At what point should the nurse determine that a client is at risk for developing mental illness? When:

a client communicates significant distress.

maladaptive responses to stress are coupled with interference in daily functioning.

thoughts, feelings, and behaviors are not reflective of the DSM-5 criteria.

a client uses defense mechanisms as ego protection.

Answer and Explanation

The Correct Answer is B

a. a client communicates significant distress. While significant distress is important to consider, it alone does not necessarily indicate a risk for developing mental illness unless it also impacts daily functioning and coping mechanisms.
b. maladaptive responses to stress are coupled with interference in daily functioning. This choice is correct because it reflects a combination of maladaptive coping (which can exacerbate mental health issues) and interference with daily functioning (a key indicator of mental illness according to DSM-5 criteria).
c. thoughts, feelings, and behaviors are not reflective of the DSM-5 criteria. While alignment with DSM-5 criteria is crucial for diagnosis, this choice alone does not address the risk aspect. The focus should be on behaviors that lead to impairment in daily functioning and coping.
d. a client uses defense mechanisms as ego protection. Using defense mechanisms is a normal part of human behavior and not necessarily indicative of mental illness risk unless these mechanisms are maladaptive and interfere with functioning.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

a. Stop the client in the hall and tell them that they must pace in the day room instead. This can be confrontational and might escalate the situation.
b. Keep hands in pockets so as not to appear threatening. While non-threatening body language is important, the focus should be on verbal communication.
c. Speak softly and calmly. De-escalation is key in such situations. A calm and non-threatening approach is essential to build rapport and assess the situation.
d. Offer the client a cup of coffee. Stimulants like caffeine might worsen anxiety.

A. experience no loss of contact with reality. B. never have mood or personality changes. C. have conflict but only use adaptive defense mechanisms to cope. D. are always aware that their behaviors are maladaptive.

Correct Answer is A

Explanation

a. experience no loss of contact with reality. The key difference is reality testing. Clients with neurosis (anxiety disorders, OCD) generally maintain contact with reality, even though their thoughts or behaviours might be distressing. Clients with psychosis (schizophrenia) experience a break with reality, such as hallucinations or delusions.
b. Never have mood or personality changes. Not true. Mood and personality changes can occur in both neurosis and psychosis.
c. Have conflict but only use adaptive defence mechanisms to cope. Défense mechanisms are used by everyone to cope with anxiety, but in neurosis, they might be less healthy or maladaptive.
d. Are always aware that their behaviours are maladaptive. Not necessarily. Clients with neurosis might have limited insight into how their behaviours affect themselves or others.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

At what point should the nurse determine that a client is at risk for developing mental illness? When:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is noted to be pacing on the unit with their hands clenched and mumbling curses. The nurse knows that the initial approach to this client would be to:

Correct Answer is C

Explanation

The nurse's approach to a client with neurotic vs. psychotic behavior is different mainly because clients with neurotic behavior.

Correct Answer is A

Explanation

A 16-year-old client diagnosed with schizophrenia disorder experiences command hallucinations to harm others. The client's parents ask a nurse, "Where do the voices come from?" Which is the appropriate nursing response?

A client, who is newly admitted with Obsessive-Compulsive Disorder, washes their hands ritualistically before any activity. They arrive late to meals and does not have time to finish eating. The appropriate nursing action would be to:

The nurse is working with a client diagnosed with Somatic Symptom Disorder. What predominant symptoms should the nurse expect to assess?

A new nurse orientee asks why a client admitted to the psychiatric unit is placed in seclusion. The nurse precepting the new nurse explains that which of the following is a benefit of seclusion?

Which nursing behavior will enhance the establishment of a trusting relationship with a client diagnosed with schizophrenia disorder?

The nurse is caring for a client who lost the ability to use their arm. All tests have ruled out any medical diagnosis. The nurse understands that the loss of use of the arm is a symptom of:

A client takes the morning dose of 10 units of insulin aspart at 0800. At what time interval would the nurse most likely see hypoglycemia?

A client tells the nurse, "I feel bad because my mother does not want me to return home after I leave the hospital." Which nursing response is therapeutic?