NSG 3450 Exam 2 Review

A nurse is conducting a mental status exam on a newly admitted client. The client is disheveled, avoids eye contact, and answers in a flat tone. Which domain of the mental status exam is the nurse assessing?

• Mood and Affect

• Appearance

• Thought Process

• Cognition

Answer explanation

Rationale: The nurse is assessing appearance, which includes grooming, hygiene, and observed behavior such as eye contact and tone. Other areas evaluated in the mental status exam include: behavior, speech, mood, affect, thought process, thought content, perception, cognition, insight and judgment.

During a therapeutic interview, the nurse says, 'It sounds like you’re feeling a lot of pressure from your responsibilities.' What communication technique is being used?

• Restating

• Exploring

• Reflecting

• Paraphrasing

Answer explanation

Rationale: Paraphrasing is a clarifying technique that involves restating the patient's thoughts and feelings in the nurse’s own words to show understanding.

A nurse is facilitating a therapeutic group session. One member begins to dominate the conversation, leaving little room for others. What is the most appropriate response by the nurse?

• Ignore the behavior and let others speak when ready.

• Ask the member to stop speaking.

• Gently interrupt and redirect the discussion to others.

• End the session early to avoid conflict.

Answer explanation

Rationale: Redirecting gently allows all members to participate while maintaining a respectful group environment. The monopolizing group member should be encouraged to limit suggestions to 1-2 per session to ensure that all members have the opportunity to participate.

Which of the following best describes the 'resistance' stage in the General Adaptation Syndrome (GAS)?

• The body’s initial response to a stressor

• A return to normal functioning after stress

• Continued physiological effort to adapt to a stressor

• Total depletion of the body's resources

Answer explanation

Rationale: The resistance stage occurs when the body attempts to adapt to the stressor through sustained physiological responses.

Other answer choices:

The body’s initial response to a stressor = Alarm stage

A return to normal functioning after stress = Resolution

Total depletion of the body's resources = Exhaustion stage

Which behavior is most consistent with conduct disorder in adolescents?

• Verbal defiance

• Destroying property

• Temper tantrums

• School avoidance

Answer explanation

Rationale: Conduct disorder involves aggressive and destructive behavior such as harming animals or destroying property.

Which behavior best indicates 'la belle indifference' in a client with conversion disorder?

• Frustration about paralysis

• Calmness despite sudden blindness

• Anxiety over health

• Obsession with cleanliness

Answer explanation

Rationale: La belle indifference refers to a surprising lack of concern about significant physical symptoms, typical in conversion disorder.

What is the primary nursing goal for a client diagnosed with dissociative identity disorder (DID)?

• Encourage isolation for safety

• Reinforce the client’s alternate identities

• Help the client integrate their identities

• Promote dependence on the care team

Answer explanation

Rationale: The goal of treatment for DID is to integrate identities and help the client function as a whole person. Grounding techniques can be helpful to bring the patient back to reality.

Which response by the nurse reflects the use of the 'exploring' communication technique?

• 'Can you describe that feeling more in detail?'

• 'Everyone feels that way sometimes.'

• 'You should try to rest more.'

• 'Tell me what your doctor said.'

Answer explanation

Rationale: Exploring is a therapeutic communication technique that encourages the client to elaborate on their thoughts or feelings.

A client diagnosed with PTSD reports difficulty sleeping and avoiding certain places. What should the nurse prioritize in the initial care plan?

• Encouraging daily journaling

• Providing education on trauma

• Establishing safety and trust

• Promoting group therapy participation

Answer explanation

Rationale: Establishing safety and trust is the foundational intervention for trauma-related disorders and supports further therapeutic progress.

A nurse is caring for a client experiencing the alarm stage of the general adaptation syndrome (GAS). What physiological finding should the nurse expect?

• Decreased respiratory rate

• Pupil constriction

• Increased blood glucose

• Decreased heart rate

Answer explanation

Rationale: During the alarm stage of GAS, the body experiences a 'fight-or-flight' response, including increased glucose for energy.