. Axis II should include information about personality disorders and/or mental retardation. Axis III should include information about general medication conditions. Axis IV should include information on the client’s psychosocial and environmental problems. Axis V provides a Global Assessment of Functioning (GAF).

PTS:	1	REF:	Page: 12	
KEY:	Cognitive Level: Knowledge | Integrated Process: Communication/Documentation

	10.	ANS:	A
The nurse should understand that clinical disorders, such as bipolar disorder, should be included in Axis I of the DSM-IV-TR diagnosis. The DSM-IV-TR uses a multiaxial system in which each axis refers to a different domain of information. Axis I should include clinical disorders and other conditions that may be a focus of clinical attention. Axis II should include information about personality disorders and/or mental retardation. Axis III should include information about general medication conditions. Axis IV should include information on the client’s psychosocial and environmental problems. Axis V provides a Global Assessment of Functioning (GAF).

PTS:	1	REF:	Page: 12	
KEY:	Cognitive Level: Knowledge | Integrated Process: Communication/Documentation

	11.	ANS:	D
The nurse should identify that a mental disorder indicates a pattern of maladaptive clinically significant behavioral or psychological problems. The DSM-IV-TR also specifies that the behavior or pattern is not an expectable and culturally sanctioned response to a particular event.

PTS:	1	REF:	Page: 5	
KEY:	Cognitive Level: Comprehension | Integrated Process: Communication/Documentation

	12.	ANS:	C
The nurse should expect that the client using the defense mechanism displacement would criticize a coworker after being confronted by the boss. Displacement refers to transferring feelings from one target to a neutral or less-threatening target.

PTS:	1	REF:	Page: 9	
KEY:	Cognitive Level: Analysis | Integrated Process: Assessment	

	13.	ANS:	B
The nurse should determine that the client’s statement reflects the defense mechanism projection. Projection refers to the attribution of one’s unacceptable feelings or impulses to another person. When the client “passes the blame” of the undesirable feelings, anxiety is reduced. Displacement refers to transferring feelings from one target to another. Rationalization refers to making excuses to justify behavior. Sublimation refers to channeling unacceptable drives or impulses into more constructive, acceptable activities.

PTS:	1	REF:	Page: 9	
KEY:	Cognitive Level: Application | Integrated Process: Analysis	

	14.	ANS:	C
The nurse should identify that the boy is using reaction formation as a defense mechanism. Reaction formation is the attempt to prevent undesirable thoughts from being expressed by expressing opposite thoughts or behaviors. Displacement refers to transferring feelings from one target to another. Rationalization refers to making excuses to justify behavior. Projection refers to the attribution of unacceptable feelings or behaviors to another person. Sublimation refers to channeling unacceptable drives or impulses into more constructive, acceptable activities.

PTS:	1	REF:	Page: 9	
KEY:	Cognitive Level: Application | Integrated Process: Assessment	

	15.	ANS:	B
The nurse should define the concept of neuroses with the following characteristics: The client feels helpless to change his or her situation, the client is aware that he or she is experiencing distress, the client is aware the behaviors are maladaptive, the client is unaware of the psychological causes of the distress, and the client experiences no loss of contact with reality.

PTS:	1	REF:	Page: 8	
KEY:	Cognitive Level: Comprehension | Integrated Process: Teaching/Learning

	16.	ANS:	B
The nurse should understand that the client with psychoses experiences little distress due to his or her lack of awareness of reality. The client with psychoses is unaware that his or her behavior is maladaptive or that he or she has a psychological problem.

PTS:	1	REF:	Page: 10	
KEY:	Cognitive Level: Comprehension | Integrated Process: Teaching/Learning

	17.	ANS:	D
The nurse should associate the client statement “I don’t drink too much!” with the use of the defense mechanism of denial. The client who refuses to acknowledge the existence of a real situation and the feelings associated with it is using the defense mechanism denial.

PTS:	1	REF:	Page: 9	
KEY:	Cognitive Level: Application | Integrated Process: Assessment	

	18.	ANS:	C
The nurse should evaluate that the client in the acceptance stage of grief because during this stage of the grief process, the client would be able to focus on the reality of the loss and its meaning in relation to life.

PTS:	1	REF:	Page: 11	KEY:	Cognitive Level: Analysis | Integrated Process: Evaluation

	19.	ANS:	C
The nurse should identify that the client who possesses a feeling of self-fulfillment and realizes his or her full potential has achieved self-actualization, the highest level on Maslow’s hierarchy of needs.

PTS:	1	REF:	Page: 4	
KEY:	Cognitive Level: Application | Integrated Process: Assessment	

	20.	ANS:	B
The nurse should immediately intervene when a client exhibits aggressive behavior toward another client. Safety and security are considered lower level needs according to Maslow’s hierarchy of needs and must be fulfilled before other higher level needs can be met. Clients who complain, have feelings of failure, or state that no one cares are struggling with higher level needs such as the need for love and belonging or the need for self-esteem.

PTS:	1	REF:	Page: 4	
KEY:	Cognitive Level: Analysis | Integrated Process: Implementation	

MULTIPLE RESPONSE

	1.	ANS:	A, B, D
The nurse should assess that fidgeting, laughing inappropriately, and nail biting are indicative of heightened stress levels. The client would not be diagnosed with mental illness unless there is significant impairment in other areas of daily functioning. Other indicators of more serious anxiety are restlessness, difficulty concentrating, muscle tension, and sleep disturbance.

PTS:	1	REF:	Page: 8	
KEY:	Cognitive Level: Application | Integrated Process: Assessment	

	2.	ANS:	A, B, D
The nurse should include physical disorders, psychosocial stressors, and the Global Assessment of Function (GAF) in the DSM-IV-TR diagnosis. The DSM-IV-TR diagnosis is multidimensional and contains information that may help guide the course of treatment. Previous suicide attempts indicate a clinical disorder such as bipolar disorder or major depressive disorder, which would be included on Axis I.

PTS:	1	REF:	Page: 12	
KEY:	Cognitive Level: Application | Integrated Process: Communication/Documentation

	3.	ANS:	A, B, C
The DSM-IV-TR is useful in the practice of psychiatric nursing because it facilitates comprehensive evaluation of the client. It considers the client’s current level of functioning, represents a holistic view, and provides a framework for interdisciplinary communication.

PTS:	1	REF:	Page: 12	
KEY:	Cognitive Level: Application | Integrated Process: Communication/Documentation