A nurse is caring for a client diagnosed with somatization disorder. The nurse
should understand that a client with this disorder will use which of the following
defense mechanisms?
A. Displacement
B. Repression
C. undoing
D. Suppression
~ B- Correct: Repression is the unconscious defens...
✓~ exam used to objectively assess a client's cognitive status by
evaluation orientation to time and place, attention span and ability to count
backwards by seven, following commands, ability to write, recalling objects
Stuporous
✓~ The client requires vigorous or painful stimuli to elicit a brief response.
She might not be able to respond verbally.
Decorticate rigidity
✓~ Flexion and internal rotation of upper-extremity joints and legs
Decerebrate rigidity
✓~ Neck and elbow extension, wrist and finger flexion
,Mood vs affect
✓~ mood: emotion
affect: objective expression of mood (such as flat affect or a lack of facial
expressions)
Milieu Therapy
✓~ orienting the client to the physical setting, identifying rules and
boundaries of the setting, ensuring a safe environment for the client, assisting
the client to participate in appropriate activities
A charge nurse is discussing mental status examinations with a newly licensed
nurse. Which of the following statements by the newly licensed nurse indicates
an understanding of the teaching? (select all that apply)
A. "To assess cognitive ability, I should ask the client to count backward by
sevens."
B. "To assess affect, I should observe the client's facial expression."
C. "To assess language ability, I should instruct the client to write a sentence."
D. "To assess remote memory, I should have the client repeat a list of objects."
,E. "To assess the client's abstract thinking, I should ask the client to identify
our most recent presidents."
✓~ Correct- A, B, C
D is incorrect because asking the client to repeat a list of objects is
appropriate to assess immediate, rather than remote memory.
E is incorrect because asking the client to identify recent presidents is
appropriate to assess cognitive knowledge rather than abstract thinking.
A nurse is planning care for a client who has a mental health disorder. Which of
the following actions should the nurse include as a psychobiological intervention?
A. Assist the client with systematic desensitization therapy
B. Teach the client appropriate coping mechanisms
C. Assess the client for comorbid health conditions.
D. Monitor the client for adverse effects of medications
✓~ Correct- D
, A- Incorrect: assisting with systematic desensitization therapy is a cognitive
and behavioral, rather than a psychobiological intervention.
B- Incorrect: Teaching appropriate coping mechanisms is a counseling or health
teaching intervention.
C- Incorrect: assessing for comorbid heath conditions is a health promotion and
maintenance intervention
A nurse in an outpatient entail health clinic is preparing to conduct an initial
client interview. When conducting the interview, which of the following actions
should the nurse identify as the priority?
A. Coordinate holistic care with social services.
B. Identify the client's perception of her mental health status.
C. Include the client's family in the interview.
D. Teach the client about her current mental health disorder.
✓~ Correct- B.
All are appropriate, but B is the best answer because assessment is the priority
action when using the nursing process.
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