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Answers to Multiple Choice Questions

Chapter 10
1.A
The clients statement about drinking only on weekends reflects denial of the problem.
Therefore, ineffective denial is most appropriate. Although situational low self-esteem may be a
problem, it is not the priority at this time. There is no evidence to suggest that the client is
confused. Although the client may be at risk for possible injury due to alcohol ingestion or
withdrawal, the priority is to have the client admit that he has a problem with alcohol.
2.D
The most appropriate outcome would be the client spending time with peers and staff members
in unit activities. By participating in unit activities with others, the client is no longer socially
isolated. In addition, this participation helps to foster a beginning sense of trust. Asking for
permission to be excused from activities would serve only to reinforce the clients isolation. The
ability to identify positive qualities in ones self and others is important but is unrelated to the
problem of social isolation. Stating that the level of trust is improved, although also important,
does not indicate that the clients social isolation is being addressed.
3.D
Because the client is homeless, has delusions, and responds to auditory hallucinations, the client
is at risk for injury. Therefore, the priority need is the clients physical safety. This need must be
met before any higher level needs, such as self-esteem, love and belonging, and selfactualization, are addressed.
4.B

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Axis II addresses personality disorders and mental retardation. Borderline personality disorder is
coded on Axis II of the DSM-IV-TR. Axis I identifies clinical disorders and other conditions that
may be a focus of attention. Axis III involves general medical conditions. Axis IV addresses
psychosocial and environmental problems.
5.D
The client is verbalizing difficulty with feelings about his capabilities, demonstrating a negative
perception of himself that has persisted over a fairly long period of time. Therefore, the priority
nursing diagnosis would be Chronic Low Self-Esteem. There is no information in the clients
statements to suggest that he is experiencing problems with cognition, which would suggest
Disturbed Thought Processes or problems indicating Anxiety. Disturbed Body Image would be
appropriate if the client verbalized feelings indicating an altered view of his bodys structure,
function, or appearance.
6.A, B, and E
Interventions appropriate for all nurses in psychiatricmental health clinical settings include
counseling interventions to help the client improve or regain coping abilities; maintenance of a
therapeutic environment or milieu; structured interventions to foster self-care and mental and
physical well-being; psychological and biologic interventions to restore the clients health and
prevent future disability; health education; case management; and interventions for mental health
promotion and mental illness prevention. Only the advanced-practice psychiatricmental health
nurse can prescribe pharmacologic agents and perform individual, group, family, and child
therapy.