NURS 230 QUIZ #2 (PICS ONLY)

A client has frequent panic attacks and often describes feeling disconnected from self during these attacks. Which behavior will the nurse document in the electronic health record?

A. Hallucinations

B. Depersonalization

C. Derealization

D. Denial

B. Depersonalization

Why (Rationale): Depersonalization is a subjective feeling of being detached or disconnected from oneself, one's body, thoughts, or emotions. Derealization is a feeling that one’s surroundings or environment feel unreal

A nurse is providing care to a client with anxiety. Which information will the nurse obtain to integrate into the plan of care about the use of defense mechanisms in the client? Select all that apply.

The clients use of defense mechanisms to attempt reduction of anxiety

The lack of awareness of the client using defense mechanisms

The clients overuse of defense mechanisms can be harmful

The client is experiencing cognitive distortions from defense mechanisms

• The client's use of defense mechanisms to attempt reduction of anxiety.

• The client's overuse of defense mechanisms can be harmful.

• The client is experiencing cognitive distortions from defense mechanisms.

• Chapter 14 (Anxiety and Anxiety Disorders), Page 230

The nurse identifies that a client is using more defense mechanisms throughout the day. Which positive outcome of using defense mechanisms will the client experience?

• A. Inhibition of emotional growth

• B. Poor problem-solving skills

• C. Difficulty with relationships

• D. Reduction of anxiety

D. Reduction of anxiety

• Why (Rationale): The main short-term purpose of defense mechanisms is to protect the person from uncomfortable feelings and temporarily reduce anxiety. Overuse is what leads to negative outcomes such as poor problem-solving and relationship difficulties.

• Chapter 14 (Anxiety and Anxiety Disorders), Page 230

A nurse is conducting a group session in the behavioral health unit for three clients on the topic of anxiety. The nurse determines that the session was successful based on which statement by the clients?

• A. “Anxiety and fear are the same.”

• B. “Anxiety cannot be completely eliminated from my life.”

• C. “Anxiety is always harmful and not productive in my life.”

• D. “Fear is feeling threatened by an unknown entity.”

B. “Anxiety cannot be completely eliminated from my life.”

• 
  

• Why (Rationale): Anxiety is an unavoidable, normal human reaction to stress that can motivate people to solve problems or resolve crises. The therapeutic goal is not to eliminate anxiety completely but rather to learn healthy coping strategies to manage it effectively.

Chapter 14 (Anxiety and Anxiety Disorders), Page 224

The nurse is planning activities for clients in the behavioral health unit. Which choice of activity will the nurse avoid when planning the activity for a client with bipolar I disorder that is experiencing mania?

• A. A group Yoga class

• B. A presentation about stress reduction techniques

• C. A craft that will take approximately 20 minutes to complete

• D. A competitive board game between four clients

D. A competitive board game between four clients

• Why (Rationale): During manic episodes, the nurse must avoid stimulating, competitive, or highly social activities that can worsen hyperactivity, increase agitation, or spark conflict. Noncompetitive, simple, and brief activities with minimal stimulation are always preferred.

• Chapter 17 (Mood Disorders and Suicide), Page 311

The nurse working in a behavioral health unit is talking with an LPN regarding a client that is on suicide precautions. Which statement by the LPN requires correction by the nurse?

• A. “The client only talked about killing themselves, they probably will never do it.”

• B. “I will look to see if there is anything they can harm themselves with in the surroundings.”

• C. “We can help this client by talking with them about suicide and any plans they may have.”

• D. “I will spend some extra time with the client today and try to involve them in an activity.”

A. “The client only talked about killing themselves, they probably will never do it.”

Why (Rationale): Every suicidal statement or threat must be taken with absolute seriousness. The nurse has a professional obligation to directly assess the client's suicidal thoughts, plans, means, and intent to maintain a safe environment.

Chapter 17 (Mood Disorders and Suicide), Pages 315–316

A client is admitted with a diagnosis of major depression and states “nothing brings me pleasure anymore.” Which behaviors will the nurse assess that correlates with the diagnosis?

• A. Pressured speech

• B. Grandiosity

• C. Flight of ideas

• D. Anhedonia

D. Anhedonia (Note: Your quiz review also indicates the nurse should assess for accompanying feelings of worthlessness and difficulty focusing)

Why (Rationale): Anhedonia—the total inability to experience pleasure or interest in previously enjoyed life activities—is a primary diagnostic feature of clinical depression. Flight of ideas, pressured speech, and grandiosity are symptoms characteristic of mania, not depression.

Chapter 17 (Mood Disorders and Suicide), Page 288

A client who is depressed begins to cry and states, “I’m just really sick of feeling this way. Nothing ever seems to go right in my life.” Which would be the most appropriate response by the nurse?

• A. “Don’t cry. Try to look at the positive side of things.”

• B. “You are feeling really sad right now. It’s a hard time.”

• C. “Hang in there. Your medication will start helping in a few days.”

• D. “Nothing ever goes right?”

B. “You are feeling really sad right now. It’s a hard time.”

• Why (Rationale): This is a therapeutic, empathetic communication response. It directly acknowledges and reflects the client's feelings without attempting to minimize their distress, challenge their thinking, or offer false reassurance.

• Chapter 17 (Mood Disorders and Suicide), Page 300