The mental status examination takes place during which part of the nursing process?

Evaluation

Assessment

Planning

Implementation

Answer and Explanation

The Correct Answer is B

Choice A reason: Evaluation is the final step of the nursing process, where the nurse determines the effectiveness of the nursing care provided.

Choice B reason: Assessment is the correct part of the nursing process for the mental status examination, as it involves collecting data about the patient.

Choice C reason: Planning involves setting goals and choosing appropriate nursing actions based on the assessment data.

Choice D reason: Implementation is the step where the nurse carries out the planned interventions.

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Correct Answer is C

Explanation

Choice A reason: Regression involves reverting to an earlier stage of development when faced with stress, which is not what Marie is doing.

Choice B reason: Repression involves unconsciously blocking out painful thoughts or feelings, which is different from Marie's conscious rationalization of her failure.

Choice C reason: Rationalization is a defense mechanism where an individual justifies an unacceptable behavior or feeling with a logical reason, avoiding the true explanation for the behavior. Marie is rationalizing her failure by blaming the instructor rather than accepting her own role in the outcome.

Choice D reason: Reaction formation involves behaving in a way that is opposite to what one truly feels, which is not applicable in Marie's case.

A. Observe the patient's nonverbal communication for data on the patient's thoughts and feelings. B. Maximize stimuli to create diversion from the anxiety. C. Discourage activities, as activities might only increase a patient's anxiety level. D. Document only positive changes in behavior. E. Encourage the patient to verbalize all thoughts and feelings. F. Observe for signs of suicidal thoughts.

Correct Answer is ["B","C","D"]

Explanation

Choice A reason: Observing nonverbal communication is a valid nursing intervention for assessing a patient's anxiety level.

Choice B reason: Maximizing stimuli can overwhelm a patient with anxiety and is not a recommended intervention.

Choice C reason: Discouraging activities is not recommended as activities can be a form of therapy for anxiety disorders.

Choice D reason: Documenting only positive changes is not appropriate as all changes, positive or negative, should be documented for a comprehensive understanding of the patient's condition.

Choice E reason: Encouraging patients to verbalize thoughts and feelings is a therapeutic intervention that can help manage anxiety.

Choice F reason: Observing for signs of suicidal thoughts is crucial as anxiety disorders can increase the risk of suicide.

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The mental status examination takes place during which part of the nursing process?

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Naxlex Comprehensive Predictor Exams

Marie has just learned that she has failed her mental health nursing class. She tells her friends, "I knew that instructor was going to fail me. She has never liked me and has just been looking for an excuse to fail me all along." Marie's behavior is an example of which defense mechanism?

Correct Answer is C

Explanation

Which of the following are NOT nursing interventions for people with anxiety disorders? Select all that apply.

Correct Answer is ["B","C","D"]

Explanation

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